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Minimally Invasive Open-Preperitoneal

Herniorrhaphy (Kugel)
Gene D. Branum, MD

The minimally invasive open-preperitoneal herniogra- surgeons are uncomfortable with the expense of this
phy (Kugel) uses a mesh patch (Surgical Sense, Inc, technique and the requirement for general anesthesia. 3-5
Arlington, TX) composed of two layers of polypropylene Stoppa's giant prosthetic reinforcement of the visceral
mesh and a proprietary monofilament self-expanding sac (GPRVS) calls on Pascal's principle of hydrostatic
ring. The design allows placement of the mesh into the pressure and the incorporation of the mesh into healing
preperitoneal space using a minimally invasive incision. connective tissue to achieve its excellent results. From an
The mesh placement mimics that of totally extraperito- engineering perspective, the principle of distributing
neal laparoscopic herniography (TEP), but is most often intra-abdominal pressure over a wide area instead of
performed under local anesthesia with sedation and relying on sutures close to a hernia defect from an
requires no specialized equipment. anterior approach is very attractive. The Kugel repair
Preperitoneal hernia repair has had many proponents. uses the same principle as the GPRVS with a minimally
Drs Nyhus and Stoppa have advocated the approach for
invasive approach.
primary and, especially, recurrent groin hernias. 1,2 The
The Kugel herniorrhaphy uses a 2.5- to 4-cm incision
laparoscopic approach to the preperitoneal space has
for access to the preperitoneal space. After digital dissec-
been popularized within the past 10 years, but many
tion and direct visualization of the space and reduction of
any direct, indirect, or femoral hernias, the two-layer,
self-expanding, polypropylene mesh patch is placed and
From the Department of Surgery, Emory University School of Medicine,
Atlanta, GA. positioned to cover the direct space, internal ring, and
Address reprint requests to Gene D. Branum, MD, Department of Surgery, femoral canal. Neither stapling nor suturing the mesh to
Emory University School of Medicine, Surgery Research, 5105 WMB, 1639 Pierce
Dr, Atlanta, GA 30322.
Cooper's ligament or the iliopubic tract is required, and
Copyright 9 1999 by WB. Saunders Company the mesh is secured to the transversalis fascia with a
1524-153X/99/0102-0010510.00/0 single stitch.

Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 203-210 203

204 Gene D. Branum


_ _ _ J

1 The landmarks for the skin incisions are the location on the skin
overlying the pubic tubercle and the location on the skin overlying the
anterior superior iliac spine (ASIS). The midpoint of this line is then used as a
guide for an incision that is one third lateral and two thirds medial to that
point. This horizontal incision is carried down to the external oblique fascia.
Local anesthetic is used in each layer and beneath the external oblique fascia.
An ilioinguinal nerve block is recommended but not essential. The incision
should be at least 4 cm above the superior border of the symphysis pubis, so
the midpoint may need to be moved I to 3 cm superiorly. This drawing shows
the location of the skin incision relative to the underlying structures. Note
that the incision is lateral to the inferior epigastric vessels and lateral to the
rectus sheath. The incision is superior and medial to the internal ring. The
ilioinguinal nerve is rarely seen, because it is inferior and lateral to the
Open Preperitoneal Herniorrhaphy (Kugel) 205

2 The external oblique is retracted and blunt
dissection with clamps exposes the transversalis
fascia, which is then incised vertically exposing the
underlying golden-yellow preperitoneal fat. It is
critical that dissection begin beneath the transversa-
lis fascia, with the epigastric vessels elevated medi-
ally using a retractor. Dissection above the transver-
salis will lead to confusion and the inability to e y
properly deploy the patch. Cooper's ligament is
palpable medially and inferiorly through the preperi-
toneal fat. Blunt dissection is used to expose Coo-
per's ligament and the symphysis pubis medially.
This blunt dissection reduces a hernia sac from the
direct space. A sponge that is completely opened and
placed medially into the space facilitates the dissec-



] The cord structures and an indirect hernia

sac are evident at the lateral aspect of the incision.
The sac is reduced through the internal ring and
is separated from the cord structures in a manner
analogous to an anterior cord dissection. The
dissection must be carried superiorly to the point
where the vas deferens and cord vessels diverge.
At this point, the sac may be transected and
removed (recommended) or packed away superi-
orly and posteriorly.
206 G e n e D. Branum


4 The striped area shows the location of the patch at final placement. These areas must be
cleared of peritoneum and preperitoneal fat. The dissection is analogous to that performed by
the preperitoneal balloon in the TEP repair. Peritoneum must be swept superiorly off of the
transversalis fascia medially and laterally, off the iliac vessels posteriorly, and from the iliacus
vessel laterally. The size of the dissected space should correspond to the size of the patch to be
inserted (ie, more room for a medium versus a small patch).
Open Preperitoneal Herniorrhaphy (Kugel) 207

5 At the completion of the medial dissection Cooper's ligament (arrow) is

visible in the base of the space with no overlying peritoneum or fat. The
inability to confirm this indicates that the dissection is not complete. A direct
defect is easily felt lateral to the tubercle and superior to Cooper's ligament,
whereas with an indirect hernia the ring is palpable and the cord is visible
exiting the ring.
208 Gene D. Branum

6 When the patch is deployed, it extends medially across the symphysis pubis and laterally
well beyond the lateral aspect of the internal ring, The mesh lies anterior to the cord and iliac
vessels and extends well below Cooper's ligament inferiorly. The preperitoneal fat and hernia
sac (if not excised) lie within the curve of the mesh. An examining finger through the hernia
defect confirms that the patch lies between the defect and the preperitoneal fat. An absorbable
stitch is then used to secure the mesh to the transversalis fascia.
Open Preperitoneal Herniorrhaphy (Kugel) 209

7 The mesh is shown in its final position from an anterior view. The transversalis
fascia is reapproximated with a single absorbable stitch, incorporating a small bite of
the mesh. The external oblique fascia and skin are closed in the usual fashion. Note
that the direct, indirect, and femoral spaces are covered by the patch.

DISCUSSION placement. The mesh placement mimics that of TEP,

therefore long-term recurrence rates should be similar.
The minimally invasive open-preperitoneal herni0rrha-
There have been no instances of ilioinguinal nerve
phy (Kugel) was developed to address the need for a
syndrome in over 1,200 cases, a distinct advantage of the
minimally invasive approach to the preperitoneal space repair compared with anterior approaches. 6,7 In 450
without the expense and time required by the laparo- cases, the author has encountered one deep mesh infec-
scopic approach, and with the ability to avoid general tion requiring removal of the mesh. This was surprisingly
anesthesia in most cases. easy, because the infection had prevented incorporation
Reddick et aP studied the Kugel and TEP approaches of the mesh into the preperitoneal tissues. Four patients
prospectively. Forty-seven percent of Kugel repairs were (0.9%) have developed seromas in the hernia pseudosac,
performed under local anesthesia with sedation, whereas none requiring aspiration. Eight patients (1.7%) devel-
all laparoscopic repairs required general anesthesia. Op- oped cord hematomas that resolved spontaneously. Two
erative time was shorter in the Kugel group (average, 44 patients developed superficial wound infections, which
minutes) than the TEP group (average, 69 minutes). required local care but no packing. Seventy-five patients
Complications were lower in the Kugel group (7% vs with bilateral hernias have had simultaneous repairs. The
16%) and average return to routine activities (8 days) was complication rate has been no different in this population
equal within the two groups. The cost of the Kugel repair than in unilateral repairs. Seventy percent of patients in
was $776 less per case than the laparoscopic repair. the author's practice have chosen local anesthesia with
The collection of long-term results for this new repair sedation.
are ongoing. The developer of the repair, Dr Robert There is a learning curve for the Kugel repair, as for
Kugel, reports a recurrence rate of less than 1% (R. Kugel, any other "new" procedure. It is the experience of those
personal communication, i999). The author has per- who train other surgeons in the technique, that surgeons
formed 450 repairs with five recurrences (1.17%). Three who have previously used the TEP or the open preperito-
of the five were caused by inadequate lateral coverage of neal approach have an easier time grasping the principles
the internal ring in large indirect hernias. Using a of the Kugel repair. It is the experience of the author, that
medium instead of a small patch would have prevented some surgeons simply cannot visualize the concept of the
this problem. Inadequate dissection below Cooper's liga- preperitoneal space, whether by TEP or the open ap-
ment with medial recurrence of a direct hernia occurred proach.
in two cases. Thirty percent to 40% of the mesh must be Surgeons who wish to apply the Kugel repair should
positioned below Cooper's ligament to ensure proper undergo didactic teaching, training on pelvic models,
210 Gene D. Branum

and be precepted or proctored for their first uses on the sac whenever feasible. As in the anterior approach,
patients. Surgeons should limit their initial experience to opening the sac, reducing the contents, and reclosing the
nonobese patients without chronically incarcerated scro- sac is sometimes necessary in chronically incarcerated
tal hernias. As experience increases, the only contraindi- hernias. At the completion of the dissection, however,
cations are prior preperitoneal surgery or the presence of every landmark can be visualized no matter how large or
infection. The patch should not be used in children. incarcerated the hernia.
Experience with the Kugel technique has led to several Medial dissection to the symphysis, lateral clearance of
observations that are critical to the ease and success of the peritoneum from the iliacus muscle, and adequate
the procedure. Beginning at the "beginning," proper dissection of the peritoneum from the transversalis fascia
placement of the incision is critical. Basing the incision is critical to allow complete deployment of the patch.
on the midpoint of a line between the ASIS and pubic Adherent attachments between the transversalis fascia
tubercle prevents opening the transversalis fascia medial and peritoneum must sometimes be divided with scissors
to the epigastric vessels or lateral to the cord. Making the or cauteW. The self-expanding ring should not have
incision at least 4 cm cephalad to the symphysis pubis bends or wrinkles at the completion of the case, and
ensures its placement superior and medial to the inguinal should resemble a taco shell that opens cephalad.
floor. When placing the skin marks for the incision, allow Kugel patches are supplied in small, medium, and
the skin to be in its resting state, not the depressed large oval sizes. The author chooses the patch based on
position sometimes required to feel the landmarks (ie, in the patient size and the size of the hernia defect. In
obese patients). Placing the skin marks in the depressed general, any defect that will admit two fingers should
position will lead to a poorly placed incision. have a medium patch. Only small defects (1 to 2 cm) are
The incision in the transversalis fascia should be in a repaired with small patches.
vertical orientation to facilitate its closure at the end of Although not exhaustive, the preceding caveats will
the procedure. Specific attention and a directed effort serve surgeons well as they apply this innovative and
must be made to assure that dissection is begun below simple minimally invasive technique.
the transversalis fascia and epigastric vessels. Placing the
mesh above the epigastric vessels will invariably lead to a
recurrence. REFERENCES
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accomplished by the dissection of the preperitoneal fat iliopubic tract repair), in Skandalakis LJ, Gadacz TR, Mansberger
and sac cephalad from the direct space. At the completion ARJr, et al (eds): Modern Hernia Repair--The Embryological and
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Cooper's ligament will invariably be visible without any Group, 1996, pp 162-163
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proaches, except that cephalad traction must be main- 6. Lichtenstein IL, Shulman AG, Amid PK, et al: Cause and preven-
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