Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_753_Библиотеки_им_академика_М_И_Перельмана.pdf
X
- •Foreword
- •Preface
- •Contents
- •1: History and Evolution of Hernia Surgery
- •References
- •2.1 Introduction
- •3.2.2 Matrix Metalloproteinases (MMPs)
- •3.2.3 Growth Factors
- •References
- •3.1 Introduction
- •3.2.1 Collagen Fibers
- •3.2.4 Elastic Fibers
- •3.3 Discussion
- •References
- •References
- •5.1 Introduction
- •5.3.2 Ultrasound
- •5.3.3 CT Scan
- •5.3.4 MRI
- •5.3.5 Herniography
- •5.3.6 Diagnostic Laparoscopy
- •References
- •6.1 Prosthetic Mesh Materials
- •6.1.1 Introduction
- •6.1.3.1 Wound Healing Process
- •6.1.3.2 The Foreign Body Reaction
- •6.1.4 The Ideal Prosthetic Mesh
- •6.2 Mesh Properties
- •6.2.1 Materials
- •6.2.1.1 Plastic (Synthetic) Meshes: Non-Absorbable
- •Polypropylene Mesh (PPM)
- •Polyester Mesh
- •ePTFE
- •cPTFE
- •PVDF
- •Polyglycolic Acid
- •Polyglactin 910
- •6.2.1.4 Composite/Hybrid Meshes
- •6.2.1.5 Biological Meshes
- •6.2.1.6 Cross-Linked Vs. Non-Cross-Linked
- •6.2.2 Mesh Construction
- •6.2.6.1 Low-Cost Mesh
- •6.3.1 Introduction
- •6.3.2 Fixation Methods
- •6.3.2.1 Suture Fixation
- •Suture Material
- •Suture Technique
- •6.3.2.2 Glue Fixation
- •6.3.2.3 Fibrin Sealant Fixation
- •6.3.2.4 Staple Fixation
- •6.3.2.6 No Fixation
- •6.3.2.7 Self-Fixing Mesh
- •References
- •7.1 Introduction
- •7.2.3 Other Tools
- •7.2.5.2 Group Members
- •7.2.6 The GRADE Approach
- •References
- •8.1 Introduction
- •8.4 Registry-Based Research
- •References
- •9.1 Introduction
- •References
- •10.1 Background
- •10.2 Trends
- •10.3 The Mesh Implant
- •10.5.1 Day Surgery
- •10.5.2 Laparoscopic Ventral Hernia Surgery
- •10.6 Actual Situation
- •10.6.1 Innovative Surgical Techniques
- •10.6.2 Sub-Specialisation
- •References
- •11.1 Hernia Epidemiology
- •11.1.1 Groin Hernia
- •11.1.2 Ventral Incisional Hernia
- •11.2 Pre-Habilitation
- •11.3 Operative Techniques
- •11.5 Robot-Assisted Hernia Repair
- •References
- •12.1 Introduction
- •References
- •13.4.1 Inguinal Hernia Repair
- •13.4.3 Incisional Hernia Repair
- •13.5 Laparoscopic Training
- •13.6 TAPP Versus TEP
- •13.7 Open Inguinal Hernia Repair
- •13.8 Mesh Controversy
- •References
- •14.1 Summary
- •15: Humanitarian Hernia Surgery: Lessons Learned
- •15.1 Introduction
- •15.2 Service Missions
- •15.2.1 Surgeon Selection
- •15.4.4 Surgeon Trainee Selection
- •References
- •15.3.5 Incisional Hernias
- •15.3.6 Anesthesia Care
- •15.3.7 Patient Follow-Up
- •15.4 Training Missions
- •15.4.1 Capacity Building
- •15.4.2 Training Method
- •References
- •17: Anatomy of the Inguinal Region
- •17.2 The Inguinal Canal (Fig. 17.7)
- •17.3 Entrance to the Channel: the Deep Inguinal Ring
- •17.5 Floor of the Channel: the Inguinal Ligament
- •17.8 Spermatic Cord and Vascular Issues
- •References
- •18: Ambulatory Hernia Surgery
- •18.2 History
- •18.4 International Comparison
- •References
- •Suggested Readings
- •20.1 Etiology
- •20.2 Clinical Manifestation
- •20.5 Treatment
- •20.5.5 Preoperative Preparation
- •20.5.7 Surgical Procedures
- •20.5.9 Surgical Procedures
- •References
- •21.2 Statistical Relevance
- •21.3 Pure Tissue Repairs
- •21.8.1 Foreign Object
- •21.9 Material-Related Changes
- •References
- •22.1 Introduction
- •22.2 Personal Experience
- •22.3 Indications
- •22.4 Surgical Technique
- •References
- •23: Bassini Repair
- •23.1 Introduction
- •23.3 Skin Incision
- •23.12 The Filzetta Stitch
- •23.13 The First Stitch
- •23.14 The Second Stitch
- •23.15 The Third Stitch
- •23.16 The Last Stitch
- •24: The Shouldice Repair
- •24.1 Introduction
- •24.2 Local Anaesthesia
- •24.3.1 Dissection
- •24.3.2 Reconstruction
- •24.4.1 Dissection
- •24.4.2 Reconstruction
- •References
- •25.1 Introduction
- •25.2 Surgical Indications
- •25.3 Surgical Technique
- •25.5 Outcomes
- •References
- •26.1 Indications
- •26.2 Patient Preparation
- •26.3 Original Technique
- •26.3.1 Anesthesia
- •26.3.2 Local Anesthesia
- •26.3.2.1 Mixture
- •26.3.3 Technique
- •26.4 Surgical Dissection
- •26.4.1 Hernia Sac Treatment
- •26.4.1.1 Medial Hernia Sac
- •26.4.1.2 Lateral Hernia Sac
- •26.4.2 The Mesh: Material
- •26.4.3 Mesh Fixation
- •References
- •27: Mesh Plug Repair
- •27.1 Introduction
- •27.2 Surgical Technique
- •27.3 Comments
- •References
- •28.1 Introduction
- •28.3 Surgical Procedure
- •28.3.1 Anesthesia
- •28.4.1 Antibiotic Prophylaxis
- •28.4.2 Preoperative Landmarks
- •28.4.3 Anesthesia
- •28.4.4 Nerve Management
- •28.4.5 Hernial Sac Management
- •28.4.6 Mesh Application
- •28.4.7 In Females
- •28.5 Discussion and Conclusions
- •References
- •29: Gilbert Technique: PHS Bilayer Repair
- •29.3 Suture Repairs
- •29.4 Anterior Mesh Repairs
- •29.9.4.1 Medial (Direct) Hernias
- •29.9.4.2 Lateral (Indirect) Hernias
- •29.9.7 Post-op Care
- •29.10 Results
- •29.13 Discussion
- •References
- •30.1 Introduction
- •30.2 The ONSTEP Technique
- •30.3 Clinical Data
- •30.5 Health Economics
- •30.6 Perspectives
- •References
- •31.1 Introduction
- •31.2 Anesthesia
- •31.3 Operative Technique: Lateral Hernia
- •31.3.1 First Step: Skin Incision
- •31.3.2 Second Step: Nerve Preservation
- •31.4 Operative Technique: Medial Hernia
- •31.6 Results
- •References
- •32: Minimal Open Preperitoneal (MOPP) Technique
- •32.1 Introduction
- •32.3 Surgical Technique
- •32.4 Indications
- •32.5 Special Cases
- •32.5.1 Female Hernias
- •32.5.2 Femoral Hernia
- •32.5.3 Scrotal Hernia
- •32.5.4 Strangulated Hernia
- •32.6 Contraindications
- •32.7 Personal Data
- •References
- •33.1 Introduction
- •33.2 Indications
- •33.3 Contraindications
- •33.4 Relative Contraindications
- •33.5 Preoperative Preparation
- •33.6 Operating Theatre Setup
- •33.6.1 Instruments
- •33.7 Surgical Technique
- •33.7.5 Hernia Reduction
- •33.7.5.1 Medial or Direct Hernia
- •33.7.5.2 Femoral Hernia
- •33.7.5.3 Obturator Hernia
- •33.7.5.4 Indirect Hernia
- •33.7.5.5 Mesh Repair
- •33.8 Postoperative Care
- •33.9 Complications
- •References
- •34: Primary Inguinal Hernia: TAPP
- •34.1 Introduction
- •34.3 The Standardized TAPP Technique
- •34.3.1 Pneumoperitoneum
- •34.3.2 Trocar Placement
- •34.3.3 Dissection
- •34.3.4 Mesh Placement
- •34.3.5 Fixation
- •34.3.6 Peritoneal Closure
- •34.3.8 Antibiotic and Thromboembolic Prophylaxes
- •References
- •35.1 Introduction
- •35.2 Biological Prosthesis
- •35.2.1 Features
- •35.4 Complications
- •35.5 Clean Fields
- •35.6 Contaminated Fields
- •35.7 Inguinal Sports Hernias
- •References
- •36: Inguinal Hernia Recurrence
- •36.1 Introduction
- •References
- •37.1 Introduction
- •37.2 Clinical Presentation
- •37.3 Literature Review
- •37.4 Surgical Technique
- •References
- •38: Pubic Inguinal Pain Syndrome (PIPS)
- •38.1 Introduction
- •38.2 Clinical Aspect
- •38.3 Diagnosis
- •38.4 Management
- •38.4.1 Conservative Treatment
- •38.4.2 Surgical Treatment
- •References
- •39.1.1 Incarcerated Hernia
- •39.1.2 Intestinal Occlusion
- •39.1.3 Strangulation
- •39.2 Diagnosis
- •39.2.1 Physical Examination
- •39.2.2 Ultrasound
- •39.2.3 Abdominal Radiographs
- •39.2.4 Computed Tomography
- •39.2.6 Laparoscopy
- •39.2.7 Deep Inguinal Ring Laparoscopy
- •39.3 Surgical Options
- •Bibliography
- •40.1 Watchful Waiting
- •40.2.1 Open Inguinal Hernia Repair
- •40.2.1.1 Mesh-Based Repair
- •40.2.1.2 Mesh Types
- •40.2.1.3 Lichtenstein Repair
- •40.2.1.6 Bilayered Mesh System
- •40.2.1.7 Self-Gripping Mesh
- •40.2.1.8 Glue Fixation
- •40.2.1.9 Preperitoneal Approaches
- •40.2.1.10 Suture-Based Open Repairs
- •40.2.2 Laparoscopic Inguinal Hernia Repair
- •40.2.3 Complications
- •40.2.3.1 Recurrence
- •40.2.3.2 Chronic Pain
- •40.2.3.4 Infections
- •40.2.3.5 Urinary Retention
- •40.2.3.6 Sexual Dysfunction
- •40.2.3.8 Seroma
- •References
- •41.2 Epidemiology
- •41.3.1 Neuropathic Pain Syndromes
- •41.3.1.1 Inguinal Nerve Involvement
- •41.3.1.2 Lower Intercostal Nerve
- •41.3.1.3 Neuroma Formation
- •41.3.2.1 Mesh-Related Pain
- •Meshoma Formation
- •41.3.2.2 Adductor Tendinopathy
- •41.3.2.3 Periostitis Pubis
- •41.3.2.4 Iliopectineal Bursitis
- •41.3.3 Combined Groin Pain Syndromes
- •41.3.3.1 Dysejaculation
- •41.4 Assessment
- •41.4.1 Patient’s History
- •41.4.1.3 Diagnostic Questionnaires
- •41.4.2 Physical Examination
- •41.4.2.4 Spine Examination
- •41.4.3 Pitfalls
- •41.4.4 Imaging
- •41.4.4.1 Ultrasonography
- •41.4.4.2 Computed Tomography
- •41.4.4.3 Magnetic Resonance Imaging
- •41.4.5 Other Diagnostics
- •41.4.5.1 Diagnostic Injections
- •Local Anaesthetic Agents
- •Corticosteroids
- •41.4.5.2 Quantitative Sensory Testing
- •41.4.5.3 Other Imaging Techniques
- •References
- •42.1 Clinical Assessment
- •42.2 Treatment
- •References
- •43.1 Surgical Techniques
- •43.1.1 Endoscopic Groin Exploration
- •43.1.2 Meshoma
- •43.1.3 Fixation
- •43.1.5 Orchialgia
- •43.1.6.1 Operative Technique
- •43.2 Results
- •References
- •References
- •45: Primary Femoral Hernia: Open Anterior Treatment
- •45.1 Introduction
- •45.4 Anaesthesia
- •45.5 Surgical Techniques
- •45.5.1 UHS: Ultrapro Hernia System
- •45.5.2 PHS: Prolene Hernia System
- •45.5.3 UPP: Ultrapro Plug
- •45.9.2 Anaesthesia
- •45.9.3 Local Complications n. 41 (16.8%)
- •45.9.4 Abdominal Complications
- •References
- •46.1 Introduction
- •46.1.2 Anesthesia
- •46.1.3 Surgical Techniques
- •46.1.3.1 The Kugel Approach
- •46.1.3.2 The Transinguinal Preperitoneal Technique (TIPP)
- •46.1.3.3 The Transrectus Sheath Preperitoneal Mesh Technique (TREPP)
- •46.1.3.4 Postoperative Recommendations
- •References
- •47: Laparoscopic Femoral Hernia Repair
- •47.5 Operative Technique
- •47.5.1 Total Extraperitoneal Repair (TEP)
- •References
- •48.1 Risk Factors
- •48.3 Surgical Technique Repair
- •48.4 Surgical Site Infection
- •48.5 Persisting Chronic Pain
- •References
- •49.1.1 Rectus Muscle
- •References
- •50: Umbilical Hernia Repair
- •50.1 Introduction
- •50.2 Open Repair
- •50.2.1 Tissue Repair
- •50.2.2 Mesh Repair
- •50.3 Minimally Invasive Repair
- •50.3.1 Laparoscopic Repair
- •50.3.2 Robotic Repair
- •References
- •51.1 Introduction
- •51.2 The MILOS Technique

260
E. Gianetta and C. Stabilini
26.4.3 Mesh Fixation
In 2002 [3] after evaluation of their experience,
the authors identied ve features of the original
technique responsible for suboptimal results and
needing revision. These so-called aws were
thought to produce two main complications of
hernia repair, recurrence and chronic postoperative pain, and considered as insufcient application of the tension-free principles, namely:
1. The mesh was not extended beyond the pubic
tubercle to overlap the pubic bone.
2. The mesh was too narrow (only 5cm) to provide enough mesh tissue contact above the
inguinal oor.
3. The mesh was kept at and, therefore, was
subject to tension when the patient stood up
from the supine position of the operation.
4. The upper edge of the mesh was xed using a
continuous suture, which potentially left the
iliohypogastric nerve at risk.
5. Passing the genital nerve and external spermatic vessel through a gap along the suture line
of the mesh with the inguinal ligament exposed
the nerve to potential risk of entrapment.
the internal inguinal ring. After xation, it should
be kept in a relaxing conguration, somewhat
redundant to overcome the problem of polypropylene shrinkage possible, as known, as far as 25%.
Using interrupted resorbable sutures and keeping
the nerves together with all cord structures helped
in reducing pain generated by suture entrapment.
The main principle of tension-free hernia
repair relies on accurate mesh xation: no tension must be introduced in the sutures while tying
the knots and on the mesh. According to the original technique, the mesh is xed with a running
nonabsorbable suture (USP 2/0 polypropylene)
to the inguinal ligament (Fig. 26.14) and with
interrupted resorbable sutures (USP vicryl 2/0)
on the aponeurotic layer of the transverse and
internal oblique muscle (Fig.26.15).
Accordingly, modications were introduced to
reduce the occurrence of adverse events and
adopted in this nal form till now. The mesh is bigger to cover all the inguinal oor, with a 2cm overlap over the pubic tubercle and 5–6cm lateral to
Fig. 26.15 Interrupted absorbable stitches to x the mesh to the aponeurotic layer of the lateral muscles and nonab-
sorbable sutures to close the slit
Fig. 26.14 Running nonabsorbable suture to x the
mesh to the inguinal ligament

26 Lichtenstein Onlay Mesh Hernioplasty: Original Technique andPersonal Modications
Authors’ Comment
• We do advise not to tie excessively the
knots on the muscles in order to reduce
the possibility of postoperative pain and
nerve entrapment.
• According to several new modications
in the surgical technique aimed at reducing the total amount of implanted material, the xation of the mesh can be
achieved also by:
Fibrin sealant: we have experienced
this material and appreciated the durable xation characteristics along with
Fig. 26.16 The external oblique aponeurosis is closed
above the cord with a continuous absorbable suture
its hemostatic power. The effect on pain,
discomfort, and numbness and the
reduction of postoperative bleeding in
26.4.4 Closure oftheSurgical Wound
high-risk patients have been shown in
several trials. For these reasons, it has
become one of our favorite xation techniques. When using brin sealant, we
usually adopt two additional sutures,
respectively, on the pubic tubercle and
to solidarize the tail of the mesh, which
represent the two weakest points of the
hernioplasty.
Synthetic glue: we have very few
experiences of cyanoacrylate glue in
Lichtenstein hernioplasty, and the application is very easy and, differently from
brin sealant, made in the form of spots
applied as common stitches. The results
in the literature are good but not superior to traditional xation with resorbable materials.
Self-gripping mesh: in our experience,
this type of mesh needs a little learning
curve for its correct deployment, but
after few cases, it eases and speeds the
In the original, Lichtenstein advised the closure
of the external oblique aponeurosis deep to the
spermatic cord to offer some additive strength to
the repair, but we do not adopt this technique nor
the embrication described by Andrews; we simply close the aponeurosis over the cord not to
introduce too much tension on the repair
(Fig.26.16). We acknowledge, however, that in
this way the cord lies unprotected in direct contact to the prosthetic material possibly exposed to
foreign body reaction, but as far as we can be
sure, no such event has ever been observed in our
series.
We usually perform a reapproximation of the
deep subcutaneous tissue solidarizing with
EOA.In our experience, this can help in reducing
the occurrence of seroma.
The cutaneous incision is closed with intracuticular sutures. When used, stitches are removed
at the rst postoperative visit occurring 1week
after surgery.
work of the surgeon. However, the current literature has still not found a clear
advantage, except for reduced operative time, of this material when analyz-
26.4.5 Patient Discharge
andAftercare
ing the effects on chronic postoperative
pain [13].
The patient is discharged in the early afternoon
after checking the surgical wound and testicle for
261

262
E. Gianetta and C. Stabilini
local complications. In our practice, causes of
unplanned prolongation of hospital stay are pain
not manageable with common painkillers, urinary retention, and fever. Postoperative painkillers are prescribed the night of the intervention
and then on patient’s request.
Lichtenstein stated that encouraging immediate postoperative ambulation “prevents muscle
spasm that initiate the pain cycle,” so at our center all patients are instructed to resume their normal activity as soon as possible, to walk
immediately after the procedure without restriction. We adopt a “do what you feel you can do”
[4] attitude, and we only prescribe no heavyweight lifting for 3 weeks. Postoperative bindings are not prescribed.
The rst outpatient visit occurs 1week after
surgery to assess the surgical wound, and then
patients are followed at 6months and yearly up to
the second postoperative year.
References
1. Lichtenstein IL. Hernia repair without disability: a
surgical atlas illustrating the anatomy, technique, and
physiologic rationale of the “one day” hernia and
introducing new concepts: tension-free herniorrhapies. Missouri: Ishiyaku EuroAmerica; 1986.
2. Lichtenstein IL, Shulman AG, Amid PK, Montllor
MM. The tension-free hernioplasty. Am J Surg.
1989;157:188–93.
3. Amid P, The K.Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty. Hernia. 2003;7:13–6.
4. Simons MP, etal. European Hernia Society guidelines
on the treatment of inguinal hernia in adult patients.
Hernia. 2009;13:343–403.
5. Smietanski M, etal. 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.
6. Gianetta E, et al. Anterior tension-free repair of
recurrent inguinal hernia under local anesthesia a
7-year experience in a teaching hospital. Ann Surg.
2000;231:132–6.
7. Gianetta E, etal. Hernia repair in elderly patients. Br
J Surg. 1997;84:983–5.
8. Al-dabbagh A.Anatomical variations of the inguinal
nerves and risks of injury in 110 hernia repairs. Surg
Radiol Anat. 2002;24:102–7.
9. Scott N, etal. Open mesh versus non-mesh for repair
of femoral and inguinal hernia. Cochrane Database
Syst Rev. 2002;(4). https://doi.org/10.1002/14651858.
CD002197.
10. Fang Z, etal. Biologic mesh versus synthetic mesh in
open inguinal hernia repair: system review and metaanalysis. ANZ J Surg. 2015;85:910–6.
11. Zhong C, etal. A meta-analysis comparing lightweight
meshes with heavyweight meshes in Lichtenstein
inguinal hernia repair. Surg Innov. 2013;20:24–31.
12. Uzzaman M, etal. Meta-analysis of randomized controlled trials comparing lightweight and heavyweight
mesh for Lichtenstein inguinal hernia repair. Hernia.
2012;16:505–18.
13. Ismail A, et al. Self-gripping versus sutured mesh
xation methods for open inguinal hernia repair: a
systematic review of clinical trials and observational
studies. Surgery. 2017;162(1):18–36. https://doi.
org/10.1016/j.surg.2016.12.028.

Mesh Plug Repair
FrancescoGossetti, LindaD’Amore,
MariaRomanaGrimaldi, FrancescaCeci,
andPaoloNegro
To Davide Fieschi (1869–1953), the pioneer of open plug repair [1].
27
27.1 Introduction
Besides the onlay prosthetic herniorrhaphy, of
which the Lichtenstein technique represents the
gold standard, mesh plug is one of the most common procedures for open tension-free groin hernia repair. The mesh plug repair (MPR) has been
proposed in the late 1980s on the basis of the
experience of Gilbert, Trabucco, and Rutkow
[2–4], but it was only when a preformed plug
(PerFix™, Bard Davol) began to be available on
the market that this technique became widespread
[5]. Since then, millions of plugs have been used
worldwide, and many other new devices have
been developed and continue to be produced by
the medical industry, designed for those surgeons
who prefer a three-dimensional (3D) technique
for groin hernia repair.
MPR is actually a deep repair, as the device
lies in the pre-peritoneal space. It requires a less
complete dissection ensuring a tension-free hernioplasty. The plug prevents protrusion of the
previously inverted peritoneal sac, so acting as a
stopper [6]. Filling the pre-peritoneal space, the
3D conguration of the plug also provides a
deeper area over which scarication takes place.
F. Gossetti (*) · L. D’Amore · M. R. Grimaldi
F. Ceci · P. Negro
Abdominal Wall Surgery Unit, Department of
Surgery, Sapienza University of Rome, Rome, Italy
e-mail: gossetti@tiscalinet.it; linda.damore@uniroma1.it
In this way, the plug prevents the recurrence of
lateral hernias following previous onlay repair, in
which a peritoneal sac can be found protruding
through the inguinal internal ring, between the
posterior wall and the onlay patch [7].
Originally, mesh plug repair was proposed for
all groin hernias, on the basis of the hernia classication described by Rutkow [4]. Today, MPR
should be indicated for the treatment of lateral
hernia, recurrent “internal” hernia, and femoral
hernia, according to a tailored management of
groin hernia.
27.2 Surgical Technique
The operation is performed under local anesthesia or sensory epidural block, as it allows the
patient to cough or strain on command. In this
way, it is possible to verify the correct positioning of the plug and to ascertain that the hernia sac
remains safely reduced. The skin incision is less
than 6 cm, and external oblique aponeurosis is
slit from the external ring to just above its location over the internal ring. Tissue dissection,
including that of the hernia sac, is minimal, and it
is accomplished with electrocautery. The cremasteric muscle is removed to allow a proper placement of the mesh. The inguinal and genitofemoral
nerves are preserved, if surgical steps allow it.
In lateral hernias, the sac is dissected off the
spermatic cord structures to the level of the
© 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_27
263

264
F. Gossetti et al.
internal ring, along with any lipomas of the cord.
The dissection of the sac should be high enough
to visualize the pre-peritoneal fat pad at the level
of the internal ring, in order to create a pocket for
positioning the plug. The internal ring is the natural passage for the cord, so the space should be
considered not virtual but real [8]. The hernia sac
is opened only if strictly necessary. Once the
freely dissected sac and any adjacent lipoma are
inverted through the internal ring into the abdominal cavity, the plug is inserted with a clamp and
placed into position beneath the crura. The plug
must be secured to the internal ring with multiple
interrupted sutures to x the device in permanent
position and prevent migration. Usually at the
end of the repair, an onlay patch is placed on the
anterior surface of the posterior wall of the inguinal canal to reinforce it inducing additional broplasia, thus preventing a medial hernia. In this
way, MPR should rather be named “plug-andpatch” repair (Fig.27.1).
In recurrent “internal” hernias, where the sac
protrudes near the pubic tubercle, the sac is simply dissected down to its base on the inguinal
oor and then circumscribed to permit full access
to pre-peritoneal space. The plug is nally
inserted into the defect and secured with multiple
anchoring sutures between the device and the
scarred margin of the oor defect and/or pubic
tubercle.
In femoral hernias, the skin incision is located
directly over the hernia impulse and the dissection is carried out on the hernia sac toward its
base, at the orice of the femoral canal. The sac
Fig. 27.1 Surgical technique: Placement of the plug
is then reduced into the femoral canal and the
plug is placed through the opening. After proper
positioning, the external layer of the plug is
secured with some sutures to the margins of the
defect.
27.3 Comments
The above described procedure points out the
surgical steps of MPR, referring to the original
technique, proposed by Rutkow and Robbins for
PerFix™ plug repair. Some modications have
been done during the years [9, 10], and a large
number of new plugs or 3D devices have been
introduced on the market, made of new materials
and displaying new proles, to meet the current
requirements of hernia surgery (Fig.27.2).
Following to the criticisms addressed to the
plug, many new devices have been developed so
to meet the emerging needs. Which are these
criticisms?
In 2009, the European Hernia Society (EHS)
guidelines on the treatment of inguinal hernia in
adults concluded that the 3D mesh repair could
be considered an alternative procedure to
Lichtenstein technique (recommendation, grade
B), although only short-term results were available at that moment [11]. In 2014, an update of
the EHS guidelines, on the basis of a larger number of available data, conrmed that 3D mesh
techniques were acceptable for hernia repair,
with outcomes comparable to the Lichtenstein
herniorrhaphy, except a shorter operative time
[12]. However, the plug repair was somehow criticized: the excessive use of foreign material, the
additional cost of the device, the chance of plug
migration/erosion, the need to enter both the posterior and anterior plane of inguinal region, and
the limited number of long-term follow-up studies. On the basis of these critics, more recently
the HerniaSurge guidelines for groin hernia
management have concluded that “the use of
other meshes or gadgets to replace the standard
at mesh in the Lichtenstein technique is currently not recommended” [13].
Many trials compared MPR and Lichtenstein
technique. We collected 15 RCTs in a systemic

27 Mesh Plug Repair
abcde
fghi l
mnopq
Fig. 27.2 Plugs and 3D devices available on the market
265
Table 27.1 MPR vs. Lichtenstein: RCTs
Lichtenstein vs. MPR
Kingsnorth AN (short-term) [14]
Kingsnorth AN (medium-term) [15]
Testini M [16]
Bringman S [17]
Adamonis W [18]
Bolognini S [19]
Horharin P [20]
Frey DN [21]
Sanders DL [22]
Droeser RA [23]
Ripetti V [24]
Lichtenstein vs. PHS vs. MPR
Nienhuijs SW [25]
Mayagoitia JC [26]
Dalenbäck J [27]
Nienhuijs SW [28]
review (Table27.1) [14–28]. These showed comparable outcomes in the short and long period, in
terms of return to normal activity, postoperative
complications, chronic pain, and recurrence rate,
with statistically signicant shorter operative
time in the plug repair group, even if the gap is
less than 10min. Two meta-analysis comparing
different open techniques, including Lichtenstein
and plug repair, conrmed that both procedures
were equivalent in most of the analyzed outcomes, with the above demonstrated shorter surgical time associated with mesh plug technique
[29, 30]. Interestingly, two trials showed, from
the surgeon’s point of view, that MPR was signicantly superior to the Lichtenstein operation
in terms of perceived difculty and surgeon’s satisfaction [25, 27]. Actually MPR had been proved
to be the fastest to perform and the easiest to
learn by 70 experts in hernia surgery [31]. Four
RCTs reported long-term results, from 36 to
76 months [23, 26–28]. None of them showed
relevant differences in recurrence, chronic pain,
or other complications, as migrating mesh plug.
In one RCT, the overall cumulative reoperation
rate was fairly higher in the Lichtenstein group
[23]. Nevertheless, the main criticism to plug
repair continues to refer to the natural history of
the mesh. The plug can shrink (meshoma), could
migrate and erode the surrounding structures
(cecum, sigmoid colon, ileum, bladder), or can
be responsible for chronic pain. The cone tip of
the device could act as a pivot, and any tilt or drift
of the plug could play a role in the pathophysiology of the mesh migration [32]. Mesh migration
might happen because of the movement toward
the path of resistance, caused by a poor
securement of the mesh, or might occur through
surrounding structures conditioned by erosion
caused by a foreign body reaction [33].
How common is the migration/erosion of the
plug really? A previous review of the literature
collected seven case reports published between

266
F. Gossetti et al.
Table 27.2 Plug migration/erosion: visceral involvement
Reference
Chuback JA
[37]
Tokunaga Y
[38]
Moorman
ML [39]
Benedetti
M [40]
Murphy JW
[41]
Ojo P [42] 8years Lower quadrant
Zubaidi A
[43]
Stout CL
[44]
Liang X
[45]
Ortiz JA
[46]
Ishiguro Y
[47]
Chen MJ
[48]
Ratajczak A
[49]
Yilmaz I
[50]
Ishikawa S
[51]
Sekiguchi
K [52]
Yamamoto
S [53]
Scaringi S
[54]
Veroux M
[55]
Time
lapse
2years Occlusion Small bowel
7years Rectal bleeding
15years Lower quadrant
2years Rectal bleeding
2years Lower quadrant
2years Colocutaneous
nr Occlusion Small bowel
3years Occlusion Small bowel
nr Necrosis
3years Colocutaneous
2years Perforation Small bowel
2years Obstruction (C
3years Occlusion Sigmoid
5years Bladder skin
13years Colocutaneous
2years Occlusion Small bowel
26years Colocutaneous
6years Hydronephrosis
Clinical
presentation Site
(D like)
pain
(D like)
pain (D like)
mass (C like)
stula (D)
(kidney Tx
recipient)
stula
like)
stula
stula
stula (D)
(kidney Tx
recipient)
Sigmoid
colon
Small bowel
Sigmoid
colon
Sigmoid
colon
Cecum
Sigmoid
colon
Ureter
Sigmoid
colon
Sigmoid
colon
colon
Bladder
Cecum
Sigmoid
colon
Ureter
1995 and 2006 [34], including two hernia recurrences, which should be excluded due to migration of the plug into the scrotum without any
other clinical involvement [35, 36]. We extended
the review over the last decade, collecting further
14 reports of plug-related visceral involvement
(Table27.2) [37–55]. In two other cases, the plug
migration was revealed as an incidentaloma at
CT scan, without any clinical sign [56, 57].
Thesigmoid colon was the site more frequently
involved, followed by the small bowel and cecum.
The plug affected the urinary tract in three cases
only. Symptoms related to plug migration or erosion apparently occur mainly in the rst 3years
after the hernia repair, even if few reports suggest
that the time interval might be longer. Clinical
ndings (occlusion, bleeding) mimicking carcinoma of lower gastrointestinal tract were frequently associated. The majority of the patients
with sigmoid involvement suffered from diverticular disease.
Some surgeons suggest that migration may
not be as uncommon as it seems to appear from
the collection of anecdotal reports in the surgical
literature [58]. Other cases of plug migration
could not come to publication for medicolegal
implications, indifference of the authors, or lack
of recognition; the actual rate, therefore, could be
underestimated. However, this opinion is in contrast with the results of population studies in
which no case of mesh migration has ever been
seen in the long run [23, 34, 59–61]. At the end of
the 1990s, an Italian national inquiry, collecting
19,700 MPRs, showed only ve cases of inner
migration of the plug [62]. At the fth
International Hernia Congress of the American
Hernia Society (AHS), we presented a search of
the US Food and Drug Administration MAUDE
for key word mesh plug (PerFix™) to nd reports
not published in the literature (from 1999 to
2011). We were able to collect only six cases of
visceral involvement due to migration/erosion of
the plug [63]. At the end of 2015, the total number reached 15 cases. In conclusion, visceral
involvement following plug repair is a very rare
complication, reported in literature as anecdotal
clinical case, as it occurs for TAPP or TEP
techniques [64].
Can the outcome of MPR be improved? Can
the risk of migration/erosion be reduced? [65].
The answer is positive. The rst suggestion consists in selecting proper indications, limiting plug
repair to the treatment of lateral hernias, to femoral hernias, and to selected types of recurrences,
and avoiding it in patients suffering from left
groin hernia and colonic diverticular disease or in
case of sliding hernias; secondly it is important to

27 Mesh Plug Repair
267
pay attention to technical details, such as to avoid
excision of the sac and lipoma, to identify and
repair any tears of peritoneum, to avoid to place
the plug too deep into the inguinal canal, and to
secure the plug with a number of sutures; thirdly
it is important to choose the proper plug. A new
generation of plugs and 3D devices, made from
lightweight or semi-absorbable or completely
absorbable materials, and improved proles are
available today on the market. Some of these
have proved to provide benets [22, 66, 67].
Others seem to show favorable effects in selected
cases [68–70]. Finally new “all-in-one” devices
allow a plug-and-patch repair without any risk of
migration [71].
We do not agree with those who consider
MPR as gadget surgery, highlighting the market-
ing of the technique. The additional cost of the
device doesn’t justify this criticism, though other
commended techniques, such as TAPP or TEP
repair, are more expensive. Instead with the same
outcome and comparable complication rate, other
parameters should be considered when selecting
the more effective repair, like the surgeon’s satisfaction [72]. MPR offers the fastest learning
curve and the shortest operative time [31]. The
plug should be kept in the armamentarium of a
general surgeon interested in a tailored approach
to groin hernia surgery.
References
1. Negro P, Gossetti F, Ceci F, Manto O, D’Amore
L.Davide Fieschi: a pioneer of plug repair in groin
hernia surgery. Hernia. 2014;18:919–23.
2. Gilbert AI. An anatomical and functional classica-
tion for the diagnosis and treatment of inguinal hernia.
Am J Surg. 1989;157:331–3.
3. Trabucco EE. Routine sutureless mesh in primary
inguinal hernioplasty. Am Coll Surg. 1989;13:541–4.
4. Rutkow IM, Robbins AW. 1669 mesh plug hernio-
plasties. Contemp Surg. 1993;43:141–7.
5. Rutkow IM, Robbins AW.Mesh plug hernia repair: a
follow-up report. Surgery. 1995;117:597–8.
6. Read R. Milestones in the history of hernia surgery:
prosthetic repair. Hernia. 2004;8:8–14.
7. Gilbert AI, Graham MF, Voigt WL.A bilayer devices
for inguinal hernia repair. Hernia. 1999;3:161–6.
8. Campanelli GP, Pettinari D, Nicolosi FM, Cavalli
M, Contessini Avesani E.Inguinal hernia recurrence:
classication and approach. Hernia. 2006;10:159–61.
9. Pelissier EP, Blum D, Dams JM, Marre P.The plug
method in inguinal hernia: a prospective evaluation.
Hernia. 1999;4:201–4.
10. Millikan KW, Cummings B, Doolas A.A prospective study of the mesh plug hernioplasty. Am Surg.
2001;67:285–9.
11. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot
JL, Campanelli G, Conze J, de Lange D, Fortelny R,
Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde
S, Nordin P, Schumpelick V, Smedberg S, Smietanski
M, Weber G, Miserez M. European Hernia Society
guidelines on the treatment of inguinal hernia in adult
patients. Hernia. 2009;13:343–403.
12. Miserez M, Peeters E, Aufenacker T, Bouillot JL,
Campanelli G, Conze J, Fortelny R, Heikkinen T,
Jorgensen LN, Kukleta J, Morales-Conde S, Nordin
P, Schumpelick V, Smedberg S, Smietanski M, Weber
G, Simons MP. 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.
13. Weyhe D.New worldwide guidelines for treatment of
inguinal hernia: the most important recommendations
from HerniaSurge. Chirurg. 2017;88(7):628. https://
doi.org/10.1007/s00104-017-0386-3.
14. Kingsnorth AN, Porter CS, Bennett DH, Walker AJ,
Hyland ME, Sodergren S.Lichtenstein patch or Perx
plug-and-patch in inguinal hernia: a prospective double-blind randomized controlled trial of short-term
outcome. Surgery. 2000;127:276–83.
15. Kingsnorth AN, Hyland M, Porter RN, Sodergren
S. Perx plug and patch versus Lichtenstein patch
in inguinal hernia: prospective randomized doubleblind study of medium-term outcome. Proceedings
from “Hernia in the 21st Century” (Toronto, 2000),
Meeting book; 2002. p.246.
16. Testini M, Miniello S, Piccinni G, Di Venere B,
Lissidini G, Greco L, Bonomo GM.Trabucco versus
Rutkow versus Lichtenstein techniques in the treatment of groin hernia. A controlled randomized clinical trial. Minerva Chir. 2002;57:371–6.
17. Bringman S, Ramel S, Heikkinen TJ, Englund T,
Westman B, Anderberg B.Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein:
a prospective randomized controlled trial. Ann Surg.
2003;237:142–7.
18. Adamonis W, Witkowski P, Smietański M, Bigda J,
Sledziński Z.Is there a need for a mesh plug in inguinal hernia repair? Randomized, prospective study of
the use of Hertra 1 mesh compared to PerFix plug.
Hernia. 2006;10:223–8.
19. Bolognini S, Orsini V, Grandinetti PP, Pata F, Sacco
R.Lichtenstein vs. Rutkow-Robbins technique in the
treatment of primary inguinal hernia. Analysis of the
long term results. Ann Ital Chir. 2006;77:51–6.
20. Horharin P, Wilasrusmee C, Cherudchayaporn K,
Pinyaku N, Phanpradi O, Phromsopha N.Comparative
study of tailor-made mesh plug herniorrhaphy versus
Lichtenstein herniorrhaphy versus Bassini operation: a
prospective clinical trial. Asian J Surg. 2006;29:74–8.

268
F. Gossetti et al.
21. Frey DM, Wildisen A, Hamel CT, Zuber M, Oertli D,
Metzger J.Randomized clinical trial of Lichtenstein's
operation versus mesh plug for inguinal hernia repair.
Br J Surg. 2007;94:36–41.
22. Sanders DL, Samarakoon DH, Ganshirt SW, Porter
CS, Kingsnorth AN. A two-centre blinded randomised control study comparing the Lichtenstein
patch, Perx plug and ProLoop plug in the repair of
primary inguinal hernia. Hernia. 2009;13:499–503.
23. Droeser RA, Dell-Kuster S, Kurmann A, Rosenthal
R, Zuber M, Metzger J, Oertli D, Hamel CT, Frey
DM. Long-term follow-up of a randomized controlled trial of Lichtenstein’s operation versus
mesh plug repair for inguinal hernia. Ann Surg.
2014;259:966–72.
24. Ripetti V, La Vaccara V, Greco S, Bono F, Valeri S,
Coppola R.Randomised trial comparing Lichtenstein
vs Trabucco vs Valenti techniques in inguinal hernia
repair. Hernia. 2014;18:205–12.
25. Nienhuijs SW, van Oort I, Keemers-Gels ME,
Strobbe LJ, Rosman C. Randomized trial comparing the Prolene Hernia System, mesh plug repair and
Lichtenstein method for open inguinal hernia repair.
Br J Surg. 2005;92:33–8.
26. Mayagoitia JC, Prieto-Díaz Chávez E, Suárez D,
Cisneros HA, Tene CE.Predictive factors comparison
of complications and recurrences in three tension-free
herniorraphy techniques. Hernia. 2006;10:147–51.
27. Dalenbäck J, Andersson C, Anesten B, Björck S,
Eklund S, Magnusson O, Rimbäck G, Stenquist
B, Wedel N. Prolene Hernia System, Lichtenstein
mesh and plug-and-patch for primary inguinal hernia
repair: 3-year outcome of a prospective randomised
controlled trial. The BOOP study: bi-layer and connector, on-lay, and on-lay with plug for inguinal hernia repair. Hernia. 2009;13:121–9.
28. Nienhuijs SW, Rosman C.Long-term outcome after
randomizing prolene hernia system, mesh plug repair
and Lichtenstein for inguinal hernia repair. Hernia.
2015;19:77–81.
29. Zhao G, Gao P, Ma B, Tian J, Yang K.Open mesh
techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg.
2009;250:35–42.
30. Li J, Ji Z, Li Y. Comparison of mesh-plug and
Lichtenstein for inguinal hernia repair: a metaanalysis of randomized controlled trials. Hernia.
2012;16:541–8.
31. Negro P, D'Amore L, Gossetti F.Mesh plug repair and
surgeon's satisfaction. Hernia. 2010;14:223–34.
32. Huang CS, Huang CC, Lien HH.Prolene hernia system compared with mesh plug technique: a prospective study of short- to mid-term outcomes in primary
groin hernia repair. Hernia. 2005;9:167–71.
33. Agrawal A, Avill R.Mesh migration following repair
of inguinal hernia: a case report and review of literature. Hernia. 2006;10:79–82.
34. Jeans S, Williams GL, Stephenson BM. Migration
after open mesh plug inguinal hernioplasty: a review
of the literature. Am Surg. 2007;73:207–9.
35. Dieter RA Jr. Mesh plug migration into scrotum: a new
complication of hernia repair. Int Surg. 1999;84:57–9.
36. Nowak DD, Chin AC, Singer MA, Helton WS.Large
scrotal hernia: a complicated case of mesh migration,
ascites, and bowel strangulation. Hernia. 2005;9:96–9.
37. Chuback JA, Singh RS, Sills C, Dick LS.Small bowel
obstruction resulting from mesh plug migration after
open inguinal hernia repair. Surgery. 2000;127:475–6.
38. Tokunaga Y, Tokuka A, Ohsumi K. Sigmoid colon
diverticulosis adherent to mesh plug migration after
open inguinal hernia repair. Curr Surg. 2001;58:493–4.
39. Moorman ML, Price PD.Migrating mesh plug: complication of a well-established hernia repair technique. Am Surg. 2004;70:298–9.
40. Benedetti M, Albertario S, Niebel T, Bianchi C,
Tinozzi FP, Moglia P, Arcidiaco M, Tinozzi S.
Intestinal perforation as a long-term complication
of plug and mesh inguinal hernioplasty: case report.
Hernia. 2005;9:93–5.
41. Murphy JW, Misra DC, Silverglide B. Sigmoid
colonic stula secondary to Perx-plug, left inguinal
hernia repair. Hernia. 2006;10:436–8.
42. Ojo P, Abenthroth A, Fiedler P, Yavorek G.Migrating
mesh mimicking colonic malignancy. Am Surg.
2006;72:1210–1.
43. Zubaidi AM, Al Saghier M, Kabbani M, Abdo
A.Colocutaneous stula after mesh plug inguinal hernia repair- a delayed complication. Ann Saudi Med.
2006;26:385–7.
44. Stout CL, Foret A, Christie DB, Mullis E. Small
bowel volvulus caused by migrating mesh plug. Am
Surg. 2007;73:796–7.
45. Liang X, Cai XJ, Yu H, Wang YF.Strangulated bowel
obstruction resulting from mesh plug migration after
open inguinal hernioplasty: case report. Chin Med J.
2008;121:183–4.
46. Ortiz JA, Palladino H, Thomas S, Zaki R.Mesh plug
and ureteral necrosis after kidney transplantation.
Hernia. 2008;12:433–5.
47. Ishiguro Y, Horie H, Satoh H, Miyakura Y, Yasuda
Y, Lefor AT.Colocutaneous stula after left inguinal
hernia repair using the mesh plug technique. Surgery.
2009;145:120–1.
48. Chen MJ, Tian YF. Intraperitoneal migration of a
mesh plug with a small intestinal perforation: report
of a case. Surg Today. 2010;40:566–8.
49. Ratajczak A, Kościński T, Banasiewicz T, LangeRatajczak M, Hermann J, Bobkiewicz A, Drews
M. Migration of biomaterials used in gastroenterological surgery. Pol Przegl Chir. 2013;85:377–80.
50. Yilmaz I, Karakaş DO, Sucullu I, Ozdemir Y, Yucel
E. A rare cause of mechanical bowel obstruction:
mesh migration. Hernia. 2013;17:267–9.
51. Ishikawa S, Kawano T, Karashima R, Arita T,
Yagi Y, Hirota M. A case of mesh plug migration
into the bladder 5 years after hernia repair. Surg
Case Rep. 2015;1(1):4. https://doi.org/10.1186/
s40792-014-0004-2.
52. Sekiguchi K, Mizuguchi Y, Mamada Y, Koizumi M,
Uchida E. Intraperitoneal migration of a mesh plug

27 Mesh Plug Repair
269
from a hernioplasty forming a colocutaneous stula
with the cecum: report of a case. J Nippon Med Sch.
2015;82:246–9.
53. Yamamoto S, Kubota T, Abe T. A rare case of
mechanical bowel obstruction caused by mesh plug
migration. Hernia. 2015;19:983–5.
54. Scaringi S, Ardu M, Zambonin D, Giudici F, Bechi
P.Sigmoidocutaneous stula 26 years after left inguinal hernia repair with mesh-plug technique. Am Surg.
2016;82:E52–3.
55. Veroux M, Ardita V, Zerbo D, Caglià P, Palmucci S,
Sinagra N, Giaquinta A, Veroux P. First case report
of acute renal failure after mesh-plug inguinal hernia repair in a kidney transplant recipient. Medicine
(Baltimore). 2016;95(13):e3199. https://doi.org/
10.1097/MD.0000000000003199.
56. Eid JJ, Rodriguez A, Radecke JM, Murr MM. An
unusual cecal mass on routine colonoscopy. J
Surg Case Rep. 2014;2014(11):rju119. https://doi.
org/10.1093/jscr/rju119.
57. Scheuer LS, Schnelldorfer T. Inguinal hernia mesh
plug migrated into the abdominal cavity. J Gastrointest
Surg. 2015;19:1187–8.
58. LeBlanc KA.Complications associated with the plugand-patch method of inguinal herniorraphy. Hernia.
2001;5:135–8.
59. Negro P, Gossetti F, D'Amore L, Proposito D, Vermeil
V, Battillocchi B, Della Rocca G, Carboni M. 1,000
prosthetic hernia repairs: experience of a dedicated
team. Chir Ital. 2000;52:279–88.
60. Pikoulis E, Daskalakis P, Psallidas N, Karavokyros
I, Stathoulopolos A, Godevenos D, Leppaniemi A,
Tsatsoulis P. Marlex mesh Prex plug hernioplasty
retrospective analysis of 865 operations. World J
Surg. 2005;229:231–4.
61. Millikan KW, Doolas A.A long-term evaluation of
the modied mesh-plug hernioplasty in over 2,000
patients. Hernia. 2008;12:257–60.
62. Negro P, D’Amore L, Gossetti F, Battilocchi B,
Vermeil V, Dandolo R. Follow-up of plug in long
run hernia surgery. Results from a national inquiry.
Hernia. 2001;5(Suppl 1):S31.
63. Negro P, Gossetti F, Dassatti M, Manzi E, D’Amore
L.Plug repair. Hernia. 2012;(Suppl 1):S42.
64. Hamouda A, Kennedy J, Grant N, Nigam A, Karanjia
N. Mesh erosion into the urinary bladder following
laparoscopic inguinal hernia repair; is this the tip of
the iceberg? Hernia. 2010;14:317–9.
65. D'Amore L, Gossetti F, Manto O, Negro P.Mesh plug
repair: can we reduce the risk of plug erosion into the
sigmoid colon? Hernia. 2012;16:495–6.
66. Mutter D, Champault G, Binot D, Vix M, Leroy J,
Marescaux J. PerFix™ plug versus 4DDOME(®)
implants for inguinal hernia repair: prospective
multicentric randomised controlled trial. Hernia.
2012;16:561–6.
67. Hirose T, Takayama Y, Komatsu S, Shingu Y,
Sakamoto E, Norimizu S, Hasegawa H.Randomized
clinical trial comparing lightweight or heavyweight
mesh for mesh plug repair of primary inguinal hernia.
Hernia. 2014;18:213–9.
68. Efthimiou M, Symeonidis D, Koukoulis G, Tepetes
K, Zacharoulis D, Tzovaras G.Open inguinal hernia
repair with the use of a polyglycolic acid-trimethylene carbonate absorbable mesh: a pilot study. Hernia.
2011;215:181–4.
69. Negro P, Gossetti F, Dassatti MR, Andreuccetti
J, D'Amore L. Bioabsorbable Gore BIO-A plug
and patch hernia repair in young adults. Hernia.
2012;16:121–2.
70. Negro P, Campanelli G, Ipponi PL, Gossetti F,
Dassatti MR, Manto O, D'Amore L.Selective use of
bioabsorbable Gore BIO-A plug and patch for groin
hernia repair. Hernia. 2013;17:795–6.
71. Gossetti F, Massa S, Abbonante F, Calabria M, Ceci
F, Viarengo MA, Manzi E, D’Amore L, Negro P.New
“all-in-one” device for mesh plug hernioplasty: the
Trabucco repair. Ann Ital Chir. 2015;86:570–4.
72. Kaafarani HM, Itani KM, Giobbie-Hurder A,
Gleysteen JJ, McCarthy M Jr, Gibbs J, Neumayer
L. Does surgeon frustration and satisfaction with
the operation predict outcomes of open or laparoscopic inguinal hernia repair? J Am Coll Surg.
2005;200:677–83.
Соседние файлы в папке Библиотека им академика М.И. Перельмана
