1. Open vs Lap Hernia Repair: Which is Better? R. Matthew Walsh, M.D., F.A.C.S. Vice Chairman, Department of General Surgery

2. Laparoscopy Versus Open Tension Free Recurrences Return to Work/Normal Function/QOL Post Operative/Chronic Pain Operative Complications Cost

3. Abdominal wall hernia repairs in 2003: Inguinal 770,000 Umbilical 175,000 Incisional 105,000 Epigastric/Spigelian 80,000 Femoral 30,000 87% performed as outpatient $2.5 billion/year surgical fees

4. Current Surgical Approaches CanadaUSA 19992003 Lichtenstein 16%37% Plug and Patch 20%34% Laparoscopic 15%14% Bassini 23% Shouldice 11%

5. Recurrence Causes Are Different Incidence Altered Surgical Expertise and Age Laparoscopic Hernia Specialist True General Surgeon Less Effect and Better Studied in Open Learning Curve Dilemna Lap:30-250 cases Most Experienced <5% Recurrence Least Experienced 20% Recurrence Open:5 Cases For <5% Recurrence  Expect Higher Recurrence With Lap Hernia

6. Causes of Recurrence Open (Medial) Incomplete Dissection Missed Hernia Mesh Shrinkage Mesh Too Small Laparoscopic (Lateral) Incomplete Dissection Missed Hernia Mesh Shrinkage Mesh Too Small Incomplete Sac Reduction Mesh Migration/Rolling Inadequate Fixation Inexperience

8. VA Cooperative Trial 456 Trial Evaluating Effectiveness Not Efficacy Randomization of 1983 Patients, 85% F/U at 2 Years Recurrence ORComplicationsOR Lap10.1%2.239.0%1.3 Open4.0%33.4%  Lap Hernia Higher Recurrence, Complications (with pain) and Costs Lap Vs Open Neumayer, EIM, 2004. Hawn, Surgery, 2006. Hynes, Jacs, 2006

9. Laparoscopic Experience and Age OutcomePredictorSurgeon AgeAORpValue RecurrenceExperienced>45 vs <450.20.036 Inexperienced>45 vs <451.720.45 Experienced Surgeon >250 Lap Repairs Neumayer, Ann Surg, 2002

10. Laparoscopic Recurrence: Experience + Age SurgeonMeanSDRange ExperienceAgeNo.Recurrence(%)(%) High (>250)<4525.8%8.20-12 >4562.6%4.10-8 Low (<250)<45323.4%5.90-18 >451518.3%26.50-100 Neumayer, Ann Surg, 2005

11. Criticisms of the VA Cooperative Trial Poor Operative Quality Control Results Indicate Poor Technique High Recurrence High Conversion High Complications

12. Return To Normal Function Complex Socioeconomic Issues Cultural Economic Motivation Work Status Effects Cost Considerations Indirect Costs  Improved Early Function in Lap Hernia Lap Vs Open

13. Post Op Pain Major Morbidity Issue With Open Repair Chronic Pain Reported In Up To 20% Effected By Age No Pain Association in Open Repair Type of Hernia Hernia Size Surgeon Experience Incision Length Operative Time Planned Nerve Transection Increased Perioperative Pain In Open Equivalent Chronic Pain Lap Vs Open

15. Multivariable Models of Patient Satisfaction At 1 Year Satisfaction with Operation ParameterAdjusted ORp Value Age < 58 year0.460.0006 Recurrence (yes v no)0.07<0.0001 Neuralgia (yes v no)0.11<0.0001 Other Complications (yes v no)0.380.001 VA Study Hawn, Surgery, 2006

16. Visceral Injuries in Randomized Trials TrialComparisonIncidence Bowel Injury Anderson (2003) Mahon (2003) MRC (1999) Neumayer (2004) TEP vs. L TAPP vs. L TAPP/TEP vs. Open TEP vs. L TOTAL: 1/81 vs. 1/87 2/59 vs. 0/60 0/462 vs. 1/453 1/989 vs. 0/994 0.25% vs. 0.12% Urinary Bladder MRC (2003) Johansson (1997) Aitola (1998) TAPP/TEP vs. Open TAPP vs. Stoppa TOTAL: 1/462 vs. 0/453 2/207 vs. 0/199 1/24 vs. 0/25 0.58% vs. 0% Vascular Injury MRC (1999) Neumeyer (2004) TAPP/TEP vs. Open TEP vs. L TOTAL: 1/462 vs. 0/453 2/989 vs. 0/994 0.21% vs. 0% L: Lichtenstein

18. Meta-Analysis Summary: Laparoscopy vs. Lichtenstein Advantages for Laparoscopy No Difference Advantages for Lichtenstein Wound Infection Hematoma Return to Work Nerve Injury Chronic Groin Pain Total Morbidity Bowel Injury Bladder Injury Vascular Injury Urinary Retention Testicular Problems Operating time Seroma Hernia recurrence

19. Costs Direct Costs Show Laparoscopic Disadvantage Longer Operative Time Disposables Tackers Total Costs Including Socioeconomic Factors Return to Productivity Recurrence Rate Complication Cost Modeling Alters Conclusions Lap Vs Open

20. Laparoscopy Versus Open Tension Free Recurrences Return to Work/Normal Function/QOL Post Operative/Chronic Pain Operative Complications Cost  Open Tension-Free Repair is the Good Standard Lab Repairs are Suitable Alternative, Surgeon Dependent