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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_753_Библиотеки_им_академика_М_И_Перельмана.pdf
Biological Prosthesis inInguinal
Hernia Repair
StefanoLafranceschina, FaustoCatena,
LucaAnsaloni, andMarioTestini
35
35.1 Introduction
Hernia surgery has developed signicantly during the two last decades. The main improvement
has taken place in the use of tension-free repair
techniques based on the use of alloplastic, nonabsorbable prosthetic materials [1–3]. It brought a
signicant reduction in postoperative pain degree
and recurrence when compared with the older
non-prosthetic hernioplasties [3]. This leads to
dene the characteristics of the ideal mesh for
repair of the inguinal hernia defects: strength,
ease of manipulation, biocompatibility, resistance to adhesion formation, low seroma formation and a low susceptibility to infection [2].
Over the years, we have been widely using nonabsorbable meshes made of polypropylene (PP),
expanded polytetrauoroethylene, polyester and
lightweight PP or a combination of these materials
S. Lafranceschina · M. Testini
Unit of Endocrine, Digestive and Emergency Surgery,
Department of Biomedical Sciences and Human
Oncology, University Medical School of Bari,
Bari, Italy
e-mail: mario.testini@uniba.it
F. Catena (*)
Department of Emergency and Trauma Surgery,
University Hospital of Parma, Parma, Italy
L. Ansaloni
Unit of General Surgery I, Ospedali Riuniti of
Bergamo, Bergamo, Italy
e-mail: lansaloni@ospedaliriuniti.bergamo.it
[4]. Permanent synthetic meshes have been used in
clean wounds with excellent long- term results, low
recurrence rates and low infectious complications
[4]. In addition, indications for mesh inguinal hernia repair are well established and widely diffused
[5]. However, controversies still exist about the
indication in using the different materials and principally about the biological ones [5]. Furthermore,
potential or certain contamination of the surgical
wound poses a dilemma as the use of nonabsorbable synthetic material historically is considered
contraindicated, given the risk of postoperative
infectious complications and need for mesh
removal. The introduction of biological prosthesis
(BP) has provided an alternative. Either allograft or
xenograft, BP might be better able to tolerate bacterial contamination and have a lower incidence of
surgical site infection. Multiple reports on their use
in abdominal wall repair have been made [1], even
if large-scale studies are still needed [2].
35.2 Biological Prosthesis
35.2.1 Features
More than a dozen of BP are currently available
(Table 35.1). All of them derive from human or
mammalian tissues [5]. These materials are all
essentially composed of an extracellular matrix
stripped of its cellular components and differ in
their source [6].
© 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_35
345
346
Table 35.1 Biological prosthesis currently on the market
Name Manufacturer Tissue source Material X-linking
AlloDerm LifeCell Human Acellular dermis No
AlloMax Bard Human Acellular dermis No
Flex HD Ethicon/MTF
DermaMatrix MTF
Permacol Covidien Porcine Acellular dermis Yes
CollaMend Davol/Bard Porcine Acellular dermis Ye s
Strattice KCI/LifeCell Porcine Acellular dermis No
XenMatrix Brennan Medical Porcine Acellular dermis No
Surgisis Cook Porcine Small intestine submucosa No
Surgisis Gold Cook Porcine Small intestine submucosa No
Lyosis Cook Porcine Lyophilized small intestine submucosa No
FortaGen Organogenesis Porcine Small intestine submucosa Ye s
SurgiMend TEI Biosciences Bovine Foetal dermis No
PeriGuard Synovis Bovine Pericardium Yes
Veritas Synovis Bovine Pericardium No
Tutomesh Tutogen Bovine Pericardium No
Tutopatch Tutogen Bovine Pericardium No
a
MTF: Musculoskeletal Transplant Foundation
a
a
Human Acellular dermis –
Human Acellular dermis No
S. Lafranceschina et al.
In contrast to current nonabsorbable prosthetic
repairs, where the prosthesis is intended to
strengthen the defect lifelong, the extracellular
remodelling process in which the host remodels
the prosthesis and his own tissues by producing
new healthy tissue [5].
matrix of BP implanted into the host has a direct
strengthening function only initially.
Subsequentially, the matrix is gradually degraded
35.2.2 Cross-Linked
while inducing neovascularization and colonization by host cells that progressively cause a sitespecic remodelling process until the reconstruction
of a new and mature autologous fascia is complete.
Eventually, this mature structure restores the original supportive function of the abdominal wall [6].
BP implants would act as a scaffold inside
which the host tissue cells and broblasts can
replicate. They also provide resistance to tension
and stress by supporting the abdominal wall until
it is fully recovered. Times of remodelling range
BP, independent from the origin, could be basically divided into two main classes: cross-linked
and non-cross-linked. The partial remodelling
(cross-linked) prosthesis is made of porcine or
human dermal collagen and bovine pericardium
collagen. The complete remodelling (not crosslinked) is principally made of swine intestinal
submucosa, swine dermis, human dermis, bovine
dermis and bovine pericardium.
between few months and few years [5]. It depends
on prosthesis characteristics and host tissue properties. One of the problems of using them is that
surgeons have not widely assumed the capability
to manage BP: the way to consider them should
be completely different from current nonabsorbable synthetic repair. These last ones are considered as a “patch applied on the hole”; essentially
they trigger a foreign body host response leading
to encapsulation of the prosthesis with intense
brous reaction. On the contrary, BP activates a
ingrowth, but different meshes can feature different
clinical attributes. Thanks to the chemical cross-
linking between the collagen chains, the presence of
additional linkages strengthens cross- linked pros-
thesis, reduces the efcacy of bacterial and host col-
lagenase enzymes and improves the resistance to
mechanical stress for a longer period. This is impor-
tant especially at the weakest moment of the remod-
elling process, when there coexists a minimal
strength due to advance prosthetic degradation and
andNon-Cross-Linked
Each type of mesh encourages host tissue
35 Biological Prosthesis inInguinal Hernia Repair
347
only minimal initial remodelling process, although
in case of infection, an increased collagenase production might enhance prosthetic degradation and
cause an early graft failure. In order to increase
early graft stability and induce a more organized
collagen deposition, cross-linked BP is used; but the
prolonged presence of chemically linked collagen
molecules might inuence the remodelling process
bringing prosthetic encapsulation [6]. These differences in remodelling times should be kept in mind
when these materials are chosen for abdominal wall
repair [5]. On the other side, non- cross- linked materials allow a faster integration, resorption, degradation and reduce foreign body sensation compared to
cross-linked devices [7]. Another factor that should
be kept in mind is that non-cross-linked material
exhibits more favourable remodelling characteristics [5]. Regardless of the type of BP used, at initial
remodelling process, it has been demonstrated that
brin sealant improves the often poor implant integration [7].
35.2.3 BP Physiopathological
Process Compared
toSynthetic Meshes
tion, foreign body sensation, postsurgical pain
and long-term discomfort are decreased over the
years using PP.If these are the physiopathological
bases that explain the success of alloplastic non-
absorbable prosthetic materials in hernia surgery,
they are also the reasons why complications such
as infections, foreign body sensation and chronic
pain require the use of different materials to be
solved [3]. On these basis, new materials have
been sought through different physiopathological
mechanisms to overcome these complications:
rst the biosynthetic meshes and second the bio-
logical ones [8].
35.3 Which Kind ofBP toUse?
A diagram to simplify the decisional process in
using BP has been elaborated by the Italian
Biological Prosthesis Work-Group (Figs. 35.1
and 35.2). It keeps into consideration the differ-
ent kinds of BP, the infection of the surgical eld
and the tissue loss. The diagram suggests the type
of BP that should be used by combining these
three variables together [5].
The use of nonabsorbable prosthetic materials
such as polypropylene, polyester and ePTFE has
hence expanded and is now widely used in reparative surgery for abdominal wall hernias [3]. When
implanted, these nonabsorbable materials,
although extremely biocompatible, stimulate a
foreign body reaction within the host. After the
initial inammatory phase, the reaction is followed by an intense deposition of nonspecic
brotic tissue and concluded by a permanent
encapsulation of the alloplastic material in the
host’s tissues. In particular PP meshes stimulate a
foreign body reaction, producing an intense deposition of nonspecic brotic tissue that concludes
with permanent encapsulation of the alloplastic
material in the host’s tissues. These physiopathologic bases explain the successful use of PP mesh
in hernia surgery. The complication rate, including intestinal obstruction and stulization, is low
when PP is placed in direct contact with abdominal viscera. The infection rate is also low; in addi-
35.4 Complications
The complexity of hernias could derive from
contamination/infection, tissue loss, dimen-
sions, anatomic position and clinical or pharma-
cological data. The introduction of tension-free
techniques, thanks to the use of prosthetic mate-
rials, has greatly facilitated the duty. On one
hand, prosthetic techniques have been demon-
strated to reduce the recurrence rate; on the
other hand, they introduced a series of new vari-
ables to take into consideration prosthetic infec-
tion, chronic pain, shrinkage, adhesion
formation, dislocation, stula formation and
skin erosion that complicate the decisional pro-
cess. The introduction of resorbable materials
has completely changed the way to face the
abdominal hernia surgery, and BP introduced
the tissue engineering in the surgical practice [5].
Some of these complications have been reduced
especially in several elds. On the contrary, it has
348
Non cross-linked
123469
Cross-linked
Inf
Tissue loss
otentially contaminated
S. Lafranceschina et al.
3
Infection:
1: P
2: Contaminated
3: Infected
3
Tissue loss:
1: 0 cm
2: 0-5 cm
3: > 5 cm
ection
1
Non cross-linked
Cross-linked
2
1
Fig. 35.1 Decisional model diagram: the product of the infection and the loss of tissue scores gives as a result the value
which indicate the kind of biological prosthesis to use
Fig. 35.2 Decisional line: the different results indicate the kind of biological prosthesis to use
been demonstrated that BP durability has a
direct impact on the recurrence rate [5, 9].
However, durability depends on the implant
intrinsic properties and also on the environment
into which the BP are placed [5]. Furthermore,
the recurrence rate in BP can be attributed to the
inexperience of surgeons: it suggests that a biologic repair might require some added technical
skill and experience [9]. Moreover, it has been
shown that the use of BP extends the operating
times, thus also resulting in an increase in costs.
All this goes together with the evident difference in cost between using a BP and synthetic
ones [7, 9]. It should be noted that only the
recurrence rate is registered as outcome in
almost all studies. Other data regarding the use
of BP as wound classication, contamination
risk/grade, associated therapy or comorbidity
are seldom reported. These data are needed to
completely assess the usefulness, the efcacy
and the versatility of BP.All reported data are
derived by retrospective uncontrolled series of
limited number of patients, and the methodol-
ogy is seldom reported and/or poorly described
[5]. Considering the complications, it should be
kept in mind that BP has a sensible improve-
ment in bodily pain and decrease postsurgical
incidence and degree of discomfort when used
in groin hernia repair [5]; and there are a few
doubts about the intraperitoneal use of BP from
the biomechanical point of view. It has been
demonstrated that the best integration is reached
if they are placed pre- peritoneally with a greater
incorporation and strength, less adhesion area
and lower adhesion scores compared with intra-
peritoneal placement [5]. In the end, compared
with synthetic meshes, better biocompatibility
is an important advantage of biologic mesh,
which theoretically may result in less incidence
of complication and limitation in patients’ daily
activities, even if actually these results require
further studies [9].
35 Biological Prosthesis inInguinal Hernia Repair
349
35.5 Clean Fields
For a long time, synthetic meshes and especially
polypropylene represented the gold standard for
the treatment of inguinal hernia in clean elds
with excellent results, low recurrence rates and
low infectious complications. Based on pathophysiological characteristics described so far, BP
act as valid alternative to synthetic meshes not
only in particular situations as in contaminated
elds. It is likely to extend their possibilities of
use in uncontaminated elds: the BP remodelling
process would be favoured not only by its intrinsic characteristics but also by a less pronounced
inammatory reaction in respect to their use in
contaminated elds. These conditions help to
limit the collagenase degradation, suffered by BP
in the early stages of the remodelling process,
and allow a more gradual and physiological
reconstruction of the abdominal wall. This
option, faced in randomized studies, seems to
improve both postoperative pain/discomfort and
foreign body sensation without a different short−/
medium-term recurrence, without however forgetting the costs of this choice [8–12].
35.6 Contaminated Fields
With increasingly complex procedures being performed across the eld of surgery, along with frequent comorbidities, hernia repair in contaminated
elds has become a frequent challenge to surgeons [13]. One avenue to combat infections was
developed with the introduction of bioprosthetics. With the ability to remodel into native tissue
and avoid permanent foreign body presence, biologic meshes were touted as a preferable alternative to permanent synthetic options for
contaminated operative elds. With respect to the
initial goal of bioprosthetic devices, recent data
call into question their “biologic” behaviour and
long-term efcacy in these challenging elds
[13]. The implant of biologic materials elicits a
cascade of events leading to new healthy tissue
deposition and prosthesis remodelling. It also
allows blood, growth and pro−/anti- inammatory
factors and drugs to reach the surgical eld dur-
ing the rst phases of the healing process. This
for sure enhances the effect against potential or
denite contamination/infection [5]. Furthermore,
when associated with bowel resection, BP pres-
ents lower incidence in terms of overall morbid-
ity and wound infection rate [2]. Compared with
BP, the assumed drawback of synthetic material
in contaminated elds has become less rigid as
several authors have proclaimed its safe use, par-
ticularly using new lightweight synthetic meshes
[1]. Despite this, in hernia repair of infected or
potentially infected elds and in patients at high
risk of developing surgical site complications
(i.e. immune-depressed patients), a potential
advantage of biologic over synthetic material was
even suggested [1, 8, 14].
35.7 Inguinal Sports Hernias
Biologic mesh has been considered for the repair
of inguinal sports hernias of young patients,
where there is a fear of leaving behind a long-
term foreign body [9]. The remodelling process
of biologic meshes clears up the low postopera-
tive pain at medium term and the low degree of
discomfort, and its features became important for
the regular practice of an agonistic activity, where
inguinal constraints can be noticeable [8, 11].
35.8 Hernia Repair inEmergency
Surgery
Nowadays it is still not likely to nd correct indication of mesh implant in emergency hernia surgery: there is still an open debate if to use
nonabsorbable prostheses in potentially or truly
infected operating elds [3]. Any area, with a
possible risk of bacterial contamination, in which
surgery is performed (bowel resections, cholecystectomy, operations on the bile duct, parastomal hernias, etc.), is potentially at risk for
prosthetic repair. On one side, there is a common
consensus on what should be done in evidently
contaminated areas such as what occurs in case
of peritonitis. In fact the opinion is not to position
any kind of nonabsorbable prosthetic material
350
S. Lafranceschina et al.
due to a very high risk of infection. On the other
side, it is not demonstrated that there is an
increased risk of contamination of the mesh in
case that simultaneous operations on the digestive tract are performed (potentially contaminated surgical elds) [3]. Considering all its
issues, in emergency hernia repair of infected or
potentially infected elds, it is already possible to
identify clear indications to the use of BP.
Conclusion
The best operative solution for hernia repair in
clean-contaminated and contaminated wounds
and in emergency hernia surgery remains not
clear. The proposed advantage of BP is that
the patient’s immune cells can inltrate the
material to defend against the bacterial load
and eventually replace the biologic mesh with
the host tissue. However, the price of biologic
grafts has caused an alarming increase in the
cost of abdominal reconstructions [4]. More
generally, the use of mesh in contaminated
hernia repair remains a hotly debated topic
with no clear consensus; furthermore, debate
on whether biologic or synthetic meshes offer
the safest and most efcacious reinforcement
in these scenarios remains active [13]. Actually
despite the risk of infections, mesh reinforcement continues to play a critical role in hernia
repair in contaminated elds, and biologic
materials are often promoted for use in cleancontaminated and contaminated elds [7].
These discrepancies are probably due to the
poorness of cases for each single centre, and
no denitive evidence-based conclusions
could be obtained from the literature. Most
surgeons stated that they use BP in “difcult”
situations, especially those with contaminated
or infected elds [5].
References
1. Atema JJ, de Vries FE, Boermeester MA.Systematic
review and meta-analysis of the repair of potentially
contaminated and contaminated abdominal wall
defects. Am J Surg. 2016;212:982–95.
2. Gurrado A, Franco IF, Lissidini G, et al. Impact of
pericardium bovine patch (Tutomesh®) on incisional
hernia treatment in contaminated or potentially contaminated elds: retrospective comparative study.
Hernia. 2015;19:259–66.
3. Campanelli G, Catena F, Ansaloni L. Prosthetic
abdominal wall hernia repair in emergency surgery:
from polypropylene to biological meshes. World J
Emerg Surg. 2008;3:33.
4. Rosen MJ, Bauer JJ, Harmaty M, Carbonell AM,
et al. Multicenter, prospective, longitudinal study
of the recurrence, surgical site infection and quality of life after contaminated ventral hernia repair
using biosynthetic absorbable mesh. Ann Surg.
2017;265(1):205–11.
5. Coccolini F, Agresta F, Bassi A, Catena F, etal. Italian
biological prosthesis work-group (IBPWG): proposal
for a decisional model in using biological prosthesis.
World J Emerg Surg. 2012;7:34.
6. Ansaloni L, Catena F, Coccolini F, etal. New “biological” meshes: the need for a register. The EHS registry
for biological prostheses. Hernia. 2009;13:103–8.
7. Gruber-blum S, Brand J, Keibl C, etal. Abdominal
wall reinforcement: biologic vs. degradable synthetic devices. Hernia. 2016. https://doi.org/10.1007/
s10029-016-1556-9.
8. Ansaloni L, Catena F, Coccolini F, etal. Inguinal hernia repair with porcine small intestine submucosa:
3 year follow-up results of a randomized controlled
trial of Lichtenstein’s repair with polypropilene mesh
versus Surgisis inguinal hernia matrix. Am J Surg.
2009;198:303–12.
9. Fang Z, Feng R, Zhou J, et al. Biologic mesh versus synthetic mesh in open inguinal hernia repair:
system review and meta-analysis. ANZ J Surg.
2015;85(12):910–6.
10. Ansaloni L, Catena F, D'Alessandro L. Prospective
randomized, double-blind, controlled trial comparing
Lichtenstein’s repair of inguinal hernia with polypropylene mesh versus Surgisis gold soft tissue graft:
preliminary results. Acta Biomed. 2003;74(Suppl
2):10–4.
11. Bochicchio GV, Jain A, McGonigal K, etal. Biologic
vs synthetic inguinal hernia repair: 1-year results of
a randomized double-blinded trial. J Am Coll Surg.
2014;218(4):751–7.
12. Bellows CF, Shadduck P, Helton WS, et al. Early
report of a randomized comparative clinical trial of
Strattice™ reconstructive tissue matrix to lightweight
synthetic mesh in the repair of inguinal hernias.
Hernia. 2014;18(2):221–30.
13. Majumder A, Winder JS, Wen Y, et al. Comparative
analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs. Surgery.
2016;160:828–38.
14. Breuring K, Butler CE, Ferzoco S, etal. Incisional
ventral hernias: review of literature and reccomandations regarding the grading and technique of repair.
Surgery. 2010;148:544–58.
Inguinal Hernia Recurrence
IvyN.Haskins andMichaelJ.Rosen
36
36.1 Introduction
Inguinal hernia repair is one of the most commonly
performed general surgery procedures [1, 2].
Despite its prevalence, there is no consensus regarding the optimal approach to inguinal hernia repair
[2]. With an estimated recurrence rate of 0.2–17%,
there is no doubt that recurrent inguinal hernias
have a signicant impact on the global healthcare system and that a durable, primary repair is ideal [3, 4]. A
thorough preoperative patient evaluation, inspection
of all potential locations of a groin hernia, and
meticulous surgical technique all contribute to primary repair success. Nevertheless, recurrent hernias
do occur, and a general knowledge of the causes for
a failed primary repair and surgical approach to
recurrent hernias is essential. In this chapter, we will
discuss the risk factors associated with inguinal hernia recurrence and the operative approach to recurrent inguinal hernia repair.
I. N. Haskins · M. J. Rosen (*)
Comprehensive Hernia Center, Digestive Disease and
Surgery Institute, Cleveland Clinic, Cleveland,
OH, USA
e-mail: haskini@ccf.org; rosenm@ccf.org
36.2 Risk Factors forInguinal
Hernia Recurrence
There are several patient and operative characteristics that increase the risk of inguinal hernia
recurrence. Patient factors include malnutrition,
immunosuppression, obesity, diabetes mellitus,
and smoking, all of which negatively impact the
wound healing process [5]. Signicant time
should be spent during the preoperative evaluation at minimizing or resolving these patient factors. One method that has been successful in
improving preoperative optimization at our institution is engaging patients in addressing their
high-risk factors. Previous studies have shown
that inguinal hernia recurrence is the most important long-term outcome and measure of success
from a patient’s perspective [6, 7]. Therefore,
instilling a sense of self-responsibility in patients
to their surgical outcome often leads to increased
motivation to achieve preoperative goals.
Technical errors also increase the risk of
inguinal hernia recurrence. Large inguinal hernias, undue tension which leads to tissue ischemia, incomplete dissection of the hernia sac,
inadequate mesh size, and wound infection all
increase the risk of inguinal hernia recurrence [4,
5, 8–10]. Larger groin hernias stretch and attenu-
ate the surrounding fascial planes to a greater
extent than smaller groin hernias. This leads to
the incorporation of a weaker tissue during repair
of larger hernias as compared to smaller groin
hernias [10]. As with other hernia repairs, mesh
© 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_36
351
352
I. N. Haskins and M. J. Rosen
utilization has led to a more durable inguinal
hernia repair, which is likely due to a reduction
of medial recurrences at the pubic tubercle [4,
9]. However, incomplete coverage of the pubic
tubercle or at the internal inguinal ring by prosthetic material can lead to recurrences at these
sites. Recurrence at the internal ring can also be
caused by improper ligation of the hernia sac [8].
General surgeons must be conscious of these risk
factors during inguinal hernia repair operations
in order to maximize the potential for successful
primary repair.
36.3 When toRepair Recurrent
Inguinal Hernias
Despite the fact that a majority of rst-time and
recurrent groin hernias are asymptomatic at presentation, the long-term teaching has been to
repair these hernias due to the perceived risk of
associated bowel obstruction and/or strangulation [11, 12]. Further studies are needed to determine the ideal approach to asymptomatic
recurrent groin hernias. Nevertheless, we do recommend surgical repair of all symptomatic recurrent inguinal hernias to prevent worsening of
patient symptoms and to avoid the associated risk
of emergency surgery should these hernias progress to bowel involvement.
36.4 Surgical Approach
toRecurrent Inguinal
Hernias
The European Hernia Society’s (EHS) recommendation for repair of recurrent inguinal hernias
is to “modify technique in relation to previous
technique. [1]” Although this may seem oversimplied, approaching a recurrent inguinal hernia in
a different surgical plane than the original operation leads to the best chance of repair success.
The reason for this is twofold. First, surgery in a
previously operated eld is distorted with scar
tissue. Scar tissue complicates the dissection in
the inguinal canal and increases the risk for
adverse outcomes such as testicular ischemia in a
male patient or missing the recurrent hernia sac
[3]. Second, the tissue in a healed wound is
always weaker than the virgin tissue. This
increases the risk for recurrence with each subsequent inguinal hernia repair [3]. Therefore,
review of prior operative reports requires scrutiny
in an effort to avoid previous operative elds during recurrent inguinal hernia repair whenever
possible.
In concert with the EHS, our recommendation for approaching recurrent inguinal hernias
can be broadly categorized based on the prior
failed surgical approach. Patients with a prior
anterior repair (i.e., tissue repair or Lichtenstein
repair) should have a posterior approach for
repair of their inguinal hernia recurrence.
Similarly, patients with a failed posterior
approach (i.e., laparoscopic repair or Kugel
repair) require an anterior repair for inguinal
hernia recurrence. Finally, patients who underwent initial inguinal hernia repair in a bilaminar
fashion with mesh in both the anterior and posterior compartments (i.e., Prolene Hernia System
repair or plug and patch repair) should undergo
repair of their inguinal hernia recurrence with an
approach that the operating surgeon has most
experience.
36.5 Anterior Approach
toRecurrent Inguinal Hernia
Repair forPrior Failed
Posterior Repairs
The anterior approach to recurrent inguinal hernia repair should be used in patients with previous posterior repairs such as laparoscopic or
Kugel-type repairs. The procedure of choice in
these cases is a Lichtenstein repair with mesh
utilization. The Lichtenstein repair is the ideal
anterior approach to recurrent inguinal hernia
repair after a prior posterior repair. This is
because it utilizes a completely different operative eld and allows for the utilization of mesh,
two factors proven to decrease the risk of inguinal hernia recurrence [3, 4, 6]. For further
details on the Lichtenstein repair, please refer
to Chap. 1.
36 Inguinal Hernia Recurrence
353
36.6 Laparoscopic Approach
toRecurrent Inguinal Hernia
Repair After Failed Anterior
Repair
The laparoscopic approach to inguinal hernia
recurrences should be used following open anterior inguinal hernia repairs. The laparoscopic
approach to inguinal hernia repair includes both
the transabdominal preperitoneal (TAPP) repair
and the total extraperitoneal (TEP) repair. The
decision to proceed with a TAPP versus a TEP
repair of a recurrent inguinal hernia is based
largely on surgeon preference.
The laparoscopic approach to recurrent inguinal hernia repair offers several advantages over
the open approach to recurrent inguinal hernia
repair which will be discussed. However, it
should also be mentioned that a missed cord
lipoma is a pitfall of the laparoscopic approach to
inguinal hernia repair [13]. Therefore, should
patients not have an identiable groin hernia during laparoscopic exploration, further investigation of the preperitoneal structures should follow
to rule out a missed lipoma.
The benets of a laparoscope approach to
recurrent inguinal hernia repair are numerous.
Similar to the anterior approach following posterior failure, the laparoscopic approach also allows
for an operation through a virgin, unscarred eld
following anterior inguinal hernia repair failure
[3]. Furthermore, the laparoscopic platform
allows for visualization of all potential hernia
sites, including the femoral and obturator canals.
In a study published from the Swedish Hernia
Registry, 42% of women with inguinal hernia
recurrence actually had a femoral hernia at the
time of reoperation [14]. In addition, several
other case series have found that 9% of all inguinal hernia recurrences are actually femoral hernias [3]. This underscores the fact that femoral
hernias are often overlooked during open inguinal hernia repair due to lack of visualization of
the femoral canal. Moreover, the laparoscopic
approach to inguinal hernia recurrence may provide for a more durable repair. A previous longterm study by Bisgaard etal. found that the rate
of re-recurrence following laparoscopic repair of
recurrent inguinal hernia was signicantly lower
than the rate of re-recurrence following an anterior approach [15]. Finally, the laparoscopic
approach offers the other proposed benets to
laparoscopic surgery, including decreased postoperative pain and earlier return to normal activity [3, 16, 17].
36.7 Approach toInguinal Hernia
Repair After Failed Anterior
andPosterior Repairs
Re-recurrent inguinal hernia poses a clinical
challenge to the surgeon. With each subsequent
inguinal hernia repair, weaker fascia and tissue
are incorporated into the repair, and the risk of
cord injury and testicular ischemia increases
[10]. These are real risks that must be discussed
with the patient during the informed consent process prior to proceeding with any surgical
intervention.
Previous studies have shown that the risk of
re-recurrence after laparoscopic inguinal hernia
repair is signicantly less than the risk of rerecurrence following Lichtenstein inguinal hernia repair [6, 15, 18]. Nevertheless, in high-risk
procedures such as re-recurrent inguinal hernia
repair, it is most important to be able to perform
an operation that addresses the hernia recurrence while keeping the patient safe. Therefore,
it is our recommendation that re-recurrent inguinal hernia repair operations be performed with
the approach that is most comfortable to the surgeon. In other words, surgeons more comfortable with an anterior approach should perform a
Lichtenstein repair, while surgeons who are better versed with the laparoscopic approach
should perform either a TAPP or a
TEP.Alternatively, a Rives-Stoppa approach to
re-recurrent inguinal hernia repair can be utilized. All re-recurrent inguinal hernia repairs
are technically challenging and should utilize
mesh for reinforcement of the weaker tissue
incorporated into the repair due to operation in a
previously scarred operative eld.
354
I. N. Haskins and M. J. Rosen
36.8 Special Attention
totheFemoral Canal
Indirect inguinal hernias remain the most common hernia in both men and women.
Nevertheless, the risk of non-inguinal hernias,
specically femoral hernias, is signicantly
higher in women [3, 19, 20]. Furthermore, the
incidence of femoral hernia repair during presumed inguinal hernia recurrence surgery is signicantly higher than at primary groin hernia
repair [14, 20]. Although femoral hernias are
typically associated with elderly women, femoral hernias following inguinal hernia repair often
occur in both middle-aged men and women [20].
The proposed pathogenesis for the increased
incidence of femoral hernia following groin hernia surgery is thought to be related to either overlooking a femoral hernia present at the time of
the original surgery or the spontaneous development of a femoral hernia postoperatively due to
widening of the femoral canal during inguinal
hernia repair [19, 20]. As femoral hernias are
associated with an increased risk of emergency
surgery, bowel strangulation, and postoperative
morbidity and mortality, we recommend the routine exploration of the femoral canal during both
primary and recurrent inguinal hernia repair
operations [20, 21].
Conclusion
Inguinal hernia recurrence remains a common
pathology encountered by the general surgeon. Preoperative evaluation and planning
must take into consideration modiable
patient risk factors for hernia recurrence and
prior surgical approaches to hernia repair. As
recommended by the EHS, approach to recurrent groin hernia repair should be different
than the original inguinal hernia repair whenever possible. In addition, special attention
should be directed to the evaluation of the
femoral canal due to the increased risk of femoral hernia diagnosis during presumed recurrent inguinal hernia repair.
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