1. 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

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

3. 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) :
Brij B. Agarwal, ASICON Debate 2012

4. 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

5. 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, PP
Read RC (2005) Hernia.9:6-11
Brij B. Agarwal, ASICON Debate 2012

6. 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

7. 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; Editorial
Agarwal BB (2010) SJG 16(1):1-2.Editorial
Brij B. Agarwal, ASICON Debate 2012

8. 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; Editorial
Agarwal BB (2010) SJG 16(1):1-2.Editorial
Brij B. Agarwal, ASICON Debate 2012

9. 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
Simon MP et al (2009) Hernia
Brij B. Agarwal, ASICON Debate 2012

10. 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
Hernia Aug;13(4):
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

11. 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

12. 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
Agarwal BB et al (2009) Surg Endosc
Brij B. Agarwal, ASICON Debate 2012

13. 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
Agarwal BB (2009) Surg Endosc
Agarwal BB (2008) Surg Endosc
Brij B. Agarwal, ASICON Debate 2012

14. 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; Editorial
Agarwal BB (2010) SJG 16(1):1-2.Editorial
Kingsnorth AN (2009) Ann R Coll Surg Engl
Simon MP et al (2009) Hernia
Brij B. Agarwal, ASICON Debate 2012

15. 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; Editorial
Agarwal BB (2010) SJG 16(1):1-2.Editorial
Dulucq JL et al (2009) Surg Endosc
Agarwal BB et al (2009) Surg Endosc
Kingsnorth AN (2009) Ann R Coll Surg Engl
Simon MP et al (2009) Hernia
Brij B. Agarwal, ASICON Debate 2012

16. Arch Surg. 2012;147(3):
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):
Brij B. Agarwal, ASICON Debate 2012

17. 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

18. 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; Editorial
Agarwal BB (2010) SJG 16(1):1-2.Editorial
Brij B. Agarwal, ASICON Debate 2012

19. 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.

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