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HERNIA SURGERY & ABDOMINAL WALL RECONSTRUCTION: time for change

2nd Europe conference, 2 – 4 Feb, 2017

Attenders and co-authors: Raimundas Lunevicius, Khalid Shahzad

Thanks to: Nikhil Misra, John Taylor

General Surgery Department Aintree University Hospital NHS Foundation Trust, Liverpool, England

14th Mar 2017

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2nd Europe conference, 2 – 4 Feb, 2017

Venue

• RCP, London

• Two co-chairs from UCL

• 300 participants

• 24 countries

David Ross & Al Windsor

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Photography, Raimundas Lunevicius

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Four key messages

1. Results of incisional hernia repair are not good

2. Centralized hernia surgery is a prerequisite for improvement of clinical outcomes

3. Center for a hernia and AWR should be an essential component of a university hospital

4. Hernia and abdominal wall reconstructive surgery is a practical and academic sub-specialisation

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Requirements for successful hernia project

1. Decision & strong institutional support - is a key2. Dedicated faculty / consultants 3. Commitment for clinical & academic excellence4. MDT 5. Dedicated general surgeons6. Plastic surgeon7. Radiologist, anesthetist, etc.8. A wound-healing specialist9. ANP10. Clinic 11. Theatre with dedicated theatre staff12. Prospectively maintained database for independent data

managers / collectors / analytics

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Global discussions (selected as examples)

1. Anatomy & assessment of the AW

2. WHO, World, European, Germany guidelines (RCS & NICE – not discussed)

3. Management of acute abdominal defect

4. Negative pressure wound therapy & dressings

5. Management of hernia disease

6. Hernia disease classifications

7. Recurrent hernia risk stratification and reduction

8. Prevention of SSI & incisional hernia

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Lectures on technical aspects of hernia surgery

• Origins of component separation for AWR (Ramirez procedure)

Ramirez OM, Ruas E, Delon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26

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Photography, Raimundas Lunevicius

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Incisional hernia repair methods• Technical details of component separation (if indicated):

• Anterior component separation (ACS) with on-lay / under-lay mesh• Importance of perforator sparing in ACS• Rives-Stoppa procedure & its further extension into • Posterior component separation (PCS) or Transverse Abdominal

Release (TAR) with under-lay mesh

• Preoperative preparation is a key when the contents of a hernia has lost their ‘right of domicile’ (radiology)1. A role of Botox type-A for pre-op. chemical component

separation2. The preoperative progressive pneumoperitoneum

• with or without use of Botox type-A

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Prosthetic materials: classification1. Synthetic non-absorbable meshes with or without

absorbable collagen layers

2. Synthetic gradually absorbed meshes (GORE BIO-A Tissue Reinforcement)

3. Fully biological prosthesis from bovine, porcine, or human matrix (Integra, Strattice, Permacol)

4. Semi-biological devices: a combination of an extracellular matric and a synthetic mesh ‘Zenapro’ (Cook Medical)

NB! Physiological response of the host is most physiologic to the biological meshes

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Management and prevention of morbidity

• Seroma• Very common after on-lay placement of a mesh• Forget on-lay placement of a mesh, when possible • Drains do not prevent; however, use them

• Visceral injury: 1-1.8% • a recognized complication in laparoscopic hernia surgery• insertion of a first port laterally is most dangerous maneuver

• Infection: • consider early surgery

• Skin necrosis: • consider early surgery

• Recurrence • Centralized work reduces recurrent hernia rate two times or even more

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Presentations from Merseyside• Whiston

• Two presentations• commercialized

• Arrow Park: • One poster

• CRP profile following hernia repair

• Aintree University• Nil

• Royal Liverpool:• Nil

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© Bimal Kumar Kanhar, NGS

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Hernia Disease: where the UK and England stands?

• Incidence

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ASIR per female person-year in 20152,300 cases per 100,000 females in 2015, UK (95% UI 2,200 – 2,400) INCIDENCE of ventral hernia among females - HIGHEST IN THE WORLD

Abdominal wall hernia incidence. EpiViz, GBD 2015

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ASIR per male person-year in 20156,000 cases per 100,000 males in 2015, UK (95% UI 5,600 – 6,600): Ventral hernia disease incidence among males is the HIGHEST IN THE WORLD in the UK

Abdominal wall hernia incidence globally. EpiViz, GBD 2015

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The UK

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ASIR per female person-year in 2015, UK2,800 cases per 100,000 females in 2015, UK (95% UI 2,700 – 2,900): North West region: HIGHEST INCIDENCE AMONG FEMALES

Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015

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ASIR per male person-year in 2015, UK6,400 cases per 100,000 males in 2015, UK (95% UI 5,900 – 7,000)

Abdominal wall hernia incidence: England, N. Ireland, Scotland, Wales. EpiViz, GBD 2015

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Aintree University Hospital• Hernia surgery activities• Elective and emergency procedures combined

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Aintree: Hernia surgery volume, 2012 – 2016(elective and emergency cases combined)

Total of Number of Procedures Year

Hernia surgery type 2012 2013 2014 2015 2016 Grand TotalIncisional hernia repair 16 6 14 8 80 124Umbilical/Periumbilical hernia repair 128 153 146 155 139 721Linea alba/Spigelian hernia repair 46 49 30 45 27 197

Inguinal hernia repair 326 367 328 340 312 1673

Femoral hernia repair 20 19 17 22 19 97

Lumbar hernia repair - 1 1 4 2 8

Other hernia repair 118 143 114 129 64 568

Grand Total 654 738 650 703 643 3388

ABI, 2017

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This funnel plot shows all primary, bilateral inguinal hernia repair procedures on adults per 100,000 population per CCG across England, for the year 2014/15. Each bubble represents a CCG, with the size of the bubble representing the number of procedures undertaken. Taken from http://rcs.methods.co.uk/pet.html

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Aintree: Hernia surgery volume, 2012 – 2016(elective and emergency cases combined)

Total of Number of Procedures Year

Hernia surgery type 2012 2013 2014 2015 2016 Grand Total

Incisional hernia repair 16 6 14 8 80 124Umbilical/Periumbilical hernia repair 128 153 146 155 139 721Linea alba/Spigelian hernia repair 46 49 30 45 27 197

Inguinal hernia repair 326 367 328 340 312 1673

Femoral hernia repair 20 19 17 22 19 97

Lumbar hernia repair - 1 1 4 2 8

Other hernia repair 118 143 114 129 64 568

Grand Total 654 738 650 703 643 3388

ABI, 2017

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Decline in hernia surgery procedures, Aintree

ABI, 2017

2012 2013 2014 2015 2016580

600

620

640

660

680

700

720

740

760

654

738

650

703

643

Grand total

2012 2013 2014 2015 20160

5

10

15

20

25

30

35

40

45

50

43.646.1

38.2

41.4

33.8

Hernia repair procedures per consultant capita a year

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Interpretation• Losing competitive battle

• Historical and current policy for a hernia and abdominal wall reconstructive surgery requires essential revision

‘The rejection of Fact, the rejection of Reason is the Path to decline’ (NY, 2017)

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A center for hernia and AWR at Aintree University Hospital NHS Foundation Trust• First job:

• To say categorical ‘YES’ in Gen. Surg. Directorate Meeting today

• Afterwards: other talks of a secondary importance such as• Planning• Structure: MTD team, data base, data manager• Pathways• SOPs• Marketing• Formal approval• Start• Regular analysis

will follow Thank you,Raimundas Lunevicius

Conclusions