ADVANCED LAPAROSCOPIC, ABDOMINAL REOPERATIVE AND HERNIA SURGERY

Patients with hernias are questioning how to avoid mesh because of a deluge of press and unsolicited email focused on a flood of lawsuit related to complications of mesh.  I'll review, in general, the groin hernia repair options, having had substantial experience and success with many techniques, and again offering the revived preference, open surgery with native tissues without mesh.

Recent surgical training has focused on Laparoscopic technique which limits trainee experience with open classical surgical techniques.  When open surgery is indicated, they depend on mesh techniques for security as needed in using Tension free or plug technique instead of laparoscopic hernia repairs which also requires mesh.

What follows is my perspective about options, after 50 years of ongoing surgical experience.  Some of my long-time associates might recall this evolution and my results.

Although the basic open Bassini (1880's) natural tissue repair was successful with a low recurrence rate in Europe, when it was adopted in the USA, certain steps were omitted resulting in a high rate of recurrence (about 25%).  This prompted trial of the different anatomic, McVay repair (1960's) which was not better, produced tension and resulted in more pain.  At the same time, the Shouldice Clinic in Canada modified the Bassini including all original steps and adding multiple reinforcing, permanently reinforcing, tension sharing, sutured layers with native tissue, with local anesthesia and a short hospital stay.  To avoid drug toxicity of local medication and untenable postoperative pain and disability, simultaneous bilateral repairs were not done.

This excellent tissue repair gained convincing appeal in the USA in the early 1980's.  A few surgeons adopted this method immediately.  Not many of these surgeons remain in practice now.  The written description was difficult to understand making reproducibility inconsistent.

I traveled to the Shouldice Clinic in 1982 to observe their technique on multiple cases, and in the next 10 years, I performed over a thousand open hernias with this Canadian, Shouldice Technique with local anesthesia and initiated ambulatory surgery in our area.  During that period, I was also referred multiple recurrent hernias which were not amenable to usual techniques and used an open preperitoneal open repair, which is similar to Laparoscopic technique.

In 1987, at the national conference, “Advances and improvements in Hernia Surgery” in Miami, I discussed:  1-open" Standardized repair of Recurrent hernias using Gortex" and, 2-How to do:  The technique for local anesthesia. Sponsors included leaders in the field:  Drs. Lrving Lichtenstein, Nicholas Obney, (Chief Surgeon at Shouldice Clinic), Arthur Gilbert (Classification of hernias and developing Prosthetic materials).

Based on scientific studies, Dr. Lichtenstein showed that postoperative hernia surgery pain and recurrence was related to tissue tension during suturing and introduced the now dominant Tension Free Technique which requires mesh.  Fast Plug techniques were developed to fill defects omitting thorough dissection and expedite volume.  The fabrication and availability of synthetic meshes has increased 100-fold since the 1970's.

In 1992, agreeing with a few other regional Surgeons, I also introduce Laparoscopic inguinal hernia repair in our area.  Laparoscopic repairs became dominant as these techniques were learned by Residents and Associates.  Adoption depended on dependent on operator laparoscopic comfort.  Preperitoneal Laparoscopic inguinal hernia repair is a superb technique.

But Laparoscopic hernia repairs do require mesh and general anesthesia.  Comorbid factors add greater risks.  Urinary retention is more frequent.  Bilateral repairs are facilitated with acceptable minimal increase pain or recovery time.  Mesh risk is less.  Permanent fixation devises can be avoided.  Overall Mesh risks in hernia surgery has been conservatively estimated at 5-6%.  There has always been unsubstantiated concern that mesh is contributory to long term pain.  Less than 10% of contemporary hernia surgery is done without mesh.

The preoperative concerns with hernia surgery that I discuss at consultation are a secure diagnosis of a hernia, symptoms like pain, bowel cramps, reducibility, previous surgery, genetic disorders, smoking, obesity, age comorbid factors, urgency, emergency, critical system risks and variable prognosis if untreated and compare contemporaneous techniques that have similar recurrence rates, but different risks and advantages.

All open surgeries are associated with a larger single incision rather than multiple small incision, more parietal wall healing and slightly greater risk of infection than laparoscopic techniques.  Postoperative Pain is not always less than with laparoscopy.  Laparoscopic technique might have small incisions but is deeper surgery in the proximity of regional major vessels, significant nerves, bowel and bladder.  Aside from marketing, the place for Robotic Laparoscopic Inguinal Hernia surgery is unclear.  Both open and laparoscopic hernia surgery deal with complicated anatomy and are subject to the main general risks of surgery:  infection, bleeding, long term pain (6-10%), recurrence, and injury to regional structures.

In many cases, general anesthesia has greater risk than local/sedation or is subjectively not desired by the patient.

Not all surgeons perform laparoscopic surgery and/ or natural tissue repairs.  This impacts recommended choices.  Choice is contingent on the surgeon's familiartity with both.  Patient aversion to mesh, and preference for open surgery and avoidance of general anesthesia are rational factors in decision making and require thorough consideration.

 

 

Policy:  Although I am out-of-network with insurance and Opt-ed Out of Medicare, I will do my best to work with remuneration, deductibles and coinsurances from the insurance policy that the patient has selected.  This will be explored with the patient in detail at no cost before our meeting to avoid any misunderstandings. Each consultation involves a long encounter, an informational discussion and advisory during consultation to assist in an appropriate shared decision for surgery, the individual choice of technique while respecting patient fears and reservation generated by readily available information.

 

 

Keywords:  Hernia repair with mesh, Hernia repair without mesh, Hernia problems caused by mesh, Natural tissue hernia repair & Shouldice hernia repair.

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    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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