Mesh repair of inguinal and femoral hernia

The authors describe a 6-year experience with mesh repair of inguinal and femoral hernia in a surgical teaching department. Two hundred and ninety-seven hernioplasties were performed in 256 consecutive patients: 237 Trabucco sutureless and 11 Lichtenstein tension-free hernioplasties for inguinal hernia; 21 tension-free hernioplasties for femoral hernia; 20 Wantz GPRVS and 8 Rutkow tension-free hernioplaties for recurrences. Local anaesthesia was used in 59% of cases. Seventy-two patients (28.1%) refused this type of anaesthesia. The hospital stay was two days in all cases. The local postoperative morbidity rate was 8.7% (wound infections: 1.0%; neuralgia: 1.3%; haematomas: 2.0%; seromas: 2.3%; no testicular atrophies). The recurrence rate was 1.9% in the group of patients undergoing surgery from 1994 to 1997 (103 herniorrhaphies; follow-up: 3-6 years) and 0% in the group of patients operated on after 1997 (170 herniorrhaphies; follow-up: 2 years-6 months). The results confirm that the use of a prosthetic mesh (patch and plug) is the treatment of choice for hernia repair. Moreover, this experience in a surgical teaching department shows that these procedures can be safely and effectively performed by all surgeons.     

无张力疝修补术治疗绞窄性腹股沟疝的体会

目的比较无张力疝修补术与传统Bassini手术对绞窄性腹股沟疝的治疗效果。方法回顾性分析2003年1月至2007年12月间急诊行手术治疗的47例绞窄性腹股沟疝。其中,行Li-chtenstein无张力疝修补术21例(A组),行Bassini手术26例(B组)。结果两组术后并发症发生率差异无统计学意义(P0.05)。B组术后住院时间明显长于A组(P0.05)。术后随访6个月~5年,病人复发率差异无统计学意义(P0.05)。结论对绞窄性腹股沟疝的病人应用Lichtenstein无张力疝修补术是安全的。     

Recurrence after hernioplasty according to Lichtenstein: analysis of the cause

The performance of surgical interventions of tension-free hernia repair has certainly reduced the recurrence rate in comparison with the previous techniques; notwithstanding this it is not uncommon to observe some recurrences also after a Lichtenstein hernia repair. The aim of this study is that to analyse the causes. In the last 2 years, 42 patients (mean age of 68 years) with recurrent hernia have been operated by Lichtenstein technique; 11 of the 42 patients had been treated before with an useful mesh hernia repair. In 8 of these patients the recurrence was produced by an insufficient medial extension of the mesh; in the other 3 patients the cause was the presence of an unrecognized indirect hernia in patients operated for a direct inguinal hernia. All the patients treated have been submitted to a 18 months time of follow-up.     

Recurrent inguinal hernia: a ten-year review

BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.     

Tension-free inguinal hernia repair: a retrospective study of 3000 cases in one center

The tension-free anterior repair of inguinal hernia using a mesh, initially described by Zagdoun in 1959 and perfectly described by Lichtenstein, was used as a basis for the technique we adapted 17 years ago. The purpose of this study was to retrospectively assess the clinical long-term results of this modified tension-free technique. Three thousand inguinal hernias were operated by the same surgeon. The Lichtenstein technique modifications were the nature and the enlarged size of the mesh (polyester-Parietex, 13 x 9 cm) and the fixation method (staples). Complications, pain, and recurrence were carefully reported on a standardized file. Immediate complications were rare and always minor: hematomas and parietal abscesses. With a mean follow-up of 8 years, 48 cases of persisting pains (2%) coming from nervous irritation were reported, and only 12 recurrences (0.5%) were detected more than 10 years after surgery. Based on follow-up of these 3000 hernias, the results of this study exhibit a very low rate of recurrence (0.5%). This technique seems to be easy, painless, safe, and effective.     

Tension-free hernioplasty in primary inguinal hernia. A series of 2054 cases

Summary This was a prospective study to analyze the results of tension-free hernioplasty in a center no specially dedicated to hernia surgery. We reviewed data of 1761 patients with 2111 primary hernias. Tension-free hernioplasty (Lichtenstein procedure) was performed in 2054 hernias and herniorrhaphy i (Marcy or Bassini repair) in 57. Loco-regional anesthesia was used in 65% of the patients. The most common complication was hematoma of the wound (1.6%). There was a very low rate of wound infection (0.1%) and in no case was necessary to remove the prosthesis. Median follow-up was 5 years. There were 5 recurrences in the Lichtenstein procedures (0.24%). Three were at the pubic tubercle and two were a disruption of the lower edge of the mesh from the inguinal ligament. All of these were at the beginning of the series.Tension-free hernioplasty is a very simple and safe method, easy to reproduce and with excellent results.     

Anterior rectus sheath in inguinal hernia repair: preliminary study.

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann-Whitney test. No difference in age (p = .08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p = .116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45-150) compared to anterior rectus sheath repair (median 65 min, range 45-125) (p = .049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.     

Lichtenstein无张力疝修补术治疗腹股沟疝4011例

目的：评估Lichtenstein无张力疝修补术治疗腹股沟疝的结果并总结临床经验。方法回顾性分析3 631例腹股沟疝患者的4011例（其中双侧疝380例）Lichtenstein无张力疝修补术的临床资料。结果 经Lichtenstein手术治疗的3 631例腹股沟疝患者平均住院3.8d,术后并发症发病率为2.4％,复发率为0.1％。结论 在局麻下对腹股沟疝患者施行Lichtenstein手术具有术后恢复快、复发率和并发症发病率低的特点。     

Inguinal hernioplasty with the Prolene Hernia System

Most tension-free hernia repair techniques achieve 0.1%–0.4% recurrence rates in patients with primary hernias. Currently, the Lichtenstein technique is considered to be the criterion standard. The Prolene Hernia System (PHS) is a recently introduced hernia-repair device that combines three proven mechanisms of action. We retrospectively reviewed early and late complications in 250 patients who underwent inguinal hernioplasties—125 performed with the Lichtenstein technique and 125 performed with the PHS—from March 1998–October 2002. Patients who underwent Lichtenstein hernia repair had nine complications, and those who underwent PHS surgery had only two; none of the complications were serious. Older male patients who underwent Lichtenstein hernia repair were more likely to have complications (P=0.04). One patient in the Lichtenstein group had a recurrence of his hernia, but there were no recurrences in the PHS group. In conclusion, the results of inguinal hernioplasties performed with the PHS are comparable to those achieved with Lichtenstein hernia repair, the criterion standard technique.     

Recurrences after prosthetic repair of inguinal hernias by the lichtenstein technique

Summary We report a 3.4% incidence of hernial recurrence (all recurrences were reoperated) after inguinal hernia repair by the Lichtenstein technique: 14 reoperated recurrences (in 13 patients) in a series of 440 inguinal hernias (375 primary and 65 recurrent) in 379 patients (62 bilateral) over 5 years (1994–1998). Some 2/3 of all recurrences appeared within a year of surgery. Eleven of these patients were operated on for bilateral and/or recurrent groin hernia, and eleven also showed at least one risk factor for recurrence, such as obesity and other general diseases (specially pulmonary and hepatic). The incidence of recurrence was 0.7% (2 in 272) for primary unilateral hernia, 3.8% for primary bilateral hernia (2 in 52), 11.1% for recurrent unilateral hernia (5 in 45) and 40% for recurrent bilateral hernia (4 in 10). Recurrences were 5 indirect hernias, 4 direct hernias and 5 femoral hernias. Indirect recurrence was attributed to technical errors, but femoral and direct hernias seem to be the consequence of a poor indication for the Lichtenstein technique. Log-rank tests showed very significant statistical differences (p<0.01) in the risk of hernial recurrence between recurrent and primary hernias. We suggest that certain conditions should be contraindications for the standard Lichtenstein technique (bilateral groin hernia, recurrent hernia, obesity, chronic pulmonary and liver disease), and propose for these either a preperitoneal repair or some modifications of the Lichtenstein technique (an extremely floppy mesh and simultaneous femoral repair with the mesh).     

ProGrip型与UHS型补片在相应术式下治疗腹股沟疝的临床研究

目的对比分析应用ProGrip自固定型补片行Lichtenstein术与应用UHS型补片行腹膜前间隙无张力修补术（Gilbert）治疗腹股沟疝的临床效果。 方法回顾性分析自2015年9月至2017年8月,山西医科大学第二医院150例男性腹股沟疝患者的临床资料,按所采用的手术方法和补片类型分为2组,每组75例。A组选用美国柯惠公司生产的ProGrip自固定型补片＋Lichtenstein术,B组选用美国强生公司生产的UHS型补片＋Gilbert术。 结果A组手术时间短于B组,术后慢性疼痛发生情况高于B组,异物感发生情况低于B组,差异均有统计学意义（t=30.21、χ²=5.37、11.04,P<0.05）;2组住院时间比较,差异无统计学意义（P>0.05）;术后2组患者均无感染,随访3个月均无复发。 结论两种不同补片及对应术式治疗腹股沟疝都有良好的近期效果,应用ProGrip自固定型补片行Lichtenstein术在缩短手术时间、减少术后异物感方面有一定优势,且具有简单易操作的特点;应用UHS型补片行Gilbert术在理论上更符合人体力学,且在预防术后慢性疼痛方面有一定优势,但操作相对复杂,术式学习曲线相对较长。     

Concurrent radical retropubic prostatectomy and inguinal hernia repair through a modified Pfannenstiel incision

OBJECTIVE: To describe a technique for concurrent radical retropubic prostatectomy (RRP) and inguinal hernioplasty, using a modified Pfannenstiel incision. PATIENTS AND METHODS: RRP is usually done through a midline lower abdominal incision but some patients with localized prostate cancer have an inguinal hernia. Concurrent inguinal hernia repair at the time of RRP with the usual method is only possible by either a preperitoneal mesh repair or formal hernioplasty, requiring an additional incision(s). A 10-12 cm Pfannenstiel incision is made along the pubic hairline centred over the pubic symphysis, and a 'Y'-shaped incision in the rectus sheath. The rectus muscle is split vertically along the midline, followed by RRP. After removing the prostate and completing the anastomosis, the surgeon identifies the inguinal canal along the inferior and lateral aspect of the transverse incision and uses a formal tension-free hernioplasty with a 3 x 5 cm polypropylene mesh. We used this technique in fifteen concurrent inguinal hernioplasties (two bilateral hernias and thirteen unilateral) at the time of RRP, with no additional incisions, using the formal tension-free Lichtenstein technique. One patient with bilateral hernias had a right indirect inguinal hernia, and all the remaining men had a direct inguinal hernia. RESULTS: All patients were discharged 2 days after surgery, with no complications associated with the procedure and no recurrences; however, the follow-up was short (mean 5.5 months). CONCLUSION: A modified Pfannenstiel incision is ideal for concurrent RRP and inguinal hernioplasty, providing excellent exposure of the pelvic structures and allowing the surgeon to use a formal tension-free mesh hernioplasty through the same incision. Wound healing and cosmetic results are excellent.     

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??Groin hernia repair in young males: mesh or sutured repair? Bisgaard T*,Bay-Nielsen M,Kehlet H. *Department of Surgery, Køge Sygehus, Køge, Denmark
Corresponding author: Bisgaard T,e-mail:thuebisgaard@tdcadsl.dk
Abstract Objective Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available. We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair. Methods Prospective recording of all inguinal hernia repairs from 1 January 1998 to 31 December 2005 in the national Danish Hernia Database, using reoperation rate as a proxy for recurrence. We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia. Results A primary sutured repair was performed in 1,120 men (median age 23 years, range 18-30) and a Lichtenstein mesh repair in 2,061 young men (24 years, range 18-30) (total 3,181 patients). The observation time after conventional hernia repair was median 62 months (range 0-96) and 41 months (range 0-96) after a Lichtenstein repair. The cumulative incidence of reoperation at 5 years was 1.6% (Lichtenstein) versus 3.9% (sutured repair), while overall reoperation rates were almost three-fold as high after a sutured repair (39 reoperations, overall reoperation rate = 3.5%) compared to a Lichtenstein repair (24 reoperations, overall reoperation rate=1.2%;P=0.0003). Conclusion Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain.     

Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach

No randomized trial exists that specifically addresses the issue of laparoscopic bilateral inguinal hernia repair. The purpose of the present prospective, randomized, controlled, clinical study was to assess short- and long-term results when comparing simultaneous bilateral hernia repair by an open, tension-free anterior approach with laparoscopic "bikini mesh" posterior repair. Forty-three low-risk male patients with bilateral primary inguinal hernia were randomly assigned to undergo either laparoscopic preperitoneal "bikini mesh" hernia repair (TAPP) or open Lichtenstein hernioplasty. There was no difference in operating time between the two groups. The mean cost of laparoscopic hernioplasty was higher (P < 0.001). The intensity of postoperative pain was greater in the open hernia repair group at 24 hours, 48 hours, and 7 days after surgery (P < 0.001), with a greater consumption of pain medication among these patients (P < 0.05). The median time to return to work was 30 days for the open hernia repair group and 16 days for the laparoscopic "bikini mesh" repair group (P < 0.05). Only 1 asymptomatic recurrence (4.3%) was discovered in the open group. The laparoscopic approach to bilateral hernia with "bikini mesh" appears to be preferable to the open Lichtenstein tension-free hernioplasty in terms of the postoperative quality of life and interruption of occupational activity.     

Tension free hernioplasty in the treatment of recurrent inguinal hernia. Our experience

BACKGROUND: Despite the new surgical approach with "tension free" techniques, recurrent inguinal hernia repair remains a difficult surgical problem. METHODS: Personal experience in 61 cases of recurrent inguinal hernia is reported; in all patients a new hernioplasty with a "tension free" technique was performed. Medium follow-up of the study was 27 months (min 6 mm, max 56 mm); 3 recurrences were observed, 2 in Lichtenstein "plug" hernioplasty and 1 with the Trabucco technique. RESULTS: No recurrences were observed in Lichtenstein "mesh" hernioplasty group. CONCLUSIONS: Lichtenstein "mesh" hernioplasty can solve every anatomical situation in hernia recurrence and good results, with little or any complications, are achievable; "plug" technique is easier but recurrences in other sites of a weak inguinal wall are possible.     

Concurrent radical retropubic prostatectomy and Lichtenstein inguinal hernia repair through a single modified Pfannenstiel incision: a 3-year experience

OBJECTIVE: To present the results of a 3-year experience of radical retropubic prostatectomy (RRP) through a modified Pfannenstiel incision and concomitant repair of an inguinal hernia at the time of RRP, using a tension-free technique with a mesh, as described by Lichtenstein, with no additional incision(s), as 5-10% of patients with clinically localized prostate cancer have a detectable inguinal hernia. PATIENTS AND METHODS: Patients who had RRP between October 2002 and July 2005 were included; we used a standard open RRP, in all cases using a modified Pfannenstiel incision. If the patient had an inguinal hernia, we approached the inguinal canal through the same incision and performed a Lichtenstein mesh repair, through the inguinal canal and avoiding placing mesh within the pelvis. Patients were followed at 1 and 6 weeks, 3-monthly for 1 year and 6-monthly thereafter. All clinical variables were entered into a database and analysed. RESULTS: In all, 450 men underwent RRP; 44 (10%) had inguinal hernia and in all, 56 hernias were repaired (32 unilateral and 12 bilateral; 16 indirect, 22 direct, six both) The mean (sd) age of the patients was 60 (7) years. Most patients were discharged within 36 h. The mean (sd) follow-up was 9 (8) months. Two patients had a superficial inguinal haematoma and one had a scrotal haematoma. They were treated conservatively with no sequelae. There were no wound infections. One patient developed a recurrent inguinal hernia. None had any clinical evidence of testicular atrophy or chronic pain. CONCLUSION: Concurrent formal mesh repair of the inguinal hernia and RRP through a single modified Pfannenstiel incision is safe and effective. The complications were minimal and recurrence rates were low. This procedure eliminates the risks involved with the preperitoneal mesh repair and avoids multiple incisions.     

Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial

BACKGROUND: The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias. METHODS: Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years. RESULTS: Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed. CONCLUSIONS: In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.     

Anterior Rectus Sheath in Inguinal Hernia Repair: Preliminary Study

Inguinal hernia repair using the anterior rectus sheath flap represents a tension-free repair with potential advantages (no foreign material or tension on the suture line). The aim of this research was to evaluate the method of inguinal hernia repair using the anterior rectus sheath and to compare it with tension-free mesh repair (modified Lichtenstein repair). In total, 62 patients were evaluated. Each patient's age, gender, type of hernia, total operating-room time, the length of postoperative hospital stay, and the recurrence-free period were recorded, as well as the total number of postoperatively administered doses of analgesics, and analyzed using the Mann–Whitney test. No difference in age (p =. 08), postoperative hospital stay (p = 0.810), or postoperative use of analgesics (p =. 116) was observed between two groups. Total operating-room time was significantly longer in patients undergoing mesh repair (median 80 min, range 45–150) compared to anterior rectus sheath repair (median 65 min, range 45–125) (p =. 049). No complications or recurrences were noted in either group. Thus, this study showed good results using the anterior rectus sheath repair for primary, uncomplicated inguinal hernias, comparable to mesh repair.     

Tension-free repair versus modified Bassini technique (Andrews technique) for strangulated inguinal hernia: a comparative study

Background: To compare tension-free hernia repair to a modified Bassini technique (Andrews technique) used to treat complicated inguinal hernia.Methods: In the period 1990–2004, 75 patients were submitted to emergency operation because of strangulated inguinal hernia. 33 patients underwent tension-free repair utilizing a polypropylene mesh (group A), whereas the remaining 42 patients underwent a modified Bassini technique (group B).Results: Mean operative time was significantly longer for group B (91.5±9.3 min vs 75.7±10.5 min, p<0.05). Postoperative hospital stay was also significantly longer in group B compared to group A (10.3±3.4 days vs 4.5±2.1 days, p<0.01). Postoperative complication rate did not differ significantly between the two groups (5/33, 15.1% vs 5/42, 11.9%, p=n.s.). No mesh had to be removed. At follow-up (mean 9±4.2 years), there was one recurrence in group A (1/33, 3%) and two recurrences in group B (2/42, 4.7%) (p=n.s.).Conclusion: The presence of a strangulated inguinal hernia cannot be considered a contraindication for the use of a prosthetic mesh.     

A new approach for transversalis fascia reinforcement in Lichtenstein’s inguinal hernia repair

Operations undertaken for inguinal hernia repair are the most common elective surgical procedures. According to the current guidelines, Lichtenstein’s tension-free method is the gold standard for elective hernia operations. The most common types of implanted mesh are polypropylene and composite mesh. We herein present Lichtenstein’s operation using a biological hemostatic mesh (Tachosil) used for transversalis fascia reinforcement, and our results after a 3-year follow-up period for 52 patients implanted with Tachosil mesh are reported. According to our results, the biological mesh can be safely implanted during hernia repair with the same recurrence rate and lower postoperative pain and complications compared to hernia repair with polypropylene mesh implantation.