1. Panel Discussion Controversies and Problems in Hernia Surgery
Moderator
Dr K Lakshman

2. The Panel Dr Pradeep Chowbey Dr Soppimath S Dr Uday Muddebihal
Dr Shreevathsa M R
Dr Durganna T

3. Do all inguinal hernias need surgery?
Arch Surg. 2012 Mar;147(3):277-81
Management of asymptomatic inguinal hernia: a systematic review of the evidence.
41 articles were found to be relevant and 2 large well-conducted randomized controlled studies
 A significant crossover ratio ranging between 23% and 72% from watchful waiting to surgery was found. In patients with watchful waiting, the rates of IH strangulation were 0.27% after 2 years of follow-up and 0.55% after 4 years 
Both treatment options for asymptomatic IH are safe, but most patients will develop symptoms (mainly pain) over time and will require operation.

4. How important is constipation in initial incidence and recurrence after repair, of hernia?
J Epidemiol Community Health. 1978 Mar;32(1):59-67.
The epidemiology of inguinal hernia. A survey in western Jerusalem
Prevalence rose markedly with age; the lifetime prevalence rate reached 40 per 100 men at the ages of and 47 per 100 at 75 and over.
The prevalence of hernia was significantly higher in the presence of varicose veins, in men who reported symptoms of prostatic hypertrophy, and, among lean men only,
No significant age-independent associations were found with chronic cough, constipation, physical activity at work

5. How important is constipation in initial incidence and recurrence after repair, of hernia?
Sugery, 2007, 141:262
A total of 1,418 eligible male subjects, 709 cases with primary inguinal hernia, and 709 age matched controls were recruited for analyses
Lifestyle measurements included smoking, chronic cough, constipation, and use of laxatives.
Disease-related factors comprised chronic obstructive pulmonary disease (COPD), congestive heart failure, chronic renal failure, cirrhosis and connective tissue disorder
Family history of hernia was the most important determinant factor for developing inguinal hernia in adult males. A male subject who has a positive family history of hernia is 8 times more likely to develop a primary inguinal hernia.

6. How important is constipation in initial incidence and recurrence after repair, of hernia?
Sugery, 2007, 141:262
A total of 1,418 eligible male subjects, 709 cases with primary inguinal hernia, and 709 age matched controls were recruited for analyses
Lifestyle measurements included smoking, chronic cough, constipation, and use of laxatives.
Disease-related factors comprised chronic obstructive pulmonary disease (COPD), congestive heart failure, chronic renal failure, cirrhosis and connective tissue disorder

7. How important is BPH in initial incidence and recurrence after repair, of hernia?
Sugery, 2007, 141:262
A total of 1,418 eligible male subjects, 709 cases with primary inguinal hernia, and 709 age matched controls were recruited for analyses
Lifestyle measurements included smoking, chronic cough, constipation, and use of laxatives.
Disease-related factors comprised chronic obstructive pulmonary disease (COPD), congestive heart failure, chronic renal failure, cirrhosis and connective tissue disorder

8. How important is BPH in initial incidence and recurrence after repair, of hernia?
South Med J. 1982 Nov;75(11):
Prostatism and inguinal hernia.
70 patients who had transurethral resection of the prostate to determine the incidence of inguinal hernia. We found inguinal hernias in 20% of the patients, a figure significantly higher than in the general population. In 47% of the patients a hernia was present on admission or herniorrhaphy had been done previously
 urine flow rate is advocated as a routine screening test for prostatism in patients with inguinal hernias

9. How important is BPH in initial incidence and recurrence after repair, of hernia?
The American Journal of Surgery 194 (2007) 611–617
Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group
Recurrent and scrotal hernias were predictors for short term and overall complications, regardless of technique
Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group
prostatism and increased body mass index were the significant predictors in the laparoscopic group.

10. Would you do TURP and hernia repair together?
BJU Int. 1999 Oct;84(6):637-9.
Combined transurethral prostatectomy and inguinal hernia repair: a retrospective audit and literature review.
 85 patients who underwent primary inguinal hernia repair with TURP
 88 primary inguinal hernia repairs with TURP (three were bilateral). Maloney's darn repair was used on 55 and a Bassini repair on 33 occasions,
Two patients developed mild wound infection after surgery, but only two patients (2%) had recurrence of hernia.
The recurrence rate after primary inguinal herniorraphy with conventional methods of repair, performed with TURP, was comparable with published results of hernia repairs alone

11. Which one would you do first ? TURP or Herniorrhaphy?
Int J Clin Pract. 2006 Feb;60(2):167-9.
Combined transurethral resection of prostate and inguinal mesh hernioplasty.
 44 patients undergoing combined inguinal herniorrhaphy and TURP (Group I) were compared with 50 consecutive cases of TURP alone (Group II) and 50 consecutive cases of inguinal herniorrhaphy alone (Group III)
Herniorrhaphy was always done first
There were no significant differences among all groups regarding post-operative complications

12. Is imaging required in management of inguinal hernia?
British hernia society guidelines – 2013
The vast majority of groin hernias present with a palpable or visible swelling in the groin; no imaging is needed.
In groin pain with no lump - a) does the patient have an inguinal hernia, and, if not, b) is there another cause for the pain that requires treatment.
US in hernia - Pooled data showed a sensitivity of ultrasound of 87.3%, a specificity of 85.5%.
CT is inappropriate as an initial investigation for possible occult inguinal hernia
There have been no studies that have evaluated MRI scanning in the diagnosis of occult inguinal hernia. MRI does have a role in diagnosing other causes of groin pain in the absence of an inguinal hernia

13. Hernia repair; Laparoscopy or Open? What is current practice?
Hernia. 2015 Oct;19(5):747-53
A national trainee-led audit of inguinal hernia repair in Scotland.
 Laparoscopic repair was used in 33 % (30 % trainee-performed). Open repairwas used in 67 % (42 % trainee-performed).
 For elective primary unilateral hernias, the use of laparoscopic repair varied significantly by region (South East 43 %, North 14 %, East 7 % and West 6 %, p < 0.001) as did repair under local anaesthesia for open cases 
 Elective primary bilateral hernia repairs were laparoscopic in 97 % while guideline compliance for an elective recurrence was 77 %

14. Hernia repair; Laparoscopy or Open? What is the consensus?
British Hernia Society Guidelines 2013
In the management of unilateral primary inguinal hernias (general population), there is conflicting information on whether laparoscopic repair reduces the incidence of chronic pain and improves other outcomes. The majority of meta analyses conclude that the incidence and severity of pain (both acute and chronic) are lower after laparoscopic repair
The open approach under LA may be beneficial in older patients or those with significant co-morbidity
The laparoscopic approach may be beneficial in patients at risk of chronic pain

15. Hernia repair; Laparoscopy or Open? Tailored approach
Front Surg. 2014 Jun 20;1:20.
Tailored approach in inguinal hernia repair - decision tree based on the guidelines
Excellent summary gleaned from current guidelines
Eighty-two percent of experienced hernia surgeons use the “tailored approach,”
The following differential therapeutic situations must be distinguished in inguinal hernia repair: unilateral in men, unilateral in women, bilateral, scrotal, after previous pelvic and lower abdominal surgery, no general anesthesia possible, recurrence, and emergency surgery

16. Elective Hernia repair; Laparoscopy or Open?

17. Elective Hernia repair; Laparoscopy or Open?

18. If open, which repair?
Acta Chir Belg. 2004 Aug;104(4):
Comparison of Shouldice and Lichtenstein repair for treatment of primary inguinal hernia.
 Shouldice repair (n: 120) and a Lichtenstein open mesh techniques (n: 121) 
recurrences differed significantly between the groups with five in the Shouldice group (4.1%) and one in the Lichtensteingroup (0.8%)
 need of analgesic medication after mesh repair was significantly lower than the Shouldice group
 shows the superiority of Lichtenstein repair against Shouldice repair in the surgical repair of primary unilateral inguinal hernia

19. If Laparoscopic, TEP or TAPP?
Surg Endosc. 2015 Dec;29(12):
TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia.
A total of 17,587 patients were enrolled prospectively; 10,887 (61.9%) had a TAPP and 6700 (38.1%) a TEP repair.
The intraoperative and general postoperative complication rates as well as the reoperation rate for complications show no significant difference between TEP and TAPP
The higher postoperative complication rate for TAPP, which could be managed conservatively, is partly explained by larger defect sizes, more scrotal hernias and older age

20. If Laparoscopic, TEP or TAPP?
British hernia society guidelines

21. Obstructed Hernia repair; Laparoscopy or Open?
Front Surg. 2014 Jun 20;1:20

22. Which anaesthesia would you prefer for open repair?
Surgeon. 2016 Feb 16. [Epub ahead of print]
Local anaesthesia versus spinal anaesthesia in inguinal hernia repair: A systematic review and meta- analysis.
Ten original RCTs were included, with a total of patients
LA patients experienced less pain, less urinary retention, less failure and greater satisfaction.

23. Which anaesthesia would you prefer for open repair?
Int J Clin Pract. 2009 Dec;63(12):
Local anaesthetic vs. general anaesthetic for inguinal hernia repair: systematic review and meta- analysis.
 total of 895 patients for meta-analysis
Local anaesthetic reduces nausea and accelerates return to normal activities following open inguinal hernia repair. The benefit of LA is sufficiently small that its use should be dictated by patient and clinician preference

24. Which anaesthesia would you prefer for Laparoscopic repair?
 General anaesthesia preferred
No specific papers for laparoscopic inguinal hernia repair
Enthusiasts have done TEP under LA

25. Which mesh would you use?
British Hernia Society Guidelines – 2013

26. How would you fix the mesh?
Indian J Surg. 2016 Aug;78(4):288-92
A Prospective Randomized Study Comparing Fibrin Glue Versus Prolene Suture for Mesh Fixation in Lichtenstein Inguinal Hernia Repair
 group A (fibrin glue group) and group B (Prolene suture group).
 mean duration in fibrin glue group being 30.6 min and that of the suture group was 43.3 min
The mean visual analogue pain score of postoperative pain at 1, 6, 12, and 24 h was significantly higher in the suture group than in the fibrin glue group 
The mean total dose of analgesia in ampoules of tramadol was significantly less in the fibrin glue group (1.56 ampoules) than that in the suture group
Glue fixation is better

27. Would you prophylactically explore or fix the contralateral side?
Hernia. 2011 Aug;15(4):403-8
Contralateral metachronous inguinal hernias in adults: role for prophylaxis during the TEP repair.
 1,479 inguinal herniorrhaphies on 976 patients were performed by a single staff surgeon. Bilateral exploration was completed in 923 (95%) 
 bilateral repair was performed on 503 (55%).
The study cohort comprises the 409 (42%) patients having a unilateral repair with a negative contralateral exploration 
When considering prophylactic repair during TEP explorations, a yearly risk of 1.2% of developing a contralateral hernia after negative exploration needs to be balanced against the low but potential risk of groin pain following prophylactic repair

28. What would you do with a cord lipoma?
Surg Endosc. 2007 Sep;21(9):1612-6
Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty.
Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. 
The overall incidence of cord lipoma was 26.5% (n = 132)
 higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma
Most of the cord lipoma cases (n = 119) were reduced; the rest (n = 13) were resected

29. Are there any Absolute contraindications for laparoscopic surgery?
Clinically obvious strangulating obstruction
Rest are relative
Blood dyscrasias
Co-morbidities
Intolerance to pneumoperitoneum
Past lower abdominal surgery
Cirrhosis of liver / ascites

30. How do you deal with postoperative chronic inguinal / scrotal pain?
J Pain Res. 2014 May 29;7:
Pain control following inguinal herniorrhaphy: current perspectives
Young age and female sex are two independent demographic risk factors
The development of CPIP is independent of technique, and identification and protection of the inguinal nerves are of upmost importance with all techniques
reduction of CPIP for lightweight mesh compared with heavyweight mesh

31. How would you deal with recurrent hernia?
British Hernia society guidelines – 2013

32. How would you deal with recurrent hernia?
British Hernia society guidelines – 2013

33. How would you deal with large hernial sacs?
Direct – open - Reduce / excise (watch sliders)
Indirect – open - Excise
Direct - Laparoscopic – reduce / leave distal sac
Indirect - Laparoscopic – leave distal sac

34. How would you prevent / treat seromas?
Ann Surg Treat Res. 2016 Sep;91(3):127-32
Use of fibrin glue in preventing pseudorecurrence after laparoscopic total extraperitoneal repair of largeindirect inguinal hernia
describe a novel technique in preventing pseudorecurrence by using fibrin sealant to close that potential dead space.
Forty male patients who underwent laparoscopic TEP for indirect inguinal hernia 
The mean volume of postoperative fluid collection was found as mL in the control group and mL in the study group,

35. How would you deal with an infected mesh?
Hernia. 2015 Apr;19(2): Conservative management of mesh-site infection in hernia repair surgery: a case series.
13 patients developed infected mesh grafts post-hernia repair surgery
Twelve patients were successfully treated conservatively with local wound care and antibiotics
eleven were treated with negative pressure wound therapy
One patient returned to theatre to have the infected meshremoved

36. How would you deal with an infected mesh?
Surg Laparosc Endosc Percutan Tech. 2015 Apr;25(2):125-8.
Laparoscopic management of infected mesh after laparoscopic inguinal hernia repair.
10 patients (6 TAPP/4 TEP) with localized deep-seated mesh infections in whom infected meshes were explanted laparoscopically
Nine patients experienced resolution of symptoms after 3 weeks of surgical intervention
One patient with recurrent abscess required surgical drainage twice.
Two patients developed recurrent hernia at 6 and 8 months after mesh explantation.

37. Would you deal with gall stones and hernia together
Would you deal with gall stones and hernia together? Which one would you do first?
Surg Laparosc Endosc Percutan Tech. 2003 Dec;13(6):382-6.
Combined procedures in laparoscopic surgery.
Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures
combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy etc.
All the combined surgical procedures were performed successfully
Morbidity no different from individual procedures

38. Single incision endoscopic hernia surgery
Asian J Endosc Surg. 2011 Nov;4(4):
Single-incision transabdominal preperitoneal and totally extraperitoneal repair for inguinal hernia: early experience from a single center in Asia.
15 patients who underwent single incision  laparoscopic inguinal hernia
13 were unilateral and two were bilateral hernias.
 no additional trocars were required, and there were no conversions to conventional laparoscopic or open inguinal hernia repair
Single-incision laparoscopic inguinal hernia is feasible in both TEP and TAPP approaches. The procedure should be performed by laparoscopic surgeons with a high level of experience in single- incision surgery

39. Single incision endoscopic hernia surgery
Hernia. 2016 Feb;20(1):21-32
Comparison of laparoendoscopic single-site versus conventional multiple-port laparoscopic herniorrhaphy: a systemic review and meta-analysis.
10 trials met the inclusion criteria
Totally, there were 595 and 514 patients underwent LESS-TEP and MP-TEP
 LESS-TEP took significantly longer-operative time than the MP-TEP
no significant differences in surgical outcomes with regard to postoperative pain scale, conversion rate, hospital stay, recurrence rate and complication rate between two groups
 Potential advantages of LESS-TEP including better cosmesis, less postoperative pain and less trocar-associated complications were not clearly shown.

40. Thank You