TEP: HOW I DO IT

Andrew Bowker Laparoscopy Auckland New Zealand

Poland October 2012

NEW ZEALAND:
population 4.6M

Size: NZ = UK

Auckland: population 1.5M

NEW ZEALAND

POLAND

LAPAROSCOPIC HERNIA REPAIR IN NZ

Public sector no data Private sector New Zealand 50% laparoscopic Auckland 80% laparoscopic

LAPAROSCOPY AUCKLAND
Purpose built laparoscopic surgical unit opened 2001 Annually: 1300+ surgical procedures

LAPAROSCOPIC EXPERIENCE (AB)

Laparoscopic hernia repairs 6280 Laparoscopic cholecystectomy 2365 Single port 30 Laparoscopic fundoplication 550

LAPAROSCOPIC INGUINAL HERNIA REPAIR

First repair 1991

Personal series 6280 TAPP 270 TEP 6010

Recurrences (TEP) 0.2% (12)

TEP: HOW I DO IT
Patient preparation Theatre setup Equipment Operative technique Economic considerations Postoperative management Results Pain post hernia repair

PREOP
Consent open vs. laparoscopic Day surgery

Preparation
Limited shave No catheter Antibiotic at induction

Infra-umbilical access Balloon dissection Ipsilateral rectus sheath

Purse string around 10mm port (avoid muscle) 0 laparoscope + 8-10mm Hg pressure 5mm ports in midline (avoid muscle)

Nurse/assistant same side Instrument table rotated Laparoscopic stack shifted Ergodynamically comfortable

 Identify landmarks:

Superior pubic ramus Inferior epigastric vessels

Dissect widely, especially laterally

15x10cm mesh

lightweight, large pore

Fix to sup pubic ramus + linea alba (avoid muscle/fascia) Local anaesthetic around umbilicus + in extraperitoneal plane

Mesh introduction

L DIRECT INGUINAL HERNIA: COMMENCEMENT

R INDIRECT INGUINAL HERNIA: TECHNIQUE

R INDIRECT INGUINAL HERNIA: TECHNIQUE

LARGE LIIH: REDUCTION OF SAC

Dissect completely

REC LDIH: AVOIDANCE OF SEROMA

ECONOMIC CONSIDERATIONS
Costs: Laparoscopic repair > open repair Laparoscopic equipment Disposables Operating ports Instruments Balloon dissection Mesh Tacker / glue Operation time: most surgeons laparoscopic > open

COST SAVINGS (AB)

Reusable instruments Home made balloon dissector Flat mesh Short tacker

Operating time laparoscopic << open

Home made balloon dissector

Hasson cannula Finger large glove 3-way tap + 60ml syringe

Commercial balloon
vs. Glove balloon

= US$100 (approximately)
= US$1 (approximately)

Cost: short tacker = 2/3 long tacker

COST SAVINGS
Reusable ports and instruments Avoid package deals (balloon+tacker+mesh) Home-made balloon dissector? Avoid light weight large pore meshes? Avoid barrier meshes Avoid fixation? Glue = more expensive Short tacker?

POSTOP
Discharge same day

Analgesics only if needed

Encourage activity (no restrictions) Review 7-10 days

Phone review at 3 months

Phone review at 12 months

POSTOP INFORMATION SHEET

Important Wound care Advice on activity Follow up instructions More important Abdominal distension Constipation likely Most important.. Warn of bruising +/- pain in testes Typically 3-4 days after operation = Cause of great concern to males Stops anxious phone calls after work hours!

NO RESTRICTIONS POSTOP!!
Records: Touch rugby Ballroom dancing Bedroom dancing Mowing lawns Basketball Indoor cricket Volleyball Cycling (50km) Rowing (single scull) Round of golf Pig hunting Fishing (117kg marlin) Skiing Running (10k) Surfing Snowboarding Pall bearing day 0 day 0 day 0 day 1 day 1 day 1 day 1 day 1 day 1 day 1 day 2 day 2 day 3 day 3 day 5 day 6 day 2

PAIN POST HERNIA REPAIR

TAPP/TEP N=989 Long term neuralgia or other pain 9.8% Open Mesh N=994 14.3%

Neumayer et al NEJM 2004;350:1819-27

TEP N=240 Chronic pain or discomfort 22.5%

Open Mesh 38.3%

Macintyre et al BJS 2002;89:1476-79

PAIN POST TEP HERNIA REPAIR AT 3 MONTHS

(male, unilateral; groin strain excluded)

Nil Restriction (N=951) Pain or discomfort (N=951) 99.9% (950) 91.1% (866)

Mild 0.1% (1)

Mod Nil

Severe Nil

8.5% (81)

0.4% (4)

Nil

Andrew Bowker personal series

PAIN: NEUROGENIC
Nerve interference Care with tacker fixation Should not experience nerve pain

PAIN: MUSCULOSKELETAL/MYOGENIC
Muscular interference Suture at umbilical access point Port placement Dissection into muscle Fixation to muscle
Mesh contraction against points of fixation = Major cause of chronic (myogenic) pain?

MECHANISM FOR PAIN WITH SOFT TISSUE FIXATION

Contraction Contraction

Dir

Ind

F Contraction Contraction

CONTRACTION with drag through tissue

+ PAIN

OPTION: NO FIXATION (OR GLUE FIXATION)

Contraction Contraction

F Contraction Contraction

No drag.. but risk of medial recurrence

ALTERNATIVE OPTION: MEDIAL BONE FIXATION ONLY

Contraction

F Contraction

No drag No risk of medial recurrence

Fixation is safe (and important) Fixation to muscle/tendon Fixation medially and laterally = potential for pain

Mesh contraction unimportant if no soft tissue fixation

TEP OPERATION: KEY POINTS

Ports in midline Dissect side of hernia only Identify landmarks + maintain orientation (0 laparoscope better?) Wide dissection especially laterally Mesh 15x10cm (lightweight wide pore?) Penetrative fixation: medially only

END