Avoiding Recurrence

SAGES Presenter Disclosure Slide George S. Ferzli, M.D., F.A.C.S. Nothing To Disclose

Avoiding Recurrences George S. Ferzli M.D., F.A.C.S. Chairman, Department of Surgery Lutheran Medical Center-Brooklyn, N.Y. Professor, Department of Surgery S.U.N.Y-Downstate Medical Center-Brooklyn, N.Y. LUTHERAN MEDICAL CENTER

Hernia Recurrence Patient Factors Surgeon Factors Technical Factors What Causes Recurrence? Anesthetic Selection Mesh Selection Choice of Operation Lack of Experience Age Modifiable Risk Factors Genetic Predisposition Gilbert,A.I., Young,J., Graham, M.F. Presented at Suvretta Meeting, 2006.

Should all patients be treated the same? ,[object Object],[object Object]

Role of the Patient in Recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object]

Role of the Patient in Recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Tailored Approach to Hernia Repair 405 Patients HEAD Score  15 HEAD Score < 15 Mesh Repair Lichtenstein/TIPP in Primary Hernias TAPP in Bilateral/Recurrent Hernias Shouldice Repair 2.65 % Recurrence Rate at 12 months Peiper et al. Presented at Suvretta meeting, 2006.

Tailored Approach to Hernia Repair ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Role of the Surgeon in Recurrence Does Choice of Operation Affect Recurrence? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Role of the Surgeon in Recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Role of the Surgeon in Recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Local, Regional, or General Anesthesia ? ,[object Object]

Local, Regional, or General Anesthesia ? Mortality and Anesthetic Choice (103 710 Hernias) ,[object Object],[object Object],1,95 – 2,64 2,27 76,07 173 57,439 General anaesthesia 1,06 – 1,59 1,31 75,69 99 29,843 Regional anaesthesia 0,39 - 0,99 0,64 31,28 20 16,428 Local anaesthesia 95% CI SMR* Expected number of deaths Observed number of deaths Number of operations

Local, Regional, or General Anesthesia ? Choice of anaesthesia and relative risk (RR) * for reoperation following 107 838 primary and recurrent hernia operations ,[object Object],[object Object]

Integrity of Mesh ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Biocompatibility of Meshes Comparison of macroscopic and histopathological findings (mean ± SD) ,[object Object]

Choice of Mesh “The ideal mesh” (TEP/TAP) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Novel Mesh Ideas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Failure to Expose Entire Myopectineal Orifice 19 Missed Hernia 20 Surgeon Frustration 22 Missed Lipoma 21 Role of the Technique in Recurrence Recurrence

Fundamentals ,[object Object],[object Object],[object Object]

Lipoma of the cord ,[object Object]

[object Object],[object Object],[object Object],[object Object],Improper Utilization of the Mesh Wrong Mesh Configuration 23 Mesh Infection 26 Inadequate Fixation 25 Indequate Mesh Size 20 Role of the Technique in Recurrence Creation of Keyhole 24 Recurrence

“ Other Causes of Recurrence?” ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Conclusion ,[object Object],[object Object],[object Object],[object Object]

Avoiding Recurrence

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Avoiding Recurrence