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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

INGUINAL HERNIA REPAIR Actual Status --------------------------------------Prof. Dr. R.Van Hee University of Antwerp Belgium European Academy of Surgical Sciences

INGUINAL INGUINAL HERNIA HERNIA REPAIR REPAIR -- ACTUAL ACTUAL STATUS STATUS (Abstract): (Abstract): Even Even in in 2006, 2006, there there are are a a lot lot of of controversy controversy about about the the best best technique technique for for inguinal inguinal hernia hernia repair. repair. The The factors factors that that influence influence the the choice choice of of the the technique technique are: are: uniuni- or or bilateral bilateral hernia, hernia, Nyhus Nyhus type type of of hernia, hernia, complicated complicated hernia, hernia, large large inguino-scrotal inguino-scrotal hernia, hernia, recurrent recurrent hernia hernia or or previous previous surgery, surgery, preferred preferred type type of of anaesthesia. anaesthesia. Surgeon Surgeon has has to to answer answer to to three three question question when when he he choices choices a a type type of of hernia hernia repair: repair: What What are are there there specific specific indications indications for for this this repair? repair? What What are are the the specific specific complications complications of of the the repair repair technique? technique? What What are are the the results results with with the the repair repair technique? technique? In In the the literature literature there there are are a a lot lot of of studies studies which which give give comparisons comparisons about about the the techniques techniques of of hernia hernia repair: repair: type type and and rate rate of of complications, complications, recurrence recurrence rate, rate, costs costs and and economic economic impact. impact. There There are are various various types types of of evidence: evidence: retrospective retrospective studies, studies, prospective prospective randomized randomized trials, trials, meta-analyses. meta-analyses. This This paper paper reviews reviews some some of of the the literature literature studies studies about: about: techniques techniques of of open open non-mesh non-mesh hernia hernia repair, repair, types types of of open open mesh mesh repair, repair, mesh mesh vs vs non-mesh non-mesh open open techniques, techniques, open open vs vs laparoscopique laparoscopique techniques techniques and and types types of of laparoscopic laparoscopic hernia hernia repair repair techniques. techniques. Conclusion: Conclusion: Open Open non-mesh non-mesh repairs repairs should should be be avoided. avoided. Lichtenstein Lichtenstein mesh mesh repair repair is is the the best best open open technique. technique. Laparoscopic Laparoscopic techniques techniques (TAPP (TAPP &TEP) &TEP) induce: induce: less less pain, pain, shorter shorter hospital hospital stay, stay, earlier earlier return return to to work, work, more more rapid rapid resumption resumption of of activities activities and and lower lower recurrence recurrence rates rates but but at at a a higher higher cost, cost, especially especially in in nonnonworking working population. population. KEY KEY WORDS: WORDS: GROIN GROIN HERNIA, HERNIA, MESH MESH REPAIR, REPAIR, TAPP, TAPP, TEP TEP

Inguinal Hernia Repair -----------------------------In 2006 : Still much controversy Still many techniques

Hernia Repair: Historical Overview ------------------------------------------Eduardo Bassini (1844-1924): own technique 1877 Bassini modifications (Halsted,Kirschner,Houdard..) Chester McVay (1911-1987): own technique 1948 Edward Shouldice (1890-1965): technique 1945-51 Lloyd Nyhus (1923): type-related techniques 1955 Irving Lichtenstein (1920): tension-free techn.1986

Hernia Repair: actual situation -------------------------------------- Open techniques Shouldice repair Lichtenstein repair Plug-mesh repair Other variants Laparoscopic techniques TAPP repair TEP repair Plug repair Other variants

Factors influencing type of repair --------------------------------------- Uni- or Bilateral hernia Nyhus type of hernia Incarceration of hernia Large inguinoscrotal hernia Recurrent hernia or Previous surgery Preferred type of anaesthesia (patient/surgeon)

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Choice of type of hernia repair -------------------------------------- Which type does one use? Are there specific indications for this repair? Are there specific complications with this repair? What are the results with this repair?

Evidence concerning Hernia Repair ---------------------------------------------1. Prolific number of clinical trials!!! 2. Various types of evidence -retrospective studies -prospective randomized trials -meta-analyses 3. Different end-points -type and rate of complications -recurrence rate -costs and economic impact

..Why does one choose this type of repair?

Evidence concerning hernia repair ------------------------------------------ Often studies give comparisons between incomparable hernia groups: a. mixing of uni- and bilateral hernias b. mixing of different Nyhus types c. mixing of primary and recurrent hernias d. multicenter studies can be accompanied by slight but important differences in technique (mesh size, type, fixation etc.)

Trials in Open non-mesh Repair -------------------------------------- Mostly before 1990 Comparing Bassini/Shouldice/McVay and other techniques Concluding evidence: Shouldice technique is best repair, with a recurrence rate of ~5% after 2 years, but often raising to 10-15% after 10 years!

Results of Trials in Open mesh Repair ---------------------------------1. Lichtenstein repair (uni- or bilateral hernia) -recurrence rate of <5% - less tension and pain 2. Stoppa repair (bilateral hernia) -recurrence rate ~ 1% after 6 years -needs general anaesthesia!

Trials comparing open mesh and non-mesh repair --------------------------------Meta-analysis performed by the

EU Hernia Trialists Collaboration (Brit.J.Surg. 2000, 87: 854-859) Conclusion: in favour of mesh repair 1. Less pain 2. Earlier return to work 3. Recurrences 1.4%mesh) vs 4.4%(non-mesh)

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Types of trials comparing Open and Laparoscopic techniques

General trials: comparisons including multiple types of both techniques Specific trials: comparisons between single or specific techniques Meta-analyses: always including several types of techniques

General Trials: open vs lap -------------------------------All open procedures vs. all laparoscopic procedures -on the short term lap techniques induce 1. earlier return to work 2. less chronic pain 3. variable rate of recurrences P.J.ODwyer Brit.J.Surg. 2004,70:105-118

General Trials: open vs lap technique -------------------------------All open procedures vs. all laparoscopic procedures -on the long term 1. recurrences identical 2. less chronic pain in lap techniques P.J.ODwyer Brit.J.Surg. 2004,70:105-118

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Specific trials: Fleming et al. Austr] (BJS, 2001) ------------------------Shouldice (n=115) vs TEP (n=117) ------------------------------------------Endpoints were: -operation time (56 vs 70 min) -hospital stay (1-day:48 vs 68%) -sick leave (30 vs 14 days) - resumption of normal activities ( 35 vs 21 days) -costs (40% cheaper vs TEP) -complications at 1 year (9 vs 21%)

Specific trials: Champault et al.[Fr] (J.Chir.,1996) -------------------Stoppa (n= 49) vs TEP (n= 51) -----------------------------------Endpoints were: - operation time (identical for unilateral; shorter for bilateral Stoppa) - hospital stay ( 7.3 vs 3.2 days) - sick leave (35 vs 17 days), - postop. pain ( less in TEP) - recurrence (6% vs 2%)

Specific trials: Wara et al.[De](BJS, 2005) ------------------Lichtenstein (n=39537) vs. TAPP (n=3606) ----------------------------------------------------Endpoint: recurrence in various hernia categories primary indirect: 1.0 % vs 0 % primary direct: 3.1 % vs 1.1% primary bilateral: 3.0 % vs 4.8 % recurrent unilateral: 4.8 % vs 4.6 % recurrent bilateral: 7.6 % vs 2.6 %

Specific trials: Eklund et al.[S]( BJS, 2006) -----------------------Lichtenstein (n=706) vs TEP (n= 665) ---------------------------------------------Endpoints were postop.pain, period of sick leave, and resumption of normal activities: ALL 3 were in favour of TEP (p<0.001) -sick leave: 12 vs 7 days -normal activities : 31 vs 20 days

Size of mesh in TEP or TAPP -------------------------------------Investigation in 10 cadavers to assess the size of a quadrangle, formed by the various hernia sites (inguinal, femoral, obturator, supravesical): mean surface of 71 cm. Conclusion: mesh should at least measure 10 x 8 cm to close all sites adequately! Tott et al. Eur.Surg.Res.,2005.

Cost Aspect in Lap Surgery (TEP) ------------------------------------------(Champault et al., J.Chir., 1994)

Hospitalisation costs higher (105 Euro), even in case of reusable material Gain in sick leave and return to work however generates a benefit of 160 Euro. Conclusion: TEP less costly only in case of working class population

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Conclusions --------------------- 1. Open non-mesh repairs should be avoided 2. Lichtenstein mesh repair : best open technique 3. Laparoscopic techniques (TAPP &TEP) induce -less pain, shorter hospital stay, earlier return to work, more rapid resumption of activities and lower recurrence rates, -but at a higher cost, specially in non-working population

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