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Open posterior mesh versus Lap posterior mesh – and local vs general anesthesia
A new paper looking at ways to place mesh similar to how it’s placed during a lap procedure but without the need for general anesthesia.
It’s still fascinating how powerful the “Guidelines” are despite the question of the validity of their foundation, by professionals in statistics, plus the fact they were sponsored by mesh companies. The people that put them together really made a strong and lasting document. Seems like a quagmire that holds on to anyone that enters.
The authors explore some uncommon open repair methods, with illustrations. Worth reading just for that if you are a student of the various methods.
I don’t know what the EuraHS quality of life scores mean or how they asses them. I did find a paper though which I will link in the following post.
https://link.springer.com/article/10.1007/s10029-022-02680-0
Excerpt –
“Purpose
International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs.” -
3 Replies
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Personally I think a posterior repair via an open approach is a terrible idea. Logistically it makes sense. All the benefits of a posterior repair without any of the logistical problems that a company intra-abdominal surgery.
But in practice I don’t think that you can deploy a posterior mesh reliably and safely blindly.
There are a lot of sensitive structures back there. Potentially more contributing to bigger problems than nerve entrapment in an anterior approach.
But you still get that nerve entrapment risk from an anterior approach because that’s how you got there in the first place. Admittedly it may be less if you’re not deploying a mesh there.
You develop a space blindly and then lay mesh back there blindly and hope that it lays out properly without interfering with any sensitive structures, all of which are in the neighborhood.
When things go wrong it’s extremely difficult to remediate.
The advantage of a posterior approach for a posterior repair is you can see exactly what you are doing to minimize complications with sensitive structures back there.
Admittedly it has many drawbacks such as violating the peritoneum and adhesion risk.
TEP seems like a very attractive approach for a posterior repair for that reason.
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I found questionnaires on the ACHQC (formerly AHSQC) web site.
Reproduced from the EuraHS form, apparently.
“Used with permission from the European Registry of Abdominal Wall Hernias (EuraHS)”
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EuraHS stands for European Hernia Society, apparently. The data is apparently collected and input to a database by individual doctors or their staff, then made available to anyone that wants to use it. A sample of a questionnaire would be interesting. I think that it is similar to efforts by the AHSQC.
This is from 2012 for ventral hernias. I assume that its use has been extended to inguinal hernias.
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