Mr John Groom The Complete Guide to Hernia

Mr John Groom The Complete Guide to Hernia

What Do They Have in Common? AA

Both Subjects Controversial! Debate 1. Laparoscopic verses Open Hernia Repair Beautiful Big splash

Debate 2. Use of Mesh in Hernia Repairs

Purpose of Talk Hernia commonest General Surgical operation You are the patients advocate; therefore understanding the choice and limitation of surgery for hernia is important.

My background 1996 Wellington today

What is a Hernia: The Anatomy A hole in the abdominal wall Congenital or acquired Laparoscopic view

What is the Risk of Getting Inguinal Hernia? US study (National health study)1971-1993 (Children excluded) Inguinal Hernia (cumulative risk ) Men 24-39yrs 7.3% 40-59yrs 15% 60-74yrs 23% Ie increase risk with age. A quarter of men will develop a inguinal hernia Women 2% (20 times more common in men) Associated risk Having an umbilical hernia (collagen disorder?) and increasing age Lower risk if overweight and obese No association with smoking. Recreation. COPD, constipation

What is the Frequency of Surgery for Hernia? Study looking at hospital admissions for hernia England (2012) Inguinal (70%) Umbilical Epigastric Incisional Femoral Main indication for surgery: Discomfort and pain

How to Diagnose Hernia Always standing up and coughing And not lying down.

What is Not a Hernia: A Divarication Painless Answer ; Lose 5kg and will go away

Differential Diagnosis Lipoma common Malignant: Usually metastasis; Lung, pancreas, melanoma. (Umbilicus= sister Joseph s nodule). Lymphoma. Rectus sheath haematoma Rare; Sarcomas. Endometrioma Investigation: Ultrasound (if uncertain especially inguinal hernia) CT scan

Standard Hernia Surgery Suture repair of muscle layers with Nylon. (non absorbable) Gold standard operation (until mid 1990 s) Problem: Hernia repaired under tension Therefore painful and Recurrence 5-30%

Evolution of Hernia Repair Relates to Using Mesh Problem: Pain and recurrence after surgery solved? Same open sutured operation. BUT Changed to Nylon Mesh since early 1990 s This meant hernia able to be repaired without tension Therefore less early pain and Less recurrence

Problem of Mesh Repair for Inguinal Hernia? 1. Recurrence up to 10% 2. Chronic pain Common (5-20%) (Due to injury or division of the adjacent nerves) 3. Mesh infection (3-5%) (Occurs within first two weeks)

What is Mesh Two types: 1. Permanent (Nylon) (+/- adhesion barrier, to protect against attachment to bowel) 2. Absorbable (Pig skin) May have benefit with infection

Why Mesh Has Had a Bad Press Mesh safe providing does not get infected. If mesh gets infected needs to be removed Mesh is inert and does not cause pain itself Problem: Gynaecological surgery; mesh used for vaginal repair Complication 1. Mesh infection and erosion 2. Dyspareunia

Evolution of Laparoscopic Inguinal Hernia Repair (1995) Made possible with the availability of mesh and adapting techniques for laparoscopic gallbladder surgery

The Blood and Guts

The Repair Mesh size is 16cm by 11cm

The Result

Laparoscopic Inguinal Hernia Repair: My Experience. Last 5000 Cases No restriction on lifting from day 1 No recurrence (0.2%) No infection (0%) No prolonged pain (0%) No complications! Bruising, urinary retention(5%)

What Makes This Operation Special! Why no recurrence?(how best to fix a leak) Mesh is placed on the inside 5 times stronger (if a pig) Why no mesh infection? Mesh inserted down port, therefore does not touch skin Why no chronic pain? Three tiny midline cuts. All surgery done away from nerves

Laparoscopic Groin Hernia Repair Possible for all groin hernia Fixes both direct and indirect hernia at same time. Possible with giant scrotal hernia Possible after lower abdominal surgery including Prostatectomy Ideal for recurrent open inguinal hernia Ideal for bilateral inguinal hernia.( no extra cut) Ideal for femoral and spigelian hernia Ideal for strangulated hernia as can check bowel Ideal for elderly as minimally invasive BUT Need a general anaesthetic (need abdominal wall to be relaxed to create small space to operate in) I

Justification by Colleagues for Still Not Learning Laparoscopic Hernia Repair (2011) The randomised data showed worse results than open hernia repair. Described as Clumsy operation Demonstrated a long learning curve N=250 cases

Why No Training in Public: Change of Policy in Public Hospital Waiting List Before 1998. Every hernia went on waiting list.( Was the commonest operation as a registrar) After 1998. Very few elective hernia done in public Prioritization (points >65%). Short term strategic decisions: to save money. National waiting times standards. (surgery < 4mths) This means Trainee s do not gain enough experience in laparoscopic inguinal hernia repair (Need> 250 cases)

The Justification by DHB for Watchful Wait (WW) Policy. For Asymptomatic and Minimally Symptomatic Inguinal Hernia Based on two randomised studies comparing elective surgery or (WW) no surgery for inguinal hernia from US and UK data from 2006 to legitimise this policy. Results: Both studies initially showed low incidence of acute complications after 3 year. Was cost effective. By avoiding surgery avoided chronic pain. BUT; (2011)after additional 7 year follow up USA 70% WW group had surgery (mainly for pain). 79% for older patients Increased complications and mortality (older patients)

Umbilical Hernia Cause: increased abdominal pressure Obesity, Pregnancy. Laparoscopic Trocar site Standard approach: Overlapping suture repair An outey equals hernia High recurrence rate (20-30%) with straight suture repair. Increases with size of hernia

How I Fix an Umbilical Hernia. Only if symptomatic or unsightly Must lose weight before surgery (reduces the constant pressure on healing scar) Open mesh repair Large or recurrent hernia: Laparoscopic repair

Femoral Hernia I in 20 groin hernia are femoral Higher incidence in older female (wider pelvis!) Surgery always indicated as higher risk of bowel strangulation.

How I Fix Femoral Hernia. Traditionally open suture repair All femoral hernia can be laparoscopically (same operation as inguinal hernia laparoscopically)

Spigelian Hernia Occur lateral to Semilunaris at arcuate line Can be occult but still rare Treat as if a inguinal hernia with laparoscopic repair

Incisional Hernia Risk: midline incisions, Colostomy, Obesity Pre-surgery: lose weight Surgery: No consensus on Lap or open Mesh repair : but where to place it Recurrence high: Not accepted by ACC

How I Fix an Incisional Hernia Much less recurrence using mesh Need to individualise as no clear advantage Small < 5 cm Lap or open Medium <8cm laparoscopic (Suture closed). Then place mesh Large >8 combination lap and open repair

What About Prophylactic Use of Mesh To prevent Para stomal hernia Place mesh at time of formation of stoma

The Future The Robot Public: No progress on Elective Inguinal hernia surgery. Painful and urgent hernia not a problem, but open repair likely. ACC Need injury, (event). Immediate Pain and immediate lump. (And not bilateral) ACC still best hope. Will accept some incisional hernias. (depends on colour of moon and how persistent) Will accept recurrent hernias if initially ACC Laparoscopic repair accepted by ACC Laparoscopic inguinal hernia repair nearly a perfect operation J.G.

Sportsman s Hernia Sudden deceleration of torso or lower limb Inguinal pain on exercise Few useful signs! ( tender over symphysis & ext inguinal ring In 50% pain will persist for > 20 weeks < 5% will have obvious hernia. (up to 40% occult hernia!) Inguinal region Tear: Tear in the conjoint or external oblique muscle in groin Tear in inguinal ligament off pubic bone (osteitis pubis) MRI. Bone scan (osteitis pubis)

How I Treat Sportsman's Groin If after 6 months pain persists Laparoscopic mesh reinforcement with division inguinal ligament (Lloyd release)

Cf. Divarication of Recti Muscle Following Pregnancy Needs plastic surgical operation