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13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 13.9 Stoppa’s recommended placement of the single suture to
fixate the giant prosthesis
Fig. 13.12 Wantz unilateral procedure makes the transverse incision
above the level of the deep inguinal ring, from the midline extending
laterally. Incise the rectus sheath and extend laterally into the aponeurosis of the oblique abdominal muscles, and note the yellow fat marking
the best entry point into the preperitoneal space
239
Fig. 13.10 The bilateral prosthesis in position, replacing the endopelvic
transversalis fascia and extending far beyond the borders of both MPOs
Fig. 13.11 Suture placement for fixation of the bilateral mesh
Fig. 13.13 The rectus muscles retracted medially and elevated to
expose preperitoneal fat. This is below the arcuate line, so there is no
posterior rectus sheath. The transversalis fascia has been incised, and
the inferior epigastric vessels are about to be divided. This is not always
necessary—they can be elevated and retracted medially with the rectus
muscle
240
Superior
Medial
Lateral
Inferior
M. Kurzer
Fig. 13.16 Arrange the mesh so it stretches transversely. Its width is
cut equal to the distance between the midline and the anterior superior
iliac spine minus 1 cm, and its length is made approximately equal to 12
cm. Wantz had an innovative way of attaching the mesh, drawing it into
place underneath the rectus muscle and superior abdominal wall with
three slowly absorbable sutures at 1, 2, and 3
Fig. 13.14 “Teasing” an indirect hernia sac out of the abdominal wall
defect
14 cm
A
A
12 cm
B
E
C
15 cm
F
Fig. 13.15 Wantz procedure—trapezoid shape of the mesh to be
inserted in preperitoneal space. The letters A–F illustrate the position of
the mesh after placement
Fig. 13.17 The abdominal wall is retracted and the properitoneal space
exposed. The superior portion of the prosthesis (1–3) is depicted indistinctly to illustrate its position after placement beneath the muscles of
the abdomen in the preperitoneal space. Clamps nos. 4, 5, and 6 along
the distal margins of the prosthesis are poised, ready to implant the
mesh inferiorly
13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
241
Fig. 13.18 Clamp no. 4 is placed medially deep into the space of
Retzius in the midline and is steadied by an assistant. A very large
curved or right-angled clamp helps keep point 4 at the midline. Next,
clamp no. 5 positions the middle of the inferior edge deep into the pelvis, followed by clamp 6 pushing laterally. Again, a complex
maneuver
Fig. 13.19 Slightly different view of the position of the Wantz prosthe-
sis. Points D, E, and F are equivalent to 4, 5, and 6 in this figure
Fig. 13.20 Final position of the prosthesis in unilateral GPRVS. The
prosthesis extends far beyond the borders of the dotted outline of the
MPO
Fig. 13.21 View from within the pelvis of the final position of the
prosthesis in unilateral GPRVS. This is essentially the same as the position of the mesh in laparoscopic repair, extending far beyond the borders of the MPO
242
M. Kurzer
trainee. In theory, if visualisation is difficult, a laparoscope
can be inserted into the preperitoneal space to assist in the
identification of the structures (negating the economic advantages of the procedure).
Apart from the Ugahary procedure, they all use ‘memory
ring’ prostheses with no or minimal fixation to facilitate
placement and positioning through small incisions. Greenburg
[28] has sounded a note of caution when using ‘devices’ with
rigid memory or recoil rings, where the follow- up period is
relatively short and the long-term performance of the recoil
ring is unknown. These devices run the risk of being a fertile
source of medicolegal litigation.
In their recent review, Andresen [29] listed nine different
preperitoneal operations, but some of these are simply variations on a theme. For instance, the TREPP technique uses an
approach that is a variation of Wantz/Nyhus. Preperitoneal
inguinal hernia repairs can be grouped as standard incision
repairs, Stoppa (bilateral) and Wantz (unilateral); as small
incision methods, Kugel, Ugahary, TREPP and Onstep; and
as trans-inguinal methods. Trans-inguinal operations are
destructive to the inguinal canal and interfere with the nerves
during the dissection:
Fig. 13.22 Location of the small incision for the Kugel repair of ingui-
nal hernia. The left and right dots denote the pubic tubercle and the
anterior iliac spine. The incision is positioned between these two
structures
More recently Koning [25] has described a ‘TREPP’
operation, which uses in essence a short Wantz/Nyhus
incision, placed slightly more medially, to access the preperitoneal space. A more medial placement of the incision
is made intending to avoid the nerves that may lie laterally
in the preperitoneal plane. Another preperitoneal procedure named ‘Onstep’ [26, 27] has been described. Apart
from the Ugahary technique, all the ‘small incision’ operations have required the use of mesh with a preformed,
memory or recoil ring in order to assist correct positioning
because of limited access.
The TREPP and Onstep developers and advocates wanted
to avoid the mesh coming in contact with the nerves in the
inguinal canal because of a possible association with chronic
groin pain, and they wanted a way of doing this that did not
need a laparoscope. The location of the incision is critical to
the performance of the procedures in an easy fashion, and
they are dependent on the surgeon’s understanding of the
local anatomy of the preperitoneal space in the inguinal area.
Carrying out a preperitoneal repair through a small incision
does not allow easy visual inspection of what is a potentially
hazardous area. It is also technically challenging. Bladder,
large blood vessel and nerve injury has been reported, and
these are certainly not procedures for the inexperienced
(1) Unilateral Wantz procedure [14]
(2) Bilateral Stoppa procedure [9]
(3) Trans-inguinal (Read [5], Rives [10], Schumpelik [30]),
Pelessier [16])
(4) Kugel procedure [24]
(5) Ugahary procedure [20]
(6) TREPP [25]
(7) Onstep operation [26]
Operative Techniques of Small Incision Repairs
Anaesthesia
Local anaesthesia has been advocated for the small incision
procedures but is only feasible if the operator is experienced
and the patient a slim and co-operative. In practice general
anaesthesia is the method of choice for the majority of
patients. Regional block (spinal or epidural anesthesia) is an
alternative but is likely to result in a high incidence of urinary retention.
The Ugahary Operation
Ugahary has described his operation in detail [20], with
numerous technical tips [25]. The incision is made approximately 3 cm above and lateral to the internal ring (Fig. 13.26).
The preperitoneal space is entered in a similar way to the
13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
243
Kugel operation. A flat mesh is used and is inserted tightly
rolled around a 300 mm forceps; it is then unrolled in situ
requiring quite a lot of technical skills (Figs. 13.23, 13.25,
13.26, 13.27, and 13.28).
The Kugel Repair
Kugel made a 3 cm transverse, slightly oblique incision at
the midpoint between the anterior superior iliac spine and the
pubic tubercle (Fig. 13.24). The technique has been described
in detail. Kugel used a bilayer piece of knitted monofilament
polypropylene a (‘Kugel Patch™’ Surgical Sense Inc.), with
an outer polyester ‘memory recoil’ ring which allows the
mesh to open up after insertion.
TREPP operation: This procedure uses a smaller but otherwise similar approach to that used by Wantz and inserts a
self-expanding mesh, often without any fixation. According
to the developers, a slightly more medial dissection is used to
avoid the ‘inguinal nerves’
Onstep: from the detailed description and illustrations in
the original paper [26], this would seem to be a trans- inguinal
procedure, forcing a hole in the posterior wall of the inguinal
c
d
a
f
e
b
Fig. 13.23 Insertion of the patch is simplified by using a malleable
retractor as a shoehorn
Fig. 13.24 Preperitoneal view showing final position of the Kugel
patch (reprinted from Am J Surg. 1999;178:298–302 with permission)
Fig. 13.25 The skin incision (f) for Ugahary’s operation. Surface anat-
omy: (a) inguinal ligament, (b) femoral artery, (c) lateral border of the
rectus muscle, (d) line perpendicular to the inguinal ligament from the
femoral artery, and (e) the deep or internal ring
Fig. 13.26 Ugahary operation—insertion and positioning of the rolled
up prosthesis
244
M. Kurzer
Fig. 13.27 Use of both retractors to spread and position the mesh
Fig. 13.28 Final position of the mesh
omy and are unforgiving of technical errors. The correct
plane has to be entered with the minimum of unnecessary
dissection, and controlling excess bleeding in a deep hole
through a small incision can be problematic. The presence of
even a small haematoma is likely to prevent the mesh from
sitting properly and will compromise the repair, although
enthusiastic surgeons with an interest in hernia surgery have
obtained good results as noted above. The preperitoneal
space at this level is a hazardous area with major vessels and
the bladder at risk. Unless a significant advantage is shown,
most surgeons may not wish to, or have the opportunity to,
invest the time in attaining technical proficiency [31].
Results
Ugahary’s gridiron operation has not been widely adopted,
probably because of the technical challenge of placing a flat
mesh accurately through a small incision Ugahary [32]. In
contrast to the Ugahary procedure, the Kugel hernioplasty
and variations that use mesh with a memory ring are supported by numerous publications from other surgical groups
who have reported it to be safe and effective, with short operative times, low complication rates, ‘minimal’ post-op pain
and a rapid return to normal activities [33].
Kugel’s own results are excellent with an overall recurrence rate of 0.4% [24]. The study by van Nieuwenhove was
a multicentre prospective trial in 450 patients with a 1.9%
recurrence at a mean follow-up of 18 months [34]. Fenoglio
[35] reported a large retrospective series of over 1000 patients
with a follow-up of 2–47 months and a recurrence rate of
0.47%. Suwa et al. obtained similar results [36, 37]. However
one study [38] of 355 patients undergoing the Kugel operation, with 6 surgeons, reported an overall recurrence rate of
18%, almost 30% for recurrent hernias, and an estimated
learning curve of at least 36 cases [38]. The authors concluded, understandably, that the recurrence rate was “unacceptably high, clearly a technically challenging procedure in
their hands”.
canal with a finger. A mesh with a ‘recoil memory ring’ is
used, the medial portion of which lies in the preperitoneal
space, while the lateral portion comes to lie between the
internal oblique muscle and the external oblique
aponeurosis.
Advocates of these small incision operations maintain
that their respective procedures are easy to perform, and
indeed in skilled hand, they are. As with most things in life,
things are easy when you know how, and when proficiently
carried out, these operations can yield excellent results.
However they require a detailed knowledge of the local anat-
TREPP
TREPP results: Following Koning’s initial description, Lange
and his colleagues reported 1000 cases operated on with the
TREPP technique [39] and provided a detailed description
with illustrative figures. The recurrence rate was low, and
patient satisfaction was high. Chronic post- operative inguinal
pain (CPIP) was reported by 5% of patients. Overall morbidity was low (19/1000:1.9%), and although two patients had to
have an infected mesh removed, this is only represented 0.2%
13 Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
245
of the cases. However in a commentary to Lange’s report,
Rosin questioned the effectiveness of this potentially challenging procedure in general surgical practice [31].
A recent Cochrane review [40] sought to compare elective
open preperitoneal mesh techniques with Lichtenstein mesh
repair in terms of pain. Three eligible trials involving 569
patients were identified. Two trials involving 322 patients
reported less chronic pain after preperitoneal repair, whereas
one trial, including 247 patients, described more chronic
pain after this repair. The authors felt that the lack of homogeneous trials prevented robust conclusions.
Indications For a ‘Classical’ Open Preperitoneal Repair
• Recurrent or multiple recurrent groin hernias following a
previous open, anterior repair. Operating in the unscarred,
virgin preperitoneal plane is simpler and safer and reduces
the risk of damage to the testicular vessels, and all poten-
tial defects can be inspected.
• Combination groin hernias where there are multiple
defects, for instance, combinations of pre-vascular, femo-
ral, indirect and direct inguinal and low Spigelian hernias.
All potential defects can be inspected.
• Giant inguino-scrotal hernias, either unilateral or bilat-
eral, where replacement of abdominal contents through
a groin incision alone would be technically difficult.
‘Pulling’ the sac contents back from behind through the
defect is simpler and safer than ‘pushing’ from the
front.
• Hernias associated with connective tissue disorders
(Ehlers–Danlos and Marfan’s syndrome).
Indications For a ‘Small Incision’ Open Preperitoneal Repair
• As a preferred technique for primary inguinal hernia
repair where avoidance of the nerves in the inguinal canal
is thought to be desirable, laparoscopic repair is not fea-
sible (lack of expensive laparoscopic equipment or wish
to avoid a general anaesthetic).
• They require no expensive specialised equipment and
therefore have economic advantages over a laparoscopic
repair.
• They are suitable for patients unfit for general anaesthesia—by using either local or regional anaesthesia.
• They avoid placing mesh in contact with the nerves that
lie in the inguinal canal.
In addition the classical ‘larger incision’ preperitoneal
approaches:
• Are probably the best procedure for repairing large recurrent or multirecurrent inguinal hernias with tissue loss,
incarcerated recurrent hernias and large sliding inguinal
hernias
• Serve as an excellent ‘stepping stone’ to laparoscopic
TEP repair, providing a means of familiarising trainees
with the complex anatomy of the preperitoneal space
Conclusion
There are two categories of open preperitoneal mesh
repair of groin hernia. The recently described ‘small incision’ open operations have been developed to avoid placing mesh within the inguinal canal in a primary repair.
No expensive laparoscopic equipment is required, they
do not necessarily need a general anaesthetic, and their
advocates claim a short learning curve, low morbidity
and a low incidence of chronic post-operative pain. It
remains to be seen whether or not they prove their usefulness in the long term, in everyday general surgical practice. In contrast the classical open preperitoneal
techniques through standard incisions provide excellent
access to the myopectineal orifice and thus permit inspection of all potential groin hernia sites in complex hernias.
The approach avoids reoperating through the distorted
anatomy and scar tissue that are present after a failed
anterior operation, and the risk of damage to the testicular vessels and the nerves within the inguinal canal is
minimised. They are an important and useful technique
even in the laparoscopic era and should have a place in
the toolkit of every surgeon who declares an interest in
hernia surgery.
Summary
With all the preperitoneal approaches:
• The learning curve is probably shorter than for laparoscopic repair.
References
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Tissue Repairs for Inguinal Hernia
Nicholas H. Carter and David C. Chen
14
Introduction
Placement of mesh is now favored in both open and laparoscopic repairs of uncomplicated adult hernias. Techniques
that rely on tissue-based repair are typically reserved for
exceptional circumstances due to an elevated risk of recurrence. Impaired collagen synthesis has been shown to contribute to hernia formation, and the tissues in the presence of
a hernia may be regarded as intrinsically abnormal. Suture
lines secure tissue under tension which is known to be associated with recurrence. Synthetic mesh materials have been
developed to be strong, lightweight, and inert. Mesh-based
repairs have been demonstrated in several randomized controlled trials to carry lower rates of recurrence [1–3].
Nevertheless, tissue-based repairs are preferred in certain
circumstances where mesh usage is contraindicated, undesirable, or unavailable. In the setting of contamination or infection, implantation of synthetic material is contraindicated.
Consideration of mesh-related pain and complications is
important and should factor into the shared patient and surgeon decision regarding repair technique. Adolescents and
young adults as well as female patients with small indirect
hernias may also be better suited for a tissue-based repair
when chronic pain and foreign body sensation are taken into
account. In underserved settings, where inguinal hernias are
more likely to present with strangulation or mesh may simply not be immediately available, tissue-based repair remains
the standard of care.
The surgical literature includes references to more than
70 different tissue-based repairs. The most common tech-
N.H. Carter
Residency in General Surgery, Vanderbilt University Medical
Center, Nashville, TN, USA
D.C. Chen (
Department of Surgery, Lichtenstein Amid Hernia Clinic at
UCLA, David Geffen School of Medicine at UCLA,
Los Angeles, CA, USA
e-mail: dcchen@mednet.ucla.edu
*)
niques in modern use include the Bassini, Shouldice, McVay,
and Desarda repairs. The latest data from the national hernia
registry in Sweden indicated that tissue repairs were used in
0.8% of inguinal operations in 2015 [4]. In this chapter, we
will describe these procedures with an emphasis on the
details of neuroanatomy and intraoperative technique.
Preoperative Considerations
Preoperative considerations for tissue-based repairs are similar to standard inguinal hernia repairs. Patients presenting
with an inguinal hernia regardless of symptoms are appropriate for operative repair barring medical contraindications.
Those with elevated cardiac or pulmonary risk can be considered for feasibility of repair under local anesthesia with or
without sedation. Patient with prohibitive medical risk may
be offered expectant management with the use of a truss for
comfort unless severity of symptoms, incarceration, or strangulation necessitate an urgent nonelective operation. The
most relevant preoperative consideration is whether the
patient is indeed an appropriate candidate for tissue-based
repair. Larger hernias and patients with intrinsic herniarelated risk factors should, in general, undergo mesh repair.
Since mesh repairs are associated with lower rates of recurrence and pain, prosthetic repairs are generally favored
unless contraindicated. Smaller hernias in a patient without
increased hernia-related risk factors, adolescents or young
adults with a likely small indirect hernia, female patients
with a small hernia, and patients that have an aversion or
contraindication to mesh should be considered for a tissue
repair. Potential contamination of the operative field and
prosthetic due to necrotic bowel, active infection, strangulation, or sepsis are considered indications for tissue-based
repair. In resource-limited settings where mesh and training
in mesh-based techniques are not readily available, tissue
repairs remain the standard treatment option for the burden
of inguinal hernia disease.
© 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_14
247
248
N.H. Carter and D.C. Chen
Patient Positioning and Theater Setup
The patient is placed in the supine position. In most cases,
tissue-based repair can be performed under local anesthesia
alone. Our preferred technique of infiltration of a mixture
of a short- and long-acting local anesthetic into the intradermal, subdermal, deep dermal, and subaponeurotic
spaces has been described in detail for Lichtenstein
repairs—the same technique works well for inguinal tissuebased repairs [5].
Incision and Access
Each inguinal tissue-based repair begins with a 5–6 cm incision along the Langer line extending laterally from the pubic
tubercle. The external oblique aponeurosis is incised sharply
with care to preserve the ilioinguinal nerve. On the medial
side, the avascular plane between the external and internal
oblique aponeuroses is bluntly dissected to reveal and preserve the iliohypogastric nerve. The genital nerve is identified along the lateral aspect of the cord at the lateral crus of
the internal ring running parallel and adjacent to the external
spermatic vein within the cremasteric bundle. The spermatic
cord and hernia sac are each identified and isolated. A direct
defect is identified along the floor of the canal medial to the
inferior epigastric vessels. The femoral canal may be
explored either through the hernia sac in the case of an indirect hernia or through the opened transversalis fascia with a
direct hernia.
Operative Steps
Bassini Repair
The Bassini repair involves extensive dissection of the spermatic cord with high ligation of the hernia sac and inguinal
floor reconstruction. Once the spermatic cord dissection is
completed and indirect hernia sac excised, the inguinal floor
is exposed. In a proper Bassini repair, the transversalis fascia
is then incised from pubic tubercle to the internal inguinal
ring, although this step is often excluded from modern adaptations of the Bassini repair. A triple-layer tissue repair is
then performed with fixation of the transversalis fascia,
transversus abdominis, and internal oblique aponeurosis to
the shelving edge of the inguinal ligament with six to eight
nonabsorbable interrupted sutures (see Fig. 14.1). A relaxing
incision may be made along the falx inguinalis if required to
minimize tension [6].
The transversalis fascia is opened widely to permit a complete three-layer closure. Medially, the sutures catch the falx
inguinalis and transversalis fascia. Laterally, the sutures
catch the transversalis fascia and the shelving edge of the
inguinal ligament:
1. Aponeurosis of the external oblique
2. Internal oblique
3. Inguinal ligament
4. Relaxing incision of the falx inguinalis
5. Transversalis fascia
6. Repair with nonabsorbable suture
Fig. 14.1 Bassini repair.
(Reproduced from [7])
2
1
5
4
6
3