We tested the hypothesis that laparoscopic inguinal herniorrhaphy using Surgisis mesh secured with fibrin sealant is an effective long-term treatment for repair of inguinal hernia. This case series involved 38 adult patients with 51 inguinal hernias treated in a primary care center.
Between December 2002 and May 2005, 38 patients with 45 primary and 6 recurrent inguinal hernias were treated with laparoscopic repair by the total extra-peritoneal mesh placement (TEP) technique using Surgisis mesh secured into place with fibrin sealant. Postoperative complications, incidence of pain, and recurrence were recorded, as evaluated at 2 weeks, 6 weeks, 1 year, and with a follow-up questionnaire and telephone interview conducted in May and June 2005.
The operations were successfully performed on all patients with no complications or revisions to an open procedure. Average follow-up was 13 months (range, 1 to 30). One hernia recurred (second recurrence of unilateral direct hernia), indicating a 2% recurrence rate.
Laparoscopic repair of inguinal hernia using Surgisis mesh secured with fibrin sealant can be effectively used to treat primary, recurrent, direct, indirect, and bilateral inguinal hernias in adults without complications and minimal recurrence within 1-year of follow-up.
Inguinal hernia; Laparoscopy; TEP repair; Surgisis mesh; Fibrin glue
Chronic Groin Pain (Inguinodynia) following inguinal hernia repair is a significant, though under-reported problem. Mild pain lasting for a few days is common following mesh inguinal hernia repair. However, moderate to severe pain persisting more than 3 mo after inguinal herniorrhaphy should be considered as pathological. The major reasons for chronic groin pain have been identified as neuropathic cause due to inguinal nerve(s) damage or non-neuropathic cause due to mesh or other related factors. The symptom complex of chronic groin pain varies from a dull ache to sharp shooting pain along the distribution of inguinal nerves. Thorough history and meticulous clinical examination should be performed to identify the exact cause of chronic groin pain, as there is no single test to confirm the aetiology behind the pain or to point out the exact nerve involved. Various studies have been performed to look at the difference in chronic groin pain rates with the use of mesh vs non-mesh repair, use of heavyweight vs lightweight mesh and mesh fixation with sutures vs glue. Though there is no convincing evidence favouring one over the other, lightweight meshes are generally preferred because of their lesser foreign body reaction and better tolerance by the patients. Identification of all three nerves has been shown to be an important factor in reducing chronic groin pain, though there are no well conducted randomised studies to recommend the benefits of nerve excision vs preservation. Both non-surgical and surgical options have been tried for chronic groin pain, with their consequent risks of analgesic side-effects, recurrent pain, recurrent hernia and significant sensory loss. By far the best treatment for chronic groin pain is to avoid bestowing this on the patient by careful intra-operative handling of inguinal structures and better patient counselling pre- and post-herniorraphy.
Hernia; Lichtenstein repair; Chronic groin pain; Inguinodynia; Mesh hernia repair; Ilio-inguinal nerve; Iliohypogastic nerve; Genitofemoral nerve
With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model.
Materials and Methods
Under general anesthesia with the animal in trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed.
All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth.
This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.
The use of mesh in the surgical repair of adult indirect inguinal hernias is widely recommended in Western countries, but no randomized controlled trials have so far been reported in Japan. The purpose of the present randomized prospective trial was to compare a mesh method with non-mesh method for surgical repair of primary adult indirect inguinal hernias in which the diameter of the internal inguinal ring was up to 3.0 cm (I-1 or I-2 of Japanese Hernia Society Classification).
Patients with a primary unilateral inguinal hernia and I-1 or I-2 surgical findings were randomized to undergo either Marcy repair or Prolene Hernia System® repair. Primary endpoints were recurrence, infection, and pain, with follow-up continued for 3 years postoperatively.
Ninety-one of 479 patients with an inguinal hernia during the study period did not meet the exclusion criteria, and 46 were allocated to Marcy repair and 45 were allocated to Prolene Hernia System® repair. No recurrence was observed in either group, and no significant differences were identified between the groups in any of the primary endpoints.
This randomized prospective trial of I-1 and I-2 inguinal hernias suggests that Marcy repair is not inferior to PHS repair. A large-scale randomized controlled trial appears warranted to confirm whether to use mesh for Japanese adult I-1 and I-2 hernias.
Prosthesis; Mesh; PHS; Tension free
The Lichtenstein technique is currently considered the “gold standard” of open, anterior inguinal hernia repair. It is not free, however, of adverse effects, which may be caused by the implemented synthetic material.
Determination the influence of the mesh employed on treatment results including immediate complications, return to everyday activities, chronic pain occurrence and hernia recurrence.
Material and methods
Tension-free hernia repair using the Lichtenstein technique was performed in all the 59 patients randomized to trial groups. Group P with heavyweight polypropylene mesh contained 34 patients; group V with lightweight, partially absorbable mesh (polypropylene/polyglactin 910) consisted of 25 people. Controlled, scheduled follow-up appointments took place after the 7th day and the 3rd and 6th month. Patients were clinically assessed and pain intensity was determined on an analogue-visual scale.
No statistically significant influence of the type of mesh on the risk of early complications, severe pain intensity, the length of hospital stay, time of recovery, or patients’ satisfaction with treatment was observed. After 6 months also no statistically significant differences were observed between groups with regard to recurrence rate (P 3.4% vs. V 4.0%), chronic pain (P 5.9% vs. V 4.0%) and ailments such as “foreign body presence” (V vs. P, OR = 0.30, 95% CI 0.077-1.219, p = 0.093) incidence, although their probability was 70% lower for V mesh.
The preliminary results confirm the effectiveness of the Lichtenstein technique for hernia repair with both types of meshes. It appears that use of a partially absorbable mesh is connected with lower risk of postoperative complications, but the final results require multicentre trials in a larger series of patients.
inguinal hernia; Lichtenstein technique; non-absorbable; partially absorbable mesh
BACKGROUND: Patients with unilateral inguinal hernias are conventionally seen at an out-patient appointment before being placed on a waiting list for surgery. Many patients are also required to attend a pre-assessment clinic prior to admission. AIM: To establish whether patients fit for day surgery inguinal hernia repair could be assessed and treated at a single hospital appointment. PATIENTS AND METHODS: Patients referred with unilateral inguinal hernias were sent an information sheet and health questionnaire by post. General practitioners were asked to help patients complete the medical details. Patients suitable for day surgery were sent a single appointment for assessment and treatment by an open, tension-free Lichtenstein mesh repair. RESULTS: Ninety-eight patients were sent an appointment for 'one-stop' inguinal hernia treatment. Ninety-two patients (93.5%) underwent inguinal hernia repair and were discharged on the same day without complication. CONCLUSIONS: Patients with unilateral primary inguinal hernias who are under 70 years old and ASA grade I or II can been seen, assessed and treated on the same day. 'One-stop' inguinal hernia surgery reduces the number of patient visits to the hospital and could be expanded to incorporate many more hernia repairs and other day case procedures.
Radiographic analysis of a NiTiNol framed, polypropylene mesh hernia device when used for laparoscopic inguinal hernioplasty showed it to be stable with regard to size, shape and position six months after implantation.
Background and Objective:
To determine whether the NiTiNol frame of a novel hernia repair device utilizing polypropylene mesh for inguinal hernioplasty remains stable and intransient without fixation after a minimum of 6 months.
Twenty patients had 27 inguinal hernias repaired using a novel hernia repair device that has a NiTiNol frame without any fixation. Initial single-view, postoperative X-rays were compared with a second X-ray obtained at least 6 months later. The NiTiNol frame, which can be easily visualized on a plain X-ray, was measured in 2 dimensions, as were anatomic landmarks. The measurements obtained and the appearances of the 2 X-rays were compared to determine the percentage of change in device size and device stability with regard to device location and shape.
There were minimal changes noted between the 2 sets of measurements obtained with an overall trend towards a slight increase in the size of the hernia repair device. The devices demonstrated intransience of position and stability of shape.
The NiTiNol frame of a novel hernia repair device utilizing polypropylene mesh exhibits radiographic evidence of size and shape stability and intransience of position without fixation when used in inguinal hernioplasty after a minimum follow-up of 6 months.
NiTiNol; Hernia; Shrinkage; Fixation
The Lichtenstein mesh hernioplasty is currently the most popular operative technique for open repair of inguinal hernia. The incidence of chronic groin pain (CGP) following this procedure is reported to be high. However, since our experience did not support this observation, this study was undertaken at our centre, to assess the incidence of CGP following Lichtenstein mesh hernioplasty.
A prospective study was conducted on all patients undergoing elective hernia repair at a tertiary care teaching hospital. The patients underwent Lichtenstein mesh hernioplasty and were followed up for the primary outcome measures of development of recurrence and Chronic Groin Pain.
A total of 470 patients were enrolled for the study. Out of these 16 patients never reported for follow up after discharge from hospital. The remaining 454 patients with 510 primary inguinal hernias were included in the study. Of these 449 patients were male and 5 were female. The mean follow-up period was 14 months (range — six months to twenty four months). One patient had recurrence of hernia and CGP was reported in four patients. In all four patients CGP was mild and was well controlled with oral NSAIDS used on SOS basis.
The incidence of CGP in our study is 0.78% for the number of operated hernias. This is not only considerably less than what is generally reported but is also less disabling.
Chronic Groin Pain; Lichtenstein Mesh Hernioplasty
In recent years, general surgeons who perform inguinal hernia repair have paid attention to successful reduction in the recurrence rate. The Lichtenstein technique is widely used because it is easy to learn and is associated with a low rate of complication and recurrences. Today, the new objective in primary hernia surgery should be to reduce complications such as chronic pain. Chronic pain after hernia repair can be disabling, with considerable impact on quality of life and there is evidence to suggest increased use of health services by patients who have chronic pain. We have proposed an international randomized controlled trial with seven referenced European centers: The TI.ME.LI. trial. The aim of this study is to evaluate pain and further disabling complications in patients undergoing Lichtenstein technique for primary inguinal hernia repair by fixing the mesh with fibrin sealant versus sutures (control group).
Chronic pain; fibrin glue; lichtenstein hernia repair
Fixation of the mesh during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase postoperative pain and lead to an increased risk of complications. We questioned whether elimination of fixation of the mesh during TEP inguinal hernia repair leads to decreased postoperative pain or complications, or both, without an increased rate of recurrence.
A randomized prospective single-blinded study was carried out in 40 patients who underwent laparoscopic TEP inguinal hernia repair with (Group A=20) or without (Group B=20) fixation of the mesh.
Patients in whom the mesh was not fixed had shorter hospital length of stay (8.3 vs 16.0 hours, P=0.01), were less likely to be admitted to the hospital (P=0.001), used less postoperative narcotic analgesia in the PACU (P=0.01), and were less likely to develop urinary retention (P=0.04). No significant differences occurred in the level of pain, time to return to normal activity, or the difficulty of the operation between the 2 groups. No hernia recurrences were observed in either group (follow-up range, 6 to 30 months, median=19).
Elimination of tack fixation of mesh during laparoscopic TEP inguinal hernia repair significantly reduces the use of postoperative narcotic analgesia, hospital length of stay, and the development of postoperative urinary retention but does not lead to a significant reduction in postoperative pain. Eliminating tacks does not lead to an increased rate of recurrence.
Hernia; Urinary retention; Endoscopic; TEP; Laparoscopic
Fascial defects are a common problem in the abdominal wall and in the vagina leading to hernia or pelvic organ prolapse that requires mesh enhancement to reduce operation failure. However, the long-term outcome of synthetic mesh surgery may be unsatisfactory due to post-surgical complications. We hypothesized that mesh fabricated from alternative synthetic polymers may evoke a different tissue response, and provide more appropriate mechanical properties for hernia repair. Our aim was to compare the in vivo biocompatibility of new synthetic meshes with a commercial mesh.
We have fabricated 3 new warp-knitted synthetic meshes from different polymers with different tensile properties polyetheretherketone (PEEK), polyamide (PA) and a composite, gelatin coated PA (PA+G). The rat abdominal hernia model was used to implant the meshes (25×35 mm, n = 24/ group). After 7, 30, 60, 90 days tissues were explanted for immunohistochemical assessment of foreign body reaction and tissue integration, using CD31, CD45, CD68, alpha-SMA antibodies. The images were analysed using an image analysis software program. Biomechanical properties were uniaxially evaluated using an Instron Tensile® Tester.
This study showed that the new meshes induced complex differences in the type of foreign body reaction over the time course of implantation. The PA, and particularly the composite PA+G meshes, evoked a milder early inflammatory response, and macrophages were apparent throughout the time course. Our meshes led to better tissue integration and new collagen deposition, particularly with the PA+G meshes, as well as greater and sustained neovascularisation compared with the PP meshes.
PA, PA+G and PEEK appear to be well tolerated and are biocompatible, evoking an overlapping and different host tissue response with time that might convey mechanical variations in the healing tissue. These new meshes comprising different polymers may provide an alternative option for future treatment of fascial defects.
Effective repair of hernia is a difficult task. There have been many advances in hernia repair techniques over the past 50 years, but new strategies must be considered to enhance the success of herniorrhaphy.
At the 30th International Congress of the European Hernia Society, nine experts in hernia repair and experimental mesh evaluation participated in a roundtable discussion about today’s unmet needs in hernia repair, including what constitutes an “ideal” hernia repair and the portfolio of “ideal” mesh prostheses. Defining characteristics of lightweight mesh, mesh alternatives, the surgeon’s role in hernia repair, adverse events, the unmet requirements for today’s hernia repair, and optimized animal models were among the topics discussed.
The ideal mesh’s construction is still in progress, but greater understanding of its critical characteristics was explored. It is hoped that these suggestions will lead to the development of improved hernia treatments and a maximally effective portfolio of hernia mesh prostheses.
Surgical mesh; Prosthesis design; Complications; Operative surgical procedure; Animal models
Anterior open treatment of the inguinal hernia with a tension-free mesh has reduced the incidence of hernia recurrence. The Lichtenstein procedure is the current reference technique for inguinal hernia treatment. Chronic pain has become the main postoperative complication after surgical inguinal hernia repair, especially following Lichtenstein. Preliminary experiences with a soft mesh positioned in the preperitoneal space (PPS) by transinguinal preperitoneal (TIPP) or total extraperitoneal (TEP) technique, showed promising results considering the reduction of postoperative chronic pain. Evolution of surgical innovations for inguinal hernia repair led to an open, direct approach with preperitoneal mesh position, such as TIPP. Based on the TIPP procedure, another preperitoneal repair has been recently developed, the transrectus sheath preperitoneal (TREPP) mesh repair.
The ENTREPPMENT trial is a multicentre randomized clinical trial. Patients will be randomly allocated to anterior inguinal hernia repair according to the TREPP mesh repair or TIPP procedure. All patients with a primary unilateral inguinal hernia, eligible for operation, will be invited to participate in the trial. The primary outcome measure will be the number of patients with postoperative chronic pain. Secondary outcome measures will be serious adverse events (SAEs), including recurrence, hemorrhage, return to daily activities (for example work), operative time and hospital stay. Alongside the trial health status, an economic evaluation will be performed. To demonstrate that inguinal hernia repair according to the TREPP technique reduces the percentage of patients with postoperative chronic pain from 12% to <6%, a sample size of 800 patients is required (two-sided test, α = 0.05, 80% power).The ENTREPPMENT trial aims to evaluate the TREPP and TIPP procedures from patients’ perspective. It is hypothesized that the TREPP technique may reduce the number of patients with any form of postoperative chronic pain by 50% compared to the TIPP procedure.
Current Controlled Trials:
Chronic pain; Inguinal; Hernia; Preperitoneal; Mesh; TREPP; TIPP; Open repair; Trial; Randomized
The concept of using a mesh to repair hernias was introduced over 50 years ago. Mesh repair is now standard in most countries and widely accepted as superior to primary suture repair. As a result, there has been a rapid growth in the variety of meshes available and choosing the appropriate one can be difficult. This article outlines the general properties of meshes and factors to be considered when selecting one.
MATERIALS AND METHODS
We performed a search of the medical literature from 1950 to 1 May 2009, as indexed by Medline, using the PubMed search engine (). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. We used the following terms: ‘mesh, pore size, strength, recurrence, complications, lightweight, properties’. We also hand-searched the bibliographies of relevant articles and product literature to identify additional pertinent reports.
RESULTS AND CONCLUSIONS
The most important properties of meshes were found to be the type of filament, tensile strength and porosity. These determine the weight of the mesh and its biocompatibility. The tensile strength required is much less than originally presumed and light-weight meshes are thought to be superior due to their increased flexibility and reduction in discomfort. Large pores are also associated with a reduced risk of infection and shrinkage. For meshes placed in the peritoneal cavity, consideration should also be given to the risk of adhesion formation. A variety of composite meshes have been promoted to address this, but none appears superior to the others. Finally, biomaterials such as acellular dermis have a place for use in infected fields but have yet to prove their worth in routine hernia repair.
Hernia; Mesh; Filament; Tensile strength; Porosity; Acellular dermi
Lumbar hernia is a rare surgical entity without a standard method of repair. With advancements in laparoscopic techniques, successful lumbar herniorrhaphy can be achieved by the creation of a completely extraperitoneal working space and secure fixation of a wide posterior mesh. We present a total extraperitoneal laparoendoscopic repair of lumbar hernia, which allowed for minimal invasiveness while providing excellent anatomical identification, easy mobilization of contents and wide secure mesh fixation. A total extraperitoneal method of lumbar hernia repair by laparoscopic approach is feasible and may be an ideal option.
Lumbar hernia; Grynfeltt hernia; Laparoscopic repair; Extraperitoneal repair
Though not entirely free of complications, the Lichtenstein technique is still considered the “gold standard” for inguinal hernia repair due to the low recurrence rate.
In our study we determined the effect of mesh type, surgeon and selected patients’ characteristics on treatment results. The latter were determined by the frequency of early complications, recovery time and return to normal activities, chronic pain and hernia recurrence.
Material and methods
Tension-free hernia repair with the Lichtenstein technique was performed in 149 male patients aged 20-89 years randomized to two trial groups. One group comprised 76 patients with heavyweight non-absorbable polypropylene mesh (HW group) and the other included 73 patients with lightweight partially absorbable mesh (LW group). The control schedule follow-up took place on the 7th day as well as in the 3rd and 6th month after the operation. Statistical analysis was performed with multi-factor regression models.
In the LW group patients returned to normal activity faster (p = 0.031), experienced less intensive chronic pain (p = 0.01) and expressed higher treatment satisfaction (p = 0.024) than the patients from the HW group. The type of mesh had an insignificant influence on the risk of early complications and hernia recurrence. Statistically significant differences were observed however with regard to surgeon, type and hernia duration, patient's general condition and body mass.
Both types of mesh are equally effective for prevention of hernia recurrence. Lightweight partially absorbable meshes are more beneficial to patients than the heavyweight non-absorbable type. The surgeon and patients’ characteristics have a significant impact on the treatment outcome.
inguinal hernia; Lichtenstein technique; non- and partially absorbable mesh
Anterior open treatment of the inguinal hernia with a tension free mesh has reduced the incidence of recurrence and direct postoperative pain. The Lichtenstein procedure rules nowadays as reference technique for hernia treatment. Not recurrences but chronic pain is the main postoperative complication in inguinal hernia repair after Lichtenstein's technique. Preliminary experiences with a soft mesh placed in the preperitoneal space showed good results and less chronic pain.
The TULIP is a double-blind randomised controlled trial in which 300 patients will be randomly allocated to anterior inguinal hernia repair according to Lichtenstein or the transinguinal preperitoneal technique with soft mesh. All unilateral primary inguinal hernia patients eligible for operation who meet inclusion criteria will be invited to participate in this trial. The primary endpoint will be direct postoperative- and chronic pain. Secondary endpoints are operation time, postoperative complications, hospital stay, costs, return to daily activities (e.g. work) and recurrence. Both groups will be evaluated.
Success rate of hernia repair and complications will be measured as safeguard for quality.
To demonstrate that inguinal hernia repair according to the transinguinal preperitoneal (TIPP) technique reduces postoperative pain to <10%, with α = 0,05 and power 80%, a total sample size of 300 patients was calculated.
The TULIP trial is aimed to show a reduction in postoperative chronic pain after anterior hernia repair according to the transinguinal preperitoneal (TIPP) technique, compared to Lichtenstein.
In our hypothesis the TIPP technique reduces chronic pain compared to Lichtenstein.
Inguinal hernia repair according to Lichtenstein technique has become the most common procedure performed by general surgeons. Heavy weight polypropylene meshes have been reported to stimulate inflammatory reaction responsible for mesh shrinkage when scar tissue evolved. Additionally, some concerns remain regarding the relationship between chronic pain and mesh fixation technique. In order to reduce those drawbacks, we have developed a new mesh for anterior tension free inguinal hernia repair which exhibits self-gripping absorbable properties.
Materials and Methods:
52 patients (69 hernias) were prospectivly operated with this mesh (SOFRADIM-France) made of low-weight isoelastic large pores knitted fabric which incorporated resorbable micro hooks that provides self gripping properties to the mesh during the first months post-implantation. The fixation of the mesh onto the tissues is significantly facilitated. The mesh is secured around the cord with a self gripping flap. After complete tissular ingrowth and resorption of the PLA hooks, the low-weight (40 g/m2) polypropylene mesh insures the long term wall reinforcement.
Peroperativly, no complication was reported, the mesh was easy to handle and to fix. Discharge was obtained at Day 1. No perioperative complication occurred, return to daily activities was obtained at Day 5.5. At one month, no neurological pain or other complications were described.
Based on the first results of this clinical study, this unique concept of low density self gripping mesh should allows an efficient treatment of inguinal hernia. It should reduce postoperative complications and the extent of required suture fixation, making the procedure more reproducible
Inguinal hernia; self-gripping mesh; tension-free repair
Inguinal hernia is a very common problem. Surgical repair is the current approach, whereas asymptomatic or minimally symptomatic hernias may be good candidate for watchful waiting. Prophylactic antibiotics can be used in centers with high rate of wound infection. Local anesthesia is a suitable and economic option for open repairs, and should be popularized in day-case setting. Numerous repair methods have been described to date. Mesh repairs are superior to "nonmesh" tissue-suture repairs. Lichtenstein repair and endoscopic/laparoscopic techniques have similar efficacy. Standard polypropylene mesh is still the choice, whereas use of partially absorbable lightweight meshes seems to have some advantages.
inguinal hernia; hernia repair; antibiotic prophylaxis; mesh; laparoscopy; Lichtenstein repair; review
Marlex® mesh was used in 31 cases of inguinal herniorrhaphy and in 15 cases incisional herniorrhaphy in a five-year period. In 14 of the inguinal and six of the incisional cases the hernias were recurrent. Marlex® mesh was used in one case to reenforce the transthoracic repair of eventration of the diaphragm, and in another to reenforce the transthoracic repair of an esophageal hiatal hernia.
There were no recurrences. In one case after inguinal herniorrhaphy the mesh was removed because of persistent drainage. Wound infections occurred in two patients with incisional herniorrhaphy, and two others had the accumulation of serous fluid subcutaneously necessitating aspiration of fluid.
The Shouldice method and other tissue-based techniques are still acknowledged to be acceptable for primary inguinal hernia repair according to the European Hernia Society guidelines. Desarda’s technique, presented in 2001, is an original hernia repair method using an undetached strip of external oblique aponeurosis. This randomized trial compared outcomes after hernia repair with Desarda (D) and mesh-based Lichtenstein (L) techniques.
A total of 208 male patients were randomly assigned to the D or L group (105 vs. 103, respectively). The primary outcomes measured were recurrence and chronic pain. Additionally, early and late complications, foreign body sensation, and return to everyday activity were examined in hospital and at 7, 30 days, and 6, 12, 24, and 36 months after surgery.
During the follow-up, two recurrences were observed in each group (p = 1.000). Chronic pain was experienced by 4.8 and 2.9% of patients from groups D and L, respectively (p = 0.464). Foreign body sensation and return to activity were not different between the groups. There was significantly less seroma production in the D group (p = 0.004).
The results of primary inguinal hernia repair with the Desarda and Lichtenstein techniques are comparable at the 3-year follow-up. The technique may potentially increase the number of tissue-based methods available for treating groin hernias.
Hernia repair is the most common surgical procedure in the world. Augmentation with synthetic meshes has gained importance in recent decades. Most of the published work about hernia meshes focuses on the surgical technique, outcome in terms of mortality and morbidity and the recurrence rate. Appropriate biomechanical and engineering terminology is frequently absent. Meshes are under continuous development but there is little knowledge in the public domain about their mechanical properties. In the presented experimental study we investigated the mechanical properties of several widely available meshes according to German Industrial Standards (DIN ISO).
Six different meshes were assessed considering longitudinal and transverse direction in a uni-axial tensile test. Based on the force/displacement curve, the maximum force, breaking strain, and stiffness were computed. According to the maximum force the values were assigned to the groups weak and strong to determine a base for comparison. We discovered differences in the maximum force (11.1±6.4 to 100.9±9.4 N/cm), stiffness (0.3±0.1 to 4.6±0.5 N/mm), and breaking strain (150±6% to 340±20%) considering the direction of tension.
The measured stiffness and breaking strength vary widely among available mesh materials for hernia repair, and most of the materials show significant anisotropy in their mechanical behavior. Considering the forces present in the abdominal wall, our results suggest that some meshes should be implanted in an appropriate orientation, and that information regarding the directionality of their mechanical properties should be provided by the manufacturers.
Laparoscopic and endoscopic hernia repair popularized the preperitoneal mesh position due to promising results concerning less chronic pain. However, considerable proportions of severe adverse events, learning curves, or added costs have to be taken into account. Therefore, open preperitoneal mesh techniques may have more advantages. The open approach to the preperitoneal space (PPS) according to transrectus sheath preperitoneal (TREPP) mesh repair is through the sheath of the rectus abdominus muscle. This technique provides an excellent view of the PPS and facilitates elective or acute hernia reduction and mesh positioning under direct vision. In concordance with the promising transinguinal preperitoneal inguinal hernia repair experiences in the literature, we investigated the feasibility of TREPP.
A rationale description of the surgical technique, available level of evidence for thoughts behind technical considerations. Furthermore, a descriptive report of the clinical outcomes of our pilot case series including 50 patients undergoing the TREPP mesh repair.
A consecutive group of our first 50 patients were operated with the TREPP technique. No technical problems were experienced during the development of this technique. No conversions to Lichtenstein repair were necessary. No recurrences and no chronic pain after a mean follow-up of 2 years were notable findings.
This description of the technique shows that the TREPP mesh repair might be a promising method because of the complete preperitoneal view, the short learning curve, and the stay-away-from-the-nerves principle. The rationale of the TREPP repair is discussed in detail.
Inguinal hernia; Preperitoneal; Open; Repair; Mesh; Posterior
The management of elective inguinal herniorrhaphy in Wales was assessed by means of a postal survey of consultant general surgeons. This included technique of repair, length of inpatient stay, follow-up, use of heparin thromboprophylaxis and advice regarding driving, strenuous activities and work. In all, 54 replies (77%) were received. The views of patients on their surgery was assessed by a questionnaire sent to 80 patients treated on a single surgical unit; 60 replies (75%) were received. Waiting times were relatively short among this group, 67.5% of patients being treated within 6 months of seeking medical advice; 16.25% suffered a complication. All wound infections occurred after discharge and 15% of patients had some groin discomfort 6 months after operation. Accuracy of clinical examination of 50 inguinal hernias by different grades of surgeon was assessed. Consultants were significantly more accurate when compared with house officers (P < 0.001). There is a wide range of repair techniques and postoperative advice practised by consultant general surgeons in Wales. Patients' main complaint was that of a sparsity of postoperative advice, although there also appears to be an appreciable postoperative morbidity. Clinical experience plays a significant role in assessment of the suitability of hernias for surgery.
Recurrences have been a significant problem following hernia repair. Prosthetic materials have been increasingly used in hernia repair to prevent recurrences. Their use has been associated with several advantages, such as less postoperative pain, rapid recovery, low recurrence rates.
In this retrospective study, 540 tension-free inguinal hernia repairs were performed between August 1994 and December 1999 in 510 patients, using a polypropylene mesh (Lichtenstein technique). The main outcome measure was early and late morbidity and especially recurrence.
Inguinal hernia was indirect in 55 % of cases (297 patients), direct in 30 % (162 patients) and of the pantaloon (mixed) type in 15 % (81 patients). Mean patient age was 53.7 years (range, 18 – 85). Follow-up was completed in 407 patients (80 %) by clinical examination or phone call. The median follow-up period was 3.8 years (range, 1 – 6 years). Seroma and hematoma formation requiring drainage was observed in 6 and 2 patients, respectively, while transient testicular swelling occurred in 5 patients. We have not observed acute infection or abscess formation related to the presence of the foreign body (mesh). In two patients, however, a delayed rejection of the mesh occurred 10 months and 4 years following surgery. There was one recurrence of the hernia (in one of these patients with late mesh rejection) (recurrence rate = 0.2 %). Postoperative neuralgia was observed in 5 patients (1 %).
Lichtenstein tension-free mesh inguinal hernia repair is a simple, safe, comfortable, effective method, with extremely low early and late morbidity and remarkably low recurrence rate and therefore it is our preferred method for hernia repair since 1994.