1. Inguinal Hernia: Future Directions
Brian Jacob MD FACS
New York, NY

2. Peter Drucker
“The only thing we know about the future is that it will be different.”
November 1909 – November Influential author, businessman

3. Inguinal Hernia Repairs: innovation
Access
Mesh
Fixation
Patient Satisfaction
Techniques

4. Evolution of Inguinal Hernia: Access Techniques
Open
Stromayr 1559
Lucas-Championnière 1881
Bassini 1889
McVay 1942
Shouldice 1945
Lichtenstein 1987
Stoppa 1989
Laparoscopic
Ger 1990
Velez and Klein 1990
Others
SILS / NOTES
Just now being described
Sachs M, Damm M, Encke A World J Surg

5. Early Inguinal Hernia Repairs
1559 Caspar Stromayr. Practica Copiosa.
Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith

6. Early Inguinal Hernia Repairs
1559 Caspar Stromayr. Practica Copiosa.
Great Ideas in the History of Surgery By Leo M. Zimmerman, Ilza Veith

7. Inguinal Hernia: Emerging Technologies
Single Port
Inguinal
Ventral
NOTES
Transgastric
Transvaginal

8. Inguinal Hernia: Emerging Technologies
Single Port
Inguinal
Ventral
NOTES
Transgastric
Transvaginal
Indications

9. Inguinal Hernia: Emerging Technologies
Single Port
Inguinal
Ventral
NOTES
Transgastric
Transvaginal

10. Worse Options:

11. Single Incision Laparoscopic Surgery (SILSTM ): Introduction
Descriptions as early as 1996
Synonyms
SPA
LESS
Others
Rapid growth since 2007

12. Single Incision Laparoscopic Surgery (SILSTM ): Introduction
Rapid growth since 2007
Growth precedes proven clinical benefits

13. Single Incision Laparoscopic Surgery (SILSTM ): Introduction
Rapid growth since 2007
Growth precedes proven clinical benefits
Demonstrated feasibility in multiple specialties
General, Colorectal, Bariatrics, Urologic, and Gynecologic

14. Single Incision Laparoscopic Surgery: Many variations on a single theme
Skin incision
Location and size

15. Single Incision Laparoscopic Surgery: Many variations on a single theme
Skin incision
Location and size
Entry method
Multiple trocars or single port access device

16. Single Incision Laparoscopic Surgery: Many variations on a single theme
Skin incision
Location and size
Entry method
Multiple trocars or single port access device
Instrumentation / Scopes

17. Single Incision Laparoscopic Surgery: Many variations on a single theme
Skin incision
Location and size
Entry method
Multiple trocars or single port access device
Instrumentation / Scopes
Retraction

18. SILSTM Inguinal Hernia: Introduction
SILSTM TEP
Filipovic-Cugura J, Kirac I, Kulis T, Jankovic J, Bekavac-Beslin M
(Surg Endosc April 2009) (Croatia) (routine)
Jacob BP, Tong W, Katz B, Vine A, Reiner M
(Hernia June 2009) (USA) (SILSTM Port)
Agrawal S, Shaw A, Soon Y
(Surg Endosc Sept 2009) (UK) (TriPort)
SILSTM TAPP
Kroh M, Rosenblatt S
(J Lap Adv Surg Tech A. April 2009) (USA) (Uni-X Single Port System)
Rahman SH, John BJ
(Hernia. Aug 2009) (UK) (roticulating graspers)
Menenakos C, Kilian M, Hartmann J
(Hernia. Aug 2009) (Germany) (TriPort)
Source: pubmed.gov as of October 5, 2009 (“single incision hernia”)

19. Question: What (if anything) is wrong with the current standard?

20. Answer: Potentially only cosmesis

21. Early Experience: TEP Animal labs 2 – 3mm instruments
Still needed at least one 5 mm
Moved to 2 incision technique
Moved to single incision with multiple trocars
Sword fighting
Air leaking
Single port access device Feb 2009

22. Hernia. June 2009

23. Hernia. June 2009

24. Hernia. June 2009

25. Hernia. June 2009

26. SILSTM TEP: bilateral inguinal hernia repair 2 week follow-up
25 mm skin incision

27. SILSTM TEP: bilateral inguinal hernia repair 1 month follow-up
25 mm skin incision

28. SILSTM TEP: bilateral inguinal hernia repair 1 month follow-up
25 mm skin incision

29. SILSTM TEP: bilateral inguinal hernia repair immediate post operative

30. SILSTM TEP: don’t celebrate too early

31. SILSTM TEP hernia: initial experience with a single access port
8 men with bilateral indirect hernias
One also with an umbilical hernia
1 man with unilateral indirect
1 woman with b/l direct and femoral hernia
2 converted to traditional 3 trocars
Peritoneum violated
Inability to reduce an adherent indirect

32. SILS TEP hernia: initial experience with a single access port
Mean follow-up 8 months
Incisional pain (1 - 6 days)
Narcotics used for 0 – 4 days
No early recurrences (up to 8 months)
No incisional hernias so far
Open umbilical hernia patient developed seroma

33. Early lessons learned
Challenges
Port insertion has a learning curve

34. Early lessons learned
Challenges
Learning curves all over again

35. Early lessons learned Challenges Many ports available
Are they needed at all?
Is one better than another?

36. Early lessons learned Challenges Many ports available
Are they needed at all?
Is one better than another?
First trocar is blunt, but blind

37. Early lessons learned Challenges Many ports available
Are they needed at all?
Is one better than another?
First trocar is blunt, but blind
Incision size
Port modifications ARE needed

38. Early lessons learned Unknown outcomes Seromas ? Incisional Hernias ?
Costs ?
Let’s be realistic ?

39. SILSTM Inguinal Hernia: conclusions
SILSTM TEP, TAPP, IPOM techniques now being described (feasible)
With and without single port access (SPA) devices
Can be performed with same instruments in use today (may limit additional costs)
Patients seem to like the single incision concept
Experiences are only in the beginning stages
Future is unknown
Growth seems inevitable

40. Inguinal Hernia Repairs: innovation
Access
Mesh
Fixation
Patient Satisfaction
Techniques

41. Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh
Jan 2002 – Jan 2004
40 males underwent lap TEP followed for one year using 10-point VAS for pain followed for a mean of 9 months
(n=20) Heavyweight (100 g/m2) (Prolene) WITH TACKS
(n=20) Heavyweight (108 g/ m2) (Davol 3DM) WITHOUT fixation
No significant difference in post op pain (p=0.15)
No significant difference in recurrent rates
Did see more urinary retention in group where tacks were used
Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS (Mayo, Minnesota)

42. Randomized prospective Study of TEP: Fixation vs No Fixation of Mesh
Conclusions
Use of tacks did not add pain (Is study under powered?)
Avoiding tacks did not change recurrence rates
Avoiding tacks can reduce costs, but keep outcomes the same
Koch CA, Greenlee SM, Larson D, Harrington JR, Farley DR. JSLS (Mayo, Minnesota)

43. Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomized clinical trial
Dec 2004 and Jan 2006
360 males underwent lap TEP (500 hernias) followed for a mean of 8.2 months. Pain scale used at office visit
Heavyweight (100 g/m2) (Prolene) WITH TACKS
Heavyweight (100 g/ m2) (Prolene) WITHOUT TACKS
WITH TACKS group had more new pain complaints (p=0.0003)
No significant difference in recurrent rates
Defect size all less than 2 cm
For bilateral patients, the NO TACK side was 5x more likely to be more comfortable
Conclusion: tacks may increase pain, costs, and may not be necessary
? Better powered than the Mayo Clinic study
Taylor C, Layani L, Liew V etal. Surg Endosc (Australia)

44. Laparoscopic TEP with nonfixation of the mesh for 1,692 hernias
3 year retrospective study
Followed for recurrences, pain at one month, seroma, and urinary retention
Recurrence rate only 0.22%
Less pain than a cohort of patients who received fixation
Conclusions: TEP without mesh fixation does not increase recurrence rates and is associated with less pain, urinary retention at 4 weeks
Garg P, Rajagopal M, Varghese V, Ismail M Surg Endosc. (Punjab, India)

45. Novel Concepts: Materials
Self Adhering Mesh
Fibrin Glues
Partially absorbing mesh fibers
Absorbable Tacks
Lightweight (40 g/m2) polypropylene coated with synthetic glue (adhesix)(cousin biotech, Fr)
Polyvinylpyrrolidone and polyethylene glycol
Disappears in 2 -3 days
Porcine animal study
Same incorporation as mesh with tacks
Champault G etal Hernia. (Paris, France)

46. Novel Concepts: Materials
Self Adhering Mesh
Fibrin Glues
Partially absorbing mesh fibers
Absorbable Tacks

47. Novel Concepts: Materials
Self Adhering Mesh
Fibrin Glues
Partially absorbing mesh fibers
Absorbable Tacks
poly(glycolide-co-L-lactide) (PGLA).
Stepped Wing
Flat Wing

48. Want to entirely eliminate morbidity? Don’t operate
New evidence to support watchful waiting until symptoms worsen without adverse events
Watchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A randomized clinical trial. Fitzgibbons RJ etal. JAMA 2006.
Observation or Operation for Patients with an Asymptomatic Inguinal Hernia: A randomized clinical trial. O’dwyer PJ etal. Annals Surg. 2006
Does delaying repair of an asymptomatic hernia have a penalty? Thompson JS etal. Am J Surg. 2008

49. Conclusions: inguinal hernia
Laparoscopic TEP / TAPP
Recurrence rates not different in highly experienced hands
Chronic pain not sig different
May have early advantages for bilateral and recurrent hernias
Lightweight mesh product
Less pain especially during first 3 months
Quicker return to work / activity
No difference in recurrence rates in experience hands
Tack fixation may not be necessary if proper overlap of the myopectineal orifice is achieved
Chronic neuropathic pain with early onset, that responds to nerve blockade (CRPS 2):
Best predictable outcome for relief following neurectomy or meshectomy

50. Peter Drucker “The best way to predict the future is to create it.”
November 1909 – November Influential author, businessman

51. Thank you