5/18/2013 What can the surgeon do to minimize these complications? 1.Recurrent hernia Complications of Inguinal Hernia Repair 2.Chronic pain University of California, San Francisco 3.Ischemic orchitis Department of General Surgery 4.Infection Jonathan Carter, M.D. UCSF Postgraduate Course in General Surgery March 2013 What can the surgeon do to minimize Recurrence: Lap or Open? these complications? 1.Recurrent hernia 2.Chronic pain 3.Ischemic orchitis Randomized 2,164 patients with inguinal hernia to open Lichtenstein vs. laparoscopic (mostly TEP) repairs. 4.Infection Primary outcome = recurrence at 2 years Secondary outcomes = complications, death, pain 1
5/18/2013 Laparoscopic or Open? Recurrence: Lap or Open? open laparoscopic 2003 Meta-analysis of over 6,000 patients enrolled in randomized trials up to 2003 RECURRENCE: OR 0.81 p=0.16 Twice as many recurrences at 2 years with laparoscopic NO DIFFERENCE!! 10x as many life-threatening complications Laparoscopic or Open? Laparoscopic or Open? SUMMARY In centers of excellence, laparoscopic Randomized 1512 patients to TEP vs. Lichtenstein with 5 year FU inguinal hernia repairs have about the same recurrence risk as open repairs. 1/3 of TEP recurrences were from 1 surgeon In the real-world, there may be twice as many recurrences with laparoscopy. But After exclusion, TEP recurrence the absolute magnitude of the recurrence was 2.4% risk is small for both techniques. (vs 1.2% open) 2
5/18/2013 What mesh technique for open inguinal hernia repair has the lowest recurrence? Lichtenstein = Prolene Hernia System > mesh plug repair What can the surgeon do to minimize Fix or don’t fix? these complications? 1.Recurrent hernia 2.Chronic pain 3.Ischemic orchitis 4.Infection 3
5/18/2013 Laparoscopic or Open? Laparoscopic or Open? 2003 Persistent pain OR 0.54 p=0.001 in favor of laparoscopy Persistent numbness OR 0.38 p=0.01 in favor of laparoscopy PAIN What mesh technique for open inguinal hernia repair has the lowest pain? 4
5/18/2013 My choice: Lichtenstein Why? 1. Teach residents 2. No posterior mesh Makes redos easier! Chronic pain Lichtenstein = Prolene Hernia System > Mesh plug Identify all nerves What can I do to reduce the risk of pain after open inguinal hernia repair? POSSIBLE STRATEGIES Strategy 1: identify all 3 nerves Strategy 2: divide ilioinguinal nerve routinely Strategy 3: use lightweight mesh Strategy 4: use self adhesive mesh (minimal sutures) Strategy 5: use local nerve block 5
5/18/2013 Divide ilioinguinal nerve routinely? Divide ilioinguinal nerve routinely? Dittrick 2004 retrospective review of 90 patients, of whom Am J Surg 66 had routine nerve excision pain paresthesia Malekour 2008 Blinded randomized controlled trial Am J Surg 121 patients: 61 nerve excised, 60 nerve preserved preserved excised preserved excised Outcome = pain in first year (VAS) nerve excision nerve preservation p-value Pain POD1 2.2 ± 0.8 2.8 ± 0.7 <0.001 Pain POD30 0.7 ± 0.7 1.5 ± 0.7 <0.001 chronic pain 6% 21% 0.033 Mui 2006 Use lightweight mesh? Self-adhesive mesh? n=30 n=30 6
5/18/2013 Other pain reduction strategies Other pain reduction strategies More urinary retention with spinal anesthesia…. What can the surgeon do to minimize What can I do to reduce these complications? the risk of pain after open inguinal hernia repair? 1.Recurrent hernia Strategy 1: identify all 3 nerves (recommended) 2.Chronic pain Strategy 2: divide ilioinguinal nerve routinely (controversial) 3.Ischemic orchitis Strategy 3: use lightweight mesh (recommended) Strategy 4: use self adhesive mesh (controversial) 4.Infection Strategy 5: use local nerve block (recommended) 7
5/18/2013 What can the surgeon do to minimize these complications? open laparoscopic 1.Recurrent hernia 2.Chronic pain 3.Ischemic orchitis 4.Infection Advice: 1. Don’t dig a hernia sac out of the scrotum. Divide it. 2. For recurrent hernia, approach it from the opposite side. Otherwise risk of ischemic orchitis is 3-5% Infection risk Use of mesh increases infection risk slightly. Here antibiotics help: 2007 meta-analysis of six randomized trials 2507 patients Results Infections prophylactic antibiotics 1.38% OR 0.48 (0.27-0.85) controls 2.89% Most patients who develop a wound infection, even if polypropylene mesh is present, can be successfully treated by aggressive antibiotic treatment without the need to remove the prosthetic material. Ann Surg. 2007;245(3):392 8
Recommend
More recommend
