Minimally Invasive Open-PreperitonealHerniorrhaphy (Kugel)
Gene D. Branum, MD
The minimally invasive open-preperitoneal herniogra-phy (Kugel) uses a mesh patch (Surgical Sense, Inc,Arlington, TX) composed of two layers of polypropylenemesh and a proprietary monofilament self-expandingring. The design allows placement of the mesh into thepreperitoneal space using a minimally invasive incision.The mesh placement mimics that of totally extraperito-neal laparoscopic herniography (TEP), but is most oftenperformed under local anesthesia with sedation andrequires no specialized equipment.Preperitoneal hernia repair has had many proponents.Drs Nyhus and Stoppa have advocated the approach forprimary and, especially, recurrent groin hernias. 1,2 Thelaparoscopic approach to the preperitoneal space hasbeen popularized within the past 10 years, but many
From the Department of Surgery, Emory University School of Medicine,Atlanta, GA.Address reprint requests to Gene D. Branum, MD, Department of Surgery,Emory University School of Medicine, Surgery Research, 5105 WMB, 1639 PierceDr, Atlanta, GA 30322.Copyright 9 1999 by WB. Saunders Company1524-153X/99/0102-0010510.00/0
surgeons are uncomfortable with the expense of thistechnique and the requirement for general anesthesia. 3-5Stoppa's giant prosthetic reinforcement of the visceralsac (GPRVS) calls on Pascal's principle of hydrostaticpressure and the incorporation of the mesh into healingconnective tissue to achieve its excellent results. From anengineering perspective, the principle of distributingintra-abdominal pressure over a wide area instead ofrelying on sutures close to a hernia defect from ananterior approach is very attractive. The Kugel repairuses the same principle as the GPRVS with a minimallyinvasive approach.The Kugel herniorrhaphy uses a 2.5- to 4-cm incisionfor access to the preperitoneal space. After digital dissec-tion and direct visualization of the space and reduction ofany direct, indirect, or femoral hernias, the two-layer,self-expanding, polypropylene mesh patch is placed andpositioned to cover the direct space, internal ring, andfemoral canal. Neither stapling nor suturing the mesh toCooper's ligament or the iliopubic tract is required, andthe mesh is secured to the transversalis fascia with asingle stitch.
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 203-210