This action might not be possible to undo. Are you sure you want to continue?
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 laparoscopic cholecystectomies and a wide variety of other advanced laparoscopic techniques, I proclaim some degree of expertise in laparoscopy. Within this framework, I have investigated the evolving laparoscopic hernia repairs 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 incorporated 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 dissection should be avoided; (4) repairs should be accomplished 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 uncontrolled 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
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 community 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 anticipate 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 laparoscopic 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, 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 proced 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 laparoscopic arm. (5) Every study attests to the greater costs of laparosc0pic repairs,, and the number of potential longterm complications of laparoscopic repairs is growing. Accordingly, many of us remain perplexed at the persisting interest and ongoing studies in developing laparoscopic 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 reasonable cost and satisfies the criteria listed previously. Our
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 197-202
198 several-year experience by "community surgeons" compares favorably with those from hernia centers, suggesting that the procedure is readily standardized. The mesh plug repair has become the primary hernia repair in our prolaparoscopic community.
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.
APPLICATION OF THE SURGICAL TECHNIQUE
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 probably 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.
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.
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 desiccation. 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
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 anesthesia when an anesthesiologist is in attendance.
Table 1. Nyhus Classification of Inguinal Hernia Type Type II Type Ilia Type IIIb Type lllc Type IV Indirect hernia: internal ring with normal size, configuration, and structure; pediatric population Indirect hernia: internal ring enlarged; posterior abdominal wall intact; hernia sac not in scrotum, Direct hernia Indirect hernia: internal ring enlarged, encroaching the posterior inguinal wall (scrotal, sliding, pantaloon) Femoral hernia Recurrent hernia: IVa, direct; IVb, indirect; IVc, femoral; IVd combined
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
Tension-Free Mesh Plug Hernioplasty
Indirect Inguinal Hernia (Nyhus I and II)
The investing cremasteric fibers are incised longitudinally 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 unnecessary 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 infiltrated 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 peritoneum, raising the possibility of peritoneal ischemia. Each
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
Preshaped conical prosthetic plugs and onlay graft (Bard-Davol, Cranston, RI).
c. Randle Voyles
Nyhus type II indirect right-inguinal hernia repair with secured plug.
3 Anterior sheet of prefashioned mesh reinforces right inguinal
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.
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.
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.
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
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 structures, the hernia sac is dissected, inverted, and plugged.
Base of direct right-inguinal hernia is scored before invagination of sac.
c. Randle Voyles
Table 2. Return to Normal Activity According to Income Group Income ($K)/yr No. of days until able to drive No. of days patient missed work *P < .05. <20 4.0 9.3 20-50 3.7 6.3* >50 3.8 3.8*
With the long-standing sliding hernia, the major difficulty 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, therefore 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 hernias are repaired with an infrainguinal approach. 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.
course, the lower income group likely has more strenuous 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.
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 inguinal 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 222:719727, 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
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 between 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
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.