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20
L.C. Pickett
to occlude the internal ring ( 8 ) . Surgical intervention was fi rst performed
by Bassini, without any prosthetic, in 1884. The “Bassini repair” was
documented with 2.6% mortality and 3.1% recurrence in 227 patients with
98% follow-up at 4.5 years (
9 ) . As experience with this procedure widened,
a variety of types of wire and suture were utilized to reinforce the abdominal
wall (
10 ) . Subsequently, early forms of mesh were created and implanted.
These consisted of stainless steel, which was too stiff; nylon, which
disintegrated too rapidly; and then polypropylene ( 11– 13 ) . At this point,
mesh was simply used to buttress or reinforce suture repairs.
Mesh Utilized in Tension-Free Repairs
Usher was the fi rst to introduce signi fi cant changes in the conceptual
repair of hernias, utilizing mesh to bridge the hernia gap, instead of just
buttress a repair performed under tension. Thus, the fi rst description of a
tension-free hernia repair was presented: “If mesh is used to bridge the
defect instead of reinforcement for tissues approximated under stress, this
factor of tension is eliminated, and recurrence becomes less likely” ( 14 ) .
The next mission was to identify the ideal location to place the mesh. Irving
Lichtenstein performed and presented an updated tension-free hernia repair
with mesh placed anterior to the transversalis fascia in 1980, and this
“Lichtenstein repair” has become accepted as a standard hernia repair
which is simple to perform, can be safely conducted under local anesthesia,
and has acceptable rates of complication and time for recovery ( 15– 17 ) .
Preperitoneal Mesh
The main concern of these repairs remained the forces of abdominal
pressure on that location of mesh placement. There was a concern that
these forces increase the risk of recurrence for mesh placed anterior to
the fascia, instead of the preperitoneal location. Thus, a line of repairs
was proposed for mesh placed in the preperitoneal location, either via
laparoscopic placement or through open repair ( 18– 20 ) .
A subset of these repairs also includes a prosthetic inserted into the
internal ring, either alone or with a hernia patch, to help prevent recurrence
( 21, 22 ) (Fig. 2.1 ). Plugs can be visualized via laparoscopy or CT scan.
Radiographically, it appears as a smooth round or oval hypodense mass
close to the inferior epigastric artery, con fi rming the importance of
radiologist’s knowledge of past surgical history when reviewing scans
( 23 ) . There are multiple reports of mesh migration from the intended
21
2. Prosthetic Choice in Open Inguinal Hernia Repair
location, including a case report of intraperitoneal migration of a mesh
plug with a small intestinal perforation ( 24 ) .
To address this risk, in 1998, Gilbert and Graham introduced a double-
layered device, which sits in the inguinal defect, combining a small plug
with both a subaponeurotic component and preperitoneal patch, all formed
of polypropylene. This mesh is called the Prolene Hernia System (PHS).
The PHS incorporates the goal of decreased suture placement with mesh
placed in the preperitoneal location. The material is polypropylene and
placed via open technique ( 25 ) . Results have been evaluated and
demonstrate 1% recurrence and 2% chronic pain with a mean follow-up
of 49 months ( 26 ) . Longitudinal follow-up has demonstrated 2.3%
recurrence and 1.8% chronic pain at 5.5 year follow-up. ( 27 ) Comparison
of fl at polypropylene mesh and PHS at 1 year demonstrates that the PHS
surgery takes 15 min longer, on average, and there was no difference in
pain, return to activity, complication, or recurrence. ( 28 )
Nonabsorbing synthetic mesh is available in ePTFE (Gortex®), which
is seldom used in the groin, and porous sheets such as polypropylene,
polyester, and Ultrapro. Porous mesh is further divided into light-, medium-,
and heavyweight mesh, based upon the density of the mesh fi bers.
Lightweight mesh has been compared with heavyweight, and the
recent data has demonstrated some bene fi t in lightweight mesh.
Lightweight mesh has been shown to result in reduced chronic groin pain
at the operation site, although there was no associated increase in quality
of life in one study ( 29 ) . In a separate study, reduced postoperative pain
Fig. 2.1. Plug, removed for chronic pain.
22
L.C. Pickett
and recurrence in the short term was found but there was no statistical
difference in recurrence rate at longer-term follow-up ( 30 ) . Mesh can also
be combined with absorbable elements to create ultralightweight mesh,
such as Ultrapro®. A literature search was performed using Medline,
Embase, and Cochrane databases to identify relevant randomized
controlled trials, and comparative studies looked at long-term complications
of prosthetic meshes, speci fi cally comparing partially or completely
absorbable meshes with conventional nonabsorbable mesh. The primary
outcomes reviewed included hospital stay, time taken to return to work,
seroma, hematoma, wound infection, groin pain, chronic pain, foreign
body sensation, recurrence, and testicular atrophy. It was concluded that
absorbable and nonabsorbable mesh repairs of inguinal hernias do not
afford signi fi cant bene fi t, but lightweight mesh was associated with a
signi fi cant reduction in prolonged pain and foreign body sensation. ( 31 )
An additional meta-analysis reviewed Vypro II (large pore) and standard
polypropylene mesh for inguinal hernia repair, looking at recurrence,
pain, urinary tract infection, seroma, foreign body sensation, and testicular
atrophy. This analysis found a difference only in the sensation of a foreign
body, which was reduced in the large-pore mesh ( 32 ) .
Self-Fixation Mesh
A more recent addition has been mechanisms of self- fi xation to avoid
the placement of sutures, which have been implicated in increased pain
(Fig. 2.2 ). A randomized study of self- fi xing mesh demonstrates decreased
operative time, decreased pain postoperative day 1 by visual analog pain
score, and decreased cumulative dose of postoperative pain medicine over
standard mesh secured with sutures. ( 33 ) Another similar study that
assessed pain after the use of a self-adhesive, light mesh with reduced
sutures demonstrates reduced early postoperative pain compared with
conventional prosthesis ( 34 ) and a rat model with similar mesh demonstrates
no harmful in fl uence on the ductus deferens in the rat model ( 35 ) .
Absorbable Mesh
Synthetic mesh is available as an absorbable prosthetic for use in
highly contaminated situations. Vicryl® and Dexon are examples of this
type of mesh. These products remain intact for just a few weeks and,
therefore, are associated with high recurrence rates and are, therefore,
generally reserved for grossly contaminated cases.
23
2. Prosthetic Choice in Open Inguinal Hernia Repair
Biologic Mesh
Biologic mesh is available for patients who are at high risk of
infection. Allografts, including Alloderm®, have limited experience and
use in the groin. Xenografts are biologics derived from nonhuman
dermis, often bovine or porcine. They are harvested cells, essentially an
acellular collagen, supported by chemical processes for stabilization.
Permacol mesh and Surgisis mesh are examples of xenografts. Additional
biologics have been studied ( 36 ) , but there is little human data and no
long-term human outcomes available. As in all prosthetics, allergies and
religious and cultural beliefs need to be taken into consideration in the
surgical placement of biologic products.
Data on outcomes of hernia repair relative to type of mesh are
available in terms of ease of use, durability/recurrence, and long-term
chronic pain. See Table 2.1 for a summary of advantages/disadvantages
of each mesh type.
In fi nal summary, there are innumerable types, shapes, and compo-
nents of mesh. Each carries a unique pro fi le of bene fi ts and risks. There is
short-term data suggesting better surgeon ease of placement and reduced
pain with both lightweight and self- fi xation meshes. Long-term results
remain unchanged, and biologic grafts remain relatively unstudied. It would
seem that surgeons should select a mesh which they feel comfortable
Fig. 2.2. Self fi xation mesh.
24
L.C. Pickett
Table 2.1. Advantages/disadvantages of each mesh type.
Mesh Advantages Disadvantages
Lichtenstein-type Heavyweight porous Safe, well studied More acute pain
Likely more chronic pain
Lightweight porous Less acute pain
Likely less chronic pain
None
Porous plus absorbable
component
No difference with addition of absorbable
material
Increased cost
Porous with self- fi xation
component
Less acute pain
Possible less chronic pain
Increased cost
Less long-term data
Plug and patch Helps overcome the force of abdominal pressure Learning curve
Potential increase in chronic pain
Collagen scaffold Ability to place in patients high risk for infection
Cross-linked have better durability
Increased cost
Little long-term data
Preperitoneal Mesh with a memory
ring
Ease of placement
Location helps overcome the force of abdominal
pressure
Less acute pain
Possible migration
Increased cost
Plug Easy to place with experience
Some data suggest it decreases recurrence
Learning curve
Plug migration
Potential increase in chronic pain
Prolene Hernia System Low recurrence
Well studied
Learning curve
Cost
25
2. Prosthetic Choice in Open Inguinal Hernia Repair
placing, place these meshes consistently to improve their comfort with the
devices, and follow these patients prospectively for outcomes. It is likely
that in this complex fi eld, there is not one right mesh for each patient.
References
1. Shouldice EE. The treatment of hernia. Ontario Med Rev. 1953;20:670.
2. Scott NW, McCormack K, Graham, P et al. Open mesh versus non-mesh for repair of
femoral and inguinal hernia. Cochrane Database Syst Rev. 2002;CD002197
3. Nieuwenhuizen J, van Ramshort GH, Ten Brinke JG, de Wit T, van der Harst E, Hop
WC, Jeekel J, Lange JF. The use of mesh in acute hernia: frequency and outcome in 99
cases. Hernia. 2011;15(3):297–300.
4. Atila K, Guler S, Inal A, Sokmen S, Karademir S, Bora S. Prosthetic repair of acutely
incarcerated groin hernias: a prospective clinical observational cohort study.
Langenbecks Arch Surg. 2010;395:563–8.
5. Merriam-Webster. Webster’s Dictionary. Spring fi eld, MA; 2000
6. Shillcutt SD, Clarke MG, Kingsnorth AN. Cost-effectiveness of groin hernia surgery
in the Western Region of Ghana. Arch Surg. 2010;145:954–61.
7. Yang J, Papandria D, Rhee D, Perry H, Abdullah F. Low-cost mesh for inguinal hernia
repair in resource-limited settings. Hernia. 2011;15(5):485–9.
8. Stoppa R, Wantz GE, Munegato G, Pluchinotta A. Hernia Healers in illustrated history.
Villacoublay: Arnette; 1998.
9. Bassini E. Ueber de behandlung des listenbrunches. Arch F Klin Chir.
1890;40:429–76.
10. Halstead WS. Reporting of twelve cases of complete radical cure of hernia by
Halstead’s method of over two years standing. Silver wire sutures. Johns Hopkins
Hosp Bull V:98–99.
11. Babcock WW. The range of usefulness of commercial stainless steel cloths in general
and special forms of surgical practice. Ann West Med Surg. 1952;6:15–23.
12. Moloney GE, Grill WG, Barclay RC. Operations for hernia: technique of nylon darn.
Lancet. 1948;2:45–8.
13. Handley WS. A method for the radical cure of inguinal hernia (darn and stay-lace
method). Practitioner. 1918;100:466–71.
14. Read RC. Francis C. Usher, herniologist of the twentieth century. Hernia. 1999;3:167–71.
15. Lichtenstein IL, Shulman AG. Ambulatory outpatient hernia surgery. Including a new
concept, introducing tension-free repair. Int Surg. 1986;71:1–4.
16. Muldoon RL, Marchant K, Johnson DD, Yoder GG, Read RC, Hauer-Jensen M.
Lichtenstein vs anterior preperitoneal prosthetic mesh placement in open inguinal
hernia repair: a prospective randomized trial. Hernia. 2004;8(2):98–103.
17. Kurzer M, Belsham PA, Kark AE. The Lichtenstein repair. Surg Clin North Am.
1998;78:1025–46.
18. Estrin J, Lipton S, Block IR. The posterior approach to inguinal and femoral hernias.
Surg Gynecol Obstet. 1963;116:547–50.
26
L.C. Pickett
19. Tinkler LF. Preperitoneal prosthetic herniorrhaphy. Postgrad Med J. 1969;45:665–7.
20. Yoder G, Read RC, Barone GW, Hauer-Jensen M. Preperitoneal prosthetic placement
through the groin. Surg Clin North Am. 1993;73:545–55.
21. Shore IL, Lichtenstein JM. Simpli fi ed repair of femoral and recurrent inguinal hernias
by ‘plug’ technique. Am J Surg. 1974;28:439–44.
22. Rutkow AW, Robbins IM. The mesh plug hernioplasty. Surg Clin North Am.
1993;75:501–12.
23. Aganovic L, Ishioka KM, Hughes CF, Chu PK, Cosman BC. Plugoma: CT fi ndings
after prosthetic plug inguinal hernia repairs. J Am Coll Surg. 2010;211(4):481–4.
24. Tian MJ, Chen YF. Intraperitoneal migration of a mesh plug with a small intestinal
perforation: report of a case. Surg Today. 2010;40(6):566–8.
25. Gilbert A. Combined anterior and posterior inguinal hernia repair: intermediate
recurrence rates with three groups of surgeons. Hernia. 2004;8:203–7.
26. Mottin CC, Ramos RJ, Ramos MJ. Using the Prolene Hernia System (PHS) for
inguinal hernia repair. Rev Col Bras Cir. 2011;38(1):24–7.
27. Faraj D, Ruurda JP, Olsman JG, van Geffen HJ. Five-year results of inguinal hernia
treatment with the Prolene Hernia System in a regional training hospital. Hernia.
2010;14(2):155–8.
28. Sutalo N, Maricic A, Kozomara D, Kvesic A, Stalekar H, Trninic Z, Kuzman Z.
Comparison of results of surgical treatments of primary inguinal hernia with fl at
polypropylene mesh and three-dimensional prolene (PHS) mesh-one year follow up.
Coll Antropol. 2010;34 Suppl 1:29–33.
29. Nikkolo C, Lepner U, Murrus M, Vaasna T, Seepter H, Tikk T. Randomised clinical
trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty.
Hernia. 2010;14(3):253–8.
30. Smietanski M, Bury K, Smietanska IA, Owczuk R, Paradowski T. Five year results of
a randomized controlled multi-centre study comparing heavy-weight knitted versus
low-weight, non-woven polypropylene implants in Lichtenstein hernioplasty. Hernia.
2011;15(5):495–501.
31. Markar SR, Karthikesalingam A, Alam F, Tang TY, Walsh SR, Sadat U. Partially or
completely absorbable versus nonabsorbable mesh repair for inguinal hernia:
a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech.
2010;20(4):213–9.
32. Gao M, Han J, Tian J, Yang K. Vypro II mesh for inguinal hernia repair: a meta-
analysis of randomized controlled trials. Ann Surg. 2010;251(5):838–42.
33. Kapische M, Schultze H, Caliebe A. Self- fi xating mesh for the Lichtenstein procedure-a
prestudy. Arch Surg. 2010;395(4):317–22.
34. Torcivia A, Vons C, Barrat C, Dufour F, Champault G. In fl uence of mesh type on the
quality of early outcomes after inguinal hernia repair in ambulatory setting controlled
study: Glucamesh vs Polypropylene. Langenbecks Arch Surg. 2011;396(2):173–8.
35. Kilbe T, Hollinsky C, Walter I, Joachim A, Rulicke T. In fl uence of a new self-gripping
hernia mesh on male fertility in a rat model. Surg Endosc. 2010;24(2):455–61.
36. Arslani N, Patrlj L, Kopljar M, Rajkovic Z, Altarac S, Papes D, Stritof D. Advantages
of new materials in fascia transversalis reinforcement for inguinal hernia repair.
Hernia. 2010;14(6):617–21.
27
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_3,
© Springer Science+Business Media New York 2013
3. Prosthetic Choice in Laparoscopic
Inguinal Hernia Repair
Emily L. Albright and J. Scott Roth
Inguinal hernia repair is one of the most common procedures
performed by a general surgeon. The management of inguinal hernias
has undergone many changes in the last fi ve decades. The advent of
prosthetic materials has decreased the recurrence rate compared to
primary repair [ 1 ] . The age of laparoscopy has brought new techniques
with well-de fi ned bene fi ts including a reduction in pain, lower wound
infection rates, and a shortened return to normal activities [ 2– 4 ] . With all
these advances have come many choices for the practitioner today
regarding prosthetic materials that differ in terms of weight, burst
strength, material composition, and in fl ammatory response. This chapter
aims to examine the different prosthetics available and delineate their
bene fi ts and shortcomings, speci fi cally relating to laparoscopic inguinal
hernia repair.
Synthetic Overview
Prosthetic materials were developed to reinforce hernia repairs and
prevent recurrence. The three most common synthetic prosthetics used
today are polypropylene, polyester, and PTFE, and they were all
developed at roughly the same time. Polyester polymers were fi rst
introduced in the United States in 1946; in 1956, Wolstenholme described
the use of polyester to repair inguinal hernias [ 5 ] . Polypropylene is the
most commonly used prosthetic in the United States following its
introduction in 1958 by Usher [ 6 ] . At the time of its introduction, there
were many advantages over the metal meshes that were currently in use.
28
E.L. Albright and J.S. Roth
It had a high tensile strength, was less affected by infection, and was
in fi ltrated by connective tissue when implanted into an animal model.
Just 4 years after its introduction, polypropylene was being used by 20%
of surgeons for complicated hernia repair [
6 ] . Polytetra fl uoroethylene
(PTFE) was initially developed by DuPont in 1938 and began to be used
in hernia repair in the 1950s. In the 1960s, a process was developed to
expand PTFE to produce a uniform structure with improved mechanical
strength (ePTFE) [
6 ] . This ePTFE was used not only for abdominal wall
reconstruction but also for vascular grafts. When laparoscopic inguinal
hernia repair was developed, technology had already made multiple
alterations to the three basic polymers—polypropylene, polyester, and
PTFE. They each have separate chemical structures and handling
properties. It is these differences in texture and porosity that lead to
differences in tissue reaction.
Polypropylene
Polypropylene is a thermoplastic polymer consisting of an ethylene
with an attached methyl group (Fig. 3.1 ). It is hydrophobic, electrostatically
neutral, and resistant to signi fi cant biologic degradation. The biologic
reactivity of polypropylene depends on the weight, fi lament size, pore
size, and architecture, in addition to the individual host response. Not all
polypropylene prosthetics are equal as structure can alter outcome. In
one study comparing various polypropylene, they found that patients
with a mono fi lament polypropylene took signi fi cantly longer to return to
work, had higher pain scores, and more impairment in everyday activities
compared to patients that had a multi fi lament polypropylene [ 7 ] . By
utilizing knitted versus woven materials, the fl exibility can also be altered
[ 8 ] . Pore size is also variable between different manufacturers. Pores
should be at least 75–100 m m to prevent against infection [ 9 ] .
Current debate exists regarding the optimal density of polypropylene.
Normal intra-abdominal pressure ranges from 1.8 mmHg when supine up
to 171 mmHg when jumping [ 10 ] . Laboratory data indicates that a
prosthetic should withstand at least 16 N/cm strain to prevent disruption
based on normal physiologic forces [ 11 ] . Many of the original
polypropylene prosthetics provide much greater strength than this.
Heavyweight meshes were designed to provide maximal strength with
thick fi bers, small pores, and a high tensile strength. Prosthetic materials
have also been found to be inappropriately stiff when compared to the
29
3. Prosthetic Choice in Laparoscopic Inguinal Hernia Repair
normal elasticity of the abdominal wall [ 11 ] . Based on this, there has been
a move to decrease the density of polypropylene implanted to provide
adequate strength while reducing the amount of foreign material.
One outcome that is of particular interest is the effect of the use of
lightweight mesh has on postoperative pain. Proponents of lightweight
mesh cite less pain and less mesh sensation as bene fi ts. However, this has
not been universally seen in all studies. One study in particular compared
lightweight polypropylene mesh with a heavyweight polypropylene
mesh in patients undergoing laparoscopic bilateral inguinal hernia repair
[ 12 ] . Lightweight polypropylene was placed in one groin and heavyweight
in the contralateral groin. They found that patients could detect a
difference and reported less pain on the side with the lightweight
polypropylene. In contrast, a comparison of patients undergoing
laparoscopic inguinal hernia repair with either a lightweight or
heavyweight mesh was published just 1 year later. This study did not fi nd
a difference in pain or discomfort at 4- or 15-month follow-up between
lightweight and heavyweight prosthetics. They also did not show a
difference in awareness of the mesh or stiffness of the groin [ 13 ] . There
are many more studies comparing lightweight mesh to heavyweight
mesh. Some demonstrate an improvement in postoperative pain [ 14– 17 ] .
However, not all series show this difference [ 18 ] .
While long-term pain and pain in the early postoperative period are
important to consider when considering a prosthetics, long-term durability
and hernia recurrence are equally important. Many of the opponents to
lightweight prosthetics express concern for increasing recurrence. In one
study, at 12-month follow-up of open inguinal hernia repair, there was a
signi fi cant increase in recurrence in patients with a lightweight
polypropylene mesh compared to traditional polypropylene [ 16 ] . Multiple
other studies fail to demonstrate an increased recurrence rate [ 14, 15,
17 ] . When lightweight mesh is used speci fi cally for laparoscopic inguinal
hernia repair, no difference in hernia recurrence was identi fi ed [ 12, 13,
18 ] . Whether the concern for an increase in hernia recurrence is justi fi ed
remains to be seen as long-term follow-up continues.
Fig. 3.1. Polypropylene.