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Hernia Surgery inAsia
DavideLomanto
12
12.1 Introduction
It is important to understand how the hernia disease may inuence any healthcare system due to
its prevalence and clinical outcome because it
represent one or if not the most common surgical
procedures performed annually in millions of
patients worldwide. And for these reasons, it is
naive to think that the surgical treatment and its
related outcome will not have any impact on our
society and that the healthcare policy maker from
government to insurance companies would not be
affected cost.
This is nothing new, Sir Cecil PG Wakeley,
President of the Royal College of Surgeons of
England in 1948, in one of his lecture to the college
was saying that “A surgeon can do more for the
Society by operating on hernia cases and seeing
that his recurrence rate is low than he can by operating on cases of malignant diseases”. A visionary,
that is merely actual in today’s world; in fact if we
consider that the hernia disease has a prevalence
that is age-related and raises from 12% at group
age of 25–34 to 30–34% above 65years old with a
lifetime prevalence of 24.3% [1–3], we can easily
calculate the entity of the problem. Moreover, the
improvement of the socio-economics, the develop-
D. Lomanto
Department of Surgery, Minimally Invasive Surgical
Centre, YLL School of Medicine, National University
of Singapore, Singapore, Singapore
e-mail: davide_lomanto@nuhs.edu.sg
ment of medical care, the affordability and availability of healthcare resources improved
signicantly the average life expectancy of individuals worldwide reaching 71.5 in 2015 from
61in 1970 and today countries like Japan (83.7),
Switzerland (83.4), and Italy (82.6) and above
80years in other several countries.
The data from the hernia prevalence, the
improved life expectancy and the rising population worldwide is an alarming news for healthcare services and providers.
Not surprisingly the incidence of hernia repair
varies widely between developed and developing
countries. Prevalence differences across regions
are likely to be caused by variations in population
age structure, access to surgical care and risk of
death from hernia accident. We estimate a global
inguinal hernia prevalence of 5.85%, meaning
that about 223 million people globally have hernias [4] and that according to marketing strategies analysts, the market value for hernia mesh
will reach four billion USD by 2020 with 11million per year of surgical repairs and ve billion
by 2024 with 13 million surgical repairs yearly.
If we look at Asia, is the world’s largest and
most populous continent that covers 8.7% of the
Earth with a population of about 3.9 billion in
169. Asia has a huge diversity in race, religions,
languages, cultures not only within the continent
itself but also within the country. For example,
600 languages are spoken in Indonesia, 800 in
India and about 100in the Philippines.
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_12
123
124
D. Lom anto
Regarding to hernia, there are not many studies on incidence and prevalence of the disease in
Asia but seems that prevalence is not different
from other countries worldwide. Therefore, we
can assume that in Asian countries like China or
India, the prevalence may easily reach over two
million yearly, about 450,000 in Indonesia,
300,000in Pakistan and Bangladesh and between
150 and 250,000in countries like Japan, Vietnam,
Thailand and the Philippines. This has a signicant impact on healthcare cost in the future of
each countries considering that today the healthcare spending is still below the global average
ranging from 200 USD per capita in Thailand to
800 USD in India and 2265 USD in China. There
is a wide gap in type of hernia repairs among the
Asian continent that with the improvement of the
socio-economic data, the healthcare infrastructures is going to be minimized to the level of
developed countries in 10–20years.
Considering that Asia has a large population, in
2014, around 62% of total number of hernia repair
procedures performed worldwide were in Asia but
only less than 50% of hernia repair were performed using mesh, which corresponds to about
20% of the market worldwide. The adoption of
mesh repair varies between 10 and 75% in various
countries and also within the countries between
the big city centre and the rural hospitals. In fact,
still a large number of hernia surgeries in countries
like India, China, Bangladesh, Myanmar, the
Philippines and others are still being performed
using the economical suture repairs with a greater
risk for recurrence and post-operative sequelae.
That’s why in Asia, awareness about “optimal
repair” is becoming more and more important.
An optimal repair that produces a good outcome,
comparable to the worldwide standard in terms of
recurrence rate, mesh-related infection, postoperative chronic pain, good quality of life after
surgery with an acceptable and affordable cost.
At this purpose, it is an important role of the
national societies and their experts, the continental Asia Pacic Hernia Society (APHS) and its
community to regularly host and update the Asian
surgical community. The Hernia Essentials programme developed and organized in several
Asian countries by the APHS is focused to make
awareness to the surgical community about the
most updated guidelines [5–8] on the indications,
diagnosis and surgical treatment for inguinal hernia repair, a wide comprehensive educational
programme based on the current guidelines and
tailored to the different reality of healthcare system, socio-economics and resources available in
the different Asian countries. APHS has also produced a standardized template for hernia surgery
educational workshops and courses that are organized in the continent.
We hope that, with the combination of several
factors like the improvement of the economic status of the nations, the availability of better healthcare resources, the awareness and better
knowledge and skills of the Asian surgical community will help to reduce the gap between
developing and developed countries for the hernia repair providing ultimately a better treatment
for all patients.
References
1. Abramson JH, Gon J, Hopp C, etal. The epidemiol-
ogy of inguinal hernia: a survey in western Jerusalem.
J Epidemiol Commun Health. 1978;32(1):59–67.
2. Rutkow IM, Robbins AW. Demographic, clas-
sicatory, and socioeconomic aspects of hernia
repair in the United States. Surg Clin North Am.
1993;73(3):413–26.
3. Rutkow IM.Epidemiologic, economic, and sociologic
aspects of hernia surgery in the United States in the
1990s. Surg Clin North Am. 1998;78(6):941–51. v-vi.
4. Beard JH, Ohene-Yeboah M, de Vries CR etal. Hernia
and hydrocele. Essential surgery. 3rd ed., vol 1. 2015.
p.151–71.
5. Simons MP, Aufenacaker T, Bay-Nielsen M, et al.
European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia.
2009;13(4):343–403.
6. 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
patients. Hernia. 2014;18:151–63.
7. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines
for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International EndoHernia
Society (IEHS)]. Surg Endosc. 2011;25:2773–843.
8. Bittner R, Montgomery MA, Arregui E, et al.
Update of guidelines on laparoscopic (TAPP) and
endoscopic (TEP) treatment of inguinal hernia
(International Endohernia Society). Surg Endosc.
2015;29(2):289–321.
Hernia Surgery inAustralasia
AndrewBowker
13
13.1 A Brief History forAustralia
andNew Zealand (and
Probably theWorld)
The modern era of hernia surgery in Australasia
(Australia, New Zealand and the surrounding
Pacic Islands) started in the early 1990s, as it
did for general surgeons around much of the
globe, as a result of the advent of videolaparoscopic surgery. Laparoscopic cholecystectomy
was the operation which brought the technology
to general surgical attention, and it was immediately apparent to most surgeons in this part of the
world that if they could not manage this new
technology, then cholecystectomy would no longer be part of their surgical repertoire. There was
a scramble to learn the technique, spawning an
era of travelling surgical roadshows where surgeons, mostly from the United States and Europe,
ran courses in Australia and New Zealand. These
were rapidly oversubscribed. Typically they consisted of the visiting experts performing procedures, which were relayed live to auditoriums,
after which delegates would proceed to animal
laboratories to practise on anaesthetised animals,
usually pigs, before returning to their home towns
to practise on humans. Unfortunately the process
following these courses was often managed in a
less than satisfactory manner, which resulted in
operations being performed poorly, with a sharp
A. Bowker
Laparoscopy Auckland, Auckland, New Zealand
rise in complications, particularly common bile
duct injury [1].
In 1991 the author enrolled in a course for
“Laser Laparoscopic Cholecystectomy”, this particular roadshow starring Leonard Schulz and
several other American surgeons. It was run at the
Adventist Hospital in Sydney, Australia, with
around 200 surgeons attending. Shultz was one
of the pioneers of laparoscopic inguinal hernia
surgery [2]. While there was no live surgical
demonstration of laparoscopic hernia repair, the
attendees had the opportunity to try transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphy on the unfortunate pigs, after the gall
bladders had been removed. At that time the
author was working in Townsville, North
Queensland, Australia. The approach in
Townsville to gaining experience with laparoscopic cholecystectomy was very well measured
and well managed. The author found he had a
particular aptitude for the technology and was
encouraged to try laparoscopic TAPP inguinal
hernia repair, once comfortable with laparoscopic
cholecystectomy. The rst case was a somewhat
daunting venture into the unknown. A session
with George Fielding, who was one of the pioneers of laparoscopic surgery in Australia [3],
improved the author’s condence, allowing him
to build his series. At this time the Townsville
surgeons had one of the few prototypical staplers,
a reloadable non-disposable device, manufactured by Johnson & Johnson. This was soon
superseded by Autosuture’s disposable stapler.
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_13
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126
A. Bowker
In the early days of laparoscopic inguinal hernia repair, all were done using the TAPP approach.
The technique received some bad press as a result
of small bowel obstruction secondary to adhesions or internal hernias [3]. Laparoscopic hernia
repair itself also had very vocal critics, who considered the procedure an unproven technique,
costly in terms of equipment used and costly in
terms of the extra time being taken to achieve the
repair [4]. The fact that general anaesthesia is
required for the laparoscopic approach was not a
valid criticism in Australasia, as very few surgeons were performing open hernia repairs under
local or regional anaesthesia anyway. A phrase
attributed to the American psychologist Abraham
Maslow, “When you have a new hammer, everything looks like a nail”, was considered by many
surgeons an appropriate epithet for those seeking
to advance the cause of laparoscopic inguinal
hernia repair.
A further driver for being critical of laparoscopic approaches to hernia repair was the anxiety experienced by many surgeons who were
struggling to achieve competence with laparoscopic cholecystectomy; they had seen their surgical practices, particularly their private surgical
practices, be adversely affected by the arrival of
this new technology and were very concerned
that the other main component of general surgical
private practice, hernia repair, might suffer the
same fate. As a generalisation, these tended to be
the senior surgeons, whose world was more
shaken than most by the paradigm shift caused by
the introduction of videolaparoscopic surgery. It
had the effect of reversing the traditional power
base of senior surgeon over junior surgeon, with
the senior surgeons being put in the position of
having to ask their juniors for help as they struggled to achieve technical competence with the
laparoscope.
13.2 Early Days inNew Zealand
It was in this environment that in 1993 the
author returned from Australia to the city of
Auckland (population 1.5 million), in his home
country of New Zealand. He and his surgical
partner, John Dunn, set up the private surgical
clinic Laparoscopy Auckland in order to further
their experience with this technology, which
both enjoyed. The author ran an audit of his
laparoscopic hernia procedures from the outset.
This was used to counter early criticism of the
technique, by presenting outcomes at Royal
Australasian College of Surgeons meetings in
NZ and Australia. In NZ there did not appear to
be any surgeons who collected data regarding
their (open) hernia practices, particularly better
data, to counter these results, which showed a
low complication rate, rapid return to full activity and a very low recurrence rate. In the early
years, all patients were contacted annually for
phone review. When the numbers became too
unwieldy, follow-up was restricted to phone
review at 3months by an assistant, with occasional batches of patients being contacted at
12 months, to check the later results. In the
early 2000s, attempts were made to contact
1000 consecutive patients at around 5 years
post-surgery. Successful contact was made with
over 700. There were no unexpected outcomes
in this group, i.e. any complications or recurrences which had not already come to attention.
The implication from this was that the data
regarding recurrences, in particular, was a fair
reection of the author’s practice. The author
now has an experience of over 7900 laparoscopic inguinal hernia repairs, 7600 of these
using the totally extraperitoneal (TEP)
approach, with a recurrence rate of two per
thousand in the TEP group.
In Australia and New Zealand in the early
1990s, there was an initial burst of enthusiasm for
laparoscopic TAPP repair of inguinal hernias, on
the back of success with laparoscopic cholecystectomy. However, complications, such as internal hernias causing bowel obstruction and large
vessel injuries, together with the increased technical challenges of achieving effective repair
with the new technology, resulted in signicant
tempering of this enthusiasm. These complications were not a feature of open repair nor was
the new phenomenon of “retained hernia”, which
was seen to occur when laparoscopic technique
was particularly lacking [5].
13 Hernia Surgery in Australasia
127
13.3 The Current Situation
forAustralia andNew
Zealand
With time laparoscopic inguinal hernia repair
has gained respectability, resulting in a steady
rise in the rate of laparoscopic repair compared
to open. In New Zealand this has been largely
driven by the private sector of surgical practice, where patient choice is a factor; good outcomes result in word of mouth recommendation,
which is particularly effective in relatively
compact societies such as New Zealand (4.5
million). There is quite marked regional variation within the private sector in New Zealand.
These differences can be inuenced by individual surgeon preference/laparoscopic skill,
particularly in the smaller communities
(Table 13.1). Uptake in the public sector has
been slower. Table13.2 demonstrates this for
unilateral and bilateral inguinal hernia repairs
respectively. The data in these tables is public
sector only for the NZ rates, combined public
and private for Australian rates.
13.4 Survey ofSurgeon
Preferences forHernia
Repair
For purposes of this chapter, the author surveyed
Australian and New Zealand surgeons regarding
their approaches to hernia surgery. The survey was
completed by 209 general surgeons, 100 of whom
were New Zealanders, representing more than 50%
of those asked, and 105 Australians, a much smaller
proportion of the surgical population of that country. Four respondents were from the Pacic Islands.
Questions were asked regarding preferences
for laparoscopic or open approaches to inguinal,
umbilical/epigastric and incisional hernias, as
well as technical aspects when performing these
operations. Overall, responses were similar for
the two surgical populations.
13.4.1 Inguinal Hernia Repair
While there are many similarities between the
two surgical populations, NZ surgeons appear to
Table 13.1 Laparoscopic versus open rates in private practice by region (New Zealand)
Inguinal hernia repair 2016 No of repairs Technique (%)
Region of NZ Laparoscopic Open Laparoscopic Open
Greater Auckland 374 111 77 23
Christchurch 160 41 80 20
Capital and Coast 111 20 85 15
Waikato 75 25 75 25
Southern 45 29 61 39
Nelson Marlborough 13 33 28 72
Bay of Plenty 9 65 12 88
Hawke’s Bay 5 41 11 89
Mid Central 9 27 25 75
Northland 9 21 30 70
Source: Southern Cross Healthcare Group, which funds 71% of New Zealand’s healthcare claims
Table 13.2 Comparative rates of laparoscopic inguinal hernia repair in New Zealand and Australia; New Zealand data
public sector only, Australian data public sector plus most private hospitals
Inguinal hernia repair 2000–2001 (%) 2004–2005 (%) 2009–2010 (%) 2013–2014 (%)
Laparoscopic unilateral NZ 13.2 13.8 24.0 27.8
Laparoscopic unilateral Australia 11.9 16.1 23.4 29.5
Laparoscopic bilateral NZ 27.9 24.5 46.5 60.9
Laparoscopic bilateral Australia 24.2 37.0 52.0 63.5
Sources: Australian Institute of Health and Welfare, Ministry of Health New Zealand
128
A. Bowker
be more embracing of laparoscopic repair for
inguinal hernias, with 49% performing more than
half of their repairs laparoscopically compared to
25% of the Australian respondents. In both countries, TEP is overwhelmingly favoured at 91%
compared to 9% for TAPP. Those preferring
TAPP tend to have learnt the technique outside of
Australasia. Over 85% of surgeons give prophylactic antibiotics for laparoscopic inguinal hernia
repairs, despite there being no good evidence of
benet [6]. Over 70% of surgeons place all operating ports in the midline. Polypropylene is used
by 64% of surgeons, polyester by 36%.
Penetrative xation is used by 80% of surgeons
to secure the mesh, 67% favouring absorbable
tacks over titanium in NZ and 75% in Australia,
presumably in the hope that if penetrative xation causes pain, there is a chance it will diminish
as the tacks are absorbed. A minority of surgeons
use either self-xing mesh (ProGrip) or glue
(brin or cyanoacrylate). If the TAPP technique
has been used, two thirds of surgeons use tacks to
close the peritoneum rather than suture.
Postoperatively, most surgeons advise patients to
avoid heavy lifting for variable periods up to a
month; only 11% encourage early/immediate
return to full activity.
With open repair, the Lichtenstein technique
is favoured by 87% of surgeons, with most of the
remainder using other mesh-based techniques.
Bassini or Shouldice (non-mesh) repairs are
favoured by 5%. No one answering the survey
has taken up the Desarda (non-mesh) technique
as their preferred option. Antibiotic prophylaxis
is given by 91%. Nearly 90% use sutures to
secure the mesh, the remainder split between
tacks and self-adhesive mesh or glue.
Postoperative restrictions on heavy lifting are
recommended by 95% of surgeons.
13.4.2 Paraumbilical andEpigastric
Hernia Repair
Over 90% of surgeons employ an open approach
for the majority of repairs. Mesh is used in 80%
of repairs, with a similar percentage receiving
antibiotic prophylaxis. Of those not giving antibiotics, most are using mesh. A wide variation is
seen regarding the need to avoid heavy lifting, up
to a month being recommended by 69% of
surgeons, longer periods by 25%. 6% do not
impose any restrictions.
13.4.3 Incisional Hernia Repair
Overall, responses are similar between the two
countries, the only difference being that laparoscopic repair appears more favoured in Australia
than NZ, with 25% of Australian survey respondents doing more than half of their incisional hernias using a laparoscopic approach compared to
11% of New Zealand surgeons. Respondents
were asked if they had changed their open or laparoscopic preferences of recent times. Thirty-one
percent of 191 surgeons answering this question
have changed, with a marked trend for fewer laparoscopic (80%) compared to more laparoscopic
(20%). A wide array of different meshes is used
for laparoscopic repair, all employing some form
of barrier. Close to 60% of surgeons doing laparoscopic repair for incisional hernias attempt to
close the fascial defect before positioning the
mesh. For mesh xation, tacks are used by 98%
of respondents, 75% absorbable, 25% titanium,
62% of surgeons supplementing the tacks with
transfascial sutures. Fewer than 5% of surgeons
use glue or self-adhesive mesh.
For the positioning of mesh when doing open
repair, most surgeons favour sublay, with the
majority placing the mesh between the peritoneum
and the posterior rectus sheath, rather than in the
retro-rectus position, on top of the closed posterior
sheath defect. Nearly a quarter of surgeons use an
onlay technique, at least some of the time.
Antibiotics are administered as prophylaxis
against infection by 98% of respondents. When
giving advice regarding activity postoperatively,
80% recommend no heavy lifting for 4–6weeks.
13.5 Laparoscopic Training
The increased rate of laparoscopic inguinal hernia repair has occurred as a result of increased
public awareness of the technique and increased
surgical acceptance of the validity of laparoscopic
13 Hernia Surgery in Australasia
129
repair, plus laparoscopic surgical skills becoming a core part of surgical training. Most trainee
surgeons learn how to carry out laparoscopic
inguinal hernia repairs during their training, but
courses in laparoscopic inguinal hernia repair
continue to have a role. From the mid-1990s, the
author has run courses in New Zealand, mainly
for small groups of qualied surgeons who wish
to add laparoscopic repair to their open skills.
Similar courses are on offer in Australia. The
author’s courses typically consist of a PowerPoint
presentation/discussion, including edited videos
highlighting aspects of technique, followed by
observation of ve or six laparoscopic repairs.
There is no option for mentoring in the author’s
private practice setting. Initially anaesthetised
pigs were used to allow some “hands on” experience for the attendees, but the pig is an unsatisfactory model for laparoscopic inguinal hernia
repair, especially for the TEP approach. Several
mechanical models were tried and discarded.
The most successful has been the use of cadavers
preserved in a manner which maintains a degree
of tissue plasticity, but availability became limited, and it is no longer an option in Auckland.
When observing colleagues applying themselves
to learning laparoscopic hernia repair, it is readily apparent to the author which surgeons are
likely to carry on and succeed in achieving competence rapidly and which surgeons are more
likely to struggle and may be best advised to
keep to a perfectly satisfactory open approach to
hernia repair. Courses of this type have contributed to the gradual but progressive uptake of
laparoscopic inguinal hernia repair in the two
countries. There have been fellowships specically for laparoscopic skill development in general surgery in Australia, but these have been
superseded as a result of laparoscopic skills
becoming increasingly embedded in general surgical practice and fellowship training over the
past 20+ years.
13.6 TAPP Versus TEP
The debate about the relative merits of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches to laparoscopic
inguinal hernia repair has had little airing in
Australia and New Zealand; TEP is overwhelmingly preferred, TAPP being practised by for the
most parts by surgeons who have learned their
skills in other countries.
13.7 Open Inguinal Hernia Repair
As in most parts of the world, preferences for
open repair of inguinal hernias have progressed
from the Bassini to Shouldice to Lichenstein
technique. There is no problem with the supply of
surgical mesh in Australasia, so it is now rare for
any form of hernia to be repaired without the use
of mesh. The Lichenstein approach remains the
most favoured of “tension-free” open repairs,
though other techniques, such as the Kugel patch,
plug and patch, prolene hernia system and
ONSTEP, have their enthusiasts.
13.8 Mesh Controversy
Of recent times there has been some interest in
the Desarda technique, which avoids completely
the use of mesh. Interest in this has been fuelled
by the public (in New Zealand), as a result of
widespread publicity regarding the problems
caused by synthetic mesh placed transvaginally
to treat urinary stress incontinence [7]. There has
been some crossover of this adverse publicity to
hernia repair, particularly with hernia patients
who have developed chronic pain issues postoperatively. In this setting there is a natural tendency to assume it must be the mesh which is the
problem, rather than neurogenic pain which can
be induced by suture, scarring or mesh, but is not
as a result of the mesh itself. These chronic pain
sufferers also have had exposure in the press,
resulting in an assumption that there may be a
systemic issue in surgery regarding the use of
mesh. In New Zealand, a pressure group acting
on behalf of women who have suffered from
transvaginal mesh (“Mesh Down Under”) has
lobbied for a moratorium on the use of all surgical mesh. Education of relevant members of the
press, general practioners and the public, through
statements made by the surgical profession, has
130
A. Bowker
helped balance the situation, but concerns regarding mesh are still frequently aired.
13.9 The Wider Inuence
ofVideolaparoscopy
onHernia Repair
Hernia surgery prior to the introduction of videolaparoscopic technology had a low prole in
day to day surgical life. Inguinal hernia repair
was the operation which junior registrars learnt
early in training and the one which they were
often left to do on their own when still relatively inexperienced. As a senior house ofcer
in England in the 1980s, the author was shown
how to do an open inguinal hernia repair by ve
different surgeons, each only once, before
being given his own list of repairs to do.
Although this was perhaps an extreme example
of attitudes to hernia repair in those times, it is
not an unrepresentative one. The challenges
and threats (as outlined above) that the new
technology has had on surgical practice has had
enormous benets for how hernia repair is managed. Scrutiny has been brought to bear on the
actual outcomes of these very common operations, bringing about an era when many surgeons look carefully at how they are doing their
repairs and how their patients fare as a result of
these repairs. This increased scrutiny has
spilled over from inguinal hernia repair to
repairs of all types of hernias, as laparoscopic
approaches have been applied to them as well.
Hernia repair was a subject which previously
had minority interest only and was usually buried within surgical conferences dealing with
more important matters. The past 25years has
seen a proliferation of conferences around the
world which are dedicated solely to discussing
hernia repair, generating healthy debate about
which techniques work best for surgeons and
patients. Important data about complications,
recurrence rates and chronic pain postoperatively has been collected and analysed from
sources such as the Danish Hernia Registry.
Centres and surgeons specialising predominantly in hernia repair have provided an
improved standard of care, causing all surgeons
to take notice of how and what they are doing.
13.10 The Pacic Island Nations
There are many countries which make up the
Pacic Islands. Feedback for the purposes of
this chapter was obtained from surgeons working in Fiji, the Cook Islands, Tonga, Vanuatu,
Samoa and the Solomon Islands. Most of these
nations are characterised by small populations
spread over vast distances. For example, Tonga
has 169 islands over 800km north to south, 36
of which are inhabited, supporting a total population of 107,000. Vanuatu has 82 islands over
1300km north to south, 65 inhabited, population 270,000. This means that health resources
are spread very thinly, the quality of service
being markedly inuenced by relative poverty;
the GDP per capita in Tonga is US$4220 and
Vanuatu US$3036.
When considering hernias, the surgeons working in these settings favour contemporary techniques for repair, most opting for Lichtenstein
mesh repair of inguinal hernias. Surgical mesh is
not always available, on account of cost and
problems of supply. It tends to be bought in large
sheets which are then divided into smaller pieces
and resterilised. While surgeons are aware that
mosquito mesh has been used in hernia repair [8]
where surgical mesh is not available, none of the
surgeons contacted by the author had any experience with using it. If mesh is not available, then
either Shouldice or Bassini techniques are
employed. Laparoscopic equipment is available
in a number of the main hospitals, but its use for
repair of hernias is a luxury, due to the high cost
of the required consumables.
Other factors compound the problems facing
hernia repair in these countries. In many areas,
the volume of work facing local surgeons is such
that the smaller, less complex hernias might not
receive priority. Hernias tend to present late anyway, at a time when they are very large or developing complications. Problems of access are an
issue for remote communities separated by large
tracts of ocean from regional hospitals. In general
13 Hernia Surgery in Australasia
131
there is not a stigma attached to hernias, but in
Tonga there is a stigma with hydrocoeles, so
inguino-scrotal hernias tend to be included. The
use of traditional healers claiming to be able to
affect cures can be a delaying factor in some
areas. Many of the remote island communities
are serviced by a nurse, who is often female, and
this can be a cause for (male) hernia patients
being reluctant to seek attention.
For incisional hernias, an open sublay
approach is generally preferred, most placing the
mesh between the peritoneum and posterior rectus sheath. Some of the island nations are periodically serviced by surgical teams, usually from
Australia or New Zealand, at which time there
are alternative options for repair of more complex hernias.
13.11 Laparoscopic Inguinal
Hernia Repair: ATheory
forPain Prevention
withPenetrative Fixation
Although the incidence of chronic pain following
laparoscopic inguinal hernia repair is signicantly less than with open repair techniques, it is
still a problem in most series [9]. As a means of
trying to reduce pain postoperatively, surgeons
have looked to avoid penetrative xation by using
none, using glues (brin or cyanoacrylate) and
using self-adhesive mesh (ProGrip). The use of
lightweight, wide-pore meshes results in reduced
mesh contraction and, theoretically, less foreign
body sensation, with the expectation that this
may reduce pain. In the author’s unpublished
data, the incidence of pain, or even awareness, at
3months postoperatively is very low (Table13.3),
as compared to most published series [9], despite
routine use of heavyweight mesh and titanium
tack xation. Following a change to using lightweight large-pore mesh, data was again collected
by the author, this time at 3 and 12 months
(Table 13.4). As anticipated, there was a reduction of awareness of the repairs with the further
passage of time. The difference in pain incidence
between the period when the author was using
heavyweight, narrow-pore mesh and lightweight,
wide-pore mesh was small, favouring the heavier
mesh slightly. The surgical literature is mixed on
the relative values of heavy- and lightweight
meshes, with some studies describing no increase
of recurrence rates with lightweight mesh and
reduced long-term pain [10]. Others detect little
difference between the two [11]. However, others
have raised concern that longer term pain may be
greater with lightweight mesh and recurrence
rates higher [12, 13]. This has been the author’s
impression, the possibility of recurrence following the use of lightweight mesh being related to
the handling characteristics of the mesh; some
lightweight meshes are very “oppy” and do not
sit as well against the posterior wall of the inguinal canal as the stiffer heavyweight meshes. As
there appears to be little difference in outcome
between the two options, it seems reasonable to
use the mesh that best suits the individual surgeon. For those with cost constraints, at heavyweight meshes tend to be cheaper than the
lightweight options. The author currently uses a
medium weight, wide-pore mesh, on account of
its favourable handling characteristics. The
answer to the very low rates of pain post laparoscopic inguinal hernia repair achieved by the
author lies in technique, attention to detail, thinking about what is being done operatively and the
possible consequences of those actions.
When using penetrative xation, most surgeons x the mesh both medially and laterally.
Moreover, the medial xation is often into soft
tissues alongside the superior pubic ramus, rather
than into the surface of the pubic ramus itself.
Many surgeons fear that some form of periostitis
may result from bony xation. Absorbable tacks
are used by some surgeons, with the rationale that
Table 13.3 Review of unilateral inguinal hernia repairs
in males, groin strain excluded
Restriction Nil Mild Moderate Severe
At 3months
(N=951)
Pain/awareness
At 3months
(N=951)
Routine titanium tack xation, heavyweight mesh
(1996–2007)
Source: Author’s database
99.9%
(N=950)
91.1%
(N=866)
0.1%
(N=1)
8.5%
(N=81)
Nil Nil
0.4%
(N=4)
Nil
132
Table 13.4 Review of unilateral inguinal hernia repairs in males
Pain/awareness Nil Mild Moderate Severe
At 3months (N=129) 85.27% (110) 11.63% (15) 3.10% (4) Nil
At 12months (N=122) 93.44% (114) 6.56% (8) Nil Nil
Restriction
At 3months (N=129) 99.2% (128) 0.78% (1) Nil Nil
At 12months (N=122) 100% (122) Nil Nil Nil
Routine titanium tack xation, lightweight large-pore mesh (2013–2014)
Source: Author’s database
A. Bowker
if pain is caused, at least it may be time limited,
as the xations eventually resorb. Fixation to the
soft tissues alongside the superior pubic ramus
may in itself be a cause of chronic pain, as penetrative xation here is effectively injuring tissue
(ligament, tendon) which has a poor blood supply
and therefore poor healing capacity. Furthermore,
if there is both medial and lateral xation, as the
mesh contracts, which all meshes do, the penetrative points of xation are dragged through the tissues towards each other, with potential to cause
pain. Wide-pore mesh contracts less than narrowpore mesh. The author suspects that any pain
reduction observed with the use of lightweight
mesh relates to the reduced contraction between
medial and lateral points of xation. If there is no
lateral xation, then mesh contraction is not a
concern.
The author has employed penetrative titanium
tack xation throughout his entire series. He
adheres the postero-medial edge of the mesh to
the surface of the superior pubic ramus with multiple tacks, which are driven into the periosteum/
bone surface. Initially, like many surgeons, he
restricted himself to two cautiously placed tacks,
but recurrence of a large direct hernia early in his
experience, when the mesh pulled the tacks off
the bone into the defect, encouraged him to be
more aggressive with tack placement into the
bone. Strong xation is even more important in
the current era of using wider-pored mesh, as the
wide pores have a tendency to slip off over the
tacks. There has not been any periostitis or osteitis pubis as a result of this practice in his series.
For 20 years lateral xation has been avoided
completely, instead relying on careful placement
of mesh such that, as the gas is released at the end
of the operation, the weight of the abdominal
contents through the peritoneum pins the mesh
against the pelvic wall. Medial contraction of the
mesh lateral to the deep ring of the inguinal canal
is not a concern, as mesh coverage in this area is
generous. Mesh contraction away from the midline, where there is little overlap medial to the
posterior wall of the inguinal canal, is prevented
by secure xation to the superior pubic ramus
+/− the linea alba further anteriorly. The mesh is
able to glide unimpeded across the pelvic wall
from lateral to medial as any contraction occurs.
The repair is secure, and immediate return to
heavy physical activity is encouraged, as the
mechanics of laparoscopic hernia repair permits
this.
Conclusion
A wide range of hernia repair techniques is
employed by surgeons operating in Australasia
and the Southern Pacic Ocean nations. The
advent of videolaparoscopic technology has
had far reaching effects on how hernia surgery
is approached and taught. For inguinal hernia
repair, laparoscopic techniques are increasingly
employed, the public sector lagging behind private practice. For laparoscopic inguinal hernia
repair, the totally extraperitoneal approach is
favoured over transabdominal preperitoneal.
For open inguinal hernia repair, the Lichtenstein
technique is still the most commonly performed
operation. There has been some disenchantment with laparoscopic repair of incisional hernias, with surgeons tending to prefer open mesh
sublay techniques. The Pacic Island surgeons
have some restraints regarding the choice of
repairs they choose, due to supply and economic factors. As with elsewhere, the surgical
profession in this part of the world has to deal
with misinformation regarding the use of mesh
in hernia repair, secondary to publicity sur-