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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Open Mesh Repair

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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Open Mesh Repair

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

71

Open Mesh Repair

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

72

Open Mesh Repair

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

73

Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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

76

Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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Open Mesh Repair

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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