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_961_Библиотеки_им_академика_М_И_Перельмана.pdf
Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Martin Kurzer
1 5
Introduction
The open preperitoneal mesh repair of groin hernia places
nonabsorbable mesh in a bloodless plane that lies outside the
peritoneal cavity, between the transversalis fascia and the
anterior abdominal wall, in the region of what is known as
the myopectineal ori fi ce (MPO) (see below). This is the same
space that is developed during laparoscopic repair of a groin
hernia. None of the open preperitoneal repairs enter the peritoneal cavity, which means they are in effect open versions
of a TEP (totally extraperitoneal) laparoscopic repair, with
access to this space gained via an abdominal incision rather
than a laparoscope.
Some surgeons would say that in the current era of laparoscopic surgery, an open preperitoneal repair is now only of
historical interest. How far this is true, I will let the reader
judge. I hope to show that it still does have indications and is
a procedure and a skill that should be in the “toolkit” of every
surgeon who declares a special interest in hernia surgery.
In this chapter I will review the history and development
of this approach, describe the variations, and outline the
advantages and indications of each. I will also brie fl y outline
the operative techniques, although more detailed descriptions by their developers are available in the original papers
and other textbooks (all well worth reading in the original),
and fi nally will describe the reported results.
The plane in which the mesh lies is outside (extraperitoneal) or in front
of (preperitoneal) the peritoneal cavity. George Wantz, and other
American surgeons, also used the term “properitoneal.”
M. Kurzer (*)
Department of Surgery , British Hernia Centre ,
London , UK
e-mail: m.kurzer@me.com
History
The preperitoneal approach to the groin is historically associated with the names of Annandale, Cheatle, and Henry,
who all recognized the excellent access afforded to the posterior aspect of the abdominal wall in the region of the inguinal canal [
Raymond Read’s comprehensive review in a recent textbook
[ 3 ] . It was seen as an ideal method of dealing with incarcerated or strangulated groin hernias, and although the access
and views that it afforded of the posterior aspect of the inguinal canal and femoral region (“The Myopectineal Ori fi ce”—
see below) were excellent, it never gained wide acceptance.
It is however still regarded by experienced surgeons as the
procedure of choice for strangulated femoral hernia.
Nyhus and Read in the USA, and Rives and Stoppa in
France, became interested in the preperitoneal approach for
recurrent and complex groin hernias in the late 1950s and
early 1960s [ 4– 7 ] . They were all dissatis fi ed with the results
obtained for recurrent hernias when operating through the
previous incision and reopening a scarred inguinal canal.
In the case of multi-recurrent hernias, often with extensive
scarring and tissue loss, and before the introduction of modern meshes, effecting a good long-term repair with a conventional approach was well nigh impossible. Recurrence rates
could be well over 50%, and many multi-recurrent hernias
were probably deemed “inoperable.” In addition, the likelihood of testicular atrophy was high [ 8 ] .
Using a preperitoneal approach through a transverse lower
quadrant abdominal incision allowed Nyhus and his colleagues access to the preperitoneal space, avoiding scar tissue from previous surgery and allowing them to operate in a
virtually virgin fi eld. They found that the dissection was
straightforward and the defect or defects were easily seen
and assessed. However, despite the advantage of easy access
and good visualization, Nyhus found that the failure rate
(hernia recurrence) was still high—as much as 30%—if the
margins of the defect were sutured. He therefore added what
he termed a “prosthetic mesh buttress” attached inferiorly to
1, 2 ] . The interested reader might like to refer to
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_15, © Springer Science+Business Media London 2013
255
256 M. Kurzer
the superior pubic ramus (Cooper’s ligament) in order to
“reinforce” his sutured repair. The incidence of re-recurrence
dropped dramatically. “There were no re-recurrences after
we adopted the routine placement of the prosthetic mesh buttress to bolster the anatomic repair” and this technique rapidly became his routine for virtually all cases. He published
a 38-year review of his work in 1993 [
nique again, and could not understand why general surgeons
refused to adopt it. He wrote, “My associates and I were perplexed about the failure of this method to fl ourish.”
At about this time surgeons in France, Rives in Reims [ 6 ] ,
and Stoppa in Amiens [ 7 ] , had also started to use a preperito-
neal method for complex, recurrent groin hernias, but from the
outset, they used mesh in every case. Rives used a trans-inguinal approach, which meant that with recurrent hernias, he still
had to operate through the scar tissue from previous surgery.
In addition in the Rives technique, the mesh was cut and
shaped in a complex fashion and sutured inferiorly to Cooper’s
ligament [ 6 ] . Other surgeons more recently have also described
trans-inguinal techniques for preperitoneal mesh placement
with the theoretical advantage of allowing preperitoneal mesh
placement under local anesthetic [ 10, 11 ] .
Stoppa developed his method to deal with complex bilateral hernias, and he accessed the preperitoneal space through a
lower midline incision in order to avoid reoperating through
scar tissue. Stoppa’s genius was in proposing the radical step
that no attempt should be made to close the actual defect, thus
avoiding any tension. Rignault put it well—“The idea of interposing a large surface of prosthetic mesh between the peritoneum and the de fi cient inguinal wall instead of ‘mending’ the
defect, represents a radical departure from previous methods
of hernia repair…. The mesh must be much larger than the
defect, since it is not sutured in place and only intra-abdominal
pressure maintains it in place over the hernia defect” [ 12 ] . This
concept has subsequently been vindicated and is of course
now standard practice in laparoscopic repair.
George Wantz in the USA was dissatis fi ed with what he
termed the “properitoneal patch hernioplasty” that had been
developed by Raymond Read—a prosthesis that was just sutured
to the edges of the defect. He was however impressed with the
Stoppa technique and agreed with Stoppa that it was much more
logical to use a large piece of mesh covering the whole of the
MPO with a wide overlap and no closure of the defect. He
modi fi ed the bilateral procedure for unilateral recurrent hernias
using the Nyhus transverse lower quadrant incision and an
innovative way of anchoring the mesh, “hanging” it from above
like a sheet on a washing line (see Fig. 15.16 ). Stoppa had
called the procedure “La Grande Prothese Reinforce de Sac
Visceral,” and this was translated verbatim by Wantz in his seminal article [
Visceral Sac. Hence, the operation is also known, somewhat
cryptically, as GPRVS.
Both the unilateral (Wantz) and bilateral (Stoppa) techniques were particularly well suited to complex and multi-
13 ] as Giant Prosthetic Reinforcement of the
9 ] , describing the tech-
recurrent defects. Like the Nyhus procedure, they were never
widely adopted, possibly because of general surgeons’ unfamiliarity with, and reluctance to venture into, the preperitoneal space. Of course, the modern era of laparoscopic surgery
started at about this time, and it is interesting to observe that
surgeons now seem to have no concerns about entering this
space with a laparoscope.
Indeed, the introduction of laparoscopic techniques
resulted in a reevaluation of the need for large incisions to
position the mesh, and new open methods were developed by
two surgeons Kugel and Ugahary to allow access to the preperitoneal space through very small incisions. The intention
was to combine the short learning curve and economic
advantages of the open approach with the potential for rapid
recovery with minimal access surgery [
14, 15 ] .
The Myopectineal Ori fi ce
All preperitoneal groin hernia repair are based on the concept of
the MPO, fi rst described by Henri Fruchaud, a French anatomist
and surgeon [ 16 ] who de fi ned groin hernias as “any hernia of
the inguino-femoral region that results from failure of the transversalis fascia to retain the peritoneum in the weak area of the
groin known as the myopectineal ori fi ce.” The borders of the
MPO are the internal oblique muscle superiorly, the iliopsoas
laterally, the rectus muscle medially, and the superior pubic
ramus inferiorly (Figs. 15.1 and 15.2 ). This bony muscular
framework is divided in two by the inguinal ligament, traversed
by the spermatic cord above and the femoral vessels below.
To quote George Wantz—“…it [the myopectineal ori fi ce] is
bridged in a drumlike fashion by the transversalis fascia only…
Protrusion of a peritoneal sac through the myopectineal ori fi ce
de fi nes a hernia. Failure of the transversalis fascia to retain the
peritoneum then becomes the fundamental cause of all hernias
of the groin” [ 17 ] . In a preperitoneal prosthetic repair (open or
laparoscopic), the prosthesis is sandwiched between the peritoneum and the anterior abdominal wall and substitutes for the
defective or weakened transversalis fascia. It is strengthened
later by an ingrowth of connective tissue. The peritoneum can
therefore no longer push through the MPO; it is effectively held
in—like a balloon in a string bag—and formal repair of the
MPO, that is, closure of the defect, is not necessary.
Indications for the Open Preperitoneal Technique
1. Recurrent or multiple recurrent groin hernias following a
previous open, anterior repair. Operating in the unscarred,
virgin preperitoneal plane is simpler and safer, and all
potential defects can be inspected.
2. Combination groin hernias where there are multiple
defects, for instance, combinations of pre-vascular,
Fig. 15.1 Fruchaud’s
myopectineal ori fi ce (MPO).
Right side , anterior view
25715 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 15.2 Fruchaud’s MPO. Right side ,
posterior view
258 M. Kurzer
femoral, indirect and direct inguinal, and low Spigelian
hernias. All potential defects can be inspected.
3 . Giant inguino-scrotal hernias, either unilateral or bilat-
eral, where replacement of abdominal contents through a
groin incision alone would be technically dif fi cult.
“Pulling” the sac contents back from behind through the
defect is simpler and safer than “pushing” from the front.
4. Incisional hernia after, for example, a Pfannenstiel incisions or the rare incisional hernia through the lateral rectus sheath (acquired Spigelian hernia).
5. Hernias associated with connective tissue disorders
(Ehlers-Danlos and Marfan’s syndrome) where multiple
points of weakness may be present.
The Operations
There are essentially fi ve open preperitoneal operations in
current use:
1. Bilateral Stoppa procedure
2. Unilateral Wantz procedure
3. Trans-inguinal [ 6, 18 ]
4. Kugel procedure [ 14 ]
5. Ugahary procedure [ 15 ]
They can be grouped as standard incision repairs, Stoppa
(bilateral) and Wantz (unilateral); small incision methods,
Kugel or Ugahary; and trans-inguinal, Rives and Schumpelik.
Apart from the possibility of operating under local anesthesia,
the trans-inguinal approach seems to offer no other bene fi t.
Advantages of a Preperitoneal Approach
The advantages of a preperitoneal approach for recurrent
groin hernia are:
(a) Avoiding reoperating through scarred distorted anatomy
(b) Avoiding the risk of damage to the testicular vessels
(c) Permitting inspection of all potential groin hernia sites
The trans-inguinal approach has been advocated by some
because of a claimed advantage in terms of post-op pain if
mesh is placed in the preperitoneal space. It seems unnecessarily complex for primary hernias and by reopening the
inguinal canal, still involves a dissection through scar tissue
in recurrent hernias. It therefore loses out on (a) and (b) and
confers no real advantage. It has not been widely adopted
and will not be described here in detail.
The Kugel and Ugahary operations avoid the scar tissue
from previous surgery; but they are carried out through small
incisions and do not allow easy visual inspection of the whole
area. Only the Stoppa and Wantz procedures combine all
three advantages.
Operative Techniques of Open Preperitoneal Repair
Preoperative Preparation
This is standard for all methods. The patient should pass
urine immediately preoperatively before coming to the operating room (OR). Some advocate routine urinary catheterization, though this has its own set of complications and I have
never found it to be necessary. Venous thromboembolism
(VTE) prophylaxis should be used and a single-shot broadspectrum intravenous antibiotic given intravenously on
induction of anesthesia, both according to up-to-date local
guidelines. The operating table is tilted 20–30° head down
(Trendelenburg position) in order to allow the intra-abdominal contents to fall away from the region of the hernia.
Choice of Anesthesia
In practice general anesthesia is the method of choice for the
majority of patients undergoing a Stoppa or Wantz procedure
because of the requirement for a relaxed abdominal wall.
Regional block (spinal or epidural anesthesia) is an alternative but is likely to result in a high incidence of urinary retention. Local anesthesia (LA) is not really feasible for the
Wantz procedure (although Wantz said it was—personal
communication) unless the operator is particularly experienced and the patient is slim and cooperative. Both Kugel
and Ugahary maintained that their procedures could easily
be performed under local anesthesia.
Operative Technique: Stoppa and Wantz
The Bilateral Stoppa Operation
Incision. Stoppa saw little merit in a Pfannenstiel incision
[ 19 ] and used a lower midline incision routinely. He avoided
the problem of subsequent incisional hernia by bringing the
mesh up high behind the incision. However, our experience
and that of others [ 11, 20 ] is that a Pfannenstiel incision gives
excellent access, less postoperative discomfort, and a better
cosmetic result (Fig. 15.3 ).
The Pfannenstiel incision is transverse and curvilinear
and is made 2 cm above the pubis. After deepening through
subcutaneous fat, incise the rectus sheath in a V, with the
point of the V 2 cm above the pubis, and raise the sheath off
the rectus muscle with a combination of sharp and gentle
blunt dissection.
25915 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Midline
Pfannenstiel
Fig. 15.3 Access to the preperitoneal space through a vertical or
Pfannenstiel incision
Identify the midline and gently separate the two rectus
muscles. Break through the transversalis fascia and you are in
preperitoneal or extravesical fat. Gentle blunt dissection will
easily open the spaces behind the pubis (cave of Retzius) and
laterally each side of the midline (space of Bogros). Open
these spaces widely, down to the superior pubic ramus, below
the spermatic cord and pedicle of an indirect hernia sac (if
present), and over (above) the iliac vessels. It is usually easier
to do this from the opposite side of the patient (Fig. 15.4 ).
Continue the dissection laterally to open up the whole area. At
this stage a direct hernia will have reduced easily. There is no
need to suture direct defects, but the dead space of a large
direct sac can be reduced by withdrawing (inverting) the transversalis fascia and suturing it to the abdominal wall.
Dealing with the Spermatic Cord: “Parietalization”
This involves separating the spermatic cord from that part of
the visceral peritoneum that lies against the anterior abdominal wall in the region of the MPO, so that the mesh can be
interposed (Fig. 15.5 ). This separation is of course now a
standard maneuver in laparoscopic repair, but a number of
earlier descriptions described splitting and then resuturing
the mesh to allow passage of the spermatic cord. This is a
less elegant technique and one more prone to lead to recurrence. As the dissection proceeds you will see the testicular
vessels and the vas diverge, the former passing laterally and
the latter passing medially giving a characteristic triangular
appearance (Fig.
15.6 ).
Insertion of the Mesh
Stoppa used a chevron-shaped prosthesis (Fig. 15.7 ) and a
complex arrangement of eight long clamps to insert the mesh
(Fig. 15.8 ), which was held by only one single midline suture
15.9 ). It was important to cleave this space widely
(Fig.
because wrinkling or folding of the mesh would occur if an
insuf fi cient space had been prepared. Figure
15.10 shows an
idealized fi nal mesh position in the bilateral operation. There
is however a real risk of mesh displacement in the early postoperative period, and most surgeons who used this technique
would anchor the prosthesis at strategic points (Fig. 15.11 ).
An alternative, which I have found easier than the single large
prosthesis, is to use two separate meshes, each 15 cm × 15 cm,
attached inferiorly at the pectineal ligament, effectively a
Wantz operation on each side (see Wantz technique below).
The Unilateral Wantz Operation
This has been clearly described elsewhere in detail by Wantz
[ 13, 17 ] . Make a transverse incision in the groin (higher than a
standard open inguinal approach) well above the deep ring
(Fig. 15.12 ). Incise the rectus sheath transversely, extend onto
the external oblique aponeurosis, and retract the rectus muscle
medially and elevate it. There is no posterior rectus sheath at
this level, and you should see the inferior epigastric vessels.
It is important to gently elevate these vessels with the muscle
so that you are beneath them at this stage. Preserve them if you
can, though they can be divided with impunity if in the way
(Fig. 15.13 ). Break through the transversalis fascia taking care
not to open the peritoneum, and widely cleave the preperitoneal
space as in the bilateral operation (Fig. 15.14 ). Parietalize the
spermatic cord by separating it from the visceral peritoneum
and an indirect sac if present. Wantz used a quadrangularshaped prosthesis, with an extended inferolateral corner to
ensure complete cover of the myopectinal ori fi ce (Fig. 15.15 ).
He had experienced the occasional lateral re-recurrence with
his original rectangular shape.
Wantz secured the upper border prosthesis to the anterior
abdominal wall with three sutures place at 3 cm intervals above
the incision and no attachment inferiorly (Fig. 15.16 ). The infe-
rior border of the mesh was then passed down below and behind
the peritoneum with three long clamps, at points 4, 5, and 6,
which grasp the two lower corners and center of the lower border (Figs. 15.17 and 15.18 ). This is a tricky maneuver, and as
with the bilateral procedure, wrinkling or folding of the mesh
will occur if an insuf fi cient space has been prepared.
I have found that securing the mesh superiorly is
dif fi cult, and my colleagues and I had four early recurrences of direct hernias, where the inferomedial corner
of the mesh had moved upward (point D in Fig. 15.19 )
19 ] . We now secure the inferomedial corner to the back
[
260 M. Kurzer
Fig. 15.4 ( a , b ) Preperitoneal view of the right groin (MPO), from the left side of the patient, showing a right indirect inguinal hernia (lateral to
the inferior epigastric vessels) prior to its reduction, and note the femoral canal medial to the femoral vein (from Stoppa [
36 ] , with permission)
Parietal
peritoneum
Spermatic
cord
Mesh
Vas deferens
Visceral
peritoneum
Bladder
Fig. 15.6 The triangular appearance of the completed dissection on
the right side, showing the vas deferens passing medially, testicular vessels passing laterally, and peritoneum. When released, the elements of
the cord will fall against the parietal pelvic wall (parietalization)
Fig. 15.5 Parasagittal section to demonstrate the mesh in the extraperitoneal or preperitoneal space, lying between the parietal peritoneum
and spermatic cord on one side and the visceral peritoneum and bladder
on the other
of the pubic bone, almost in the midline (point D in
Fig. 15.20 and point 4 in Fig. 15.21 ), and place one or
two sutures to attach the inferior border of the mesh to
the superior pubic ramus (point E in Fig. 15.20 and point
5 in Fig. 15.21 ). The illustrations show the idealized
fi nal position of the mesh.
Choice of Prosthesis
Both Stoppa and Wantz advocated Mersilene (polyester)
( trademark ) mesh claiming that its fl exibility allowed it to
conform to the complex curvatures of the abdominal wall.
Wantz’s criteria for an ideal prosthesis were:
Flexibility or suppleness to allow it to curve to the shape •
of the abdominal wall
“Graininess” to grip the peritoneum and prevent slippage •
early on
26115 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 15.7 The cardinal points of positioning of the clamps on the single bilateral prosthesis to aid in its insertion
Fig. 15.9 Stoppa’s recommended placement of the single suture to
fi xate the giant prosthesis
Fig. 15.8 ( a ) The chevron-shaped prosthesis is seized by eight long-
curved clamps. ( b ) Operator view of the insertion of the bilateral mesh
prosthesis, which is being pushed with clamps nos. 1–5. The numbers
show the order in which the clamps have been used. Clamps nos. 6–8 will
be used for the placement of the left part of the prosthesis. This is a complex maneuver, requiring the surgeon to have a good 3D appreciation of
the space as well as a good assistant (from Stoppa [
36 ] , with permission)
Fig. 15.10 The bilateral prosthesis in position, replacing the endopelvic transversalis fascia and extending far beyond the borders of both
MPOs
Reactive enough to induce a fi broblastic response to •
ensure rapid fi xation
He thought polypropylene too rigid and in fl exible, though
this has not been our experience, nor that of the exponents of
TEP lap repair who are happy with the newer “lightweight”
polypropylene meshes.
Operative Technique (Kugel and Ugahary): Open “Minimal Access” Preperitoneal Placement of the Prosthesis
The phrase “open minimal access” might appear at fi rst to be
a contradiction in terms, but these two operations were
designed speci fi cally to allow access to the preperitoneal
262 M. Kurzer
Fig. 15.11 Suture placement for fi xation of the bilateral mesh
Fig. 15.12 Wantz unilateral procedure makes the transverse incision
above the level of the deep inguinal ring, from the midline extending
laterally. Incise the rectus sheath and extend laterally into the aponeurosis of the oblique abdominal muscles, and note the yellow fat marking
the best entry point into the preperitoneal space
Fig. 15.13 The rectus muscles retracted medially and elevated to
expose preperitoneal fat. This is below the arcuate line, so there is no
posterior rectus sheath. The transversalis fascia has been incised, and
the inferior epigastric vessels are about to be divided. This is not always
necessary—they can be elevated and retracted medially with the rectus
muscle
Fig. 15.14 “Teasing” an indirect hernia sac out of the abdominal wall
defect
26315 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 15.15 Wantz procedure—trapezoid shape of the mesh to be
inserted in preperitoneal space. The letters A–F illustrate the position of
the mesh after placement
space through small incisions—perhaps 3–4 cm in length.
Their developers maintained that these operations could be
performed with local anesthesia, so that in theory, they
offered the advantages of a preperitoneal inguinal hernia
repair without the need for general anesthesia or expensive
laparoscopic equipment. The plane in which the mesh was
placed is the same as that used for the Wantz/Stoppa procedures (and for laparoscopic repair), that is, posterior to or
below the epigastric vessels and the transversalis fascia.
As with all preperitoneal methods, patients are tilted head
down to move the intestines away from the lower abdomen
and pelvis. With both repairs the location of the incision is
critical to the performance of the procedure in an easy fashion. They are also both highly dependent on the surgeon’s
understanding of the local anatomy of the preperitoneal
space in the inguinal area. They are certainly not procedures
for the inexperienced trainee.
The Kugel Repair
Kugel designed a mesh patch that incorporated a memory
recoil ring that allowed the patch to spring back open after
being inserted through a small incision. A number of the
larger patches (placed intraperitoneally and used for incisional hernia repair) were found to have faulty memory recoil
rings and were recalled around 2005. A modi fi ed and
improved device is currently in use.
Kugel made a 3-cm transverse, slightly oblique incision at
the midpoint between the anterior superior iliac spine and the
pubic tubercle (Fig.
15.22 ). The external oblique aponeuro-
sis is opened, and the abdominal muscles split in the line of
their fi bers. The preperitoneal space is entered by incision of
the transversalis fascia in a vertical direction. The dissection
should allow just enough free space to accommodate the
prosthesis. The entrance is small so the space has to be developed with the use of either forceps or other instruments. The
cord structures are separated from the peritoneum 3 cm
above the internal ring to expose Cooper’s ligament and the
pubic bone, and great care has to be taken not to injure either
the inferior epigastric or testicular vessels.
Having formed the correct size space, the operator’s index
fi nger is inserted into the slit that was on one side of the mesh
and the prosthesis rolled onto the fi nger (Fig.
15.23 ). A mal-
leable retractor is used to maintain the space created by the
preperitoneal dissection while the mesh is inserted.
When properly placed, the patch should lie completely
fl at and open, parallel to the inguinal ligament and covering
the entire inguinal fl oor and the femoral space (Fig. 15.24 ).
A single absorbable suture fi xes the lateral edge of the
patch.
The Ugahary Operation
Ugahary has described his operation in detail elsewhere,
with numerous technical tips [ 21 ] , and I have summarized
the essential steps below. The incision is made approximately
3 cm above and lateral to the internal ring (Fig. 15.25 ).
Because of the location and direction of the incision, it has
become known as the gridiron hernioplasty. As with the
Kugel repair, the preperitoneal space is entered by a musclesplitting dissection of the internal oblique and transversus
abdominis muscles, followed by incision of the transversalis
fascia in a transverse direction.
The space is developed using special long thin retractors,
and the cord structures are separated from the peritoneum. A
10 × 15 cm prosthesis is tightly rolled around a 30-cm forcep
with the side that will be facing the inguinal fl oor on the outside of the roll. The rolled mesh on the forceps is then inserted
into the space with the very distal end placed behind the pubis
(Fig. 15.26 ). The retractors are carefully removed, and one is
then reinserted into the roll of the mesh. The second retractor
is then used to unroll the mesh by a sweeping and rotating
motion (Fig. 15.27 ). The two retractors are used in sequential
fashion, one to hold the mesh in place while the other completes the fl attening against the anterior abdominal wall in the
region of the MPO. Finally, one absorbable suture is used to
fi x the lateral corner of the mesh to the transversus muscle. In
theory the polypropylene mesh should then be lying exactly
behind the MPO, similar to its position after a laparoscopic
repair or the unilateral open repair of Wantz (Fig. 15.28 ).
264 M. Kurzer
Fig. 15.16 Arrange the mesh so it stretches
transversely. Its width is cut equal to the
distance between the midline and the anterior
superior iliac spine minus 1 cm, and its length
is made approximately equal to 12 cm. Wantz
had an innovative way of attaching the mesh,
drawing it into place underneath the rectus
muscle and superior abdominal wall with three
slowly absorbable sutures at 1, 2, and 3
Fig. 15.17 The abdominal wall is retracted and the properitoneal
space exposed. The superior portion of the prosthesis (1–3) is depicted
indistinctly to illustrate its position after placement beneath the muscles
of the abdomen in the preperitoneal space. Clamps nos. 4, 5, and 6
along the distal margins of the prosthesis are poised, ready to implant
the mesh inferiorly
Personal Comment (MK)
Both Kugel and Ugahary maintained that their respective procedures were easy to perform, and indeed in skilled hand they were.
Fig. 15.18 Clamp no. 4 is placed medially deep into the space of
Retzius in the midline and is steadied by an assistant. A very large
curved or right-angled clamp helps keep point 4 at the midline. Next,
clamp no. 5 positions the middle of the inferior edge deep into the pelvis, followed by clamp 6 pushing laterally. Again, a complex
maneuver
As with most things in life, things are easy when you know how,
and when pro fi ciently carried out, these two operations did yield
excellent results. But they required a detailed knowledge of the
local anatomy and were unforgiving of technical errors. The correct plane had to be entered with the minimum of unnecessary
dissection. Trying to control excess bleeding in a deep hole