open mesh repair of inguinal hernias
TRANSCRIPT
Open Mesh Repair of Inguinal Hernias
Indications for operative intervention:
All inguinal hernias in children should be repaired without
delay because of the risk of complications of incarceration and
strangulation, which include gangrene of the bowel, testis, or ovary,
and because of the increased wound infection and recurrence rate
following these operations. It has been estimated that the
complication rate when operation is urgently done for a strangulated
hernia in a child is 20 times that of a planned procedure. An elective
pediatric hernia repair should be a pleasant and minor ambulatory
procedure with practically no complications and no mortality.
(Abrahamson, 1997).
Almost all groin hernias should be surgically repaired. When
the potential complications as incarceration and strangulation are
weighed against the minimal risks of hernia repair (particularly when
local anesthesia is used), the early repair of groin hernias is clearly
justified. This is especially true in the case of femoral hernias, since
the rigid borders of the femoral canal increase the risk of
incarceration. (Tim Box et al, 1999).
Surgical repair of a hernia is not warranted in terminally ill
patients with any evidence of incarceration. The one group of patients
in whom surgery should not be routinely recommended is elderly
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men with small and obviously direct hernias which are not causing
symptoms. Patients with ascites generally should not undergo
elective herniorrhaphy until their ascites is controlled. (Tim Box et
al, 1999)
While some surgeons believe that broad-based direct hernias do
not need to be repaired, the uncertainty of determining the status of a
hernia preoperatively argues against this practice. The presence of
incarceration or strangulation usually mandates urgent operative
repair. (Tim Box et al, 1999)
Types of inguinal hernia repair:
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Table (2): Inguinal hernia repair procedures.
> Choice of operation:
The various repair procedures fall into two categories: Tension-
free prosthetic repairs and these may be performed by the open
approach or laparoscopically/or endoscopically. The facial repairs
and these are the oldest. Their only advantage is the avoidance of
prosthetic material, which may become infected, but they carry the
highest incidence of recurrence, particularly the Bassini operation
since the repair can not be affected without tension. In practice,
infection of the prosthetic has proved to be a rare occurrence, and this
category of hernia repair operations is much more favored nowadays
in view of the uniformly reported good results and low recurrence
rates. (Cuschieri, 2002).
Present evidence points to mesh repair as the procedure of
choice for adult hernias. In children, herniotomy alone is the
operation of choice. The choice between herniotomy alone and mesh
repair enters a grey area in the late teens but. Over the age of 25, all
hernias should be repaired using a mesh.
The Lichtenstein repair is currently the most appropriate
operation for primary inguinal hernias. It is associated with excellent
outcome in the hands of non-specialist surgeons and results in less
post-operative pain, earlier return to normal activities and a lower
recurrence rate, when compared with sutured repairs. For bilateral
hernias, on the other hand, a laparoscopic transabdominal
preperitoneal (TAPP) /or total extraperitoneal (TEP) technique
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remains the choice. They are associated with less pain and an earlier
return to normal activities for the patient than a bilateral Lichtenstein
technique. Similarly, for recurrent hernia, the surgeon is almost
always dealing with virgin tissue planes and the procedure is no more
difficult than for a primary procedure. Using an open technique to
deal with a recurrence after a previous mesh procedure can be
particularly difficult. (Cushieri, 2002)
I. Liechtenstein tension free hernioplasty
Less than two decades, Liechtenstein described a tension-free
onlay of polypropylene mesh for inguinal hernia repair.
(Lichtenstein, 1986)
There is biochemical evidence that some adult male inguinal
hernias are associated with impaired hydroxylation of proline,
resulting in decreased levels of hydroxyl-proline. These changes lead
to weakening of the fibro-connective tissue of the groin and
development of inguinal hernias (Read, 1992). To use this already
defective tissue, especially under tension, is a violation of the most
basic principles of surgery (Amid, 2002). In addition, it was
recognized that suture line tension was at the heart of failed hernia
repairs and that solving this problem would largely eliminate
recurrences (Lichtenstein, 1986).
In the tension-free hernioplasty, instead of suturing anatomic
structures that are not normally in apposition, the entire inguinal floor
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is reinforced by insertion of a sheet of mesh. The prosthesis, which is
placed between the inguinal floor and the external oblique
aponeurosis, extends well beyond Hasselbach's triangle in order to
provide sufficient mesh tissue overlap. Upon increased intra-
abdominal pressure with straining, contraction of the external oblique
applies counter pressure in favor of the repair. The procedure is both
therapeutic and prophylactic in that it protects the entire region of the
groin susceptible to herniation. (Amid, 2002).
Lichtenstein advocated this technique for all groin
hernias, large or small, complex or straightforward. (Lichtenstein,
1986)
• Anaesthesia:
Hernia repair may be performed using general, regional
(spinal/epidural) or local anesthesia. Several studies have found that,
with proper preoperative preparation, more than 90 percent of groin
hernias can be repaired with patients receiving only a local
anesthetic. The advantages of local anesthesia include the very short
recovery time and the ability to test the repair intraoperatively with a
Valsalva maneuver. Use of local anesthesia also avoids the
respiratory and immune depressive effects of general anesthesia. This
advantage is particularly important in elderly and frail patients. (Tim
Box et al, 1999)
A 50:50 mixture of 1% lidocaine (Xylocaine) and 0.5%
bupivacaine (Marcaine) with 1/200.000 epinephrine combines the
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rapidity of onset of the former with the long acting effect of the latter.
An average of 45 ml of this mixture is usually sufficient for a
unilateral hernia repair, (lidocaine max dose is 3mg/kg and with
adrenaline it reaches 5mg/kg, while bupivacaine is 2mg/kg and with
adrenaline it teaches 4 mglkg). (Amid, 2002)
Local anesthesia alone does not allow for comfortable and
technically optimal herniorrhaphy in patients with a very high anxiety
level. Either general or regional (spinal) anesthesia may be used in
these patients. General anesthesia provides the most comfort, but it
has the highest risk. Patients occasionally respond poorly to a general
anesthetic and require overnight hospitalization because of nausea,
excessive sedation or urinary retention.
Spinal anesthesia provides excellent pain control during
herniorrhaphy, and it carries slightly less risk than general anesthesia.
The disadvantages of spinal anesthesia include the time required for
the anesthetic to be placed and the possibility of incomplete sensory
blockade. Urinary retention or a delay in the return of normal lower
extremity sensation may mandate overnight observation following
herniorrhaphy performed with regional anesthesia. (Tim Box et al,
1999)
• Choice of prosthetic material:
The factors which influence this choice are firstly, pore size.
The mesh should not contain pores of less than 10 um. In diameter as
these may harbor bacteria making them inaccessible to leukocytes.
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Conversely, the mesh should contain pores of larger than 90um, in
order to promote the most rapid ingrowths of blood vessels and
fibroblasts and the optimal laying down of collagen. Polypropylene is
the most widely used material and of the brands available, both
Marlex (C.R. Bard Inc., Burlington, USA) and Prolene (Ethicon Ltd,
Edinburgh, UK) are monofilament meshes. Surgipro (Tyco, U.S.S.C.
Norwalk, and Ct, USA) is multifilament mesh, with a pore size of
less than 90um, although a monofilament version is now available.
Mersilene (Laboratories Bruneau, Boulogne, France) is a
multifilament knitted polyester mesh, which, because of small pore
size, carries the theoretical increased risk of infection. Its principal
advantage is "lack of memory", which is a considerable advantage
when repairing large ventral hernias. For inguinal hernias, for both
the open and laparoscopic procedures, Prolene fulfills the theoretical
criteria and is easy to handle. (Maclntyre, 2001)
• Operative technique:
The skin incision is placed l cm. above and parallel to the
inguinal ligament. It should extend from the pubic tubercle medially
to about 1 cm lateral to the deep ring. Dissection is deepened into the
sub-cutaneous fat where two veins, the superficial epigastric and the
superficial external pudendal should be divided between ligatures
whilst smaller vessels can be diathermied. (Amid, 2002)
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The external oblique aponeurosis is identified now and exposed
along the length of the incision. The inguinal canal is opened along
the line of the fibers of the external oblique aponeurosis extending
the incision into the superficial ring. An incision, 2 cm above the
inguinal ligament, provides a large lower leaf for optimal closure.
A gentle sweep with the finger under the external oblique
aponeurosis opens this plane widely for the later insertion of the
mesh. When lifting the cord, care should be taken to include the
ilioinguinal nerve, external spermatic vessels, and the genital nerve
with the cord. This assures that the genital nerve, which is always in
juxta-position to the external spermatic vessels, is preserved. The
cremasteric sheath is then incised longitudinally at the deep ring.
Complete stripping and excision of the cremasteric fibers is
unnecessary, and can result in injury to nerves, small blood vessels,
and vas deferens, and can lead to the testicles hanging too low.
(Amid, 2002)
If an indirect sac is present, it is now dissected free from the
cord structures which are safeguarded and retracted. In an obese
patient the sac may not be immediately obvious but it should lie
above and in front of the cord structures while a direct sac is
posteromedial to the vas deferens. In a large indirect hernia, where
the sac extends beyond the inguinal canal, it should not be dissected
beyond the external ring, but divided at that level leaving the distal
part of the sac undisturbed. However, the anterior wall of the distal
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sac can be incised to prevent postoperative hydrocele formation.
(Amid, 2002)
The Lichtenstein group recommends that an indirect sac should
not be routinely opened to ensure that it is empty, but merely
invaginated after being freed from the cord to a point beyond the
neck of the sac. It has been suggested that ligation of the highly
innervated peritoneal sac is a major cause of postoperative pain.
Besides, it has been shown that non-ligation does not increase the
chance of recurrence. (Amid, 2002)
There is general agreement that a direct sac should not be
opened but inverted and sutured to flatten the posterior wall. If the
sac is bulky, a continuous, plicating, absorbable suture to tack this
down may make it easier to seat the mesh. (Kurzer et al, 2003)
Before the mesh is inserted ensure that the plane between the
external oblique and conjoint tendon is opened up as widely as
possible. Inferiorly, the full length of the inguinal ligament should be
exposed; medially, it should extend up to the mid-line and superiorly,
up to the fusion between the two layers.
A 6x11 cm polypropylene mesh, as described by Amid et al,
1996, should now be trimmed to fit this space, with a slit cut laterally
to accommodate the spermatic cord. The mesh should lie with the
medial edge 1-2 cm medial to the pubic tubercle.
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Figure (17) The lower edge of the two tails are sutured to inguinal
ligament (Parviz and Amid, 2007)
After moving the mesh, with further trimming if necessary until
it lies in the ideal position, it should be fixed inferiorly first starting at
the medial end. Using continuous 2/0 prolene, the first bite is taken
into mid-line aponeurotic tissue, but not pubic periosteum. As it
proceeds laterally, the continuous suture takes the internal surface of
the inguinal ligament and continues laterally as far as the incision
will allow. Where the cremasteric pedicle and the genitofemoral
nerve have been preserved, they should be led from the canal as clear
of the mesh as possible. (Kurzer et al, 2003)
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Figure (18) the upper edge of the mesh is sutured to the internal oblique aponeurosis and the two tail of the mesh are crossed ( parviz and amid 2007)
Figure (18) The upper edge of the mesh is sutured to the internal oblique
aponeurosis and the two tails of the mesh are crossed (Kurzer et al, 2003)
Three or four interrupted sutures are used to fix the mesh
superiorly. The two tails are now overlapped lateral to the deep ring
and secured by two or three interrupted sutures making sure that the
cord is not constricted. (Kurzer et al, 2003)
Having checked for 2001) haemostasis and safeguarded the
iliohypogastric nerve, the cord is replaced, external oblique
aponeurosis closed with absorbable suture, and wound closed in
routine fashion. (Kurzer et al, 2003)
Figure (19) Slit is made at the lateral end of the mesh (Parviz and Amid, 2007)
Advantages of lichtenstein tension-free hernioplasty:
1. The procedure is both therapeutic and prophylactic in that it
protects the entire susceptible region of the groin to
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herniation from future mechanical and metabolic adverse effects.
(Amid, 2002)
2. Large series and randomized studies indicate that excellent
results from the open tension-free operation are less
dependent on the experience of the surgeon than results from
conventional tissue repair and laparoscopic operation, an indication
of the simplicity of the operation and short learning curve. (Wantz,
1998)
3. The same technique can safely be applied to all inguinal
hernias, indirect and direct, as well as recurrent hernias. (Amid and
Lichtestein, 1998)
4. Open tension-free hernioplasty can safely be performed
under local anesthesia and allows the patient's immediate
mobilization, keeping hospital stay, cost and patient
discomfort to a minimum. (Amid, 2002)
5. Tension-free mesh repair of inguinal hernias results in
minimal postoperative pain, requiring only moderate analgesia
for a period of 1 to 4 days. (Amid, 2002)
6. Lichtenstein technique has proved to have a high patient
acceptance as a consequence of the much reduced postoperative
discomfort, which has permitted immediate ambulation and early
return to work activities. In general, return to work after tension-free
hernioplasty is between 2 and 14 days, depending on the patient's
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occupation with overall median time was 8 days. (Kurzer et al,
2003)
7. The reported recurrence rate for this procedure is less than
1%. (Amid, 2002). In a study, the use of this prosthetic screen onlay
technique in 1000 patients was reported with minimal complications
and a zero recurrence rate after a follow-up of between 1 and 5 years.
(Lichtenstein et al, 1989)
As a local anesthetic day care technique without the need for
complex and expensive instrumentation, overall costs can be kept to a
minimum without compromising the safety of the long-term success
of the procedure. (Kurzer et al, 2003)
9. Some concern exists about the long-term safety of implanted
prosthetic material, particularly the potential for infection or erosion.
However, extensive accumulated experience with the hernia mesh
has begun to alleviate many of these concerns, and tension-free repair
continues to gain popularity. (Rutkow and Robbins, 1995)
• Complications:
A. Anaesthetic complications:
1. Local anaesthesia:
Local anaesthesia is the least expensive anesthetic technique,
and in studies that compare the recovery profiles of local, general,
and regional anaesthesia, it is shown to require the shortest
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postoperative interval to discharge. Cardiovascular instability and
urinary retention in the postoperative period occur at very low rates.
(Amado, 2003)
Contraindications to local anaesthesia are few and include
patient refusal, some complex or irreducible hernias, laparoscopic
hernia repair. (Amado, 2003)
Complications include:
i. The instillation of large amounts of local anaesthetic renders
the tissue somewhat boggy and distended, hindering the
identification and dissection of important structures and precluding
the free use of electrocautary.
ii. The clumsy too rapid injection of local aneasthetic is quite
painful, certain structures are difficult to anaesthetize completely
(particularly cord structures) and must be handled gently, and the
surgeon must stop from time to time to anaesthetize structures.
(Amado, 2003)
2. Regional anaesthesia:
When compared with general anaesthesia, spinal and epidural
blocks are associated with lower incidence of postoperative nausea
and vomiting, enable one to avoid instrumentation of. the airway, and
provide greater comfort in the recovery period by the production of
preemptive analgesia and through addition of opiods to the
anaesthetic drug. They are less expensive than general anaesthesia,
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and because they can be used modest doses of sedatives, this allows
speedy discharge. (Amado, 2003)
Complications include:
i. Possibility of post dural-puncture headache, urinary retention,
transient profound bradycardia or cardiac arrest.
ii. Compared to local anaesthesia they are more expensive, and
require a larger recovery' period. (Amado, 2003)
3. General anaesthesia:
i. Most complications are cardiopulmonary in nature.
ii. General anaesthesia may lead to postoperative coughing and
straining,
iii. Requires certain levels of fitness of the patient.
(Stephenson, 2003)
Nowadays, the introduction of short acting volatile agents
together with the laryngeal mask airway and the cuffed
oropharyngeal airways allow one to secure the airway without
stimulation of the vocal cords. (Amado, 2003)
B. Surgical complications:
I- General Surgical Complications:
The general complications include pulmonary atelectasis,
pulmonary embolism, chest infection, and urinary retention. All can
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be avoid by good preoperative preparation and early postoperative
ambulation. (Abrahamson, 1997)
Postoperative urinary retention should be a rare phenomenon.
Prostatic patients with symptoms severe enough to need
prostatectomy should be dealt with first and the hernia repaired some
weeks later. If the prostatic complaints are borderline and there is no
clear indication for prostatectomy, the problem can be overcome by
the introduction of urinary catheter immediately after the induction of
anaesthesia to be removed 24 hours postoperatively.
The most potent cause of postoperative urinary retention is
probably distention atony brought about by overfilling of the bladder
owing to over infusion of fluids during and after the operation. So,
the infusion may be removed within an hour of cessation of the
operation and oral fluids can be taken few hours later.
(Abrahantson, 1997)
II. Local surgical complications:
1. Testicular and spermatic cord complications:
a) Ischaemic orchitis and testicular atrophy:
They are rarely the result of tearing and ligation of the
testicular artery, but more likely are the result of tying of the veins in
the spermatic cord when the cremasteric muscle is resected, and
when the distal part of the sac is dissected unnecessarily, resulting in
intense venous congestion of the testicle with thrombosis of the veins
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in the spermatic cord, and infarction of the testicle. (Abrahamson,
1997)
In a series of 4114 groin hernioplasties, ischemic orchitis was
reported in 25 patients (0.61%) and testicular atrophy in 14 (0.34%).
(Wantz, 1989)
In another study, testicular atrophy was 12.7 times more
common following repair of recurrent hernias compared to primary
hernia repairs. With reoperations for recurrence, it was found that the
incidence of testicular atrophy increases by a factor of 3 to 4 with
each successive recurrence. (Bendavid, 1998)
Management :
1. Prevention of this problem is the best option. This can be
achieved through avoiding extensive dissection of the cord, keeping
the testicle within the scrotum during the repair and leaving the distal
sac open especially in large hernias without removal. (Wantz, 1995)
2. For a patient with established ischemic orchitis, there
agreement that the testicle should not be removed and that surgical
intervention do not appear to change the course of the events.
(Richards, 2002)
b) Hydrocele :
Hydroceles complicating inguinal hernia repair have been
reported to be 0.7%. (Bendavid, 1998)
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The potential for hydrocele formation after repair of an indirect
inguinal hernia exists if a patent processus vaginalis exists. This
occurs especially if the distal sac is ligated; conversely, if the distal
sac is left unclosed, the incidence decreases. (Richards, 2002)
Virtually .all these Hydroceles resolve spontaneously, if they
cause discomfort they should be aspirated once. Operation is rarely
required. (Delvin and Kingsnorth, 1998)
c) Haematocele :
This is collection of blood in the distal sac in a patient with
patent processus vaginalis. It presents early postoperatively, within
the first 12 to 24 hours. The source of bleeding in these patients is
either from the cut edges of the distal sac, from the testicular artery,
from the pampiniform plexus of veins injured. (Richards, 2002)
Treatment is usually conservative unless it becomes very tense.
If this should be the case, surgical evacuation may be required.
(Richards, 2002)
2. Complications involving the vas deferens:
a) transection of the vas:
Transection of the vas is a mishap that usually occurs through
open repair, particularly in recurrent hernioplasty. (Bendavid, 1998)
If it is detected, it is imperative that the two ends of the severed
vas are freshened by cutting them across and an end-to-end
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anastomosis performed over a small stent, such as a length of nylon
suture, which can be brought out of the vas further along and through
the skin of the groin as a pullout. This anastomosis is done using
magnifying loupes or an operating microscope to obtain exact
apposition. (Richards, 2002)
b) Obstruction of the vas and dysejaculation syndrome:
The vas deferens may also be damaged especially in children,
by undue pressure, traction, kinking and especially by squeezing
between the ends of a dissecting forceps. These traumas lead to
damage of the wall and mucosa of the vas, with consequent fibrosis
and obstruction (Abrahamson, 1997). Also, following hernia, the
vas may become adherent to the posterior inguinal wall in a sinuous
pattern and form kinks that may represent outflow obstruction.
(Bendavid, 1998)
Scarring and narrowing of the lumen of the vas results in the
dysejaculation syndrome which consists of a searing, burning, painful
sensation throughout the groin, preceding, during or just following
ejaculation. The symptoms have been related to the sudden distension
of the vas and its smooth musculature. The incidence is about 0.04%.
(Bendavid, 1998)
Most patients with dysejaculation syndrome improve without
active treatment, although symptoms may persist for as long as 5
years. (Bendavid, 2002)
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3. Vascular injuries:
a) Subcutaneous haematoma or ecchymosis:
The discoloration may appear alarming, but the blood absorbs
and disappears within a matter of days. (Abrahamson, 1997)
b) Scrotal haematomas:
During resection of the cremasteric muscle, careless ligature of
the external spermatic vessels can result in a tense hematoma and
ecchymosis that extends to the scrotum. (Bendavid, 1998)
Scrotal hematomas may reach large proportions but usually
absorb with time-. Sometimes they may need to be aspirated or
evacuated surgically. Rarely these hematomas may become infected,
and the resulting abscess must be drained. (Abrahamson, 1997)
c) Injury of the inferior epigastric vessels:
Division of the transversalis fascia (posterior inguinal wall)
requires attention at the medial edge of the deep onguinal ring to
avoid injury of the inferior epigastric vessels (one artery and two
veins). (Bendavid, 1998)
Serious haemorrhage occurring during the operation as a result
of the injury during suturing is handled by ligating these vessels.
(Abrahamson, 1997)
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d) Injury to the femoral vessels:
This may occur during reconstruction of the posterior wall near
the deep inguinal ring, a site where the. iliofemoral artery is situated
1-1.5 cm deep to the transversalis fascia, or during fixation of the
mesh in the inguinal ligament. (Bendavid, 1998)
4. Nerve injuries:
Nerve entrapment is perhaps the most significant complication
of inguinal hernioplasty. Most nerve entrapment syndromes are self-
limited, respond to non-steroidal analgesics and resolve with time.
However, chronic neuralgia can develop. (Condon and Nyhus,
1989)
The main nerves that are often injured during the repair are the
iliohypogastric, ilioinguinal and the genital branch of the
genitofemoral nerve. In theory, they should be preserved but in
practice this is not always possible. The iliohypogastric nerve is often
transected when the upper leaf of the external oblique muscle is
elevated. The ilioinguinal nerve may be torn when the cord is
mobilized, and the genital branch is usually resected when the
cremasteric mucle is excised. (Abrahamson, 1997)
Entrapment of the ilioinguinal nerve produces pain in the groin
and scrotum; extension of the hip frequently exacerbates the pain.
Injury to the genital branch of the genitofemoral nerve can cause
hypersensitivity of the groin, scrotum and upper thigh, and can be
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associated with ejaculatory dysfunction. Injection of a long-acting
local anesthetic along the course of these nerves is often helpful for
diagnosing entrapment. (Condon and Nyhus, 1989)
Following a period of non-operative care, some patients with
nerve entrapment need to be referred for surgical exploration and
excision of the involved nerve. However, this corrective approach
provides relief in less than 60 percent of patients. (Condon and
Nyhus, 1989)
While laparoscopic hernioplasty tends to offer greater
protection to the ilioinguinal and iliohypogastric nerves, injuries to
the femoral or the lateral femoral cutaneous nerves have been
reported. Patients with such injuries present with pain in the groin
and thigh. While these syndromes are often self-limited, surgery has
been necessary to remove the staples that caused the neuralgia. These
procedures have not provided pain relief in all patients.
(Abrahamson, 1997)
5. Visceral injuries:
a) Urinary bladder injury:
Trauma to the urinary bladder may occur with the open or
laparoscopic techniques. The urinary bladder may be opened
accidently when dissecting the sac of a direct or large indirect hernia.
This usually can be avoided if direct sacs are not dissected but simply
inverted when the posterior wall of the canal is repaired. Recognition
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of the injury and repair of the opening in the bladder in two layers
with uretheral catheter placed in the bladder for 8 days will correct
the complication. (Bendavid, 1998)
b) Bowel injuries:
Small bowel may be injured if caught in the transfixion suture
when the sac is ligated. Cecum or sigmoid colon may be opened or
devascularised when they form part of the wall of a sliding hernia.
These complications are avoided if the sac is invaginated and not
suture ligated. (Abrahamson, 1997)
6. Bony injuries (osteitis pubis):
Osteitis pubis as a complication of hernia repair seems to have
disappeared with the elimination of sutures through the perioesteum.
(Bendavid, 1998)
7. Wound complications:
a) Seroma formation
b) Wound infection:
Infection following hernia repair is nearly always secondary to
bacteria that contaminate the wound during the operative procedure.
Contaminates gain access to the wound from the patient's skin, from
surgical instruments or the surgeon's gloves, or from environmental
contamination via the air within the operating room. Staphylococcus
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aureus is the most common pathogen to be encountered in elective
groin hernia repair. (Fry, 2002)
In groin hernias, certain factors have been recognized. Women
have significantly higher infection rate than do men, 2.1 times. Older
patients, specifically over 70 years of age, show a 3.2 fold higher
incidence of wound infection. Presence of a drain and length of that
presence increased infections by a factor of 9. Duration of surgery
also is a significant factor, as seen in operations that lasted 30
minutes or less (2.7%) or 90 minutes (9.9%). Incarcerated and
recurrent hernias also showed increases of infection rate, namely
7.8%, and 10.8% respectively. Obesity increases infection rates in
hernia patients, most likely because of the relatively a vascular
character of the large subcutaneous reservoir that is presented to
potential bacterial contaminants. Pre-existing diseases such as
diabetes, renal failure, alcoholism, and malnutrition are additional
variables that may affect the timing of operation or the risks of
pursuing hernia repair at all. (Fry, 2002)
• Prevention:
The site of the operation should not be shaved the night before
the procedure, and should only have hair removed immediately prior
to the operation. (Fry, 2002)
Diabetic patients, obese ones, and those with co-existing
diseases may benefit from a single dose of a systemic antibiotic
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immediately preoperatively that has activity against S. aurous and the
common gram negative bacteria. (Fry, 2002)
Hemostasis is obviously important. Postoperative suction
drainage only in large hernias, recurrent hernias, difficult hernias
requiring too much dissection and complicated hernias helps to
reduce the incidence of wound hematoma. (Fry, 2002)
c) Infected mesh:
The rate of mesh infection remains very low with modem mesh
production and sterilization techniques. (Ahmed and Beckingham,
2004)
The presence of infection does not necessarily imply removal
of a polypropylene or polyester mesh unless the mesh is sequestered
and bathing in a purulent exudates. (Bendavid, 1998)
Mesh infection in the inguinal hernia wound often leads to
removal of the entire mesh. Systemic antibiotics are used to treat the
cellulitis of the infection. These patients will require a return to the
operating room for removal of the mesh. The complete mesh is
removed including the sutures used to secure it. The mesh is seldom
incorporated into the tissue, but rather can be bluntly freed because of
the sustained infection. Anatomic landmarks are quite obscured, and
care must be taken to avoid permnant damage to the cord structures.
(Fry, 2002)
The removal of the mesh often leaves an unprotected posterior
inguinal wall leading to recurrence. The reoperation requires the
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insertion of a new prosthesis. It is recommended to establish relative
assurance that the field is sterile before attempting to insert
prosthesis. (Deysine, 1998)
d) Stitch sinus (Fry, 2002)
* Recurrence rates:
The recurrence rate for modern hernia repairs in expert hands
appears to be improving steadily and is generally accepted to be
about 1%, regardless of approach, as long as mesh is used. (Voyles,
2003)
Most recurrences appear within 2 to 3. Years of the primary
repair. This "early" group of recurrences is mainly caused by failure
on the part of the surgeon and by infection. Those appearing after this
time and even many years later make up a smaller "late" group
commonly blamed on tissue failure. (Abrahamson, 1998).
II- Perfix Mesh Plug Repair
Gilbert established the tension-free "mesh plug method" in the
late 1980s, using a polypropylene plug with the configuration of an
umbrella for occluding initially indirect hernias only. He embedded
the folded prosthesis through the inner inguinal ring into the
preperitoneal space, assuming that the prosthesis would unfold
there and occlude the inner inguinal ring without tension. In 1993,
Rutkow and Bobbins were the first to describe the tension-free
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mesh umbrella technique as a standard method for repair of primary
and recurrent inguinal hernia. (Muschaweck, 2002(.
• Indications :
Recurrent inguinal hernias as well as femoral hernias are
considered to be the primary indications for a mesh umbrella
application. When there is only a localized defect with the rest of the
wall intact and sufficiently stable, the mesh umbrella implant
provides a tension-free occlusion of the defect, without the need to
resect stable scar tissue. (Muschaweck, 2002)
• Advantages:
A growing number of articles in the surgical literature attest to
the efficacy of the Prefix-plug hernioplasty. It is a technically simple
surgical operation, which can be used to treat most groin hernias.
(Rutkow, 2003)
The Prefix-plug hernioplasty helps reduction of the operative
morbidity and short-term and long-term postoperative discomfort.
The repair requires a minimal amount of dissection that could
otherwise compromise the spermatic cord, as well as other intact
tissue. (Rutkow, 2003)
In contrast to a flat mesh patch, a Prefix-plug is technically
easier to work and far simpler to secure to surrounding tissues. The
three-dimensional, umbrella-shaped configuration forms a total
occlusion of the defect. (Rutkow, 2003)
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• Disadvantages:
1. Recurrence: the technical literature reports a recurrence rate
after mesh plug implantation between 0.5% and 1.5%.
(Muschaweck, 2002)
2. Mesh shrinkage: numerous studies have dealt with the
problem of mesh shrinkage. The inflammation that is induced by the
mesh, which is mainly determined by the material and the size of the
mesh, influences the extent of shrinkage. For instance, mesh
shrinkage of 20% in length and 30% to 40% of total area was
reported. (Muschaweck, 2002)
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III. Stoppa repair
(Bilateral Giant Prosthetic Reinforcement of the Visceral Sac):
Giant prosthetic reinforcement of the visceral sac (GPRVS) is
the descriptive term for Stoppa's revolutionary and innovative
bilateral preperitoneal prosthetic hernioplasty with the polyester
Dacron. The essential feature of GPRVS is the replacement of the
transversalis fascia in the groin by a large prosthesis that extends far
beyond the myopectineal orifice. The prosthesis envelops the visceral
sac, held in place by intra-abdominal pressure and later by connective
tissue ingrowth. The mesh adheres to the peritoneum and renders it
inextensible so that it cannot protrude through the parietal defect.
Parietal defects are not and, should not be closed. GPRVS differs
from classic and patch prosthetic repair by focusing on retaining the
peritoneum. Rather than on repairing the abdominal wall defects.
GPRVS is a sutureless and tension free repair. (Wantz, 1998)
Bilateral GPRVS may be achieved through a subumilical
midline or pfannensteil incision, where the size of the prosthesis is
measured on the patient. The correct transverse dimension is equal to
the distance between both anterosuperior iliac spines minus 2 cm, the
height being equal to the distance between the umbilicus and the
pubis. The mean values are 24 cm transversally and 16 cm vertically.
(Stoppa, 2002)
• Indications:
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The procedure, although useful for the repair of all hernias of
the groin, in practice is mainly used to manage complex hernias at
high risk for recurrence and recurrent groin hernias. (Wantz, 1998)
• Advantages of Bilateral GPRVS:
GPRVS via a transabdominal incision directly accesses the
preperitoneal space and the parietal defects of hernias without
dissection of the inguinal canal, spermatic cord, and sensory nerves
of the groin. It is specially suited for the repair of recurrent groin
hernias because it minimizes the risk for complications, specifically
testicular atrophy and chronic neuralgia. (Wantz, 1998)
Most problems related to sliding hernias are solved by the
preperitoneal approach. One obtains the correct diagnosis by opening
the sac at the appropriate level. Reduction of the contents and
eventual limited resection of the sac are performed without difficulty.
The prosthetic repair abolishes the hazards resulting from the large
hernial orifice. (Stoppa, 2002)
When the groin hernias are bilateral in elderly patients, they
profit from a large prosthetic repair, with short operative time (30 to
40 min), which is important specially in those with risk factors for
anaesthesia. (Stoppa, 2002)
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• Disadvantages of GPRVS:
1. The median preperitoneal approach may induce the risk of
incisional hernia.
2. When a pfannensteil incision is used, opening and closing
the wall are time consuming; the risk of damaging superficial nerves
is present.
3. The hospital stay is relatively long. Hospital discharge
occurs between the third and fifth day.
4. In a study, haematoma rate after GPRVS were 3.2%.
(Stoppa, 2002)
• Unilateral GPRVS:
Unilateral GPRVS is the Stoppa procedure applied to a single
groin hernia. The preperitoneal mesh in such case is implanted
through a lower quadrant transverse abdominal incision or through an
anterior groin incision either trans-inguinally or sub-inguinally.
(Wantz and Fischer, 2002)
Currently, the chief indication for unilateral GPRVS is when
Stoppa operation is unnecessary or inapplicable, when an
unanticipated complex hernia is encountered during hernioplasty with
an anterior groin incision, or for repair of the groin after removal
of a previously implanted prosthesis. (Wantz and Fischer, 2002)
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Main disadvantage was a recorded recurrence rate of 1.8% in
455 complex and recurrent hernias of the groin managed by unilateral
GPRVS in the period 1986-97. (Wantz and Fischer, 2002)
Recurrence was mainly caused by technical errors. These were
inadequate cleavage of the preperitoneal space; incorrect sizing,
shaping and placement of the mesh. (Wantz and Fischer, 2002)
• The bilayer prosthetic device (prolene hernia system) :
The bilayer polypropylene device known as the Prolene Hernia
System was released in 1998 by Ethicon, Inc. It is constructed as a
three-in-one model. Its underlay component is designed to protect the
canal's posterior wall. Inferiorly, it will reach beyond Cooper's
ligament to protect the femoral triangle; superiorly, it will reach well
above the transversus arch; medially, it reaches behind the pubic
ramus; and laterally, it reaches well beyond the internal ring. It
should be placed deep to the epigastric vessels. Its 2cm diameter
connector will slit within the defect or the internal ring. The onlay
component of the device covers and protects the entire posterior wall.
Laterally, it is positioned between the internal and external oblique
muscles, and medially, it extends over the transversus arch and the
pubic bone. It extends along the shelving edge of the inguinal
ligament, protecting entirely the Hasselbach's (medial) triangle and
the tissues of the lateral triangle. The design of the onlay patch makes
it wide and long enough to cover full width and breadth of the
posterior wall. (Gilbert and Graham, 2002)
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Main advantage is that its recurrence rate is impressively low
that it essentially eliminates the lost time and expense related.
(Gilbert and Graham, 2002)
Main disadvantage is that the device is comparatively costly
compared to other methods of hernia repair. (Gilbert and Graham,
2002)
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