Mesh Plug Repair of
Inguinal Hernias
Presented by:
V.K Ashok, M.D, F.A.C.S
April 2, 2011
About V.K. Ashok, M.D
Practicing general and vascular surgeon in private practice based in Freehold, NJ for the last 25
years
Scope of practice includes specializing in inguinal and ventral hernias
Most hernia operations performed in an outpatient setting
About The Hernia Center
Established in 1986 by Drs. Robbins and Rutkow
Serving the Greater New Jersey/New York area Perform approximately 350 inguinal hernia
“No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate,
anatomical knowledge with surgical skill than Hernia in all its varieties.”
Objective
To demonstrate the benefits of the anterior open tension free repair of inguinal hernias
Outline
Incidence of hernia
Types of hernia Diagnosis
Goals and types of hernia repair Types of mesh
Post-operative recovery Complications
Quick Facts on Hernias
Most commonly done surgery in any operating room
Approximately 770,000 operations done annually in the United States
$2.5 billion annual cost for care of hernia patients
“Inguinal Hernia in the 21st Century: An Evidence-Based Review” Current Problems in Surgery, April 2008
Incidence
Males: 27% in their lifetimes
Men affected more than women (9:1)
Femoral hernia incidence higher in women (4:1)
“Laparoscopic versus Open Inguinal Hernia Repair.” Jon Gould, MD. Surgical Clinics of North America, April 2008
Types of Inguinal Hernias
Direct
Indirect
Pantaloon
Diagnosis
Clinical exam Imaging studies ultrasound CT scan MRI herniographyGoals of Hernia Repair
To operate or not?
Easy repair
Minimal dissection
Minimal post-operative pain
Least amount of complications
Rapid return to work
Lower incidence of recurrence and
Types of Surgical Repair
Open (anterior approach)
Non mesh-based
Halstead, Bassinni, McVay, Shouldice
Mesh-based
Lichtenstein, Plug and patch, PHS
Laparoscopic (posterior approach)
TEP
Tension Free Repair
Concept began in the late 1980s/early 1990s
70% of all hernias are tension-free open repair
Types of Mesh Used in Repair
Lichtenstein
Mesh plug
Synthetic (Perfix, PHS, etc.)
Absorbable - biologic
Partially absorbable/ultrapro Lightweight
Lightweight Perfix Plug and Patch
Types of Anesthesia Used in
Hernia Repair
Local
General
Open Anterior Approach - Mesh
Plug Repair
Short learning curve Shorter operating time Minimal dissection Tactile sensation Results are comparable to other types of repair
Operative Technique
Operative Technique
Operative Technique
Open inguinal canal and pick up cord structures at pubic tubercle
Operative Technique
Operative Technique
Operative Technique
Operative Technique
Place onlay patch on the floor of the inguinal canal with three point fixation
Operative Technique
Operative Technique
Subcuticular closure of skin and use of steri-strips
Post-operative Recovery
Resume normal activity immediately
Working from home/self-employed: Next day
Return to (office) work: 4 to 5 days Return to labor-intensive/
manual/construction work: 3 weeks
Post-operative Pain
Management
Inject local anesthesia into wound
Pain ball – On-Q Oral analgesics
Complications Resulting from Open
Hernia Repair
Longstanding pain (uncommon)
Hematoma, seroma
Infection (superficial)
Open vs. Laparoscopic
Technique
Rate of recurrence is less
Less time in the operating room
Regional anesthesia
Incidence of complications is less
Return to work – one day later Costs less to perform procedure
Faster learning curve for trainees in
Recurrence
Less than laparoscopic
More common amongst smokers and with those that experience weight gain
Recurrence Study
Study done by Veterans Affairs
1983 veterans underwent open or laparoscopic inguinal hernia repair
2 year follow up completed in 85% of
patients
Recurrence more common in the
laparoscopic group vs. open group (10.1% vs. 4.9%)
“Laparoscopic versus Open Inguinal Hernia Repair.” Jon Gould, MD. Surgical Clinics of North America, April 2008.
Operative Time and Recovery Study
Study done by Dr. Rutkow at Hernia Center
4401 patients during a 15 year period between
January 1989 and October 2003
3904 (89%) primary hernias and 497 (11%)
recurrent
Average operative time was 24 minutes for
primary and less than 30 minutes for recurrent
4120 (95%) returned to normal daily activity
within 3 days, 98% by the end of week 1
“The Perfix Plug Repair for Groin Hernias.” Ira M. Rutkow, MD, MPH. Surgical Clinics of North America, 2003
Chronic Pain Study
Study done at Chirurgische Praxiklinik Sauerlach, Germany
Study of 300 patients with primary inguinal hernia repair with Ultrapro mesh
No cases of chronic pain related to hernia repair nor a mesh-related complication
“Low Recurrence Rate in Hernia Repair – Results in 300 Patients with Open Mesh Repair of Primary Inguinal Repair.” Holzheimer, RG. European Journal of Medicine, January 2007
Cost Analysis Study
Study done at Central Hospital, Sweden
1370 patients, 665 in the laparoscopic (TEP) and 705 in the open group
Total hospital cost was 710.6 Euros higher
for laparoscopic repair
Cost-minimization analysis showed that laparoscopic inguinal hernia repair had a small but significant increase in overall costs compared to open
“Long-Term Cost-Minimization Analysis Comparing Laparoscopic with Open Inguinal Repair.” Eklund et. al., British Journal of Surgery, February 2010.
Conclusion
“Open mesh inguinal primary hernia repair
can be safely performed with excellent success and good cosmetic results in
patients in a specialized ambulatory clinic and is therefore an economic alternative for in-hospital treatment.”
– Holzheimer, European Journal of Medicine
“The open technique is superior to the
laparoscopic technique for mesh repair of primary hernias.”
Conclusion
For primary unilateral inguinal hernia
repair, open tension free repair with mesh is a cost-effective technique with low
incidence of recurrence and complications and can be performed by most surgeons (and trainees) with ease.
Thank you for your attention!
Contact Information:
V.K. Ashok, M.D, F.A.C.S
E-mail:
saint48@aol.com
Phone: (732) 462-5995
www.theherniacenter.com
