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Hello everybody from Vietnam! #APHS Congress

Hello everybody from Vietnam!

As usual, very interesting APHS Congress!

This year, in Ho Chi Minh city, Vietnam. With the warm invitation of Prof LE QUAN ANH TUAN! thank you so much professor.

It was again the opportunity for me to speak about the real Minimal invasive surgery concerning the “simple surgery “ about groin Hernia repair and primary ventral hernia repair. Even if everybody speak today, mostly about Endoscopic surgery, and Robotic surgery. After that Congress, I had a long talk with Professeur Reinhard Bittner a pioneer Of the endoscopic surgery In general and for abdominal wall surgery in particular. During the congress, I presented my experience about the TIPP/MOPP Technique . I had some good comments in particular from Vietnam and South Korea. I presented also my experience about the open, minimal invasive procedure to treat the small ventral defect. During this session as I told it to the audience, it seems to me to be like a black sheep, because all the speakers in the panel were only speaking about robotic and endoscopic surgery . But the reasons is that the patients are not the same. So eventually perhaps I am not the Black sheep…

But after the talk with Professeur Bittner, and after I gave to him numerous explication why I prefer minimally open versus endoscopic or robotic ,everything start to be very clear for me!

In my daily practice, since years i stopped to do important endoscopic procedure for intestinal surgery.

And In the private hospital where I am working, it is not possible to do the major abdominal wall surgery, because for this it is necessary to have an height level reanimation département.

So for abdominal surgery, I do mostly the most simple cases ( Including big scrotal hernias , multi recurrent hernias or reducible incisional hernias).

Usually in the congresses about the ventral hernias , the speakers talk about very sophisticate procedures for difficult cases, with sophisticated prosthesis, and advanced costly materials. Indeed for this cases it is very important to improve the techniques, and of course the technology must help. Concerning the small ventral hernia repair I think that it is not the case. And I see in the club hernia date base that the surgeon puts big meshes into the Abdominal cavity (even for a very small primary hernia) and attachs the prosthesis with tackers, frequently without closing the hole. And specifically, with this techniques some specific problems are possible.

In the other hand now we know that the surgeon assisted by the robot can works more easily for some difficult ventrale procedure , putting the mesh outside the abdominal cavity and with a short learning curve, said the promotors. For some selected procedure an hight level of technology is and will be more and more necessary. But even if you have a robot, it is not necessary to use it for the simple cases! The more simple cases must not be the field to learn how to operate with a robot! The problem is the cost of the process and the need to preserve the resources. This is specifically the case for the groin hernia repair!

The North American experience deserves to be analysed! )( very strong increase in groin hernias treated with a robot)

About the groin hernia repair the surgeons start very slowly at the biginning to use the endoscopic surgery they have respected (mostly)the good principles but also with some few specific complications. But as I mentioned it in my presentation, after the analysis of the French club hernia Data base, even the endoscopic surgeons uses less frequently the endoscopic surgery for the elderly! The patients are not the same endoscopic versus Lichtenstein-open preperitoneal (older and ASA status superior for the second group)

Of course is it not possible to know, only one technique to treat all the groin hernias (even if we consider only the primary repair) .

The problem is that for the fragile and elderly patients quite often the endoscopic surgeons prefers to do a very different technique as Lichtenstein . But it should be more logical to do an open preperitoneal repair, with a less invasive anesthesia. With Lichtenstein we have more crural recurrence and more chronic pain.

Here is probably the place to speak about the accreditation of the surgeons and the concept of the Hernia Center. It will be necessary to accelerate the reflection on this subject in France to improve the service to patients.

But back on topic.

I strongly believe that some patients should be removed from endoscopy and robotic assistance.

- Most of the umbilical hernias and primary ventral hernias (85% are less than 2cm in diameter).

- the groin hernia ! robotically assisted groin hernia surgery will have difficulty in proving its advantage for the patient compared to laparoscopic surgery. And now laparoscopic surgery does not seem superior to open preperitoneal, according to the few studies published and one in the process of being published with large numbers!

There again, with equal results, it would be important to argue the additional cost.

However, it is interesting to point out that colleagues now admit to having suffered a lot physically from certain laparoscopic procedures, and that switching to a robot for the same procedure considerably improved the ergonomics and the comfort.

This is a point that should be studied and possibly taken into account in relation to the additional cost!

Some reactions from you?!

We will have years for fighting.

But the more important as Pr Bittner said is that we have to Controle our results.using data bases….

During the next APHS congress I hope to present 2000 groin hernias repair an around 500 primary ventral hernias repair….

Bests regards

Marc »

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