Tension-Free Mesh Plug Hernioplasty
C. Randle Voyles, MD, MS
I begin this discourse with a confession: I do not consider
myself a "herniologist." Rather, I am a full-time clinical
surgeon with a published interest in the very practical
aspects of surgery. After performing over 2,200 laparo-
scopic cholecystectomies and a wide variety of other
advanced laparoscopic techniques, I proclaim some de-
gree of expertise in laparoscopy. Within this framework, I
have investigated the evolving laparoscopic hernia re-
pairs with considerable interest, but found them lacking;
too much potential risk and extra expense, and precious
little data to support the additional risks and costs for my
patient. Paradoxically, the intense interest in laparoscopic
hernia repair brought existing open hernia repairs into
focus: After a fairly intensive overview, the mesh plug
repair (Bard-Davol, Cranston, RI) seemed to offer several
advances over both conventional and laparoscopic hernia
repair. An audit of our early results showed outcomes that
compare favorably with all published laparoscopic series.
In selecting what would be the ideal hernia repair for a
wide range of surgeons, several factors and constraints
must be recognized. Because hernias are repaired in
virtually every community in the civilized world, by
surgeons with varying levels of interest and expertise, it is
imperative that the ideal operation be readily duplicated
and easily standardized. I submit that common sense
combined with a critical review of existing literature
supports several technical concepts that might be incor-
porated into the ideal procedure: (1) easy operations are
easy to perform, hard ones are more difficult; (2) less
dissection is associated with less pain; (3) blind dissec-
tion should be avoided; (4) repairs should be accom-
plished free of tension; (5) prosthetic mesh replacement/
reinforcement is preferred to simple reapproximation of
attenuated tissues; and (6) the preperitoneal placement
of mesh offers theoretical advantages over an anterior
onlay.
There are recurring problems, mostly related to uncon-
trolled bias within the existing hernia literature. Almost
every hernia repair, regardless of technique, can be
From the Department of Surgery, University of Mississippi School of Medicine,
Jackson, MS.
Address reprint requests to C. Randle Voyles, MD, MS, Department of Surgery,
University of Mississippi School of Medicine, 1421 North State St, Nol 304,
Jackson, MS 39202.
Copyright 9 1999 by WB. Saunders Company
1524-153X/99/0102-0008510.00/0
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 197-202
supported by glowing reports of success. To make
matters worse, much of the technique-specific literature
emanates from technique-specific "hernia centers"; many
offer comparisons to either historical controls or commu-
nity standards that are inferior to the work of good
surgeons. The observer bias in the published literature
may come from the surgeon, the editor, and even the
patient. 1 Accordingly, the critical reader should antici-
pate and correct for this pervasive influence. The early
enthusiasm with laparoscopic cholecystectomy may have
given laparoscopic hernia repair an overly exuberant
introduction. To complicate matters further, many laparo-
scopic studies and training centers were funded and
supported by a medical industry that would benefit from
the sale of laparoscopic instrumentation. As has been
shown numerous times before, the absolute and correct
answer is often best found between the written lines by
the highly critical reader:
"And thus do we of wisdom and of reach,
9 and with assays of bias
By indirections find directions out."
--William Shakespeare, Hamlet
A cross-study analysis of the control groups of several
comparative trials shows several interesting points: (1)
The need for improvement in community hernia repair is
undeniable, 2 especially if the community standard is a
nonmesh repair. 3 (2) Standardization of technique--a
process that improves outcomes with any surgical proce-
d u r e - w a s more fully implemented in the experimental
arm of the trials. (3) In the largest meta-analysis of
comparative trials, 4 there is a major difference in control
groups favoring open-mesh repairs over open-sutured
control groups. (4) In the meta-analysis, the outcomes of
open-mesh repairs are the same as !aparoscopic repairs;
this latter point is especially significant because bias and
standardization should favor the experimental laparo-
scopic arm. (5) Every study attests to the greater costs of
laparosc0pic repairs,, and the number of potential long-
term complications of laparoscopic repairs is growing.
Accordingly, many of us remain perplexed at the persist-
ing interest and ongoing studies in developing laparo-
scopic hernia repairs9
The mesh-plug hernia repair has been incorporated
into our practice as a simple, expeditious, and reliable
repair. 5 This technique can be accomplished at a reason-
able cost and satisfies the criteria listed previously. Our
197
198
several-year experience by "community surgeons" com-
pares favorably with those from hernia centers, suggest-
ing that the procedure is readily standardized. The mesh
plug repair has become the primary hernia repair in our
prolaparoscopic community.
APPLICATION OF THE SURGICAL
TECHNIQUE
Patient Education
Preoperative patient education is critical for an early
recovery with any operation because many patients have
preconceived ideas about an unnecessarily long recovery.
The success of our educational program is evidenced by
an increasing tendency for well-motivated patients to
request Friday operations so that the weekend can be
used for recovery prior to a return to work on Monday.
Oftentimes, patients are referred for, or initially request a
laparoscopic hernia repair, whereupon we offer that the
"latest" hernia repair is an evolutionary product arising in
the aftermath of earlier ]aparoscopic efforts.
Ambulatory Care Center vs Hospital
If t h e goal of the surgeon and insurer is to limit
unnecessary costs, perhaps the most important decision
(after the choice of the appropriate operation) is to select
the most appropriate facility for the operative procedure.
The free-standing ambulatory surgery center seems most
appropriate for all but the sickest patients, because the
costs associated with the center are typically about 60%
of those in hospitals. The geographic proximity of the
preoperative holding area, the operative suite, and the
recovery area provide convenience for the patient and
surgeon. Numerous studies attest to the success of
discharge within i to 3 hours after open hernia repair, but
early discharge occurs more reliably with open rather
than laparoscopic hernia repair.
Anesthesia
The mesh plug repair can be accomplished with either
local, regional, or general anesthesia. Although epidural
anesthetics offer a theoretical benefit, our community
practice is to use general anesthesia for healthy patients
and local anesthesia for the more infirm. Local anesthesia
is generally given with moderate intravenous sedation
monitored by an anesthesiologist in our center. There is
little cost-differential between local and general anesthe-
sia when an anesthesiologist is in attendance.
Preparation
The skin is shaved unilaterally in the preoperative
holding area, which will ensure that the correct side is
repaired. Although some have suggested that shaving is
c. Randle Voyles
unnecessary, skin closure and application of dressings are
generally facilitated by the absence of hair. The surgical
preparation can be accomplished by either iodine or
alcohol solution, depending on local preferences and
patient allergies. If the alcohol preparation is used, drying
must be assured before the use of the electrosurgical
instruments to avoid flash burns.
Skin Incision
The skin incision is typically 5 to 8 cm in length. Larger
patients generally require larger incisions to provide
adequate exposure at the fascia] level. The amount of
pain that the patient experiences postoperatively prob-
ably correlates more with the tension placed on the fascia
rather than length of the incision. Furthermore, even a
longer incision in the bikini line is quite acceptable
cosmetically. Even when a general anesthetic is used, the
lateral and peripheral aspect of the incision is infiltrated
with bupivacaine at the initiation of the procedure.
Excessive infiltration of the incision site increases the
conductivity of electricity and diminishes the precision
of desiccation by electrosurgery.
General Exposure
Once the skin incision is completed, the subcutaneous
tissue is separated down to the fascia of the external
oblique using electrosurgery for both cutting and desicca-
tion. Using a scalpel, the external oblique fascia is opened
and the fasciotomy extended into the superficial ring
with scissors. Care is taken not to injure the ilioinguinal
nerve during elevation of the external oblique. A finger is
then used to elevate the external oblique off the deeper
structures. Using careful blunt and sharp dissection, the
cord structures are mobilized medially, looped with a
Penrose drain, and elevated up to the deep ring. The
ilioinguinal nerve is mobilized along with the cord
structures. The genitofemoral nerve is not dissected.
During elevation of the cord structures, the integrity of
the structural floor of the inguinal canal is readily
assessed. The hernia classifications have recently been
modified by Dr Lloyd M. Nyhus based on the integrity of
the posterior wall of the inguinal canal (Table 1).6
Table 1. Nyhus Classification of Inguinal Hernia
Type Indirect hernia: internal ring with normal size, configuration,
and structure; pediatric population
Type II Indirect hernia: internal ring enlarged; posterior abdominal
wall intact; hernia sac not in scrotum,
Type Ilia Direct hernia
Type IIIb Indirect hernia: internal ring enlarged, encroaching the poste-
rior inguinal wall (scrotal, sliding, pantaloon)
Type lllc Femoral hernia
Type IV Recurrent hernia: IVa, direct; IVb, indirect; IVc, femoral; IVd
combined
Tension-Free Mesh Plug Hernioplasty
Indirect Inguinal Hernia (Nyhus I and II)
The investing cremasteric fibers are incised longitudi-
nally in an anteromedial location. No effort is made to
"skeletonize" the cord structures. Using a combination of
sharp and gentle blunt dissection, the inguinal hernia sac
is identified. The Nyhus type I and II hernia sacs are
readily dissected free from adjacent structures and then
mobilized proximally into the deep ring. The occasional
lipoma of the cord is either removed or inverted, along
with the peritoneal sac. It is important to emphasize that
the well-innervated peritoneal sac is not the cause of the
hernia but, rather, is the aftermath of a weakness of the
fascial floor. The hernia sac is not opened but instead is
simply inverted or invaginated to its original location.
Transection and suturing of the peritoneum is unneces-
sary and may be a source of discomfort with conventional
hernia repairs.
The invaginated hernia sac is held in position by
placement of a prosthetic conical plug (see Fig 1). As a
matter of concept, the composite of the invaginated
peritoneum and prosthesis provides a matrix or bridge
that fills the fascial defect in a preperitoneal location.
Moreover, the prosthetic material is subsequently infil-
trated by a fibroblastic proliferation, and contraction
occurs. The prostheses are provided in varying sizes. As a
key concept, the plug needs to be large enough to fill the
fascial defect, but not so large as to stretch the perito-
neum, raising the possibility of peritoneal ischemia. Each
1 Preshaped conical prosthetic plugs and onlay graft (Bard-Davol, Cranston, RI).
199
plug may be tailored by either trimming the edges or
removing internal petals.
T h e p r o s t h e s i s m u s t b e s t a b l e in its appropriate
l o c a t i o n . With some early indirect hernias (Nyhus type
I), only one or two absorbable sutures (if any) may be
required. With larger hernias, more sutures are needed (see
Fig 2). However, it is not essential to have deep-seated
sutures; rather, a "stuff-to-stuff' suture simply holds the
prosthesis in place until a fibroblastic reaction occurs in a
matter of a few days. If the operation is performed under
local or regional anesthesia, a patient cough or valsalva
assures the surgeon of the security of the prosthesis.
After the fascial defect has been "plugged", the floor of
the canal is reinforced by an anterior onlay of a sheet of
mesh (see Fig 3). A prefashioned elliptical sheet of mesh
contains a "keyhole" and lateral tails for the passage of
the cord structures. The mesh should be large enough to
cover the pubic tubercle and surrounding fascial margins,
but should be positioned without major wrinkling; an
occasional superficial "tacking" suture may be required
for the latter.
The n u m b e r of sutures required to secure the anterior
onlay has been debated. If the inguinal floor is strong,
there may be no need to suture the onlay mesh to the
inguinal ligament or the internal oblique fascia. Larger
hernias with attenuated tissues require more sutures.
Each suture increases the potential for hematoma or local
tension; accordingly, these sutures should be absorbable
200 c. Randle Voyles

2 Nyhus type II indirect right-inguinal hernia repair with secured plug.

'tCediel

3 Anterior sheet of prefashioned mesh reinforces right inguinal

floor.
Tension-Free Mesh Plug Hernioplasty
and used sparingly. My preference in all cases is to place
at least one suture to secure the tails of the mesh around
the keyhole, making sure that the prosthetic "deep ring"
is of adequate size for the cord structures. In addition, I
think the composite concept is reinforced when at least
one suture adjoins the anterior onlay to the prosthetic
plug, especially with larger hernias.
After the cord structures are replaced within the canal,
the external oblique fibers are reapproximated with
running absorbable suture. Additional bupivacaine is
infiltrated underneath the external oblique and into the
subcutaneous tissues of the incision. The subcutaneous
tissue is loosely reapproximated and the skin is closed
with a running absorbable suture: Occasionally, adhesive
strips help to reinforce the skin closure and then a
transparent dressing is applied, allowing the patient to
observe the incision and shower on the day of the
operation if desired.
Direct Inguinal Hernia
Direct inguinal hernias are approached with the same
incision just described. Once the cord structures are
elevated, the direct hernia sac is dissected sharply to its
base, which consists of attenuated transversalis fascia.
The hernia sac is elevated and the "neck" of the sac is
scored with electrocautery, leaving an anterior edge of the
floor through which the hernia sac and contents are
invaginated. As outlined with indirect hernia repair, a
plug size is chosen that will fill the new defect in the
4 Base of direct right-inguinal hernia is scored before invagination of sac.
201
floor, but avoid tension on the deeper structures. Do not
place such a large plug that it does not rest comfortably
within the invaginated hernia. Only on rare occasions
will more than one prosthesis be needed. The mesh plug
is secured to the scored edge of transversalis with several
sutures (see Fig 4); larger defects require more sutures,
but all must be sutured. Similarly, large hernias with very
attenuated tissues may require more extensive suturing
of the onlay prosthesis, m u c h like the earlier Lichtenstein
tension-free repair. Before placing the onlay, the surgeon
must be assured that there is no coexisting indirect
hernia sac.
Pantaloon Hernia
The pantaloon hernia includes a combination of indirect
and direct inguinal hernias. Each defect is repaired
separately. As would be expected, complex hernias are
more difficult to repair and are associated with more
discomfort postoperatively.
Recurrent Hernia
Most recurrent hernias are easily repaired using the mesh
plug technique. In our previous audit, recurrent hernias
took about 8 minutes longer to repair compared with
primary hernia repairs. Depending on the initial repair,
the dissection with recurrent hernias may be more
complicated; rather than attempting to identify all struc-
tures, the hernia sac is dissected, inverted, and plugged.
202
Sliding Hernia
With the long-standing sliding hernia, the major diffi-
culty is separating the hernia contents from the sac and
then deciding how m u c h of the sac to remove from the
cord structures. Although it may seem aesthetically
pleasing to have the entire sac removed, damage to the
cord structures and ischemic orchitis are common, there-
fore the distal sac is opened widely and left in situ. Thus,
the goals of dissection should include circumferential
transection of the hernia sac near the deep ring; we then
close the peritoneal defect with sutures and repair the
large fascial defect with a heavily sutured anterior onlay
of mesh. The additional benefit of the mesh plug in these
particularly difficult cases is not readily apparent.
Femoral Hernia
Femoral hernias are repaired with an infrainguinal ap-
proach. The prolapsed hernia sac often requires opening
in order to reduce the sac and contents. The femoral
hernia defect is generally quite small. After the tissues
and sac are reduced, they are held in place by a small plug
that is fashioned by rolling a small piece of polypropylene
mesh on itself. Any lateral suture should be quite
superficial to avoid injury to the femoral vein.
Postoperative Instructions
In a recent audit, discharge was accomplished in a mean
of 2 hours and 6 minutes after operation. Patients are
routinely encouraged to resume all normal activities as
their discomfort allows. The average patient takes be-
tween three and four narcotic pain tablets and drives an
automobile within 3 to 4 days. Interestingly, return to
work correlates with income (Table 2), with the higher
income group returning to work in less than 4 days. Of
c. Randle Voyles
Table 2. Return to Normal Activity According to Income Group
Income ($K)/yr <20 20-50 >50
No. of days until able to drive 4.0 3.7 3.8
No. of days patient missed work 9.3 6.3* 3.8*
*P < .05.
course, the lower income group likely has more strenu-
ous physical tasks to perform, thus playing a role in
longer recovery. Nonetheless, the demonstrated early
return to work compares favorably with all prospectively
accumulated series of other repairs.
Patients are seen at 1 week postoperatively and then as
needed until all postoperative problems have resolved. It
has been difficult to ask patients to return for annual
examinations because the recurrence rate is no more than
1%. However, they are instructed to return for any
perceived problems.
REFERENCES
1. Barkum JS, Wexler MJ, Hinchey EJ, et al: Laparoscopic vs. open
inguinal herniorrhaphy: Preliminary results of a randomized
controlled trial. Surgery 118:703-709, i995
2. Liem NSL, Van der Graaf Y, van Steensel CJ, et al: Comparison of
conventional anterior surgery and laparoscopic surgery for ingui-
nal hernia repair. N EnglJ Med 336:1541-1547, 1997
3. Hay JM, Boudet MJ, Fingerhut A, et al: Shouldice inguinal hernia
repair in the male adult: The gold standard? Ann Surg 222:719-
727, 1995
4. Chung RS, Rowland DY: Meta-analysis of randomized controlled
trials of laparoscopic vs conventional inguinal hernia repairs. Surg
Endosc 13:689-694, 1999
5. Rutkow IM, Robbins AW: "Tension-free" inguinal herniorrhaphy: A
preliminary report on the "mesh plug" technique. Surgery 114:3-8,
i993
6. Nyhus LM: Individualization of hernia repair: A new era. Surgery
114:1-2, i993