WHY LAP INGUINAL HERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE

WHY LAP INGUINAL HERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE

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  WHY LAP INGUINALHERNIA REPAIR IS PROGRESSING AT SLOW MOMENTUM ? OUR EXPERIENCE Authors: DR. AYMEN KHAN DR. HRIDAY HALOI DR. D K CHOUDHURY DR. H K BHATTACHARYA Department of Surgery Gauhati Medical College
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  After introduction oflap cholecystectomy laparoscopy continues to explore in different advanced surgical field . Lap inguinal hernia repair is considered to be a widely accepted procedure all over the world at present But it seems that the procedure is not getting the fast momentum like laparoscopic cholecystectomy in common in our society.
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  AIMS AND OBJECTIVES Toevaluate possible factors for which the procedure is less commonly done by even highly skilled lap surgeon in spite of large volume of inguinal hernia cases in our society To obtain views of the patients presenting with inguinal hernia towards laparoscopic repair To share our experience while doing both lap inguinal hernia repair and open repair
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  MATERIALS AND METHODS We studied60 cases of inguinal hernia attending our OPD in last six months Complicated hernia excluded from study Hernia in pediatric age group also excluded Hernia with morbid condition like cardiac cause and above 70 years excluded from the study
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  All 60 casesof the study were asked the following question Do you know that there are two methods of operation for inguinal hernia, which are open operation and laparoscopic repair ?? 56 (93.3%) cases of total 60 cases of inguinal hernia of our series were un aware of the lap hernia procedure 4(6.7%) Patients were aware of the lap hernia procedure
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  Only 4(6.7%) casesout of 60 cases attended our OPD for lap hernia repair Rest 56 cases out of 60 cases attend to get operated to get rid of their hernia problem
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  Following informations were givento the patients You can be operated either by laparoscopy or by open technique In laparoscopy few holes will be made and in open , incision will be made You will need to undergo general anaesthesia in laparoscopy Spinal anesthesia will be sufficient for most of the cases in open repair Both the cases you need to be hospitalized for one day
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  56 cases raisedthe following question Which procedure is better according to the surgeon Accordingly the patients will decide the type of procedure to undergo
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  Patients were informedthe following No favouritism was given to any procedure Both the technique has their own pro and cones Laparoscopy is cosmetically better Post operative pain is said to be less than open Regarding recurrence both the technique carries almost same recurrence Cost will be high if tacker wants to be used But we can cut down cost by suturing and avoiding tacker
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  38(63.3%) cases of56 cases refused to undergo laparoscopic hernia repair after getting proper information from us as NICE guideline 16(26.6%) cases refused to undergo the procedure initially because of high cost but agreed to undergo lap by suturing technique Two patients who were unaware of the procedure were convinced to undergo lap repair with tacker
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  Intra Operative Observation Allthe patients opted for laparoscopy were done by TAPP procedure Right sided inguinal hernia repair comparatively have easier ergonomics than left side for us during the surgery Duration of surgery was more in initial learning curve up to 2 and half hours to three hours where tacker was avoided and repair was done by suturing Later duration was reduced to 1 and half hours to 2 hours We found direct hernia is easier to dissect than indirect hernia Careful dissection required specially during paritalisation to prevent vascular injury
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  Post Operative Observation Postoperative pain was 50% less in lap procedure than open Both group were kept hospitalized for one day Oral feeding started after 24 hours in both groups Both the groups were mobilised next day
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  COMPLICATIONS LAP HERNIA REPAIR OPENREPAIR WOUND INFECTION I 2 SEROMA 1 NIL HYDROCELE NIL NIL INDURATION OF CHORD AND TETIS NIL 7 ATYPICAL MYCOBACTERIA INFECTION 1 0 MESHNEURALGIA NIL 3 PARASTHESIA OF GROIN NIL 1
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  LAP HERNIA OPENHERNIA SKILL OF LAPAROSCOPY NEEDS HIGH AND TO BE LEARNED BY SURGEON BY HIMSELF BY PRACTISCE WITH PATIENCE NORMAL COST HIGH NORMAL LIFE THREATINING COMPLICATIONS CHANCES ARE HIGH IF CARELESS VERY RARE COST REDUCTION ATTEMPT SUTURING IS NOT ENJOYED BECAUSE OF POOR ERGONOMICS OF SUTURING NOT REQUIRED MOTIVATION OF PATIENTS DEPENDS UPON SURGEONS’ CONFIDENCE NOT REQUIRED
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  SUMMARY Post operative painwas less in lap hernia repair group than in the open group Better cosmesis in lap hernia group than open group No significance difference of complications observed in either group Cost is high in lap hernia because of use of large size mesh and tacker
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  If suturing isdone in stead of tacker to curtail cost it requires extra time and strain to the surgeon In terms of recurrence the rate is same in both open and lap cases . There is no difference in recurrence in both technique in reported large studies also Open repair can be done either in spinal or local anesthesia
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  CONCLUSION Cost of theprocedure is much higher than the open technique which is not usually accepted by average patients volume in first look Lap hernia repair cannot claim ,at present moment, any boosting results in terms of recurrences, complication, return to work in comparison to open repair except in terms of cosmesis and post operative pain . Lap hernia repair requires complex and careful dissection in vital area as opposed to very simple open lichtenstein repair so learning curve of the surgeon is high to acquire skill Motivation of patients for lap hernia will mostly depend on surgeon and his credibility to deliver the similar result like open hernia without compromising the overall safety of the patients.
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