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Fig. 29.7 PP “true yellow fat”
Fig. 29.8 Sponge dissection of PP space
grasped with hemostats, and the protruding contents are dissected from behind the fascia with an
opened dry 4×4 gauze sponge, to actuate the PP
space. The sponge’s traction on the PP fat helps
to separate it from the TF supercial to it
(Fig.29.8) . This can also be done by sweeping
the index nger or with forceps and cautery. The
dissection goes medially behind the PT, inferiorly behind CL, superiorly behind the TA, and
laterally behind the deep epigastric vessels. The
space is essentially avascular, except for small
branches of the ilio-pubic vein which runs transversely along the ilio-pubic tract and CL.If the
patient has no lateral defect, we limit the lateral
dissection behind the epigastrics at this point,
preferring not to place mesh along the spermatic
cord internally, potentially avoiding scarring in
that area. We rely on the overlay to protect the
oor lateral to the internal ring.
J. Young and A. I. Gilbert
29.9.4.2 Lateral (Indirect) Hernias
Once the entire sac or ligated sac has been fully
dissected, it is grasped with forceps and invaginated through the internal ring. The surgeon’s
forenger is inserted through the internal ring
adjacent to the forceps and palpates the iliac
artery, pulsating lateral to it. The forceps are
extracted, leaving the forenger in place, hooking it under the TA laterally. An opened dry 4×4
sponge is passed on the medial side of the forenger to develop the PP space and separate the
hernia contents from the elements of the cord. We
prefer creating this space with the sponge, but it
is also possible to do it with the index nger
alone or forceps and cautery. The sponge is temporarily left in place to maintain the passageway
and facilitate continuing the insertion maneuver.
Medially, we dissect behind the deep epigastric
vessels and under the oor of the medial triangle—an army-navy retractor placed behind the
epigastric vessels facilitates this dissection. The
dissection is extended further medially behind
the PT, inferiorly behind CL, and superiorly
behind the TA. Superiorly and laterally to the
internal ring, the dissection is behind the TA, and
inferiorly between the hernia contents and the
cord contents. This result is that the lateral and
medial PP space is connected as one. For small
lateral hernias, we prefer not to enlarge the internal ring opening. The mesh can be inserted
through an opening in the medial triangle, and
the indirect space can be covered by the overlay.
In some cases of pantaloon hernias with large
openings in both the medial and lateral triangle,
the TF is opened both medial and lateral to the
epigastrics, a Penrose drain is placed around the
epigastric vessels, (or the vessels can be ligated
and divided) and the two spaces are joined. This
facilitates insertion and deployment of the
underlay.
29.9.5 Deployment ofUnderlay
The PHS overlay tails are pulled up and “triplefolded” longitudinally and then grasped with a
sponge stick near the connector, creating an
appearance of a “taco” in the underlay (Fig.29.9).
This allows easy visualization and deployment of
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Fig. 29.9 Triple fold with trimmed underlay
293
dissected structures—medially behind the PT,
inferiorly behind CL, superiorly behind the TA,
and laterally behind the deep epigastric vessels.
Successful deployment can be conrmed by the
tip of the nger. The underlay will have some
radial folds to accommodate the conical shape of
the space—it will not be at, but trimming will
reduce these folds and prevent it from having the
effect of a plug. If there is no signicant indirect
hernia, the underlay can be trimmed laterally
where it will be placed behind the epigastric vessels, thereby avoiding dissection along the cord
and vessels and having the cord lay against the
mesh. The oor lateral to the epigastrics will be
protected by the overlay. The opening in the TF
of the medial triangle is closed snugly around the
connector with one or two gure-of-eight absorbable sutures, leaving it comfortably seated
(Fig.29.12). If there is a femoral hernia, prior to
Fig. 29.10 Insertion of PHS
the underlay after insertion. The underlay is
trimmed to t into the space created by the dissection allowing it to lay close to the undersurface of the oor without folding and penetrating
deeper like a plug (Fig.29.9). The sponge stick is
rotated before insertion to line up the overlay
with the inguinal ligament. The device is inserted
until the perimeter of the underlay is beneath the
oor (Fig. 29.10). For inguinal hernias, sutures
are not necessary in the underlay—the intraabdominal pressure pushes the mesh against the
oor and holds it in place.
For medial hernias, the device is inserted
straight down, at a right angle to the opening. The
edge of the underlay patch is deployed by unrolling the perimeter of the mesh from its connector
using the forenger, as the overlay component
isgently extracted (Fig.29.11). The edges of the
underlay are placed behind the previously
Fig. 29.11 Deployment of underlay
Fig. 29.12 Closure of TF
294
inserting the device, a single 2–0 Prolene suture
can be placed to secure the underlay to CL.
For lateral hernias, we usually trim the
underlay on the inferior and superior side prior to
insertion, to make an oval shape that will t into
the dissected space. The surgeon’s forenger is
placed under the lateral aspect of TA through the
opened internal ring, and the device is slid down
the medial side of the nger into the PP space—
the direction of insertion is superior and lateral,
aiming toward the shoulder. The perimeter of the
underlay is placed behind the TA superiorly and
laterally, while medially it is deployed behind the
epigastric vessels and the PT. Inferiorly the
perimeter is directed more posterior, covering the
femoral canal and the tissues behind CL, and it
separates the hernia contents from the cord contents. Typically, when repairing a lateral hernia,
unless it is a three-nger defect or larger, the
internal oblique is not tightened around the
connector—the obliqueness of the internal ring
offers additional protection to the underlay patch.
Effectiveness of the underlay patch alone can be
evaluated by having the patient cough and perform the Valsalva maneuver before the overlay is
deployed. After the operation, when the patient
stands, intra-abdominal pressure that attens the
underlay is against the abdominal wall between
the peritoneum and the TF.
J. Young and A. I. Gilbert
Fig. 29.13 Medial xation suture
Fig. 29.14 Slit with “T” for cord
29.9.6 PHS Overlay Placement
andFixation
Using the sponge stick, the overlay is extracted to
the level of the internal oblique (IO) and released,
and the tips are pulled apart to a at shape. The
overlay is laid at over the transversus arch with
the medial end positioned 1–2 cm over the PT
where it is sutured above and medial to the PT to
the rectus aponeurosis with a 2–0 Vicryl
(Fig.29.13). A slit must be cut in the overlay to
allow the cord contents to pass through. One
option is in the inferior edge of the overlay at the
internal ring, near the connector, adjacent to the
midportion of the internal ring, with a “T” to
make it larger (Fig.29.14). The cord structures
are passed through the slit, and the edges of the
Fig. 29.15 Slit suture to shelving edge of IL
slit are sutured to the shelving edge of the inguinal ligament (Fig. 29.15). Another option is an
overlay slit from the lateral edge toward the
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295
Polymyxin® solution. The EOA is closed with a
2–0 Vicryl® running suture, beginning at the internal ring, being careful not to make it too tight,
anticipating that some swelling of the cord structures will occur. It is not necessary to re-create the
external ring. The subcutaneous layer is closed
with 3-0 Vicryl® sutures, and the skin with a subcuticular 3-0 Vicryl Rapide® suture. The skin is
covered with Dermabond® or Steristrips®.
29.9.7 Post-op Care
Fig. 29.16 Overlay application
connector favoring the inferior edge and adding a
small keyhole near the connector. The tails are
then wrapped around the cord contents, not
unlike a LCHT patch, and sutured together with a
Vicryl suture—it is not necessary to suture these
to the inguinal ligament. The opening should be
large enough to comfortably accommodate the
spermatic cord and its contents without compression. An absorbable suture can be placed to
secure the upper edge of the overlay to the IO at
the middle of the transversus arch (using an air
knot and avoiding the IH-N) and one at the middle of the inguinal ligament if the surgeon feels it
is necessary. It is not necessary to suture the lateral part of the overlay that lies at in the anterior
space where it is covered by the EOA.The overlay should be trimmed on the inferior edges laterally and medially if any excess is noted where the
mesh might fold on itself, especially in thin
patients (Fig.29.16).
For large hernias and recurrent hernias, 2–0
Prolene sutures can be used to secure the mesh
medially and to anchor the slits to the shelving
edge of the inguinal ligament. Additional sutures
can be placed at the surgeon’s discretion, but we
do not recommend nonabsorbable sutures on the
upper edge of the mesh. On occasion, for very
large hernias with a complete blowout of the
oor, bilayer sutures are placed that go through
both layers with the oor in between.
The cord contents with the II-N are replaced
on top of the overlay medially in the inguinal
canal. All layers are irrigated with Bacitracin
®
-
Most patients go directly to the outpatient discharge area or to the recovery room if they are too
sleepy or need monitoring. An ice bag is applied
immediately and is used for 2days. After voiding, the patient leaves the ambulatory center, usually 45–90min after the operation. The patient is
encouraged to ambulate often (if not lightheaded) on the day of surgery and to resume all
activities that are not uncomfortable. Milk of
magnesia is recommended if the patient has not
had a bowel movement by the second day.
Patients are told that they will have some ecchymosis around the incision and into the scrotum
and often some testicular swelling that will last
for several days. Swelling in the wound forms a
rm wound healing ridge that lasts 6–8 weeks.
As the healing ridge becomes more prominent, it
narrows and rises before it attens. Patients are
told to expect mild to moderate pain, sometimes
going down to the testicle, for 1–2 days, after
which the pain diminishes signicantly. All
patients are given a prescription for an NSAID
such as naproxen (if there is no history of GERD)
and a narcotic analgesic such as oxycodone and
acetaminophen. Patients who live locally are seen
in 1–2weeks for follow-up. Out-of-town patients
are seen on the day after surgery and are followed
by telephone in 1week regarding their progress.
29.10 Results
April 1998 through December 2016, ve surgeons doing only hernia surgery used the PHS to
repair over 12,000 groin hernias in over 11,000
296
J. Young and A. I. Gilbert
patients at the Hernia Institute of Florida. Male
patients outnumbered female patients 15:1.
Simultaneous bilateral repairs were done in 10%.
One in eight repairs was for recurrences of one to
six times. Femoral hernias accounted for 1.5%
and were more common in women. Our PHS size
preference is 60% extended, 35% large, and 5%
medium—mostly in women. Follow-up for all
hernia patients is very difcult as there is no
national registry. Most patients who are doing
well do not want to take time to come in for a
checkup. All patients are given the surgeon’s cell
phone number. Our telephone and email followup showed a 30% compliance. All patients,
including those covered under workers’ compensation, were emphatically instructed to call or
return if they suspected a recurrence or were
bothered by unrelenting discomfort. Most of our
patients call if they have a problem.
To the best of our knowledge, the total number
of known recurrences in our series since April
1998 is 34. In our ofce, where we have done
between 400 and 800 PHS repairs per year, we see
1–2 patients of our own per year who have a
recurrence. If we assume there are two or three
times as many recurrences that we are not aware
of, our percentage is well below one half percent,
a gure that we use in the pre-op discussion.
Other surgeons using PHS have reported similar
low recurrence rates [16].
Supercial infection, hematoma, or serous
drainage, which required opening the wound,
occurred in 40 patients—these were managed
with topical and oral antibiotics—the patients
were instructed to shower and change dressings
twice daily, and most of these healed within
10–14 days. Infection requiring mesh removal
occurred in four patients—the mesh was
removed, and a suture repair was done with a
monolament absorbable suture. Two patients
had MRSA—one with a prior history in another
location and one who was an unidentied carrier.
We currently ask patients about MRSA history
prior to all hernia repairs. In all other cases,
infections were supercial, and the mesh did not
have to be removed to get complete wound healing. There were 8 hematomas that required
drainage—2in the OR, and 60 documented sero-
mas, of which 10 persisted and required
aspiration.
Thirty percent of patients used only acetaminophen for pain. The remainder used the prescribed NSAID or narcotic, on the average taking
four narcotic tablets over 2days. Ninety-ve percent used no analgesics after the rst 2 days.
Most patients with ongoing discomfort were
given naproxen. Ten percent of workers had
ongoing pain that lasted between 3 and 6months.
One hundred twenty patients had chronic pain,
i.e., pain more than 6 months after surgery.
Twelve patients, including eight workers, had
signicant chronic postoperative pain lasting longer than 6 months and were referred for pain
management. Two patients had the mesh removed
for pain by us, and a third had the mesh removed
by a surgeon elsewhere. Patients who experienced some degree of testicular pain from epididymitis were treated with sitz baths, naproxen,
and Cipro®—all reported that the pain subsided
in 3 to 8weeks.
29.11 Quality ofLife Issues
As recurrence rates after hernia surgery have
been reduced with the use of mesh techniques,
increased attention has been directed to quality of
life (QOL) issues, particularly the problem of
chronic post-herniorrhaphy inguinal pain (CPIP),
a consequence occurring in many patients after
hernia surgery. Symptoms of somatic, visceral,
and neuropathic pain, as well as testicular pain,
dysejaculation, and claims of sterility, have stimulated considerable evaluation and discussion at
surgical meetings and in the literature, and discussions on the Internet are readily available to
patients—these are often confusing and misleading. Almost all patients who present to the ofce
in the past 5years come with questions related to
CPIP and the use of mesh. It is important to discuss these with the patient to make sure they
understand the risks and benets of mesh placement as part of the informed consent process.
We explain that post-op pain problems are a
known consequence of hernia surgery, in part
related to the scarring which occurs in both non-
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mesh and mesh repair. The percentage of patients
complaining of CPIP varies according to the
methodology and denition of chronic pain—it
ranges from 0.6 to 30% in different studies, but
for severe chronic pain affecting the activities of
daily living, it is 0.5–6% [17]. However,
Cunningham had reported that the incidence of
signicant CPIP in patients after suture repairs
without mesh is around 10% [7].
The use of mesh results in immediate strength
of the repair. In addition, the mesh induces an
inammatory reaction and scarring, making the
repair stronger as the scar creates a plate of tissue. This inammatory reaction may affect structures which are in direct apposition to the mesh, a
situation that is present in all types of hernia
repairs. Lateral to the internal ring, the mesh is
placed on top of the IO, and unavoidably comes
into contact with the IIN and IHN, which may
result in inammation and scarring involving
these structures. In routine hernia repairs, nerves,
muscle, the spermatic cord, and all structures in
the inguinal canal may come in contact with the
mesh. This is true in open anterior repairs or open
PP or LAP repairs.
There have been suggestions that the incidence
of CPIP can be reduced by following recommended surgical technique. These include avoiding nerve trauma by blunt dissection, traction, and
electrocautery; limiting dissection close to the
spermatic cord to reduce scarring that may result
in cord dysfunction, obstruction, and possible
injury to the nerves and vessels that are present in
the adventitia of the vas; avoiding placement of
mesh in direct opposition to the vas when possible; using absorbable sutures with air knots and
placing sutures in the IO away from visible
nerves; dividing a long indirect sac near the internal ring and avoid dissecting near the spermatic
cord distally; and avoiding placement of sutures
into the periosteum of the PT [18]. Over the years,
we have modied our surgical technique to limit
dissection in the area of the nerves and the spermatic cord to attempt to reduce the incidence of
these problems. In addition, “watchful waiting”—
conservative management of asymptomatic hernias—is an acceptable course of management in
the appropriate patient [19].
29.12 Selection ofTechnique:
Tailored Repair
To perform lasting groin hernia repairs, surgeons
must have a stronger appreciation for the techniques available to protect the entire
MPO.Patients have different anatomy, and their
hernia problems differ by size and location. Some
patients may be more susceptible to recurrence
because of age, occupation, activities, body habitus, collagen disorders, and smoking. Although a
single technique can be used to repair all different types and sizes of inguinal hernias, the choice
of procedure for an individual patient should be
based on the anatomical ndings and the type of
defect, the needs of the patient, and the expertise
of the surgeon with the technique being used.
Some techniques are easier to perform, but may
not offer as good results. The success of the procedure will ultimately depend on the skill of the
surgeon—both in choosing the correct procedure
and performing it.
Since its inception in 1985, over 30,000 inguinal hernias have been repaired by surgeons at the
Hernia Institute of Florida. Our selection and
modication of technique has evolved over the
years based on technological advances and
results. Initial procedures were classical Bassini
or McVay suture repairs. The major change
occurred in the 1980s with the popularization of
mesh techniques, including the umbrella plug,
plug and patch, and LCHT repairs. In 1998, the
PHS was designed and became our primary hernia repair technique, with over 8000 repairs done
between 1998 and 2008 with a recurrence rate of
less than 0.5%. With the success in prevention of
recurrences achieved, and more attention given to
patient satisfaction and CPIP, our focus has been
to modify our technique selection according to
the needs of the patient. Since 2006, the LCHT
technique using middle weight mesh has been
used in 10–15% of our cases, with equivalent
recurrence rates, but there has been no decrease
in the incidence of post-op pain. We do not use
ultralight-weight mesh products because we feel
they are not strong enough for many of our
patients. In patients with a high risk for recurrence, we use a sandwich technique with
298
J. Young and A. I. Gilbert
“bilayer” Prolene sutures passed through both
mesh layers and the fascia in between. Some new
products and xation techniques have been tried
for LCHT where suture xation of the mesh to
the inguinal ligament is necessary, but this is
irrelevant for PHS which is held in place by the
synergy of the bilayer design, without any permanent sutures.
Not all surgeons have the benet of the experience with large numbers of repairs with different
techniques. The surgeon’s choice of technique
should depend on their personal experience and
ability as well as the needs of the patient.
29.13 Discussion
There have been several studies reporting results
of PHS repairs compared to other mesh techniques. Recurrence rates for PHS are equal to or
lower than any other hernia repair technique, and
QOL outcomes are favorable when compared to
other mesh or suture techniques. Kingsnorth
compared PHS to the Lichtenstein technique and
reported less postoperative pain, earlier return to
normal activities and work, shorter duration of
operation, and fewer recurrences in the PHS
group [20]. General surgeons trained in the PHS
technique by Hernia Institute instructors have
been able to reproduce our own results. In 2006,
in a report of 21,791 PHS repairs by 42 trained
general surgeons, there were only 28 recurrences,
for a failure rate of 0.0013 [21]. Some RCT and
meta-analyses included in the 2014 update of the
EHS guideline compare the efcacy and safety of
PHS and LCHT and P&P techniques. With follow-up in the range of 1–4years, there was no
difference between PHS and LCHT with regard
to recurrence, CPIP, or other complications [22].
While PHS requires entry to the PP space, LCHT
requires permanent sutures which may contribute
to pain.
However, in 2015, Cox and Heniford et al.
reported on an international, prospective, multicenter study of 1341 patients comparing recurrence and QOL outcomes of PHS, LCHT, and
P&P repairs. The techniques had equal recurrence rates, while the variance between the most
common techniques appears to be QOL [23].
LCHT and P&P demonstrated equal short- and
long-term QOL.The PHS repair showed superior
1month and 2year QOL outcomes compared to
LCHT and P&P. At 1 month and 2 years, PHS
patients had less pain, less mesh sensation, and
activity limitation, compared to LCHT and P&P.
Although there are many different hernia repair
techniques available, we preferentially use PHS
for our repairs unless the patient’s needs direct us
to other techniques. The PHS repair satises all of
the desired qualities of the ideal hernia repair.
Results are reproducible by all surgeons after a
very short learning curve. Surgeons inexperienced
with dissection of the PP space learn very quickly
to become comfortable working in this relatively
avascular space and can achieve high success
rates equivalent to our outcomes.
References
1. Fruchaud H. Textbook: anatomie chirurgicale des
hernies de l'aine. Paris: Doin; 1956.
2. Gilbert AI.The lateral triangle of the groin. Hernia.
2000;4:234–7.
3. Alexandre JH.The story of EHS-GREPA 1979–2014.
Hernia. 2015;19:349–54.
4. Gilbert AI, Graham MF, Voigt WJ. A bilayer
patch device for inguinal hernia repair. Hernia.
1999;3:161–6.
5. Bassini E. Sulla cura radicale dell’ernia inguinale.
Arch Soc Ital Chir. 1887;4:380.
6. Bendavid R.The Shouldice repair. In: Fitzgibbons RJ,
Greenburg G, editors. Hernia. 5th ed. Philadelphia: JB
Lippincott; 2009. p.129–38.
7. Cunningham J.Cooperative hernia sturdy: pain in the
postrepair patient. Ann Surg. 1996;224:598–602.
8. Usher F, Fries J, Oschner JL. Clinical studies. Arch
Surg. 1959;78:138–45.
9. Lichtenstein IL, Shulman AG.Ambulatory outpatient
hernia surgery. Including a new concept, introducing
tension-free repair. Int Surg. 1986;71(1):1–4.
10. Campanelli G, Pascual MH, Hoeferlin A, et al.
Randomized, controlled, blinded trial of Tisseel/
Tissucol for mesh xation in patients undergoing
Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg.
2012;255(4):650–7.
11. Rönkä K, Vironen J, Kössi J, etal. Randomized mul-
ticenter trial comparing glue xation, self-gripping
mesh, and suture xation of mesh in Lichtenstein
hernia repair (FinnMesh study). Ann Surg.
2015;262(5):714–9; discussion 719–20.
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12. Stoppa RE. The midline preperitoneal approach and
prosthetic repair of groin hernias. In: Fitzgibbons
Jr RJ, Greenburg AG, editors. Nyhus and Condon’s
hernia. 5th ed. Philadelphia: Lippincott Williams &
Wilkins; 2002. p.199.
13. Gilbert AI.Sutureless repair of inguinal hernia. Am J
Surg. 1989;157:331–5.
14. Rosenberg J, Andresen K.Onstep—open new simplied totally extraperitoneal technique for inguinal hernia repair. In: Campanelli G, editor. Inguinal hernia
surgery. NewYork, NY: Springer; 2016.
15. Young J, Gilbert AI, Graham MF. The use of ultrasound in the diagnosis of abdominal wall hernias.
Hernia. 2007;11:347–51.
16. Gilbert AI, Young J, Graham MF. Combined anterior and posterior inguinal hernia repair: intermediate recurrence rates with three groups of surgeons.
Hernia. 2004;8(3):203–7.
17. Poobalan AS, Bruce J, Smith WC, etal. A review of
chronic pain after inguinal herniorrhaphy. Clin J Pain.
2003;19:48.
18. Aleri S, Amid PK, Campanelli G, etal. International
guidelines for prevention and management of post-
operative chronic pain following inguinal hernia surgery. Hernia. 2011;15(3):239–49.
19. Fitzgibbons R, et al. Watchful waiting vs repair of
inguinal hernia in minimally symptomatic men—a randomized clinical trial. JAMA. 2006;295(3):285–92.
20. Kingsnorth A, Wright D, Porter CS, et al. Prolene
Hernia System compared with Lichtenstein patch:
a randomised double blind study of short-term and
medium-term outcomes in primary inguinal hernia
repair. Hernia. 2002;6:113–9.
21. Gilbert A, Graham M, Young J, et al. Closer to an
ideal solution for inguinal hernia repair: comparison between general surgeons and hernia specialists.
Hernia. 2006;10:162–8.
22. Miserez M, Peeters E, Aufenacker T, et al. Update
with level 1 studies of the European Hernia Society
guidelines on the treatment of inguinal hernia in adult
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comparison of open inguinal hernia repair techniques:
two-year quality of life (QOL) and recurrence outcomes in more than 1300 patients. JACS. 2015;4:S72.
Open New Simplied Totally
Extraperitoneal (ONSTEP)
Technique forInguinal
Hernia Repair
JacobRosenberg andKristoerAndresen
30
30.1 Introduction
The ONSTEP technique for inguinal hernia
repair was developed by two surgeons from
Portugal, Lorenzo and da Costa [1]. For several
years there has been a trend toward placing the
mesh in the preperitoneal space rather than below
the external aponeurosis as in the Lichtenstein
repair. The reason for this has been reports of
reduced pain after surgery, especially levels of
chronic pain, with the preperitoneal mesh
replacement as in laparoscopic repair [2].
There are several different operative techniques available for preperitoneal mesh replacement including the transinguinal preperitoneal
(TIPP) approach [3] and transrectus sheath extraperitoneal procedure (TREPP) [4] and others, but
these techniques may be difcult to approach for
the novice surgeon. Thus, Lorenzo and da Costa
thought that there was a need for a new method
with a technically easier approach and therefore a
shorter learning curve for the young surgeons.
The present status for the ONSTEP technique
is that it is currently used in several surgical
departments, and there are also a few ongoing
research projects evaluating the technique [5, 6].
Currently, the technique has only been spread to
some countries in Europe, mainly because the
J. Rosenberg (*) · K. Andresen
Department of Surgery, Herlev Hospital,
Herlev, Denmark
e-mail: jacob.rosenberg@regionh.dk
mesh has not been available in the United States
until recently. Surgeons in the United States and
Asia will soon be exposed to this new technique,
hopefully resulting in more scientic trials evaluating the pros and cons.
The aim of the present chapter is to introduce
the ONSTEP technique and give an overview of
the current available clinical data. Furthermore,
we discuss the technique’s perspectives and the
possible future role of ONSTEP in inguinal hernia repair in adults.
30.2 The ONSTEP Technique
The ONSTEP technique is special because it
involves both the preperitoneal space as well as the
space between the external and internal aponeurosis. Thus, it can be seen as a mixture of a preperitoneal technique and a fully external approach [1].
Because of space limitations, the reader is kindly
referred to a detailed description of the operative
technique published previously [1].
30.2.1 Why aTechnique Involves Two
Dierent Planes
An intriguing part of this surgical technique is that
it involves two different planes. The medial part
of the mesh is placed in the preperitoneal space,
the space of Retzius, and the lateral part of the
mesh is placed between the internal and external
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aponeurosis, i.e., the same place as we place the
mesh in the conventional Lichtenstein repair. The
mesh is not sutured to tissue, and this special
mesh placement will ensure that it stays in place
even though it is not xated to the body structures.
This special mesh placement also has the special
effect that it will grab the abdominal wall, especially when the patient is standing up, where gravity will put force on a at mesh placed
simultaneously between the external and internal
aponeurosis (lateral part) as well as a mesh placed
in the preperitoneal space (medial part). In the
ONSTEP technique, the mesh has a kind of a
handgrip shape holding the abdominal wall and
thereby keeping the hernias in place. This may be
the mechanism of action of the ONSTEP technique and could explain the low-recurrence rates
and, together with the lack of mesh xation and
the very gentle dissection technique, probably
explain the extremely low risk of chronic pain [7].
30.2.2 The Onex Mesh
A special mesh has been designed for the
ONSTEP operation (Fig. 30.1). This mesh is
called the Onex mesh. It has a stiff ring along
the border of the mesh in order to keep it deployed
in the preperitoneal space. The ring is made of
absorbable material so that it will not cause con-
cern for the patient. Before the Onex mesh was
available, we used the Polysoft mesh for the
ONSTEP operation. This mesh has a nonabsorbable ring, so that skinny patients could sometimes
feel it and had pain from especially the lateral
part of the mesh which lies between the external
and internal oblique aponeurosis. If the patient is
skinny and has the Onex mesh in the correct
position, then even though he or she may feel the
lateral part of the ring in the beginning, these
complaints will disappear when the ring is
absorbed. The mesh is made of polypropylene
and is low-weight, with large pore sizes. This
should enable better ingrowth in the healing
period after mesh placement. Furthermore, it has
a pocket which will make it easier to position the
mesh in the preperitoneal space. When the mesh
is positioned, the pocket is meant for the index
nger of the surgeon.
30.2.3 Pain fromtheRecoil Ring
There are thousands of patients who have had the
ONSTEP procedure with the Polysoft mesh. In
the Polysoft mesh, the ring is nonabsorbable, and
if the patient is skinny, there may be complaints
from the lateral part of the mesh where the ring
will lie close to the skin. In such a case, we usually recommend that the patients should wait for
6months in order for the mesh to be fully integrated into the tissue, especially in the preperitoneal position and on the muscle plate between the
two aponeuroses. Then the patient is offered a
small reoperation where an incision of about
1cm is performed on top of the palpable part of
the ring corresponding to the lateral part of the
mesh. Then the two ends of the ring are dissected
and cut, and the ring can be withdrawn in full. We
have made a video clip of this procedure [8].
Usually after ring removal, the patient will have
no complaints.
30.2.4 Recurrence Repair After
Previous ONSTEP
Fig. 30.1 The Onex mesh for ONSTEP inguinal hernia
repair. Reproduced with permission from Bard-Davol Inc
Some surgeons may have concern about how to
repair a recurrence after previous ONSTEP
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