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260
E. Gianetta and C. Stabilini
26.4.3 Mesh Fixation
In 2002 [3] after evaluation of their experience, the authors identied 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 insufcient 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 5cm) 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 conguration, 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, modications 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 2cm over­lap over the pubic tubercle and 5–6cm 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 andPersonal Modications
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 modications 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 oftheSurgical 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 1week 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
andAftercare
ing the effects on chronic postoperative pain [13].
The patient is discharged in the early afternoon after checking the surgical wound and testicle for
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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 1week after surgery to assess the surgical wound, and then patients are followed at 6months 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, etal. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009;13:343–403.
5. Smietanski M, 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.
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, etal. 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, etal. 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, etal. Biologic mesh versus synthetic mesh in open inguinal hernia repair: system review and meta­analysis. ANZ J Surg. 2015;85:910–6.
11. Zhong C, etal. A meta-analysis comparing lightweight meshes with heavyweight meshes in Lichtenstein inguinal hernia repair. Surg Innov. 2013;20:24–31.
12. Uzzaman M, etal. 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

FrancescoGossetti, LindaD’Amore, MariaRomanaGrimaldi, FrancescaCeci, andPaoloNegro
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 [24], 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 conguration of the plug also provides a deeper area over which scarication 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 clas­sication 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
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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 orice 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 modications 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 proles, 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, conrmed 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 (Table27.1) [1428]. 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 signicant shorter operative time in the plug repair group, even if the gap is less than 10min. Two meta-analysis comparing different open techniques, including Lichtenstein and plug repair, conrmed 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 sig­nicantly superior to the Lichtenstein operation in terms of perceived difculty 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, 2628]. 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] 8years 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
2years Occlusion Small bowel
7years Rectal bleeding
15years Lower quadrant
2years Rectal bleeding
2years Lower quadrant
2years Colocutaneous
nr Occlusion Small bowel
3years Occlusion Small bowel
nr Necrosis
3years Colocutaneous
2years Perforation Small bowel
2years Obstruction (C
3years Occlusion Sigmoid
5years Bladder skin
13years Colocutaneous
2years Occlusion Small bowel
26years Colocutaneous
6years 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 (Table27.2) [3755]. In two other cases, the plug migration was revealed as an incidentaloma at CT scan, without any clinical sign [56, 57].
Thesigmoid 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 3years 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, 5961]. 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 proles are available today on the market. Some of these have proved to provide benets [22, 66, 67]. Others seem to show favorable effects in selected cases [6870]. 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 classica-
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: classication 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 Perx 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. Perx 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.
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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, Perx 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.
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