Laparoscopic hernia repair has not yet become the gold standard No, it satisfies to be the gold standard Dr. Brij B Agarwal Senior Consultant Department of General Surgery Sir Ganga Ram Hospital Brij B. Agarwal, ASICON Debate 2012

NO CONFLICT OF INTEREST TO DECLARE Disclosure Slide NO CONFLICT OF INTEREST TO DECLARE Brij B. Agarwal, ASICON Debate 2012

Abbreviations Used PRO-Patient Reported Outcomes CGP-Chronic Groin Pain, Inguinodynia TEP- Totally Extra-peritoneal Repair ATFR-Anterior Tension Free Repair A totally extraperitoneal approach was first executed by Cheatle in 1920 Van Hee R (2011) Jurnalul de Chirurgie, Iaşi. 7(3) : 301-319 Brij B. Agarwal, ASICON Debate 2012

TEP-a holistic ‘Win Win’ For the Herniologist Surgeon-Enhanced self prestige For the Patient Enhanced experience of surgery, Improved the clinical outcomes For the society Improved quality of life Reduced work hours Brij B. Agarwal, ASICON Debate 2012

Herniologist Surgeon-Enhanced self prestige Herniorrhaphy was considered an ‘infra dig’ “Most herniorrhaphies are done by unsupervised registrars; my reputation depends on a schedule of four gastrectomies a morning” Norman Tanner TEP is considered advanced laparoscopic procedure. It has shifted “Gold Standard” opinion of hernia surgeon being a back bencher in surgical pantheon. Being an hernia surgeon is no more an “infra dig” but an “adde Dignatas” Tanner HC (1978). In: Nyhus L, Condon R (eds) Hernia, 2nd Edition. JB Lipincott Co, PP259-263 Read RC (2005) Hernia.9:6-11 Brij B. Agarwal, ASICON Debate 2012

Improved outcomes for the Patient Laparoscope is an Instrument only, it has taken our hands & eyes closure to pathology. Improved outcomes for the Patient Brij B. Agarwal, ASICON Debate 2012

March of Herniology “Whoever wishes to foresee the future must consult the past” Machiavelli But for debates like this, status quoists would have stayed with Hernia Bandages devised by Mammoon of Hamburabi Surgery was forbidden by Church till renaissance 1871 – Marcy published first paper on herniorraphy 1887-Edoardo Bassini 1896 – Billroth – 1st prosthetic repair – silver filigree – prosthesis rejected 1945 – Shouldice repair quoted as gold standard 1956 – Marlex introduced by Usher 1967 – Stoppa and Rive principle of underlay unfastened mesh 1982 – Ralph Ger published laparoscopic herniorrhaphy 1989 – Tension free prosthetic repair by Usher high jacked by Litchtenstein Agarwal BB (2012) GRJ:2;260-264.Editorial Agarwal BB (2010) SJG 16(1):1-2.Editorial Brij B. Agarwal, ASICON Debate 2012

Herniology so far More than 70 techniques but only three have recommendatory scientific evidence. The Shouldice, the anterior flat mesh and endoscopic posterior flat mesh Shouldice technique-recurrence <2% (?10% in Bassini ), still enjoys level 1 A evidence and grade A recommendation. “Gold Standard” to be used when a non-mesh repair is considered Mesh based repairs—We are Debating Agarwal BB (2012) GRJ:2;260-264.Editorial Agarwal BB (2010) SJG 16(1):1-2.Editorial Brij B. Agarwal, ASICON Debate 2012

Hunterian Lecture 2009 “Over the last 30 years inguinal hernia surgery has developed into evidence based practice. The 2009 EHS guidelines provide the basis for such practice to remain valid till 2012” Kingsnorth AN (2009) Ann R Coll Surg Engl 273-79 Simon MP et al (2009) Hernia 343-403 Brij B. Agarwal, ASICON Debate 2012

2009 EHS hernia guidelines Based on Level 1 evidence with Grade A recommendations McCormack K et al (2003) Cochrane Database Syst Rev CD001785 Wake WL et al (2005) Cochrane Database Syst Rev CD004703 McCormack K et al (2005) Health Techmol Assess 1-223 Kuhry E et al (2007) A Systemic Review Surg Endosc 161-6 Kouhia ST et al (2009) DBRCT on Recurrent Hern. Ann Surg 384-7 Bisgaard T et al (2009) TEP for recurrence Ann Surg 707-711 Hernia. 2009 Aug;13(4):343-403. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J, de Lange D, Fortelny R, Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde S, Nordin P, Schumpelick V, Smedberg S, Smietanski M, Weber G, Miserez M. Brij B. Agarwal, ASICON Debate 2012

EHS Guidelines & Metrics for Evidence based outcomes in Hernia Surgery Recurrence Postoperative pain Return to work Chronic inguinodynia TEP over tension free repair on all these parameters Brij B. Agarwal, ASICON Debate 2012

TEP Scores on all. Why so? Recurrence is purely a technical surgical failure, mesh failure is still unreported in inguinal hernia Postoperative pain is better due to lesser potential insult to nerves Earlier return to work i.e. with in 2-3 days as against 2-3 weeks (No level 1 studies) Chronic pain has been shown to be much lower with TEP Dulucq JL et al (2009) Surg Endosc 482-86 Agarwal BB et al (2009) Surg Endosc 242-47 Brij B. Agarwal, ASICON Debate 2012

TEP Benefits are based on Mathematical principles for herniorrhaphy Stoppa’s principle of underlay un-sutured overlapping prosthesis Avoid direct breach of structures overlying the prosthesis. Laplace Law-Equi-distribution of pressure along the surface of prosthesis Minimising the exposure of cord structures to prosthesis Minimize wound morbidity of TFR (suturing alien structures like mesh to muscles Agarwal BB (2010) Int J Surg. 44–47. Agarwal BB (2009) Surg Endosc 1684-85 Agarwal BB (2009) Surg Endosc 242-47 Agarwal BB (2008) Surg Endosc 1557-58 Brij B. Agarwal, ASICON Debate 2012

Cost The Criticism of TEP Societal cost on incremental basis for upto 25 years as well as quality adjusted life years is much less No additional instruments are used; same as laparoscopic cholecystectomy – a gold standard equipment for gold standard procedure Agarwal BB (2012) GRJ:2;260-264.Editorial Agarwal BB (2010) SJG 16(1):1-2.Editorial Kingsnorth AN (2009) Ann R Coll Surg Engl 273-79 Simon MP et al (2009) Hernia 343-403 Brij B. Agarwal, ASICON Debate 2012

The Criticism of TEP Learning Curve Operating time Subjective, can’t be an excuse in an era of patient reported outcomes based EBS Operating time Again subjective: Duluq does it in 15’ Agarwal BB (2012) GRJ:2;260-264.Editorial Agarwal BB (2010) SJG 16(1):1-2.Editorial Dulucq JL et al (2009) Surg Endosc 482-86 Agarwal BB et al (2009) Surg Endosc 242-47 Kingsnorth AN (2009) Ann R Coll Surg Engl 273-79 Simon MP et al (2009) Hernia 343-403 Brij B. Agarwal, ASICON Debate 2012

Arch Surg. 2012;147(3):256-260 In short term, TEP was associated with higher operative costs; however, total costs were comparable for the 2 procedures and less for TEP on societal basis. Chronic pain and impaired inguinal sensibility were more frequent after ATFR. Overall hernia recurrence rates were comparable for both procedures, recurrence rates among experienced surgeons were significantly lower after TEP. Patient satisfaction was significantly higher after TEP. Therefore, TEP should be the Gold Standard. Arch Surg. 2012;147(3):256-260 Brij B. Agarwal, ASICON Debate 2012

Inguinodynia- the current metrics for hernia surgery Laparoscopic repair seems favourable in terms of better preservation of testicular functions, lower incidence of acute and chronic groin pain, and significant improvement in quality of life when compared to open repair. Open mesh repair is a significant risk factors for chronic groin pain. Brij B. Agarwal, ASICON Debate 2012

Unique benefits of TEP Incision precision-Simultaneous bilateral if needed Visualization of entire myopectineal orifice of Fruchaud Identification of occult contralateral hernia Absence of cord handling hence less risk of insult to testicular functions Potentially less dysejaculation Better abdominal wall compliance Agarwal BB (2012) GRJ:2;260-264.Editorial Agarwal BB (2010) SJG 16(1):1-2.Editorial Brij B. Agarwal, ASICON Debate 2012

Shifting “Gold Standards” TEP related evidence is what it should be for a ‘Gold Standard’ TEP is better than ATFR but the best is yet to come. Debates will continue. ?Claytronics is the future.

Thank You Acknowledgements- Ramneek Kaur, Krishna Adit Agarwal & Nayan Agarwal Brij B. Agarwal, ASICON Debate 2012