Tension Free Hernia Repair

Basrul Hanafi
Digestive Surg, Dept. of Surgery Padjadjaran
University, Hasan Sadikin Hospital
Bandung

HERNIAS:

Prevalence,Causes,
and Repairs
Estimated incidence in the general population is 3% 1
Male-to-female ratio: 25:12
More than 700,000 hernia repairs performed annually
in the United States3
Indirect 2:1 Direct
Type 4 direct is single most common

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.
2. Abrahamson et al. Maingots Abdominal Operations. 9th ed. Appleton & Lange: East Norwalk, Conn;
1990:chap 11.
3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

HERNIAS:

Recurrence Rates
10% to 30% recurrence rate with primary
inguinal hernia repair1
Estimated 35% or higher recurrence rate
with recurrent hernia repairs2

1. Abrahamson. Maingots Abdominal Operations. Vol 1. 9th ed. Appleton & Lange:
East Norwalk, Conn; 1990:chap 11.
2. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.

Abdominal wall layers

1.
2.
3.
4.
5.
6.
7.
8.

Peritoneum
Subperitoneal fat
Transversalis fascia
Transversus abdominis muscle
Internal oblique muscle
External oblique muscle
Subcutaneus fat
Skin

INGUINAL REGION
Rectus m.
Linea alba

External
oblique m.
& apon.

Inguinal
ligament

Spermatic
cord

INGUINAL REGION
External
oblique
apon.

External
oblique

Cremaster

Internal
oblique m.
& apon.

Conjoint
Tendon

Inguinal
ligament

Saphenous
v.

Femoral
vein

INGUINAL REGION
External
oblique
apon.

External
oblique m.

Transv.
fascia

Internal
oblique m.

Conjoint
tendon

Transversus
abdominus
m.
Cremaster
(sperm.
cord)

Coopers
ligament

Inferior epigastric
vessels
External inguinal ring

INGUINAL REGION
Inferior epigastric
vessels
Transversus
m.
Internal
inguinal
ring

Rectus m.

Preperitone
al View

Iliac
vessels

Transversal
is fascia

Spermatic
cord

Inguinal
ligament
Pubi
s

Coopers lig
Lacunar
ligament

INGUINAL REGION
Preperitoneal fat

Iliac vessels

Transversalis
fascia

Abdom.
muscles
External
oblique apon.
Testicular
vessels

Parietal
peritoneum
Inferior epigastric
vessels

Vas Deferens
Spermatic cord

Coopers lig.
Inguinal lig.

Pubis
Lacunar lig.

Femoral
vessels

INGUINAL REGION
Abdominal
aorta

Iliac vessels

Iliac crest

Inguinal lig.
Coopers lig.

Pubis
Lacunar lig.

Femoral
vessels

INGUINAL REGION
Iliac vessels

Abdom. m.

Rectus m.

Iliac crest

Pyramidalis m.

Peritoneum
Ext. oblique
apon.

Ext. inguinal
ring

Transv.
fascia

Sperm. cord

Inguinal lig.

Femoral
vessels

HESSELBECHS TRIANGLE
inferior
epigastric
artery
internal ring
rectus
sheath
inguinal
ligament

pubis

Inguinal Hernias:
Classification

Type 1

Type 2

Type 4

Type 3

Type 5

From Gilbert. Perspectives in General Surgery. 1991;2(1):113-129.

Milestones in Hernia Repair

Marcy (1870s)
Recognized importance of transversalis fascia
and internal ring closure
Used carbolized catgut to suture the ring

Lucas-Championniere (1880s)
Slit external oblique aponeurosis to expose the canal
Dissected and ligated sac at internal ring under
direct vision

From Abrahamson. Maingots Abdominal Operations. Vol 1. 9th ed. Appleton & Lange:
East Norwalk, Conn; 1990:chap 11.

Milestones in Hernia Repair

(Contd)

Bassini (1880s) Father of Modern Herniorrhaphy

Dissected and reconstructed inguinal canal
to preserve functional anatomy
Repaired transversalis fascia and reinforced
the canals posterior wall

Shouldice (1945)
Multi-layered repair, suturing only local tissues
without prosthetic material; local anesthesia

From Abrahamson. Maingots Abdominal Operations. Vol 1. 9th ed. Appleton & Lange:
East Norwalk, Conn; 1990:chap 11.

Milestones in Hernia Repair

(Contd)

Martin and Shureih (1983)

Used MarlexTM mesh deep to the transversalis fascia
in primary inguinal hernia repair

Stoppa (1984, 1987)

Extensive prosthetic reinforcement of the peritoneum
using MersileneTM (Dacron) mesh between the
peritoneum
and transversalis fascia1
1. Abrahamson. Maingots Abdominal Operations. Vol 1. 9th ed. Appleton & Lange:
East Norwalk, Conn; 1990:chap 11.

Milestones in Hernia Repair

(Contd)

Lichtenstein (1986) e.g. Prolene Mesh

Used nonabsorbable sutures and prosthetic mesh screen
to reinforce new canal floor2

2. Lichtenstein. Am J Surg. 1989;157:188-193.

Milestones in Hernia Repair

(Contd)

Gilbert (1987)1
Used internal ring as direct access to the peritoneal space
Used polypropylene plug (later changed to the patch)
to repair indirect hernias

Gilbert (1991)2
Used sutureless hand-fashioned umbrella polypropylene
plug to open as an underlay patch

1. Gilbert. South Med J. 1987;80:191-195.

2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.

Milestones in Hernia Repair

(Contd)

Robbins and Rutkow (1993)3

Fabricated, cone-shaped plug, with sutures and onlay
graft
without sutures for indirect and direct hernias

3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

TENSION-FREE REPAIR:

Principles

High dissection of inguinal sac

Head, neck and shoulders of the sac
Prevent recurrence at the internal ring
Reinforce the canal floor without tension

SHOULDERS
NECK
HEAD
SPERMATIC
CORD

Image courtesy of Arthur Gilbert, MD.

TENSION-FREE REPAIR:

Advantages

Simple
Rapid
Less painful
Effective
Prompt resumption of unrestricted
physical therapy
Low recurrence rate

Common
Tension-Free Repairs
Lichtenstein repair patch1
Plug and patch3
Kugel Repair
Lap Hernia Repair
The Prolene Hernia System

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.
2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.
3. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

Common
Tension-Free Repairs Lichtenstein
Solid repair with good reported results
Anterior support
Suture intensive
No posterior support
Take about 40 minutes
Effective
Low recurrence rate
No migration

Pre-shaped mesh in the inguinal box

Closure of the aponeurosis

Common
Tension-Free Repairs - Plug &
Patch
Good idea and has some good results
reported
Suture intensive (the plug and the overlay
mesh)
No posterior support
Can take as much as 40 - 60 minutes
No protection of the femoral canal

Reported cases of mesh migration

Reported cases of patient discomfort longer
term

Plug & Patch

(also known as umbrella)

Erosion of a shrunken soft Marlex plug

into the bladder wall.
Image courtesy of Parviz K. Amid, MD.

3 plugs in one patient with a recurrence.

Image courtesy of Karl LeBlanc, MD.

Common
Tension-Free Repairs - Kugel
Patch

Good idea. The repair is in the preperitoneal space

Difficult to visualize the anatomy (approach)
A few anecdotal reported cases of mesh migration
Reported cases of recurrence
High cost of the mesh

Common
Tension-Free Repairs - Lap
Hernia
Solid repair!
More challenging than open approach
General anesthesia
Cost!!!

Common
Tension-Free Repairs - The
PHS
Combines the three most common repairs (overlay,

plug, underlay)
Non-Suture intensive
Posterior support. Protects Femoral Canal from
anterior approach
Can be done in 20 minutes
Conforms to anatomy in posterior space.
Patient comfort longer term!
To date, no reported cases of recurrence

Appeal of The PROLENE* Hernia

System

Surgeons who want a posterior repair from a simple

anterior approach.

Surgeons who want a procedure under local or

regional anesthesia.

Surgeons who want to test the repair in OR.

Surgeons using alternative methods and have grown

concern with issues of mesh shrinkage, plug
migration, patient comfort, cost, and recurrence rates.

The Onlay/Underlay
Patch Device
Overlay
Mesh

Cylinder
Connector
Underlay
Mesh
From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.

The PHS Innovative Three-In-One

Design:
combines the three most popular
free techniques utilized today
tension
The Onlay Patch, like the Lichtenstein flat mesh repair, covers the entire floor of the
in
the
repair
inguinal
hernias
canal;
the system
overlaps of
the pubic
tubercle for added
support, and provides the security of
conventional patch techniques.

The Connector, provides the simplicity of a plug repair. Additionally, it secures the underlay
patch to minimize incidence of migration. Its profile is a significant improvement over the bulk of
conventional plugs

The Underlay patch, like a laparoscopic repiar, provides posterior support from a simple
anterior approach. This underlay patch lays in the preperitoneal space and opens to cover the entire
Myopectineal orifice.

Covers both the Femoral and Inguinal regions to minimize the possibility of recurrence.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy
of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Image courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Repair of Indirect Hernia Using

Onlay/Underlay Patch Device
(Contd)

Images courtesy of Arthur Gilbert, MD.

Onlay/Underlay Patch Device

Incorrectly Positioned During Hernia
Repair

Image courtesy of Arthur Gilbert, MD.

Summary and
Overview of Available
Resources

Mesh plug repair vs Lichtenstein patch

repair
26 male pts, unilateral, primary, inguinal hernia repair
Randomised to 2 groups : plug and patch repair
Operating Ease of
time (mins) operation*

Return to
work (days)

Return to
normality
(days)

Pain score**

Analgesia
(no. of
tablets)

Lichtenstein
mean (+/- SD)

38 (7)

4.6 (2.1)

29 (18)

35 (12)

3.9 (1.8)

19 (10)

Mesh plug
mean (+/- SD)

29 (6)

2.7 (0.9)

22 (13)

25 (11)

2.1 (1.5)

13 (9)

P value

0.01

0.02

0.4

0.04

0.01

0.15

* Score out of ten(zero being the easiest and ten the most difficult by visual analogue scale).
** Score out of ten (zero being no pain and ten the worst experience ever).

Open and Laparoscopic Approaches:

A Comparison
Factor

Open

Laparoscopic

No Limits

Not for very

young or old

Usually local/regional

General

Expenses
Operating room time
Procedure time
Equipment

Less
Less
Less

Greater
Greater
Greater

Complications
Minor
Major

Equal
Less

Equal
Greater

Recurrence Rate

Lower

Higher

Selection by patient age

Anesthesia

From Gilbert. Int Surg. 1995;80:4-8 and Gilbert, personal communication.

Open and Laparoscopic Approaches:

A Comparison (Contd)
Factor

Open

Laparoscopic

Surgeon Experience
Training
Acceptance

Less
Greater

More
Less

Less

Greater

Less
Equal or greater
Equal

Greater
Less or equal
Equal

Equal
Equal

Equal
Equal

Difficulty of Procedure
Patient Discomfort
Initial 2 hr
248 hr
After 48 hr
Activity Resumption
Normal
Strenuous

From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-512 and Gilbert, personal communication.

PROLENE Polypropylene
Hernia System:

Characteristics and Benefits

Designed to repair all abdominal wall hernias

Produces minimal tissue reaction
Strong tensile and bursting strengths
Maximum exposed flat mesh surface
for tissue ingrowth
Large pore size

From King et al. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Boca Raton, Fla:
CRC Press Inc;1994:chap 15.

PROLENE Polypropylene
Hernia System:
Summary

Tension-free techniques reduce the likelihood

of hernia recurrences
Prosthetic mesh is ideal for bridging defects
in the abdominal wall
Posterior-wall defect can be repaired with combined underlay
and onlay patches
Tension-free repair made possible with mesh prosthetics
allows repair without distortion of normal anatomy and sutureline tension

Sekian