Asian Journal of Surgery (2017) 40, 152e157

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.e-asianjournalsurgery.com

ORIGINAL ARTICLE

Initial experience with application of single

layer modified Kugel mesh for inguinal
hernia repair: Case series of 72 consecutive
patients
Pao-Hwa Chen a,c, Heng-Chieh Chiang a,*,c, Yao-Li Chen b,
Jesen Lin a, Bai-Fu Wang a, Meng-Yi Yan a, Chun-Chi Chen a,
Hung-Jen Shih a, Jian-Ting Chen a

a
Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
b
Transplant Medicine and Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan

Received 28 April 2015; received in revised form 25 June 2015; accepted 5 August 2015
Available online 10 March 2016

KEYWORDS Summary Objective: This is an initial review of the safety and efficacy of anterior preperi-
herniorrhaphy; toneal modified Kugel (MK) mesh herniorrhaphy application without using optional onlay mesh.
inguinal; Methods: We retrospectively reviewed patients who underwent herniorrhaphy by a single sur-
Kugel; geon from July 1st, 2009 to December 31st, 2010. During these 18 months, a total of 72 patients
preperitoneal; underwent single-layer MK mesh herniorrhaphy. Anterior preperitoneal approach was used to
transinguinal place the mesh. If the patient’s inguinal hernia defect did not exceed the memory ring of MK
mesh, the onlay mesh was omitted. Postoperative results (wound infection, recurrence, and
chronic pain/discomfort) were recorded and analyzed.
Results: A total of 72 patients underwent anterior preperitoneal single layer MK mesh hernior-
rhaphy. One patient had recurrent hernia after 1 year and was treated with a laparoscopic
transabdominal preperitoneal operation. The most common postoperative complaint was mild
soreness which was self-resolving after 1 month. Mean total operative time (skin to skin) was
73 minutes. The average hospital stay was 2 days. Most of the postoperative complications
including soreness (14%), pain for > 3 months (1.4%), and scrotal hematoma (1.4%) were
self-resolving. One patient experienced wound infection, which was treated with oral antibi-
otics. One patient had recurrence 1 year after the operation.
Conclusion: The postoperative complication and recurrence rates of single-layer MK mesh

Conflicts of interest: All contributing authors declare no conflicts of interest.

* Corresponding author. Department of Surgery, Division of Urology, Changhua Christian Hospital, 135 Nanxiao Street, Changhua City,
Changhua County 500, Taiwan.
E-mail address: 49264@cch.org.tw (H.-C. Chiang).
c
Equal first authors.

http://dx.doi.org/10.1016/j.asjsur.2015.08.001
1015-9584/ª 2017 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services by Elsevier B.V. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Modified Kugel mesh for inguinal hernia repair 153

herniorrhaphy was comparable with previously reported tension-free repair. Single-layer appli-
cation is safe and feasible. A longer follow-up period and larger study group with a control
group are needed to verify our method.
ª 2017 Asian Surgical Association and Taiwan Robotic Surgical Association. Publishing services
by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2.2. Surgical method

Inguinal hernia repair has a long history dating back to as
early as the 19th century, the era of tension repair. As the
technique and technologies evolved over time, the era of
tension-free repair was ushered in with the discovery of
synthetic polymers in 1935.1 In 1999, Dr Kugel introduced
the posterior approach herniorrhaphy, which offers the
benefits of both laparoscopic and open methods but at a
cost of a higher learning curve compared with the tradi-
tional anterior approach.2e7 To minimize the learning
curve, BARD (BARD-Davol Inc., Cranston, RI, USA) intro-
duced the modified Kugel (MK) mesh. The MK mesh is
different from other commercial mesh due to the Posiflex
ring, a hard spring-like material that prevents bending and
folding, and therefore ensures flat placement of mesh.8
The anterior transinguinal preperitoneal (TIPP) approach
in placement of MK mesh has been described in several
studies with similar recurrence and complication rates as in
the posterior approach.9,10 The manufacturer recommends
using the onlay mesh, when the MK mesh is unable to cover
the entire groin area (direct, indirect, and femoral her-
nia).8 We feel this definition is vague and most surgeons at
our institution rarely discard the onlay for fear of future
recurrence. We wanted to narrow the definition and at the
same time try to eliminate excess foreign material being
inserted into patients, hence we started this retrospective
study. Prosthetic mesh has been known to cause injuries to
surrounding tissue.11e15 In theory, the inflammatory
response will decrease with the amount of implanted
prosthetic mesh. Chronic herniorrhaphy pain after Lich-
tenstein repair has been reported to be as high as 40% in
some studies.3,12,16,17 One explanation regarding the high
postoperative discomfort of Lichtenstein repair is the
involvement of the three nerves in the inguinal canal.17e19
This is a review of initial experience using single-layer MK
mesh herniorrhaphy.
2. Methods
2.1. Patients
After obtaining approval from the institution’s review board
(IRB number: 130211), we searched patients who under-
went herniorrhaphy from July 1st, 2009 to December 31st,
2010. A total of 73 consecutive patients underwent the TIPP
approach single-layer MK mesh herniorrhaphy using a small,
oval 8 cm  12-cm MK mesh. An onlay patch was omitted if
the MK mesh was able to cover the entire hernia defect.
A single surgeon (H.C.C.) performed the herniorrhaphy
under spinal anesthesia. General anesthesia was performed
in selected cases where spinal was contraindicated or pa-
tient refusal. A single dose of prophylactic antibiotics
(cefazolin) was used 30 minutes before incision unless there
was a previous allergic reaction. After the induction of
anesthesia, the inguinal region was shaved, and then
cleansed with Hibitane solution.
The incision skin was then disinfected with alcoholic
povidoneeiodine solution, and aquaeb-iodine was used for
the scrotal region. The patient was then draped with sterile
drapes. A 4e5-cm incision was made parallel to the inguinal
ligament. After the hernia defect was identified and
dissected, the preperitoneal space was then created using
wet surgical gauze. We routinely use seven gauzes to create
the preperitoneal space. Using the index finger to protect
the major vessels, the gauzes were inserted in the direction
of the pubic bone, internal ring, conjoint tendon, and
inguinal ligament. An additional three gauzes were piled on
top to dissect the preperitoneal space further and left in the
space for 30 seconds allowing for compression. The MK mesh
was then prepared for insertion into preperitoneal space
with help of a Kelly clamp (Figure 1A). The wet gauzes were
then removed and counted to insure no gauze was left in the
preperitoneal space. After the dissected hernia sac was
pushed back into the peritoneal space, a long forceps was
used to depress the preperitoneal space and the MK mesh
was pushed (Figure 1B and C) in the direction of the pubic
bone. The operator’s index finger was inserted in the middle
slit of the mesh to ensure flat placement (Figure 1D). The
mesh was then secured onto the transversalis fascia and
inguinal ligament with the help of prolene sutures. The
inguinal canal and subcutaneous was then closed using
absorbable sutures. The epidermis was approximated using
3M Steri-Strips (3M Health Care, St. Paul, MN, USA) and
Tegaderm (3M Health Care, St. Paul, MN, USA), which were
removed during subsequent outpatient department follow
up. After the operation, we asked all of our patients to
abstain from heavy work and exercise for a minimum of 4
weeks (1 month) and if possible up to 12 weeks (3 months).
2.3. Patient evaluation
After obtaining review board approval (number: 130211),
medical records were obtained and reviewed, including:
preoperative and postoperative (7 days) physical examina-
tions; postoperative pain evaluated with visual analog scale
scores; and postoperative complications (wound infections,
recurrences, and chronic pain/discomfort). A questionnaire
154 P.-H. Chen et al.

Figure 1 (A) Preparation of modified Kugel (MK) mesh before insertion. The mesh is folded longitudinally like a taco. (B)
Preparation of the preperitoneal space before insertion. The blunt end of the forceps is first inserted into the previously dissected
space pushing the preperitoneal space downward. (C) Insertion of the MK mesh. The folded mesh is placed on top of the long
forceps and slid down into the preperitoneal space. (D) Flattening of MK mesh. An index finger is inserted in the middle slit of the
MK mesh.

Table 1 Telephone questionnaires.

Question 1: Since the last visit/interview, have you experience bulging appearance in the groin region during your daily
activities? (if no, skip to question 4)
Question 2: Does your job require heavy lifting? What other physical activity do you participate on a daily basis?
Question 3: Did you notice the bulging mass or groin pain when you stand up, lift heavy objects, straining, or cough?
Question 4: Have you seek another doctor’s advice or received surgical treatment for the bulging mass or groin pain?
Question 5: Have you experience any pain in groin, scrotum or abdomen? (Assess pain with VAS score)
Question 6: Is there anything that will make the pain worse or better?
Question 7: If persistent pain, have you need to seek medical advice for the pain? Was pain medication prescribed?

with a series of questions (Table 1) was used during tele- 3. Results

phone interviews conducted 3 months, 6 months, and 12
months following the procedures. Any patients with suspi-
cion of recurrence were asked to return to the OPD (Out- 3.1. Patient characteristics
Patient Department) for further examination. The Clav-
ieneDindo system was used to record postoperative com- During the initial 1.5 years, H.C.C. performed anterior the
plications (Table 2). This system was described by Dindo TIPP approach single-layer MK mesh herniorrhaphy on 73
et al20 in 2004 and is a widely used system to classify sur- patients. One patient required an optional onlay patch;
gical complications. therefore, he was excluded from this retrospective study.
At the time of the surgical interventions, the median age
was 68 years and ranged from 30 years to 90 years. The
Table 2 Post-operative complications. median body mass index was 23.62 kg/m2, and the majority
of the patients were male (Table 3). Most patients under-
Complications N Z 72 (%) went spinal anesthesia (n Z 63), and general anesthesia
Soreness 10 14.0% was done on patients who were deemed unfit by the
Recurrence 1 1.4% anesthesiologist (n Z 9). Seven patients had bilateral dis-
Pain < 3 months 2 2.8% ease and three were recurrent cases. The median hernia
Pain > 3 months 1 1.4% repair time (from skin incision to mesh placement) was 25
Wound infection 1 1.4% minutes. The average total operative time including anes-
Scrotal hematoma 1 1.4% thesia and preoperative preparation was 73 minutes and
hospital stay was 2 days (Table 3).
Modified Kugel mesh for inguinal hernia repair 155

familiar surgical approach.10 According to the manufac-

Table 3 Basic data for the initial 72 patients.
turer’s technical guide, the optional onlay mesh can be
Basic Data omitted if the MK mesh covers the entire groin area.
Total number 72 Because most surgeons at our hospital insist on placing
Age (years) 65.32 onlay mesh for fear of future recurrence, we feel that the
BMI (kg/m2) 23.62 definition of omitting onlay mesh needs to be more precise.
Male:Female 70:2 In previous large patient population studies using MK mesh,
Right:Left:Bilateral 33:32:7 the use of onlay mesh was not stated.9,10 In this study, we
Anesthesia method have narrowed the definition of onlay omission (when MK
Spinal 63 mesh covers the posterior wall defect) and demonstrated
General 9 the safety and efficacy. With any new surgical technique, a
Mean hospital stay (day) 2.30  0.51 learning curve is to be expected.6,21,23,24 In the series re-
Mean total OP time (min) 73.32  35.87 ported by Robert Kugel in 19992 and 2003,4 recurrence
happened within the first 6 months of developing the new
method with a total recurrence rate of 0.62%. Several
studies have tried to reproduce the results without suc-
3.2. Complications cess.2,4,6,7,9,10 The two studies with recurrence rates
similar to Dr Kugel’s original study had >500 patients.25,26
Self-resolving complications included 10 patients with Van Nieuwenhove et al7 had a recurrence rate of 1.78%
soreness, two patients with pain for <3 months, and one with a learning curve estimated to be around 25e35 cases.
scrotal hematoma (ClavieneDindo Grade I; Table 4). One Schroder et al6 reported a recurrence rate of 7.25% with an
person experienced chronic postherniorrhaphy pain (>3 estimated learning curve of 40 cases. Because most sur-
months) with a visual analog scale score of 3, which geons are acquainted with anterior approach hernior-
required pain medication (ClavieneDindo Grade II). Wound rhaphy, the anterior TIPP mesh placement will result in a
infection occurred in one patient, which resolved with lower learning curve compared with posterior or laparo-
antibiotic use (ClavieneDindo Grade II). One patient scopic methods.6,7,22,24,27e30 The unfamiliar anatomy,
required laparoscopic preperitoneal repair for bilateral approach method, and inadequate mesh placement are
recurrence 1 year after the operation (ClavieneDindo culprits for recurrence when learning Kugel’s posterior
Grade IIIb). approach.6,10 The anterior TIPP approach, combined with
adequate preperitoneal dissection, will result in a low
learning curve and smooth mesh placement. We estimate
4. Discussion the learning curve to be around 5e10 cases. Our recurrence
rate of 1.4% (1 in 72) is similar to the previous reported
Since the introduction of Kugel posterior herniorrhaphy in series of the posterior and anterior approach
1999, the procedure offers minimal invasive preperitoneal (0.1e7%).6,7,9,10,25,26 Our one recurrence happened within
mesh placement with low complication and recurrence our first 20 cases; the patient underwent laparoscopic
rates.2,4e7,21 However, the posterior approach is associated transabdominal preperitoneal operation. Upon reviewing
with a steep learning curve and high recurrence rate during this case, we suspect that inadequate dissection of the
the early learning period.6,7,10,21,22 By contrast, the ante- preperitoneal space (initially we used 3 wet gauzes for
rior TIPP approach is advantageous for surgeons due to the space dissection) resulted in an inadequate space for mesh

Table 4 ClavieneDindo classification of surgical complications.

Grade Definition
I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical,
endoscopic, and radiological interventions
Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics, electrolytes, and
physiotherapy.
This grade also includes wound infections opened at the bedside
II Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood
transfusions and total parenteral nutrition are also included
III Requiring surgical, endoscopic or radiological intervention
IIIa Intervention not under general anesthesia
IIIb Intervention under general anesthesia
IV Life-threatening complication (including CNS complications)* requiring IC/ICU management
IVa Single organ dysfunction (including dialysis)
IVb Multiorgan dysfunction
V Death of a patient
156
placement. Along with the poor mesh placement, the pa-
tient’s work history, frequent exercise, and poor compli-
ance (he resumed work and exercise within 3 weeks
postoperatively) all contributed to his recurrence. Since
then, we have standardized our preperitoneal dissection
with seven wet gauzes. Since implementing the new
dissection protocol, we noticed a smoother and flatter
mesh placement. Previous reported series defined chronic
pain as pain experienced for >3 months, which occurs in
1e20% of cases.11,12,31e33 In our current study, only one
patient (1.4%) experienced chronic pain postoperatively,
which is comparable with a series using Kugel
mesh.2e4,6,7,11,22 Similar to other studies, we suspect that
the low rate of chronic pain is due to decreased foreign
body inflammatory response and uninvolved inguinal canal
nerves.11,17e19,34
The limitations of our study include: (1) retrospective
study without a control group; (2) the need for a longer
follow-up period with office visits; and (3) telephone
interview as the only follow up modality. Because of the
limited resources and current medical environment in
Taiwan, the second and third limitations would be very
difficult to overcome even with a prospective randomized
study. The questionnaires were set up to serve as history
taking sessions. In cases with suspected recurrence, we
would highly recommend an office visit for further physical
examination.
5. Conclusion
In this study, we reported the safety and efficacy of the
TIPP approach single-layer MK mesh herniorrhaphy. We
have narrowed the definition for onlay mesh applications
and described the method for adequate preperitoneal
dissection. Our study showed that single-layer MK mesh is
adequate without compromising recurrence or complica-
tion rates. A randomized prospective study using a larger
study population and longer follow up would prove our
theory.
References
1. Read RC. Herniology: past, present, and future. Hernia. 2009;
13:577e580.
2. Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal,
and sutureless, inguinal herniorrhaphy. Am J Surg. 1999;178:
298e302.
3. Dasari B, Grant L, Irwin T. Immediate and long-term outcomes
of Lichtenstein and Kugel patch operations for inguinal hernia
repair. Ulster Med J. 2009;78:115e118.
4. Kugel RD. The Kugel repair for groin hernias. Surg Clin North
Am. 2003;83:1119e1139.
5. Kurihara Y, Yamakawa T, Yoshino M, et al. Experience with
direct Kugel patch method for repair of adult inguinal hernia. J
Nippon Med Sch. 2008;75:28e31.
6. Schroder DM, Lloyd LR, Boccaccio JE, Wesen CA. Inguinal
hernia recurrence following preperitoneal Kugel patch repair.
Am Surg. 2004;70:132e136. discussion 6.
7. Van Nieuwenhove Y, Vansteenkiste F, Vierendeels T, Coenye K.
Open, preperitoneal hernia repair with the Kugel patch: a
prospective, multicentre study of 450 repairs. Hernia. 2007;11:
9e13.
P.-H. Chen et al.
8. BARD MK patch with Posiflex Memory Technology: Technique
Guide. 2008.
9. Li J, Zhang Y, Hu H, Tang W. Early experience of performing a
modified Kugel hernia repair with local anesthesia. Surg Today.
2008;38:603e608.
10. Zhou X. Comparison of the posterior approach and anterior
approach for a Kugel repair of treatment of inguinal hernias.
Surg Today. 2013;43:403e407.
11. Hompes R, Vansteenkiste F, Pottel H, Devriendt D, Van Rooy F.
Chronic pain after Kugel inguinal hernia repair. Hernia. 2008;
12:127e132.
12. Inaba T, Okinaga K, Fukushima R, et al. Chronic pain and
discomfort after inguinal hernia repair. Surg Today. 2012;42:
825e829.
13. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. Cause and
prevention of postherniorrhaphy neuralgia: a proposed proto-
col for treatment. Am J Surg. 1988;155:786e790.
14. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with
polypropylene mesh causing inguinal vasal obstruction: a pre-
ventable cause of obstructive azoospermia. Ann Surg. 2005;
241:553e558.
15. Uzzo RG, Lemack GE, Morrissey KP, Goldstein M. The effects of
mesh bioprosthesis on the spermatic cord structures: a pre-
liminary report in a canine model. J Urol. 1999;161:
1344e1349.
16. Amid PK. The Lichtenstein repair in 2002: an overview of
causes of recurrence after Lichtenstein tension-free hernio-
plasty. Hernia. 2003;7:13e16.
17. Koning GG, Keus F, Koeslag L, et al. Randomized clinical trial of
chronic pain after the transinguinal preperitoneal technique
compared with Lichtenstein’s method for inguinal hernia
repair. Br J Surg. 2012;99:1365e1373.
18. Koning GG, de Schipper HJ, Oostvogel HJ, et al. The Tilburg
double blind randomised controlled trial comparing inguinal
hernia repair according to Lichtenstein and the transinguinal
preperitoneal technique. Trials. 2009;10:89, 1e6.
19. Koning GG, Koole D, de Jongh MA, et al. The transinguinal
preperitoneal hernia correction vs Lichtenstein’s technique; is
TIPP top? Hernia. 2011;15:19e22.
20. Dindo D, Demartines N, Clavien PA. Classification of surgical
complications: a new proposal with evaluation in a cohort of 6336
patients and results of a survey. Ann Surg. 2004;240:205e213.
21. Hoste W, Van Nieuwenhove Y, Vierendeels T. Early Belgian
experience with the Kugel patch inguinal hernia repair. Acta
Chir Belg. 2006;106:44e46.
22. Reddy KM, Humphreys W, Chew A, Toouli J. Inguinal hernia
repair with the Kugel patch. ANZ J Surg. 2005;75:43e47.
23. Hernandez JD, Bann SD, Munz Y, et al. Qualitative and quan-
titative analysis of the learning curve of a simulated surgical
task on the da Vinci system. Surg Endosc. 2004;18:372e378.
24. Lau H, Patil NG, Yuen WK, Lee F. Learning curve for unilateral
endoscopic totally extraperitoneal (TEP) inguinal hernioplasty.
Surg Endosc. 2002;16:1724e1728.
25. Ceriani V, Faleschini E, Bignami P, et al. Kugel hernia repair:
open “mini-invasive” technique. Personal experience on 620
patients. Hernia. 2005;9:344e347.
26. Fenoglio ME, Bermas HR, Haun WE, Moore JT. Inguinal hernia
repair: results using an open preperitoneal approach. Hernia.
2005;9:160e161.
27. Frost BM, Hilton J, Stephenson BM, Millikan KW, Doolas A. A
long-term evaluation of the modified mesh-plug hernioplasty in
over 2,000 patients. Hernia. 2008;12:327e328.
28. Millikan KW, Cummings B, Doolas A. The Millikan modified
mesh-plug hernioplasty. Arch Surg. 2003;138:525e529. dis-
cussion 9e30.
29. Takayama S, Imafuji H, Funahashi H, Takeyama H. Laparo-
scopic Spigelian and inguinal hernia repair with the Kugel
patch. Surg Laparosc Endosc Percutan Tech. 2010;20:e76ee78.
Modified Kugel mesh for inguinal hernia repair
30. Takayama S, Sakamoto M, Takeyama H. Laparoscopic inguinal
hernia repair with the Composix Kugel Patch. Int Surg. 2010;95:
54e56.
31. Cunningham J, Temple WJ, Mitchell P, Nixon JA, Preshaw RM,
Hagen NA. Cooperative hernia study. Pain in the postrepair
patient. Ann Surg. 1996;224:598e602.
32. Kumar S, Wilson RG, Nixon SJ, Macintyre IM. Chronic pain after
laparoscopic and open mesh repair of groin hernia. Br J Surg.
2002;89:1476e1479.
157
33. Losanoff JE, Richman BW, Jones JW. Chronic pain after lapa-
roscopic and open mesh repair of groin hernia. Br J Surg. 2002;
89:1476e1479.
34. Singh AN, Bansal VK, Misra MC, et al. Testicular functions,
chronic groin pain, and quality of life after laparoscopic and
open mesh repair of inguinal hernia: a prospective randomized
controlled trial. Surg Endosc. 2012;26:1304e1317.