A complication of the use of Prolene Mesh in the repair of abdominal wall hernias

Summary The use of Prolene Mesh has become standard practice in the repair of inguinal hernias and has so far proved to be virtually free of complications [Liechtenstein 1987]. Its use in the repair of other difficult hernias, particularly incisional hernias, has obvious attractions. We present complications encountered in the use of prolene mesh in the repair of three very large abdominal hernias.     

无张力性腹股沟疝修补术

采用聚丙烯(Prolene)网片对59制较大的腹股沟疝进行无张力性修补。与传统的修补方法比较，本方法不破坏正常的解剖结构，没有缝合处的张力．并且操作简单、安全；患者疼痛较轻，可很快恢复正常的体力活动。本组除发生切口浅表血肿和硬结各一例外．未发生手术或网片材料引起的并发症。作者认为无张力性疝修补求是一有效的治疗腹股沟疝的方法，特别对复发性或较大的腹腔沟疝效果更为明显。     

First laparoscopic totally extraperitoneal repair of Laugier’s hernia: a case report

An atypical femoral hernia developing through the lacunar ligament is called Laugier’s hernia. Preoperative diagnosis of these atypical hernias is very difficult because of their rarity and similar clinical appearance to conventional femoral hernias. A 52-year-old female presented with right groin swelling. During laparoscopic totally extraperitoneal (TEP) inguinal hernia repair, a hernia sac through an opening in the lacunar ligament was diagnosed and repaired with mesh covering the inguinal floor. The surgeon should be alert to the possibility of an atypical femoral hernia when examining patients with inguinal hernias. A laparoscopic approach should be chosen instead of a conventional approach for the treatment of femoral hernias because of its high diagnostic and therapeutic capacity for all types of femoral hernia, including Laugier’s.     

Repair of inguinal hernias using the mesh technique during extraperitoneal pelvic lymph node dissection.

PURPOSE: This article describes our experience of using a totally extraperitoneal approach for endoscopic pelvic lymphadenectomy and inguinal hernia repair with the mesh technique in one procedure. MATERIALS AND METHODS: A total of 52 patients underwent modified pelvic lymph node dissection for the staging of prostate cancer. Eight of them had hernia defects; 1 was recurrent. Five patients with direct and 3 patients with indirect inguinal hernias were treated by totally extraperitoneal hernia repair with the placement of a mesh measuring at least 10 x 15 cm (prolene mesh with incision and flap). RESULTS: The mean duration of the lymphadenectomy itself was decreased from 150 min (first 20 patients) to 70 min (n = 21-52). The mean additional procedure time for hernioplasty was 15 min. The overall lymph node-positive rate was 9.6%. The complication rate was 7.7%. Four patients developed symptomatic lymphoceles, 1 of whom developed deep venous thrombosis. No complications occurred which were attributed to hernia repair. Morbidity did not rise, and hospitalization time did not increase for the patients who underwent hernioplasty. There were no recurrences or neuralgias on follow-up up to 2 years. CONCLUSIONS: By avoiding entry into the peritoneal cavity, the extraperitoneal approach obviates intra-abdominal complications (ileus, bowel injury, peritonitis) in both techniques. The extraperitoneal approach for pelvic lymph node dissection allows concomitant inguinal hernia to be repaired with low morbidity and within an acceptable operating time.     

Rare late mesh complications following inguinal prolene hernia system hernioplasty: report of three cases

We have treated three patients who developed late mesh infections 7?years after inguinal hernioplasty caused by contact of an underlay prolene hernia system (PHS) patch with the intestines. In two patients, the cause was the development of a fistula between the underlay patch preperitoneally positioned in Bogros space and the appendix, and in one, a sigmoid colon fistula that developed as a consequence of penetration of the underlay PHS patch into the sigmoid colon. In the patients with contact of an underlay PHS patch with the appendix, total PHS excision, appendectomy, McVay herniorrhaphy and drainage through a direct inguinal approach were applied. In the patient with a sigmoid colon lesion, total PHS excision, left hemicastration, suturing of the sigmoid colon fistula, and a McVay herniorrhaphy with drainage were performed through a direct inguinal approach, followed by midline laparotomy and protective bipolar ileostomy. Late mesh infection developing several years after PHS inguinal hernioplasty is usually the consequence of intestinal erosions and fistulas due to contact between the underlay PHS patch and the intestines.     

Ambulatory inguinal hernia repair with prolene hernia system (PHS)

Study was conducted to evaluate the feasibility and benefits of inguinal hernia repair with prolene hernia system (PHS) mesh under local anaesthesia as a day surgery procedure in a multinational society of United Arab Emirates. One hundred and seventy-eight inguinal hernias in 172 consecutive adults of whom 154 (89.5%) fitted the criteria of inclusion in the day-case surgery settings were operated upon including one early recurrence. Conversion from local to general anaesthesia was required in five (2.8%) patients. The mean operation time was 65 min, including the anaesthesia injection. The mean hospital stay was 2.1 days for all patients and 1.01 days for those who fitted in the ambulatory surgery program. Inguinal hernia repair using the PHS technique under local anaesthesia could be mastered by many of the surgeons in our hospital with minimal morbidity and short hospital stay with a potential to lessen recurrence.     

Modified Rives technic in the treatment of recurrent inguinal hernia

After the introduction of prosthetic material in hernia surgery the fundamental changes in operative strategy occurred. This is because the coverage of myopectineal orifitium with non-absorbable prosthesis decreases the incidence of recurrences. Because of the appearance of lateral re-recurrences after the classical Rives procedure, we modified the operative technique. The modified Rives technique consists of the following: always polypropilen mesh 15x10 cm; creation of the new internal inguinal ring between Poupart's ligament and mesh; no lateral notching the mesh and anchoring mesh 2-3 cm from the medial, inferior, lateral and superior edge. During the period January 2001-December 2003, 34 cases of recurrent hernias were operated on 7th dept. of I Surgical Clinic of CCS. The recurrences were managed by classical (10/34) or modified Rives technique through direct inguinal approach (22/34), less frequently Lichtenstein procedure (1/34) and McVay (1/34) technique. Among 10 patients with recurrent inguinal hernias managed by classical Rives technique 2 re-recurrences appeared (indirect and interstitial) and 2 cases of infection (immediately after the operation or 7 months after the operation), and in the group of 22 cases with recurrent inguinal hernias managed by modified Rives technique the aim complications didn't appear. Using the modified Rives technique we managed the primary hernias in 56 cases without recurrences and infections. The modified Rives technique, because of the way of mesh fixation (all around), no lateral notching of mesh and remaining hem in all directions secures abdominal wall protection 2-3 cm from the line of fixation and prevents any movement of the mesh. This procedure enables management of all inguinal hernias regardless to their size and full protection of the medial, femoral and lateral inguinal triangle. The modified Rives technique is the technique of choice for big multiple defects (giant inguino-scrotal and re-recurrences), especially among patients with increased intra-abdominal pressure when other techniques may be insufficient because of mesh protrusion.     

Bilateral Spigelian hernia treated by two‐layered prolene mesh

Spigelian hernia is an uncommon variety of abdominal hernias. It has been traditionally treated by tension‐free mesh hernioplasty. We report a rare case of a bilateral Spigelian hernia in an elderly male that was treated by bilateral two‐layeyed prolene mesh hernia system. Rare ventral hernia such as Spigelian hernia with weak abdominal wall can be safely treated by tension‐free mesh repair using bilayered prolene mesh system.     

Complex inguinal hernia repairs

Introduction  Complex inguinal hernia treatment is a challenge for general surgeons. The gold standard for the repair of inguinal hernias is the Lichtenstein repair (anterior approach). However, when multiple recurrent hernias or giant hernias are present, it is necessary to choose different approaches because the incidence of poor results increases. There are many preperitoneal approaches described in the literature. For example: (a) open procedure—Nyhus and Stoppa (b) laparoscopic technique—transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP). In this study, we show how we repair complicated cases using open access in huge unilateral or bilateral, recurrent, or multiple recurrent inguinal hernias. Methods  The present study includes the period from November 1993 through December 2007. One hundred and eighty-eight patients, divided into 121 with unilateral hernias and 67 with bilateral hernias, totaling 255 inguinal hernia repairs, were treated by the Nyhus or Stoppa preperitoneal approach, depending on whether they were unilateral or bilateral. We used progressive preoperative pneumoperitoneum for oversize inguinal hernias in all patients. Results  Orchiectomy was necessary on only two occasions. Despite the repair complexity involved, we had only two known recurrences. The mortality was zero and the morbidity was acceptable. Conclusions  We conclude that an accurate open preperitoneal approach using mesh prosthesis for complex inguinal hernias is safe, with very low recurrent rates and low morbidity. Progressive preoperative pneumoperitoneum for giant hernias was shown to be an important factor in accomplishing good intraoperative and immediate postoperative results.     

Laparoscopic herniorrhaphy with porcine small intestinal submucosa: a preliminary study.

INTRODUCTION: Using mesh or a synthetic prosthesis during the laparoscopic repair of inguinal hernias has been demonstrated to be safe and effective. A new material, porcine small intestinal submucosa (SIS mesh), has been successfully used in canine and rodent animal models with excellent results. This mesh is degradable and resorbable with a marked decrease in the possibility of becoming infected. However, the amount of fibroblast ingrowth is equal to that with polypropylene mesh. METHODS: A comparison was made between this new SIS mesh to repair 15 inguinal hernias in 12 patients and polypropylene mesh used in 12 similar patients. A preperitoneal approach with balloon dissection was used in all patients. RESULTS: Demographics were similar in both groups. The results were excellent and compared equally. Complications (seroma, discomfort) were minimal in both groups and were similar. CONCLUSIONS: Porcine small intestinal submucosa, SIS mesh, can be used for laparoscopic repair of inguinal hernias. Long-term follow-up will be necessary to confirm these preliminary results.     

Recurrent abdominal laxity following interpositional human acellular dermal matrix

Repair of large complex abdominal hernias with significant loss of domain requires component separation in combination with either a synthetic or biologic interpositional material. We previously described an algorithm for complex abdominal hernia repair, which incorporates Alloderm as an interpositional material and selective use of prolene mesh as an overlay. We now report recurrent laxity in a series of patients who were repaired with interpositional Alloderm alone without prolene mesh overlay. We reviewed all patients who underwent repair of massive ventral hernias and identified 7 patients who presented with abdominal wall laxity following component separation with interpositional Alloderm alone. All patients developed laxity within 12 months and required a secondary procedure. At the time of re-exploration, severe attenuation in the Alloderm was noted. The segment was excised, the edges closed primarily, and prolene mesh was placed as an onlay. Although Alloderm has been reported to be an effective biologic material for abdominal hernia reconstruction, we have noted significant laxity requiring secondary intervention.     

腹股沟疝后进路无张力修补152例分析

目的评价后进路（腹膜前）无张力疝修补方法治疗腹股沟疝的疗效。方法对本组于2001年8月-2005年10月,采用后进路单层网片修补治疗152例腹股沟疝进行回顾性分析。并对手术时间、住院时间、平均住院费用、恢复工作时间、手术并发症和复发率等进行统计。结果本组病人术后腹股沟区疼痛不适的发生率和复发率较低,平均手术时间为32．2min、平均住院时间为5d、恢复日常生活时间为9．2d、平均住院费用为4243元。结论采用后进路单层网片修补方法对治疗腹股疝是一安全有效的方法,适合我国的国情,具有推广的价值。     

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis®, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex®, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.     

裁剪式双层prolene网片在老年腹股沟疝无张力修补术中的应用

目的 探讨裁剪式双层prolene网片在老年腹股沟疝无张力修补术中的临床应用价值。方法 对1997年7月至2005年7月应用裁剪式双层prolene网片行老年腹股沟疝无张力修补术56例的临床资料进行回顾性分析。结果 56例中，原发性腹股沟疝19例（33．9％），复发性腹股沟疝37例（66．1％）。巨大疝环12例（21．4％），伴发其他疾病44例（78．6％）。并发症发生率为10．7％（6／56）。平均手术时间45min；平均住院3．2d；随访6个月至8年，无术后复发。结论 应用裁剪式双层prolene网片进行腹股沟疝无张力修补术，符合老年腹股沟疝的解剖特点和“个体化”要求，尤其适合于老年巨大疝环者或复发性疝。由于操作简便、安全和经济等特点，易于广泛推广。     

轻量型网片和普通聚丙烯补片在腹股沟疝修补术中的对比研究

目的探讨轻量型网片（强生UPP）在腹股沟疝无张力修补中的作用。方法回顾分析90例次腹股沟疝无张力修补患者的临床资料,其中47例次行普通聚丙烯材料修补,43例次行强生UPP修补。结果强生UPP修补组与普通聚丙烯材料修补组比较,早期并发症发生率（切口疼痛、切口积液、伤口感染、肺部感染、尿道损伤以及尿潴留等）和住院时间差异无统计学意义。在6个月时强生UPP修补组其局部切口疼痛、异物感的患者明显少于普通聚丙烯材料修补组,腹壁顺应性明显好于普通聚丙烯材料修补组,在6个月时两组均没有复发。结论轻量型网片在腹股沟疝无张力修补中,其后期并发症明显减少,有望成为腹股沟疝无张力修补的首选材料。     

双切口法Ⅰ期无张力网片修补绞窄性腹股沟疝(附16例报告)

目的探讨Ⅰ期无张力网片修补绞窄性腹股沟疝的可行性与安全性。方法16例腹股沟绞窄性疝患者,采用Ⅰ期无张力网片修补。首先于患侧采取中下腹探查切口进入腹腔,对有肠管坏死的14例进行切除及吻合,合并化脓性腹膜炎的6例患者,予腹腔冲洗及放置腹腔引流管,然后在内环口行荷包缝合结扎,关腹。重新消毒铺巾,更换器械,再取患侧内环口至外环口体表投影切口,按常规前入路进入腹股沟管,游离精索(不必分离疝囊),于精索后用网片修补加固腹股沟管后壁。结果术后腹部切口感染1例,腹股沟切口无感染,16例随访12~90个月,未见复发。结论双切口法Ⅰ期无张力网片修补绞窄性腹股沟疝是一种安全有效的方法,可避免Ⅱ期手术,减轻患者痛苦,同时也可减轻患者的经济负担。     

The preperitoneal approach and prosthetic buttress repair for recurrent hernia. The evolution of a technique.

Repair of recurrent groin hernias is associated with a high incidence of repeat recurrences (2-19%). Reported herein is a 10-year experience of the management of recurrent groin hernias through the use of the preperitoneal approach with the addition of a reinforcing prosthetic mesh buttress. Two hundred and three recurrent groin hernias in 195 patients (192 men, three women) were treated between July 1975 and October 1986. The preperitoneal approach to the inguinal region was performed under regional anesthesia to define the nature of the recurrent hernia. Initial experience in a randomized trial between the use of local endogenous tissue repair versus endogenous repair with a prosthetic polypropylene mesh buttress demonstrated superiority of the latter in reducing repeat recurrences of anatomically defined direct or combined recurrent hernias. Pure indirect and femoral recurrences did not mandate mesh reinforcement. Long-term follow-up was available for 115 hernias (56%) in 102 patients (52.3%) over a period of 6 months to 10 years. Eight patients had repeat recurrences a mean of 30 +/- 22 months after repair. Six recurrences (four direct, two indirect) occurred in an early experience, when no mesh was used. Two recurrences (one indirect and one lateral to the mesh) representing 1% of all hernias (1.7% of those followed-up) have occurred after routine use of the mesh buttress, with the last re-recurrence seen in December 1982. Three ventral hernias (1.5%) occurred at the wound of entry, but none have occurred since placement of the mesh was modified to cover this wound. There were five (2.5%) wound infections and one (0.5%) hydrocele with no re-recurrences. It is concluded that the preperitoneal approach to recurrent groin hernias, together with the appropriate use of a reinforcing mesh buttress, is safe, allows anatomic definition of the hernial defect, and is followed by few repeated recurrences. The evolution of this approach during the last 10 years has made it the procedure of choice for the management of all recurrent groin hernias at the University of Illinois College of Medicine.     

轻量型和普通聚丙烯补片在腹股沟疝修补术中的对照研究

目的：比较使用普通聚丙烯补片f普理灵）和轻量型聚丙烯补片（薇普Ⅱ）进行腹股沟疝修补术后的疗效。方法：2006年10月至2008年3月间,我院对609例腹股沟疝病人,行Lichtenstein修补术,病人分成2组,一组使用普理灵补片,另一组使用薇普Ⅱ补片。比较两组平均手术时间、术后炎症反应程度、并发症及恢复工作的时间,并根据SF-36对病人术前和术后6个月内的生活质量进行评估。使用疼痛的数字评分法（NRS）对术后第2天和6个月的疼痛情况进行评分．以此判断术后6个月腹股沟区是否仍有异物感。结果：与普理灵补片相比,使用薇普Ⅱ补片可减轻术后导致的腹壁活动受限,炎性反应和纤维组织的生成也减低;术后6个月运动时疼痛的比例也降低（P〈0．05）;腹股沟区有异物感的病人较少。结论：腹股沟疝行Lichtenstein修补术中更适宜使用轻量型聚丙烯补片。     

The Rives technique (direct inguinal approach) in treatment of large inguino-scrotal and recurrent hernias

In solving inguinal hernias, surgeons today have in front of them many variations of different operative procedures (both tensional and non-tensional techniques). They are performed through operative or endoscope approach. Classical tension techniques present the operation of choice for smaller indirect, direct or femoral hernias among younger patients while non/tensional techniques are the best solution for all types of inguinal hernia among older patients with big destruction of transversal fascia and the best solution for most of recurrent hernias. Positioning of mesh with non-tensional techniques can be completed on different levels, with big hernias where the biggest part of transversal fascia of miopectineal orifitium is destroyed it is anatomically the most useful to place the mesh in preperitoneal space. Rives technique is the base of that concept and it presents one of good solutions in that kind of situations. In the period January 2001 until december 2002 using different operative techniques the authors treated 99 inguinal hernias of which 78 were primary and 21 recurrent hernias. Rives technique was performed in 46 cases (46.5%) among which 26 cases were primary inguinoscrotal hernias (3 patients IIIA, 22 patients IIIB, 1 patient IIIC, according to Nyhus classification) and 20 cases were recurrent hernias (6 patients IVA, 11 IVB, 3 IVD). Complications after Rives technique were the following: 1 recurrence (2.17%), 1 ischemic orchitis (2.17%) and 1 scrotal hematoma (2.17%). Infections and chronic pain were not present. The follow up was from 30 days to 2 years. Authors have shown that Rives technique is reliable solution for primary indirect, direct and femoral hernias with big hernial defect (especially for big, so called "giant" inquinoscrotal hernias) and for all types of recurrent hernias. The advantage of the technique is an easy performance without some previous special training because of the fact that dissection and preparation is the same as for the tension techniques. With small amount of prosthetic material all weak points of miopectineal orifitium are closed. The real risks of this technique are ischemic orchitis and chronis neuralgia in treatment of recurrent hernias and the presence of polypropylene mesh in Bogras space.     

Single-Incision Laparoscopic Repair of Spigelian Hernia

Introduction:Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.Methods:From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.Results:There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m². An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1–15 months).Conclusions:Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.