Dr. Ponsky, professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery and Dr. Michael Rosen, professor of surgery at Cleveland Clinic Lerner College of Medicine,
Discussion Topic: Inguinal Hernias.
Work up for groin bulge
"How do you approach an 89 year old patient with asymptomatic bulge in your clinic?”
There are many patients that are sent to me where their primary care physician thinks they felt a hernia and in fact on my exam they don’t. First, you need to confirm it. And just remember that every time someone stands up and coughs and does a Vasalva maneuver the cord structures will give you an impulse so you want to make sure you see a bulge and a true hernia. Assuming it is you, want to take a detailed history and if this hernia is asymptomatic to minimally symptomatic, in the elderly patient, there is evidence that you can just watch these.
Role of watchful waiting
"You are referring to the Bob Fitzgibbons study, which suggested that perhaps we can watch these asymptomatic hernias?”
Bob Fitzgibbons original study 1000s of VA patients had minimally symptomatic to asymptomatic hernias. They were in their 70s to 80s and were randomized to two groups. Open surgery with mesh and observation. There are two key findings: The risk of presenting with an emergency problem needing an operation was less than 1%. It is safe to watch people. But the problem of this study is almost a third of the patients went on to develop symptoms and needed an operation. They didn’t do worse when they were operated on so it was safe to watch them. By 5 years almost three quarters of patients developed symptoms. So if you see someone in your office who has an asymptomatic hernia and was 89 yrs. old, I think its okay to wait and watch because the odds are in a couple of years they might not have any symptoms and will be okay. But, in a young patient the odds are against them that they are going to live the rest of their life without t becoming symptomatic so for that patient I would say, "when the time is right in your life, it is probably something that you ought to get fixed.”
Contraindications to repair
"Both of us occasionally see patients who have difficult co-morbidities to manage. They may have severe cardiac disease, ascites, blood clotting, low cardiac output and we see these patients and they have perhaps even a large hernia that is reducible. But under any ordinary circumstances we would operate on these patients but they are horrible operative risks. "
Those patients really need be carefully counseled.. If it is not symptomatic, I would certainly wait and see. I would teach them how to reduce it and wear a Truss. But if they are symptomatic I think it is something that needs to be done. It is much worse for them to present in the middle of the night with an emergency problem. If symptomatic and difficult to reduce they ought to be offered repair
Open versus laparoscopic approach
"How do you select the correct repair for a patient who has never had a hernia repair before, has a reducible uncomplicated but symptomatic inguinal hernia, [and] is a reasonable operative risk [with] no co-morbidities of significance?”
I think that ultimately it has been shown in literature the best approach is what you do best. Now having said that. If I had a young healthy active patient with unilateral hernia, that would be a laparoscopic inguinal repair. With laparoscopy you are putting mesh away from nerves and the risk of chronic pain in laparoscopic inguinal hernia, when done right, is lower than the risk in opening inguinal hernia.
The front door versus the ceiling: TAPP vs TEP laparoscopic repair
"There are many surgeons who do [TAPP repair]. But, there is an equal number that like TEP repair using balloon for dissection. Is there significant difference in literature between those two procedures?”
No. It has not been studied well enough to give you level 1 evidence. They both have their advocates. They both have their limitations. I think that TEP repair is more expensive because you need to use a balloon and there is smaller space but perhaps the angles are easier to operate with. [With] TAPP you get better view, better working space, you can look intra-peritoneal and see if you reduced the hernia, which is a common issue when you are learning to do laparoscopic inguinal hernias. They are both appropriate. It is the same room. One comes through the front door. One comes through ceiling.
"When you talk to patients how do u present the advantages and disadvantages of each [approach]?”
One of the things I say this to everybody when we talk about different approaches is if it was my family member who called me, "I would say make sure you pick someone you like who has done this operation a lot.” In my hands [open and laparoscopy] are both equivalent but the laparoscopy repair offers you a week to 10 days earlier recovery. It offers you place to place mesh away from the nerves. The disadvantage of it is you have to operate near intestines whereas in open you are in separate plane so there is risk of intestinal injury and injury to major blood vessels. But, if you are safe and know those planes that risk should be incredibly low and the consequence of chronic pain with open mesh repair is not worth it in a young healthy active patient who can tolerate general anesthesia and would likely benefit from getting back to activity 1 week or 2 faster. In an elderly patient, any anesthetic risk, or anyone on anticoagulation I don’t want to dissect out that retroperitoneal space: they get an open operation.
Incidental contralateral hernia: To fix or not to fix?
"I think [if] any question of hernia on opposite side the laparoscopic approach lets you see the other side and fix it. So that is an advantage?”
It is a pro and a con. The problem is you see something you would not have seen open and now you are doubling anesthesia time and you increase risk of hematoma so in an elderly patient I don’t. In a younger active patient [there is] the chance it will go on to be symptomatic.
Special cases: Check your minimally invasive ego at the door
"Patients with reduced cardiac capacity? "
I think the pneumo-peritoneam is rarely a problem. It is something we worried about in the past. I think if you know cardiac function you insufflate v slowly work at lower pressures possible. It is a rare issue but I think that you also have to remember the benefits of laparoscopy are small for the vast majority of patients. You have to check your minimally invasive ego at the door and make sure you can also do open inguinal hernias. If you are pushing laparoscopy in a sick co-morbid patient, more often or not u are not comfortable doing open.
"Previous abdominal surgery?”
Can be done [via] laparoscopy but would not be done in my hands.
"Previous prostate surgery?”
Today in my practice it would be open.
Laparoscopic repair: technical tenants
"Do you vary your repair based on type of hernia? For example if you see a femoral hernia versus do you vary your TAP repair?”
I think a basic tenet [is] you need a wide dissection plane. Earlier, there was a lot talk about lateral dissection. That is the easiest space to create but it is least relevant for recurrence. If you go back and read Stoppa’s original description, if you are doing a unilateral inguinal hernia, never use less than 15 by 15 cm piece of mesh which is much bigger than the vast majority of laparoscopic preformed meshes.
If there is a femoral hernia I dissect more into space of Retzius. If there is an Obturator hernia I will go much lower than I routinely do. But direct and indirect are generally same dissection. But for direct hernia you should use heavier weight material.
You’ve stepped into it now: Which mesh?
"Okay so you stepped into it now. What kind of mesh should I really use? What has proven to be better and what are the costs?”
There is a litany of meshes now and its created more confusion, more expense and particularly for inguinal hernias [without] any clinical benefit over standard piece of mesh. But in general, uncoated polypropylene mesh is heavy weight, mid-weight and light weight and those categories were defined based on marketing companies with theoretical advantages of one over the other. The advantages to lower weight are you feel it less, it contracts less, with less foreign body reaction but there is less material and there is a risk of it fracturing. There are a couple of reports that are starting to show up now where you have central mesh failures where they break. Heavier weight mesh rarely breaks but sometimes people feel it in their groin. So I think you should tailor mesh to your patient.
Also, now there are preformed meshes for inguinal hernia. They are technically easier to place but one word of caution; surgeons tend to down size that mesh to a lot smaller piece of mesh. If you are doing an inguinal hernia I don’t think you should make the preformed mesh smaller. Take out the mesh and dissect bigger.
Fixation of mesh?
"How do you fix mesh in place? How about absorbable v non-absorbable tacks?”
I believe you should fix it with pro tacks. Some people use glue. Some use no fixation. Every one does fixation for big direct. [There is] no evidence that absorbable causes reduction in pain, better fixation or improved long-term outcomes. So, I use permanent fixation.
Contaminated field: To mesh or not to mesh
"What to do when you have an infected field or a contaminated field?
There is mounting evidence that you can put medium weight polypropylene mesh in a contaminated field. We have done several in ventral hernias. Depending on the level of contamination and indication of operation, it is perfectly appropriate to do that. I also think it is perfectly appropriate to do Bassini operation or McVay. I still think that is a great operation for a vast majority of cases.
Femoral hernias: Best approach?
"Talk about your approach to femoral hernias.”
I make a vertical incision, dissect right down to the hernia sac. If there is compromised piece of intestine you can actually bring it out and resect it infra-inguinally, do your anastomosis and then the hard part is getting it back in.
The inguinal ligament comes down medial to the femoral space [and] gives off the lacunar ligament. Put your right angle in and let the bowel or the hernia be lateral, cut medially and you can get an extra centimeter by releasing the lacunar ligament. Then I will do a reverse McVay: [look] infra-inguinally and [take] the inguinal ligament down to coopers ligament before taking the inferior border of the inguinal ligament and sewing it down. I start medially so I see the femoral vein to make sure you don’t impinge on it and I can enclose from below.
I have [plugged with mesh] in the past but femoral hernias tend to be thin women and I had a DVT due to irritation of the femoral vein so I just do a reserve McVay and if they get a recurrence then I go back laparoscopically from another place
Complicated hernias: recurrent, bilateral, incarcerated
"Recurrent hernias, which is you favorite approach?”
For recurrent hernias go where no one has gone before and if someone has gone both places than you should go where you are best.
"If you have a patient with bilateral hernias what do you do?”
[If] you are a skilled laparoscopic surgeon, laparoscopy is the way to go
"Finally, the incarcerated hernia done laparoscopically?”
[Laparoscopically], if you only do TAP that is not good idea because you want to reduce the contents. You can actually go in laparoscopically and cut the internal ring while looking at the epigastric and going at the 2 o’clock position to get it to reduce back in but If I cant reduce it I will open it. You can open, reduce and go back and put the mesh in via laparoscopy.
A skilled inguinal hernia surgeon should understand the open and laparoscopic option, be good at both and choose the one that is most optimal for his patients.