2008 Warmup Miserez Hernia TEP

8/10/2019 2008 Warmup Miserez Hernia TEP

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BAST/BGES Workshop 5th Edition Warm-up Package in LaparoscopyIRCAD/EITS Strasbourg (France).

Teacher : Prof. Dr. Marc MISEREZ U.Z. Gasthuisberg/LeuvenApril 17+18, 2008.

Laparoscopic Inguinal Hernia Repair TEP

Future of laparoscopic approach 1

Laparoscopic inguinal hernia repair:

future of laparoscopic approach

M. MiserezM. Miserez

Department of Abdominal SurgeryDepartment of Abdominal Surgery

University Hospitals Leuven, BelgiumUniversity Hospitals Leuven, Belgium

WarmWarm--up Packageup Package Fifth editionFifth editionStrasbourg, April 18th, 2008Strasbourg, April 18th, 2008

large prosthesiswithreinforcementof the whole myopectineal orifice

~ minimally invasive STOPPA repair~ minimally invasive STOPPA repair (GPRVS)Chirurgie, 1973; 99: 119-123

EndoscopicEndoscopic groingroin herniahernia repairrepair


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Groin hernia: endoscopic repairGroin hernia: endoscopic repair

TAPP (Transabdominal Preperitoneal)more easy to learn - endoscopic suturing

transperitoneal approachhigher risk for postoperative intestinal obstructionDu ro n e t al , Ar ch Su rg 2000 Br in gm an an d Bl om qv is t, Her ni a 2005

laparoscopic exploration

TEP (Totally ExtraPeritoneal)more difficult to learn

anatomy more difficult to understand

limited working space

preservation of peritoneal integrity safer?laparoscopic exploration also easily possible

ResultsResults ofof metaanalysesmetaanalyses andandsystematicsystematic reviewsreviews

Pro openPro open surgerysurgery

OperatingOperating time 8time 8--1515 minutesminutes shortershorter

HigherHigher riskrisk forfor rarerare butbut potentiallypotentially seriousseriousvisceralvisceral (esp bladder) and(esp bladder) and vascularvascular injuriesinjuries

HospitalHospital costscosts

MemonMemon et al, Br Jet al, Br J SurgSurg 20032003McCormackMcCormacket al,et al, HealthHealth TechnologyTechnology AssessmentAssessment 20052005

0.14%0.14%0.16%0.16%0.65%0.65%VisceralVisceralinjuriesinjuries

0%0%0%0%0.13%0.13%VascularVascularinjuriesinjuries

openopenTEPTEPTAPPTAPP

role of learning curve!


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ResultsResults ofof metaanalysesmetaanalyses andand

systematicsystematic reviewsreviews

ProPro laparoscopiclaparoscopic surgerysurgery

PostoperativePostoperative painpain TimeTime toto dischargedischarge fromfrom hospitalhospital (3.43h)(3.43h) ReturnReturn toto normalnormal activityactivity (4.73(4.73 daysdays)) ReturnReturn toto workwork (7(7--3939 daysdays))

LessLess persistingpersisting pain andpain and numbnessnumbness CostCost--effectivenesseffectiveness seemsseems betterbetter (TEP >(TEP > TAPPTAPP))

whenwhen productivityproductivity costscosts and QUALYand QUALY includedincluded OnlyOnly oneone smallsmall RCTRCT comparingcomparing TAPP and TEPTAPP and TEP


Gholghesaei et al, Surg Endosc 2005

ResultsResults ofof metaanalysesmetaanalyses andandsystematicsystematic reviewsreviews

NoNo differencedifference

RecurrenceRecurrence raterate



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WeWe needneed more datamore data onon thethe potentialpotentialinterestinginteresting groupgroup ofof

bilateralbilateral//recurrentrecurrent herniahernia

For symptomatic bilateral hernias, it islikely that laparoscopic repair would

be more cost-effectiveMcCormack et al, Health Technology Assessment 2005

For recurrent hernias after anteriorrepair, a posterior approach is logical

BilateralBilateral andand recurrentrecurrent herniashernias

Guidelines UK, NetherlandsGuidelines UK, Netherlands

Primary inguinal hernia: open meshPrimary inguinal hernia: open mesh

Bilateral inguinal herniaBilateral inguinal hernia

Recurrent inguinal herniaRecurrent inguinal hernia(after anterior repair)(after anterior repair)

NationalNational InstitueInstitue for Clinical Excellence (NICE);for Clinical Excellence (NICE);Guidance on the use of laparoscopic surgery for inguinal hernia.Guidance on the use of laparoscopic surgery for inguinal hernia.

London, 2001London, 2001

Association of Surgeons of the Netherlands, 2003Association of Surgeons of the Netherlands, 2003

consider TEP(if expertise present(if expertise present)


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RecommendationsRecommendations

NationalNational InstitueInstitue for Clinical Excellence (NICE);for Clinical Excellence (NICE);Guidance on the use of laparoscopic surgery for inguinal hernia.Guidance on the use of laparoscopic surgery for inguinal hernia.

LondonLondon

Update 2004Update 2004

Laparoscopic surgery is

one of thetreatment options

for the repair of primary inguinal hernia

2005 Society of American Gastrointestinal Endoscopic Surgeons (S2005 Society of American Gastrointestinal Endoscopic Surgeons (SAGES)AGES)annual meeting debateannual meeting debate

PuriPuri et al,et al, SurgSurg EndoscEndosc 20062006

TailoredTailored surgerysurgery

UnilateralUnilateral oror bilateralbilateral

PrimaryPrimary oror recurrentrecurrent

AgeAge

of theof the

patientpatient

(eg adolescent)(eg adolescent)

ComorbidityComorbiditypreviousprevious surgerysurgery

Type ofType of anesthesiaanesthesia

ReconvalescenceReconvalescence -- socioeconomicalsocioeconomical aspectsaspects


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Recurrence rate in the mesh eraRecurrence rate in the mesh era

1.4%MetaMeta--analysis Collaboration EH, Br Janalysis Collaboration EH, Br J SurgSurg 20002000

6-year cumulative incidence

of reoperation for recurrenceSwedish Hernia Register, 2005

4.5%

recurrence rate 1.4-2.3x higherKald et al

Haapaniemi et al

~ effectiveness

~ efficacy

TEPTEP:: meshmesh fixationfixation

NoNo meshmesh fixationfixation necessarynecessaryFerzliFerzli et al, J Amet al, J Am CollColl SurgSurg 19991999

SmithSmith et al, 1999et al, 1999

MinimalMinimal meshmesh fixationfixation withwith fixationfixation devicesdevicesinin selectedselected casescases

KhajancheeKhajanchee et al,et al, SurgSurg EndoscEndosc 20012001LauLau andand NivrittiNivritti,, ArchArch SurgSurg 20032003

onon CooperCooperss ligamentligament

largelarge direct herniadirect herniafemoralfemoral && obturatorobturator herniahernia

avoidavoid triangletriangle of painof pain

FibrinFibrin SealantSealant ((FSFS)?)? TopartTopart et al,et al, SurgSurg EndoscEndosc 20052005 Biodegradable and biocompatible

Adhesive and hemostatic properties


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Risk factorsRisk factors forfor chronicchronic painpain afterafter herniaherniasurgerysurgery:: SwedishSwedish Hernia RegisterHernia Register

Franneby et al, Ann Surg 2006

primary inguinal hernia repair in patients 15-85 years old2-3 years postop; 59 hospitals

validated pain questionnaire to investigatepain behaviour rather than imaginary descriptors of pain

n=2456

31% some pain6% interference with daily activities

posterior approach

LaparoscopicLaparoscopic vs. openvs. open meshmesh::RCTRCT onon chronicchronic painpain

LaparoscopyLaparoscopy betterbetterDouekDoueket al, BMJ 2003et al, BMJ 2003

McCormackMcCormacket al,et al, CochraneCochrane LibraryLibrary 20032003 ((metameta--analysisanalysis))GrantGrant et al, Br Jet al, Br J SurgSurg 20042004

SchmedtSchmedt et al,et al, SurgSurg EndoscEndosc 20052005 ((metameta--analysisanalysis))

NoNo differencedifferenceWrightWright et al, Annet al, Ann SurgSurg 20022002

NeumayerNeumayer et al, Net al, N EnglEngl JJ MedMed 20042004

LaparoscopicLaparoscopic TEPTEP resultsresults in thein thelowestlowest prevalenceprevalence ofof chronicchronic painpain

PoobalanPoobalan et al,et al, ClinClin J Pain 2003 (J Pain 2003 (reviewreview))

in most of these studies,chronic pain was not the primary endpoint


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LongLong--termterm effectseffects of openof open oror

endoscopicendoscopic meshmesh repairrepair ((RCTRCT))

> 200> 200 patientspatients, FU, FU 55 yearsyears,, clinicalclinical examinationexamination

17 vs. 1**(p=0.005)

50128300Non-mesh vs.

Lichtenstein

van Veen2007

5 vs. 33(p


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AndAnd whatwhat aboutabout??

TheThe costscosts

TheThe prostateprostate

TheThe learninglearning curvecurve

HowHow toto reducereduce hospitalhospital costscosts

ReusableReusable instrumentsinstruments

TrocarsTrocars

FixationFixation devicesdevices

AmbulatoryAmbulatory surgerysurgery

LocalLocal reimbursementreimbursement incentivesincentives


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RadicalRadical prostatectomyprostatectomy afterafter TEP/TAPPTEP/TAPPRetropubicRetropubic procedure moreprocedure more complicatedcomplicated ororimpossibleimpossible

IpsilateralIpsilateral pelvicpelvic lymphadenectomylymphadenectomy difficultdifficult

ObliterationObliteration ofof RetziusRetzius spacespace afterafter bilateralbilateral repairrepair

Prostatic mobilisation

Vesicourethral anastomosis

KatzKatz et al, Jet al, J UrolUrol 20022002CookCooket al, BJU Int 2003et al, BJU Int 2003RassweilerRassweiler et al, Jet al, J UrolUrol 20012001

ProstateProstate screeningscreening

30307070 yearsyears oldold

RectalRectal examinationexamination

PSA +PSA + freefree fractionfraction

FamilialFamilial historyhistory!!

ProstateProstate cancercancer oror highhigh--gradegrade PIN in 4.9% of 137PIN in 4.9% of 137consecutiveconsecutive malemale candidatescandidates

forfor laparoscopiclaparoscopic inguinalinguinal herniahernia repairrepair

HsiaHsia et al, Annet al, Ann SurgSurg 2004; 240: 9222004; 240: 922


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RadicalRadical prostatectomyprostatectomyEarlyEarly detectiondetection increasesincreases thethe raterate ofof clinicallyclinically localizedlocalized((pelvicpelvic nodenode negativenegative)) prostaticprostatic cancercancer (cT1(cT1--cT2)cT2)

nono needneed forfor pelvicpelvic lymphadenectomylymphadenectomy

revival ofrevival of perinealperineal approachapproachwithoutwithout needneed forfor obturatorobturator lymphadenectomylymphadenectomy via separatevia separate approachapproach

BorchersBorchers et al,et al,UrolUrol Int 2001Int 2001MartisMartis et al, Jet al, J SurgSurg OncolOncol 20072007

retropubicretropubic??perinealperineal??laparoscopiclaparoscopic transperitonealtransperitoneal??laparoscopiclaparoscopic extraperitonealextraperitoneal??

externalexternal beambeam radiotherapyradiotherapy??

TheThe learninglearning curvecurve forfor endoscopicendoscopicinguinalinguinal herniahernia repairrepair isis steepsteep


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TheThe learninglearning curvecurve forfor endoscopicendoscopic

inguinalinguinal herniahernia repairrepair isis steepsteep50-100 procedures to become experienced

with the first 30-50 being most criticalLiem et al, Surg Endosc 1996 DeTurris et al, J Am Coll Surg 2002

Voitk, Can J Surg 1998 Edwards and Bailey, SurgLaparoscEndosc Percutan Tech2000Feliu-Pala et al, Surg Endosc 2001 Lau et al, Surg Endosc 2002

Bittner et al, Br J Surg 2002 Wake et al, Cochrane Database Syst Rev 2005

Recurrence < 2% if >80 procedures (TEP)Recurrence < 2% if >80 procedures (TEP)median followmedian follow--up 7 years (1up 7 years (1--11 years)11 years)Lamb et al, Surgeon 2006Lamb et al, Surgeon 2006

TAPP: > 75TAPP: > 75LovisettoLovisetto et al,et al, SurgSurg EndoscEndosc 20072007

At least 250 ? (especially in surgeonsAt least 250 ? (especially in surgeons 45 years of age)45 years of age)Minimum experience of 25 proceduresMinimum experience of 25 proceduressmall mesh sizesmall mesh sizeNeumayerNeumayer et al, Net al, N EnglEngl J Med 2004;J Med 2004; NeumayerNeumayer et al, Annet al, Ann SurgSurg 20052005

SurveySurvey BelgianBelgian surgicalsurgical residentsresidents((yearyear 33--4; n=34 )4; n=34 )

Which techniques are necessaryWhich techniques are necessaryto know?to know?

74% Lichtenstein (25)74% Lichtenstein (25)

68% TEP (23)68% TEP (23)

35% TAPP (12)35% TAPP (12)

18%18% ShouldiceShouldice (6)(6)

12% Every possible technique (4)12% Every possible technique (4)


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TheThe learninglearning curvecurve dependsdepends alsoalso onon thethe

structurestructure of the training program!of the training program!

Intraoperative continous expert supervision tips & tricks

StructureStructure of the TEPof the TEP inguinalinguinalherniahernia repairrepair training programtraining program

ExhaustiveExhaustive cognitivecognitive webweb--basedbased inputinput onon

preperitoneal (laparoscopic) anatomy (+ intraoperatively)

EHS Hernia Classification

surgical technique

different consecutive steps

systematic dissection tips & tricks

pitfalls to avoid

MorenoMoreno--EgeaEgea et al,et al, MedMed SciSci MonitMonit 20052005 FaureFaure et al,et al, SurgSurg RadiolRadiol AnatAnat 20062006

Hernia, 2007: 11: 113-116


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StructureStructure of the TEPof the TEP inguinalinguinal

herniahernia repairrepair training programtraining program

IntraoperativeIntraoperative continuouscontinuous expertexpertmentoringmentoring = teaching= teaching

proctoringproctoring == supervisionsupervision

CarefulCareful patientpatient selectionselection at the startat the start((avoidavoid recurrentrecurrent oror scrotalscrotal hernia,hernia,

postpost appendectomyappendectomy))

expert surgeon!expert teacher!

time and motivation

SystematicSystematic TEPTEP inguinalinguinal herniaherniarepairrepair in 10in 10 consecutiveconsecutive stepssteps

1.1. IntroductionIntroduction ofof firstfirst trocartrocar2.2. IntroductionIntroduction ofof secondsecond trocartrocar3.3. DissectionDissection toto BogrosBogros spacespace andand

introductionintroduction ofof thirdthird trocartrocar

4.4. ReductionReduction of directof direct inguinalinguinal herniahernia5.5. ReductionReduction ofof femoralfemoral//obturatorobturator herniahernia6.6. ReductionReduction of indirectof indirect inguinalinguinal herniahernia7.7. LateralLateral dissectiondissection andand reductionreduction ofof

preperitonealpreperitoneal lipomalipoma7 C ontralateral dissec tion

8.8. PreparationPreparation andand introductionintroduction of theof the meshmesh9.9. Placement of thePlacement of the meshmesh andand fixationfixation

inin selectedselected casescases10.10. DesufflationDesufflation basic advanced


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VideoVideo

http://www.uzleuven.be/diensten/abdominal_surgery/video/

extensive narrative and

visual comments


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HowHow toto decreasedecrease patientpatient exposureexposure

toto learninglearning curvecurve errorserrors ininTEPTEP inguinalinguinal herniahernia repairrepair ??

PrerequisitesPrerequisites forfor the residentthe resident experience in laparoscopic cholecystectomy

cognitive input on laparoscopic hernia repair assimilated

logbook for TEP

PrerequisitesPrerequisites forfor the mentor:the mentor: intraoperativeintraoperativeassistanceassistance

AssistAssist fullfull proceduresprocedures n=5n=5 PerformPerform step 1step 1--22 n=5n=5

PerformPerform step 1step 1--33 n=5n=5 PerformPerform step 1step 1--66 n=5n=5 PerformPerform step 1step 1--88 n=5n=5 PerformPerform fullfull procedure (1procedure (1--10)10) n=5n=5

totaltotal:: n=30n=30

during 3 month residency period with the same mentor

acceptable

operative time &mental effortfor both parties

ConclusionsConclusions: the: the futurefuture of theof thelaparoscopiclaparoscopic approachapproach

NotNot oneone singlesingle techniquetechnique Anterior approach: Lichtenstein

Posterior approach: TEP > TAPP

ProstateProstate screeningscreening

StructuredStructured training programtraining program More researchMore research neededneeded

Efficacy and effectiveness studies (RCT; prospective cohort studies; registries)

TEP vs. TAPP

Bilateral and recurrent hernias

Cost-effectiveness (type of employment, regional differences)

New techniques for posterior repair (Kugel, Polysoft)

ManyMany decisionsdecisions drivendriven byby locallocal reimbursementreimbursement systemsystem((socialsocial securitysecurity,, insurancesinsurances)) No discouraging reimbursement for laparoscopic surgery

Ambulatory surgery for (open and laparoscopic) inguinal hernia repair

We areWe are surgeonssurgeons,,notnot laparoscopiclaparoscopic oror openopen technicianstechnicians

tailoredtailored approachapproach


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2008 Warmup Miserez Hernia TEP