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228
D.L. Sanders et al.
Fig. 12.29 Sutures are placed between the transversalis abdominis
arch and Cooper’s ligament as far as the femoral vein
the pubic tubercle and continued laterally to the medial edge
of the femoral vein. Each is placed carefully under direct
vision and held before serial knotting (Fig. 12.29) and placed
between the transversus arch the ‘white line’ and the iliopectineal (Cooper’s) ligament. The femoral vein is retracted and
protected by a retractor. The femoral canal is then narrowed by
placement of two or three transition sutures of non- absorbable
sutures between Cooper’s ligament and the anterior femoral
fascia (sheath). The lateral suture is placed just lateral to the
last suture in Cooper’s ligament; the medial two or three are
medial to this and go between the Cooper’s ligament sutures
(Fig. 12.30). The repair is now continued laterally between the
transversus abdominis arch and the anterior femoral fascia
with the line of sutures just displacing the internal ring laterally but not placing any sutures lateral to the cord. These
sutures are of monofilament, non-absorbable material. The
sutures are now tied beginning medially and a new internal
ring created such that a haemostat can be inserted between the
last tied suture and the cord.
Closure
Fig. 12.30 The femoral canal is closed with two or three transition
sutures between Cooper’s ligament and the anterior femoral fascia
Remembering that aponeurotic wounds are slow to regain
strength, non-absorbable sutures are used for this layer. A
new superficial inguinal ring is constructed at the medial end
of the canal. Care should be taken during the suturing to
spare the ilioinguinal nerve from the suture line. The repair
is now complete, and if all the layers have been sutured
exactly as described, the loads on the suture lines should be
well distributed; there should be no undue tension and no
splitting of fibre bundles. Indeed, the structures should have
just ‘rolled together’ (Fig. 12.31).
Subcutaneous Tissue and Skin Closure
The subcutaneous tissue is carefully closed with interrupted
absorbable sutures. No ‘dead spaces’ should be left, and the
fat should be closed so that the skin is closely approximated.
If there is much tissue trauma or dead space, a closed drain is
useful in this layer but seldom necessary (Fig. 12.32). The
skin is closed with a subcuticular absorbable suture
(Fig. 12.33).
External Oblique Aponeurosis
Now that the cord has been replaced, the external oblique
aponeurosis can be closed over it. This can be performed as
a single continuous suture or a ‘double breasting’ technique.
Postoperative Management
Pain is an unavoidable feature of any postoperative course,
and the optimal treatment for this remains controversial.
It is clear, however, that early postoperative pain can be
12 Anterior Open Repair of Inguinal Hernia in Adults
Fig. 12.31 The external oblique aponeurosis is closed anterior to the
cord. Thus, the inguinal canal is reconstituted with the superficial ring
recreated
229
Fig. 12.33 The skin is closed with a subcuticular continuous absorbable suture
Fig. 12.32 Closure of the subcutaneous tissue using an absorbable
suture
reduced by the infiltration of local anaesthetic in either
the subcutaneous or subfascial plane or regional nerve
blocks. It reduces the need for supplemental analgesia and
as such is recommended for all open groin hernia repairs.
The use of paracetamol and a NSAID or selective COX-2
inhibitor is recommended for the delayed pain and upon
discharge.
The advice given to patients regarding returning to
employment and physical activity is highly variable and is
often not evidence based. There is currently no evidence of
an increased risk of recurrence or complications in patients
who return to normal activities early. An RCT of 2365
patients demonstrated that a short recovery period can be
safely recommended without increasing recurrence risk. The
most common reasons given for delayed return to activity are
pain and wound-related problems [101]. Other studies have
recorded convalescence periods in patients with non-
restrictive postoperative recommendations and reported a
1-week absence from domestic activities [31, 102–108],
1–2 weeks away from work [102–105, 109–118] and
1–3 weeks before return to physical activities [102, 104, 106,
110, 113, 117].
The available evidence appears to suggest that all activities can be safely resumed within 3–5 days in most cases,
without increasing their risk of complications.
Conclusions
Despite the countless procedures performed since the
sixteenth century, complications still occur, which impact
on patient’s quality of life and infer increased cost to the
healthcare system. It is also apparent, however, that there
is no single optimal technique for inguinal hernia repair.
Every patient is different, and the ability to offer multiple
techniques is now a key part of a hernia surgeon’s
armoury. From hernia-related factors (size, site, primary
or recurrent) to patient-related factors (gender, co-mor-
bidities, importance of cosmesis) to surgeon experience
and preference, identifying the best technique for the
patient in front of you is a challenge faced by all sur-
geons. A widely used classification system may aid in
this decision as it will allow long-term follow-up and
research into outcomes for different repair techniques in
different populations. Until this is achieved, we rely on
experience and shared knowledge to build our skill set
and enable us to provide the optimal service to our
patients.
230
D.L. Sanders et al.
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Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Martin Kurzer
13
Introduction
Open preperitoneal mesh repairs of groin hernias place nonabsorbable mesh through an abdominal incision in a plane
outside the peritoneal cavity, between the peritoneum and the
anterior abdominal wall. They are in effect open versions of
a totally extraperitoneal (TEP) laparoscopic repair.
What I would call the ‘classical’ preperitoneal repairs
were developed just prior to the laparoscopic era as a way of
dealing with difficult recurrent groin hernias with extensive
scarring and tissue loss. When this chapter was first written,
5 years ago, I therefore questioned whether, in the current era
of laparoscopic surgery, open preperitoneal repair would
become obsolete. However there has recently been a resurgence in interest in placing mesh in the preperitoneal plane.
However these more ‘modern’ preperitoneal techniques are
being advocated for primary inguinal hernia repair, devised
in the expectation of reducing the incidence of long-term
post-operative discomfort that is possibly related to the presence of mesh in the inguinal canal.
This chapter reviews the history and development of the
classical approach and describes the newer small incision
techniques with their reported results. Detailed descriptions
of the various methods are available in the original papers
and textbooks, all well worth reading. However I would
strongly encourage visiting and watching the procedure
being carried out by an expert as the best way to learn.
History
The preperitoneal approach to the groin is historically associated with the names of Annandale, Cheatle and Henry who
all recognised the excellent access afforded to the posterior
aspect of the abdominal wall in the region of the inguinal
M. Kurzer
St John and St Elizabeth Hospital, London, UK
e-mail: m.kurzer@mac.com
canal [1, 2]. It was seen as an ideal method of dealing with
incarcerated or strangulated groin hernias. The interested
reader might like to refer to Raymond Read’s comprehensive
review [3].
It was Nyhus and Read in the USA in the late 1950s who
first became interested in and reported its use for recurrent
and complex groin hernias [4–6]. In the case of multirecurrent hernias, often with extensive scarring and tissue loss,
and before the introduction of modern meshes, effecting a
good long-term repair with a conventional approach was
almost impossible. Recurrence rates could be well over 50%,
and many multirecurrent hernias with extensive scarring and
tissue loss were deemed ‘inoperable’. In addition the likelihood of testicular atrophy was high [7]. Read used a transinguinal approach, but Nyhus was dissatisfied with the
results obtained for recurrent hernias when operating through
the previous incision to entering a scarred inguinal canal, and
he devised a preperitoneal approach through a transverse
incision sited above the level of the inguinal canal. This
allowed the operation to be carried out in a virtually virgin
field with excellent views, completely avoiding scar tissue
from previous surgery. Nyhus reported that the dissection
was straightforward and the defect or defects were easily
seen and assessed. However despite the advantage of easy
access and good visualisation, the failure rate was still
high—as much as 30%—if the margins of the defect were
simply sutured. He therefore added what he termed a ‘prosthetic mesh buttress’ attached to the superior pubic ramus
(Cooper’s ligament) in order to reinforce his sutured repair.
The incidence of re-recurrence dropped dramatically [“There
were no re-recurrences after we adopted the routine placement of the prosthetic mesh buttress to bolster the anatomic
repair”], and this technique rapidly became his routine for
virtually all cases. It is puzzling that although the access and
views that the preperitoneal approach afforded of the posterior aspect of the inguinal canal and femoral region (the
myopectineal orifice) were excellent, it never gained wide
acceptance amongst other surgeons. Nyhus published a
38-year review of his work in 1993 [8], describing the
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_13
235
236
M. Kurzer
technique again, and could not understand why general surgeons refused to adopt it. Nyhus wrote, ‘My associates and I
were perplexed about the failure of this method to flourish’.
The Myopectineal Orifice
In the early 1960s, surgeons in France, Stoppa in Amiens [9]
and Rives in Reims [10], also began using a preperitoneal
method for complex, recurrent groin hernias, and from the
outset, they used mesh in every case. Stoppa developed his
procedure based on the work of Henri Fruchaud, a French
anatomist and surgeon [11] who described a weak area of the
groin known which he called the myopectineal orifice
(MPO). The borders of the MPO are the internal oblique
muscle superiorly, the iliopsoas laterally, the rectus muscle
medially and the superior pubic ramus inferiorly (Figs. 13.1
and 13.2). This bony muscular framework is divided into two
by the inguinal ligament, traversed by the spermatic cord
above and the femoral vessels below. Failure of the transversalis fascia in this area to retain the peritoneum then becomes
the fundamental cause of all hernias of the groin, and protrusion of a peritoneal sac through the myopectineal orifice
defines a hernia [12]. In a preperitoneal prosthetic mesh
repair (open or laparoscopic), the mesh prosthesis substitutes
for the defective or weakened transversalis fascia, and the
peritoneum is held like a balloon in a string bag so that closure of the defect is not necessary. Thus Stoppa’s genius was
in proposing the radical step that no attempt should be made
to close the actual defect, thus avoiding any tension. Rignault
put it well—‘The idea of interposing a large surface of prosthetic mesh between the peritoneum and the deficient inguinal wall instead of ‘mending’ the defect represents a radical
departure from previous methods of hernia repair. The mesh
must be much larger than the defect, since it is not sutured in
place and only intra-abdominal pressure maintains it in place
over the hernia defect [13]. This concept has subsequently
been vindicated and is of course now a standard practice in
laparoscopic repair where the use of a prosthesis with a wide
overlap of the area is mandatory.
Classical Preperitoneal Methods
Stoppa called the procedure ‘La Grande Prothese Reinforce
de Sac Visceral’, and this was translated verbatim, by George
Wantz, as giant prosthetic reinforcement of the visceral sac
[14]. Hence the operation is also known, somewhat cryptically, as GPRVS.
At that time Rives was using a trans-inguinal approach, as
was Raymond Read, and thus in doing so, they still had to
operate through the scar tissue from previous surgery. In
addition, in the Rives technique, the mesh had to be cut and
shaped in a complex fashion [10]. Other groups have also
described trans-inguinal techniques for preperitoneal mesh
placement with one claimed advantage being the ability to
carry out the procedure under local anaesthesia [15, 16].
Wantz in the USA was impressed with the Stoppa’s technique and modified it for unilateral hernias [14]. He was dissatisfied with what he termed preperitoneal ‘patch
hernioplasty’ (developed by Raymond Read—a prosthesis
that was just sutured to the edges of the defect [17]), and he
Fig. 13.1 Fruchaud’s myopectineal orifice (MPO). Right side, anterior
view
Fig. 13.2 Fruchaud’s MPO. Right side, posterior view
ab
13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
237
saw the sense of using a large piece of mesh with a wide
overlap, as is now a standard practice with a laparoscopic
repair. His unilateral version of the operation used the Nyhus
transverse lower quadrant incision combined with Stoppa’s
technique of inserting a large piece of mesh, covering the
whole of the myopectineal orifice on that side, without
attempting to close the defect.
Both the unilateral (Wantz) and bilateral (Stoppa) techniques were particularly well suited to complex and multirecurrent defects. Like the Nyhus procedure, they were never
widely adopted, possibly because of general surgeons’ unfamiliarity with, and reluctance to venture into, the preperitoneal space. Of course the modern era of laparoscopic surgery
started at about this time, and it is interesting to observe that
surgeons today have no concerns about entering this space
with a laparoscope.
Operative Technique: Stoppa and Wantz
Both procedures require a wide deep dissection and a relaxed
abdominal wall.
Stoppa used a lower midline incision routinely, but a
Pfannenstiel incision [18, 19] gives excellent access, less
post- operative discomfort and a better cosmetic result
(Fig. 13.3) [12, 20] (Figs. 13.4, 13.5, and 13.6).
The Stoppa prosthesis was chevron shaped (Fig. 13.7),
and a complex arrangement of eight long clamps was used to
insert the mesh (Figs. 13.7, 13.8, 13.9, and 13.10) which was
held by one single midline suture (Fig. 13.11).
The unilateral Wantz operation has been comprehensively
and clearly described elsewhere in detail by Wantz [17, 22].
Wantz positioned and secured the prosthesis as shown [23],
again using clamps to position the lower edge of the prosthesis deep in the pelvis (Figs. 13.12, 13.13, 13.14, 13.15, 13.16,
13.17, 13.18, 13.19, 13.20, 13.21, and 13.22).
‘Small Incision’ Preperitoneal Methods
Kugel and Ugahary [20, 24] described methods that allow
access to the preperitoneal space through small incisions.
Believing that placing mesh behind the myopectineal orifice
was desirable, the original aim of these techniques was to
combine the relatively short learning curve and economic
advantages of the open approach with the rapid recovery of
‘minimal access’ surgery.
Fig. 13.3 Access to the preperitoneal space through a vertical or
Pfannenstiel incision
Fig. 13.4 (a, b) Preperitoneal
view of the right groin
(MPO), from the left side of
the patient, showing a right
indirect inguinal hernia
(lateral to the inferior
epigastric vessels) prior to its
reduction, and note the
femoral canal medial to the
femoral vein (from Stoppa
[21], with permission)
238
M. Kurzer
Fig. 13.7 The cardinal points of positioning of the clamps on the sin-
gle bilateral prosthesis to aid in its insertion
a
Fig. 13.5 Parasagittal section to demonstrate the mesh in the extraperi-
toneal or preperitoneal space, lying between the parietal peritoneum
and spermatic cord on one side and the visceral peritoneum and bladder
on the other
b
Fig. 13.6 The triangular appearance of the completed dissection on the
right side, showing the vas deferens passing medially, testicular vessels
passing laterally, and peritoneum. When released, the elements of the
cord will fall against the parietal pelvic wall (parietalization)
Fig. 13.8 (a) The chevron-shaped prosthesis is seized by eight long-
curved clamps. (b) Operator view of the insertion of the bilateral mesh
prosthesis, which is being pushed with clamps nos. 1–5. The numbers
show the order in which the clamps have been used. Clamps nos. 6–8
will be used for the placement of the left part of the prosthesis. This is
a complex maneuver, requiring the surgeon to have a good 3D appreciation of the space as well as a good assistant (from Stoppa [21], with
permission)