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Published by marquete72
Kugel Hernia repair
Kugel Hernia repair

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Published by: marquete72 on Jan 21, 2009
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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
204 Gene D. Branum
The landmarks for the skin incisions are the location on the skinoverlying the pubic tubercle and the location on the skin overlying theanterior superior iliac spine (ASIS). The midpoint of this line is then used as aguide for an incision that is one third lateral and two thirds medial to thatpoint. 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 incisionshould be at least 4 cm above the superior border of the symphysis pubis, sothe midpoint may need to be moved I to 3 cm superiorly. This drawing showsthe location of the skin incision relative to the underlying structures. Notethat the incision is lateral to the inferior epigastric vessels and lateral to therectus sheath. The incision is superior and medial to the internal ring. Theilioinguinal nerve is rarely seen, because it is inferior and lateral to thedissection.
Open Preperitoneal Herniorrhaphy (Kugel) 2052 The external oblique is retracted and bluntdissection with clamps exposes the transversalisfascia, which is then incised vertically exposing theunderlying golden-yellow preperitoneal fat. It iscritical 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 toproperly deploy the patch. Cooper's ligament ispalpable 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 thedirect space. A sponge that is completely opened andplaced medially into the space facilitates the dissec-tion.
e y
] The cord structures and an indirect herniasac are evident at the lateral aspect of the incision.The sac is reduced through the internal ring andis separated from the cord structures in a manneranalogous to an anterior cord dissection. Thedissection must be carried superiorly to the pointwhere the vas deferens and cord vessels diverge.At this point, the sac may be transected andremoved (recommended) or packed away superi-orly and posteriorly.

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