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388
M. A. Garcia
Summary
In summary, hernias with loss of domain represent a great surgical challenge due to
the complexity of their management. The complexity of these cases and associated
morbidity requires them to be treated by experienced teams in high-volume institutions. With the correct selection of cases, expert multidisciplinary equipment, preoperative optimization of the patient, detailed preoperative study, application of
adjuvant techniques, knowledge of advanced techniques of hernioplasty and protocolized postoperative care, and the treatment of hernias with loss of domain can be
carried out safely and with good results.
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Fixation vs. No Fixation inMIS Inguinal
Hernia Repair
ChristopherYheulon andS.ScottDavis Jr.
Introduction
Fixation of mesh during minimally invasive inguinal hernia repair is a highly
debated topic. The main reason to advocate for xation is to prevent mesh migration, theoretically decreasing the likelihood of recurrence. The main argument
against certain forms of xation is a risk of acute pain and chronic pain due to xation into muscles, nerves, and bone. Some surgeons advocate for no xation at all,
while those advocating xation use many methods including absorbable and permanent forms of sutures, staples, and tacks applied to various structures within the
posterior inguinal anatomy. Alternative to penetrating xation such as surgical glue
and self-xating mesh is also being widely utilized, potentially changing if and how
most surgeons xate mesh in minimally invasive inguinal hernia repair.
28
Advocacy forFixation
In 1994, Phillips etal. published a multicenter retrospective review of 3229 patients
who underwent laparoscopic inguinal hernia repair (LIHR) to determine risk factors
for recurrence [1]. In this data set, there were 54 recurrences. The authors cite that
undersized mesh is the leading cause of recurrence (60%), while the second most
common (32%) was because “the mesh was never stapled.” The authors concluded
to recommend secure stapling during LIHR.However, there was no standardization
C. Yheulon • S. S. Davis Jr. (*)
Division of General and GI Surgery, Department of Surgery, Emory University School of
Medicine, Atlanta, GA, USA
e-mail: sdavisj@emory.edu; christopher.yheulon@emory.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_28
391
392
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C. Yheulon and S. S. Davis Jr.
of the procedure or description of xation methods. In addition, there was no data
analysis comparing the recurrence group with patients who did not recur to discern
causality. This is further convoluted as 42% of recurrences associated with lack of
xation were repaired in a laparoscopic “plug-and-patch” method, a technique
largely considered antiquated today. Of those that were performed with more current methods, there were no recurrences in the 578 totally extraperitoneal (TEP)
repairs, and only 6 recurrences out of 1944 transabdominal preperitoneal (TAPP)
repairs attributed to lack of xation/stapling (0.3%). This may indicate that technique as opposed to xation was more predictive of recurrence.
In 1998, Felix etal. published a retrospective review of 10,053 TEP or TAPP
repairs with 35 failures noted [2]. All surgeries were performed by experienced
surgeons, varied slightly in technique, but all xated both medially and laterally. In
this study, 12 recurrences (34%) were associated with inadequate xation alone.
Again, it was impossible to compare the adequacy of xation in patients who did
not recur limiting the ability to dene inadequate xation as causal. Yet this study in
particular served as a benchmark for xation in LIHR for well over a decade [3].
Fixation Versus No Fixation
As LIHR grew in popularity, surgeons began to debate the need for xation.
Although studies as those mentioned above argued for xation to decrease recurrence, others implicated xation techniques in nerve injury, chronic pain, and
increased operative costs. In 2011, Teng etal. published a meta-analysis 772 patients
within randomized controlled trials (RCTs) comparing xation of mesh versus no
xation of mesh during LIHR [4]. Patients were followed for a period of
8–36months. There was no signicant difference with regard to recurrence (OR
2.01 favoring xation, p=0.43), or postoperative pain, but there were signicant
reductions in operative time (4min, p=0.02). However, this study is limited by its
rate of recurrence. There were only 4 recurrences within the 992 hernias repaired,
3 in the non-xation group, and 1 in the xation group. This rate of recurrence
(0.4%) for either method is markedly better from larger meta-analyses (2.7%) [5].
A larger sample size or longer follow-up period may be necessary to discern true
recurrence rates.
In 2016, Claus etal. performed a study investigating mesh migration in 60 TEP
repairs. Although patients were randomized, only 10 were assigned to the control
group (xation), while 50 were assigned to the experimental group (non-xation).
The mesh in each group was marked with three surgical clips for future radiographic
investigation, and X-rays were taken immediately postoperatively and at 30days
from surgery. There was no difference in the distance of migration in either group
(0.1–0.3cm in xated group, 0.1–0.35mm in non-xated group) [6]. The results of
this study are encouraging toward non-xation; however, the short follow-up period
and small sample size make the results challenging to apply clinically. In addition,
although there was no difference in the mean migration between the two groups,
perhaps a more appropriate analysis would compare the percentage of patients in
28 Fixation vs. No Fixation inMIS Inguinal Hernia Repair
each group who had a total migration beyond the upper limit of normal. It would be
reasonable to expect those extreme outliers to have an increased rate of recurrence.
However, no such analysis was performed.
393
Permanent Versus Absorbable Tacks
The debate surrounding xation not only involves the decision to xate but also how
to xate, should it be performed. Some surgeons theorize that metal tacks will cause
more pain than absorbable tacks given their permanence. However, there are no
published human studies comparing permanent versus absorbable penetrating xation methods in LIHR.The best data available related to this topic is inferred from
ventral hernia repair. Animal models in ventral hernia repair demonstrate that permanent tacks have more tensile strength but also cause more inammation and
adhesions [7]. Christoffersen etal. published a study examining the rate of recurrence of 816 patients who underwent incisional hernia repair while comparing the
use of permanent or absorbable tacks [8]. Over a follow-up period of up to 4years
via survey results, there was a signicantly higher rate of recurrence with absorbable tacks (HR 1.53, p=0.008), but no difference in severe chronic pain. Overall,
there is a paucity of data comparing permanent and absorbable tacks in LIHR leaving us unable to conclude any signicant differences in outcomes between the two
xation modalities.
Penetrating Fixation Versus Glue Fixation
As xation itself has been implicated in some studies to increase chronic pain, surgeons began to investigate noninvasive xation methods such as surgical glue as an
alternative. There are two types of glue studied including biologic (brin) and biosynthetic (cyanoacrylate). In a 2012 review of surgical sealants, brin glue costs
approximately $50 per mL, while cyanoacrylate sealant costs $175 per 0.5mL [9].
This is compared to the cost of a permanent penetrating xation device, costing
approximately $225 [10]. No studies exist comparing the two glue xation methods
to each other. Although some studies have demonstrated a signicant reduction of
cost with glue xation, it is difcult to extrapolate such ndings due to country and
hospital contracts [11].
In 2016, Antoniou etal. published a meta-analysis including 9 RCTs and 1454
patients comparing tacker mesh xation versus glue mesh xation during
LIHR.Patients were followed for 6–24months [12]. There was no signicant difference in rates of recurrence or overall morbidity. There was a signicant reduction
in chronic groin pain in the glue xation group (OR 0.46, 0.22–0.93). However,
only 5 of the studies included relevant data on chronic pain decreasing this population to 454 patients, which is not powered to detect such a reduction.
Overall, glue xation likely decreases chronic pain, does not lead to increased
recurrence, and may be less costly than penetrating xation techniques.
394
C. Yheulon and S. S. Davis Jr.
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Self-Fixating Mesh
Self-xating mesh (SFM) has existed for less than a decade. Although there is a
paucity of data regarding its use for LIHR, there is literature regarding its use in
open repair. In 2017, Ismail etal. published a meta-analysis of 3722 patients investigating the outcomes of SFM compared to suture xated mesh in open inguinal
hernia repair [13]. There was no difference with regard to recurrence or overall
morbidity. However, there was a reduction in operative time (−7.85min, p=<.0001)
as well as a nonsignicant trend in reducing chronic groin pain in the SFM groups
(OR 0.75, p=0.09).
To date, there are only two small RCTs examining the use of SFM in LIHR.In
2012, Cambal etal. examined 50 patients undergoing TAPP with SFM versus 50
patients xated with brin glue [14]. There was a signicant decrease in operative
time in the SFM group (4.5min, p=0.006), but no difference with regard to acute
or chronic pain. There were no recurrences in the study, but the follow-up period
was only 3 months. In 2016, Ferrarese et al. performed a similar study with 60
patients followed for a mean of 11months [15]. There were no recurrences, and
there were no signicant differences between the SFM and brin glue groups in any
outcome to include operative time.
Conclusions
There are both a wealth and dearth of literature regarding xation techniques for
LIHR.The data regarding SFM is encouraging, but larger randomized controlled
trials must be performed. Perhaps the only benet with SFM is improved opera-
tive time. Even so, reducing operative time has been shown to improve outcomes
in a variety of minimally invasive surgeries to include a nonsignicant trend in
LIHR (p=0.14) [16]. Overall, we agree that the best guidance on xation for
LIHR mirrors the 2015 International Endohernia Society guidelines on laparo-
scopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [17].
Evidence
Level 1A: Fixation and non-xation of the mesh in TEP are associated with equal
risk of postoperative pain or recurrence.
Level 1B: Fibrin glue xation is associated with less chronic pain than stapling.
Recommendations
Grade A: If TEP technique is used, non-xations must be considered in all types of
inguinal hernias except large direct defects.
Grade B: In case of TAPP repair, non-xation should be considered for primary
and rst recurrences of both direct and indirect hernias.
28 Fixation vs. No Fixation inMIS Inguinal Hernia Repair
395
Grade B: For xation, brin glue should be considered to minimize the risk of
acute postoperative pain.
References
1. Phillips EH, Rosenthal R, Fallas M, etal. Reasons for early recurrence following laparoscopic
hernioplasty. Surg Endosc. 1995;9(2):140–4; discussion 144–5.
2. Felix E, Scott S, Crafton B, etal. Causes of recurrence after laparoscopic hernioplasty. A mul-
ticenter study. Surg Endosc. 1998;12(3):226–31.
3. Fischer JE. Fischer’s mastery of surgery. 6th ed. Philadelphia: Wolters Kluwer Health/
Lippincott Williams & Wilkins; 2012.
4. Teng YJ, Pan SM, Liu YL, etal. A meta-analysis of randomized controlled trials of xation
versus nonxation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg
Endosc. 2011;25(9):2849–58.
5. McCormack K, Scott NW, Go PM, Ross S, Grant AM.Laparoscopic techniques versus open
techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1):CD001785.
6. Claus CM, Rocha GM, Campos AC, etal. Prospective, randomized and controlled study of
mesh displacement after laparoscopic inguinal repair: xation versus no xation of mesh. Surg
Endosc. 2016;30(3):1134–40.
7. Reynvoet E, Berrevoet F.Pros and cons of tacking in laparoscopic hernia repair. Surg Technol
Int. 2014;25:136–40.
8. Christoffersen MW, Brandt E, Helgstrand F, etal. Recurrence rate after absorbable tack xa-
tion of mesh in laparoscopic incisional hernia repair. Br J Surg. 2015;102(5):541–7.
9. Spotnitz WD.Hemostats, sealants, and adhesives: a practical guide for the surgeon. Am Surg.
2012;78(12):1305–21.
10. Sajid MS, Ladwa N, Kalra L, McFall M, Baig MK, Sains P.A meta-analysis examining the use
of tacker mesh xation versus glue mesh xation in laparoscopic inguinal hernia repair. Am J
Surg. 2013;206(1):103–11.
11. Chan MS, Teoh AY, Chan KW, Tang YC, Ng EK, Leong HT. Randomized double-blinded
prospective trial of brin sealant spray versus mechanical stapling in laparoscopic total extraperitoneal hernioplasty. Ann Surg. 2014;259(3):432–7.
12. Antoniou SA, Kohler G, Antoniou GA, Muysoms FE, Pointner R, Granderath FA. Meta-
analysis of randomized trials comparing nonpenetrating vs mechanical mesh xation in laparoscopic inguinal hernia repair. Am J Surg. 2016;211(1):239–249.e2.
13. Ismail A, Abushouk AI, Elmaraezy A, etal. Self-gripping versus sutured mesh xation meth-
ods for open inguinal hernia repair: a systematic review of clinical trials and observational
studies. Surgery. 2017;162(1):18–36.
14. Cambal M, Zonca P, Hrbaty B.Comparison of self-gripping mesh with mesh xation with
brin-glue in laparoscopic hernia repair (TAPP). Bratisl Lek Listy. 2012;113(2):103–7.
15. Ferrarese A, Bindi M, Rivelli M, Solej M, Enrico S, Martino V. Self-gripping mesh versus
brin glue xation in laparoscopic inguinal hernia repair: a randomized prospective clinical
trial in young and elderly patients. Open Med (Wars). 2016;11(1):497–508.
16. Jackson TD, Wannares JJ, Lancaster RT, Rattner DW, Hutter MM. Does speed matter? The
impact of operative time on outcome in laparoscopic surgery. Surg Endosc. 2011;25(7):2288–95.
17. Bittner R, Montgomery MA, Arregui E, etal. Update of guidelines on laparoscopic (TAPP)
and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg
Endosc. 2015;29(2):289–321.
Open Techniques: Mesh andNon-mesh
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Anatomical Repairs
AndrewBates andSalvatoreDocimo Jr.
Open inguinal herniorrhaphy remains the most commonly performed repair for
inguinal hernias in the world. The surgical management of hernias has undergone
extensive evolution over the past century, always with the goal of denitive repair
with minimal morbidity for the patient. The choice of repair should be tailored to
the patient and the clinical circumstances. Both tissue repairs and tension-free
repairs have merit in experienced hands and in the correct setting.
Evolution ofInguinal Herniorrhaphy
Standardized inguinal hernia repair began as tissue repairs. More than 70 different
types of named tissue repairs for inguinal hernia exist in the surgical literature.
Three of the more commonly studied and practiced open tissue repair techniques—
Shouldice, Bassini, and McVay—are still in use today. The Bassini repair was rst
performed in 1887 and became a standard of care for inguinal hernia repairs. Bassini
championed reinforcement of the posterior inguinal canal using the transversalis
fascia, transverse abdominal muscle, and internal oblique muscle. However,
increased recurrence rates in the hands of less experienced surgeons allowed for the
Shouldice repair to gain prominence in the early 1950s [1].
29
A. Bates (*) · S. Docimo Jr.
Division of Bariatric, Foregut, and Advanced GI Surgery, Department of Surgery,
Stony Brook University Hospital, Stony Brook, NY, USA
Stony Brook Surgical Associates, Stony Brook, NY, USA
e-mail: salvatore.docimo@stonybrookmedicine.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_29
397
398
A. Bates and S. Docimo Jr.
In the 1950s and 1960s, Francis C.Usher introduced the use of polyethylene
in the repair of inguinal hernias. The concept of a “tension-free” repair was rst
developed in the 1980s and aimed to improve upon the well-established tissue
repairs that had been performed since the 1800s [2]. The tissue-based repair,
rst popularized by Bassini, helped to standardize the repair of inguinal hernias.
However, despite renements to the method, by Shouldice, McVay, and others,
recurrence rates remained between 10 and 15% in most published literature. The
use of prosthetic mesh creates a tension-free repair by eliminating the need to
pull fascial layers together during the procedure [3]. The mesh is placed between
the layers of external and internal oblique, becoming well-incorporated in the
lower abdominal wall. The use of this technique results in a reduction in recurrence risk by 50–75% [4]. Furthermore, a Cochrane review of over 20 randomized trials comparing Lichtenstein with tissue repairs showed less chronic pain,
faster return to normal activities, and shorter hospital stays. As a result, the
tension-free repair quickly became the standard of care for inguinal herniorrhaphy [5].
The minimally invasive techniques that were subsequently developed for inguinal hernia all utilized the same tension-free principles. As such, while there are
differences in wound morbidity and postoperative pain, there is no signicant difference in the recurrence rate between open and minimally invasive tension-free
repairs.
Relevant Neuroanatomy
There are three nerves within the inguinal canal: the ilioinguinal, the genital
branch of the genitofemoral, and the iliohypogastric nerves. The ilioinguinal
nerve is typically the rst nerve encountered during surgery, located over the
spermatic cord within the investing fascia of internal oblique muscle. This fascia
should be preserved, as it helps protect the nerve from mesh and reduces perineural scarring.
The genital branch of the genitofemoral nerve lies on the underside of the
spermatic cord, running adjacent to the spermatic vein (seen as a “blue line”
under the cord). During dissection of the spermatic cord, this nerve and vein
together should be kept with the deep cremasteric fascia that covers it.
Excessively traumatic dissection may also damage the vas deferens and sensory
nerve bers of the testicle, producing orchialgia, azoospermia, and dysejaculation [6, 7].
The iliohypogastric nerve runs between the internal and external oblique,
protected from mesh by the investing fascia of the internal oblique muscle.
Laterally, the nerve becomes intramuscular within the internal oblique. The
nerve can be exposed by opening the anatomic cleavage between the internal
and external oblique, exposing superiorly to visualize the aponeurosis of the
internal oblique.
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
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399
General Principles
Patients are placed in supine position with arms fully extended. Administration of
local anesthetic may be performed prior to or after sterile draping is completed. For
most open inguinal hernia repairs, administration of local anesthetic is sufcient for
completion of a tissue repair. However, general anesthesia is also acceptable. A solution of 0.25% bupivacaine with epinephrine is commonly utilized, with the total
possible volume dependent on the patient’s weight. Local anesthetic is placed medial
to the anterior superior iliac spine (ASIS) to provide an ilioinguinal nerve block and
along the length of the proposed incision to create a surgical eld block [8].
A straight line between the ASIS and the pubic tubercle should guide the initial
incision. Some surgeons prefer an oblique incision 2–3cm above the ASIS-pubic
tubercle line. Others may prefer a more horizontal incision within the Langer lines
of skin tension. Regardless, following the skin incision, the external oblique aponeurosis is exposed by dissecting through the Scarpa’s and Camper’s fasciae [8].
The external oblique aponeurosis is opened through the external inguinal ring.
The medial and lateral edges of the external oblique aponeurosis are grasped with a
hemostat and pulled away from the cord structures. The iliohypogastric nerve may
be identied at this time and preserved. The cord structures are then bluntly mobilized off the external oblique and inguinal oor. A swipe of the index nger under
the cord structures at the pubic tubercle will allow for circumferential mobilization
and placement of a Penrose drain around the cord structures. Mobilization of the
cord structures will expose the shelving edge of the inguinal ligament and the iliopubic tract. Division of the cremasteric muscle in a longitudinal fashion occurs next.
Once mobilized, the cremaster muscle is ligated. Following identication of the
hernia sac, the surgeon may proceed with either a high ligation or complete reduction of the sac into the preperitoneal space without excision [8]. A relaxing incision
is created by making a vertical incision from the pubic symphysis and extending it
superior only to the anterior rectus sheath for 3–4cm, thereby exposing the rectus
abdominis muscle.
Bassini Repair
The initial steps in the procedure are described above in the general principles. The
reconstruction begins by opening the transversalis fascia from the internal inguinal
ring to the pubic tubercles, exposing the preperitoneal fat. Opening of the transversalis fascia allows for the creation of the “triple layer” (transversalis fascia, transversus abdominis, and the internal oblique muscle). The rst stitch involves the
triple layer, the pubic tubercle, and the rectus sheath. The repair is carried out laterally, with the triple layer sutured to the shelving edge of the inguinal ligament, in an
interrupted fashion, until the internal ring is closed medially (Fig.29.1). Typically,
six to eight nonabsorbable interrupted sutures are required. The external oblique
aponeurosis is then closed using an absorbable suture [9].
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