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30
E.L. Albright and J.S. Roth
Polyester
Polyester is a category of polymers that contain an ester in the main
chain (Fig. 3.2 ) and has many applications in daily life, from clothing to
jet engines. While polypropylene is used extensively for hernia repair,
polyester is also commonly used. Multiple studies exist comparing these
two materials. One study compared patients that had previously
undergone laparoscopic inguinal hernia repair either with polypropylene
or polyester prosthetic [ 19 ] . A phone survey was conducted on patients
with a minimum of a 1-year follow-up with questions focused on pain,
perception of the mesh, return to work, and satisfaction. In this study,
there was an increase in chronic inguinal pain, feeling of a lump, and
feeling the mesh in the polypropylene group compared to the polyester
group. There was no difference in recurrence rate. Another study citing
the bene fi ts of polyester prosthetics was in a series of 337 patients
undergoing laparoscopic inguinal hernia repair with polyester mesh [ 20 ] .
After a mean follow-up of 11 months, there were no recurrences, no
mesh infections, and chronic pain in three patients. Despite multiple
studies, there exists no clear bene fi t of polypropylene versus polyester,
and choice remains based on surgeon preference.
One concern regarding the use of polyester prosthetics is the
degradation that occurs over time. In one study examining explanted
polyester vascular grafts, there was hydrolytic degradation of the grafts
with increasing time implanted [ 21 ] . Further analysis showed that
polyester grafts lost 31.4% of their burst strength at 10 years and 100%
in 25–39 years. The earliest graft failure in this study was after 19 years.
If the same is true of polyester grafts for inguinal hernia repair, this
clearly would not be a problem for an inguinal hernia repair in a 90-year-
old patient but would affect an 18-year-old patient.
Polytetra fl uoroethylene
Polytetra fl uoroethylene is a synthetic polymer of tetra fl uoroethylene
consisting of carbons and fl uorines with multiple applications (Fig. 3.3 ).
It is most well-known by the brand name Te fl on and can be found as a
Fig. 3.2. Polyester.
31
3. Prosthetic Choice in Laparoscopic Inguinal Hernia Repair
nonstick coating for pans, a lubricant in gears, and a roo fi ng material. In
the medical profession, PTFE is used for hernia repair as well as in
vascular grafts.
With the increasing usage of polypropylene and polyester prosthetics,
PTFE is not used as frequently for inguinal hernia repair. However, when
laparoscopic techniques were fi rst introduced for inguinal hernia repair,
PTFE prosthetics played a key role in intraperitoneal onlay mesh repair
(IPOM). Results of a prospective study looking at the ePTFE peritoneal
onlay laparoscopic inguinal hernioplasty were published in 1996 [ 22 ] .
Over a period of 2.8 years, 351 patients underwent repair. They found
that on average patients only required 24 h of analgesics, returned to
work in 7.7 days for unilateral repairs, and returned to work in 10.1 days
for bilateral repairs. There were 13 patients in the series with persistent
neuralgia and 17 patients with recurrences (3.8%). Another prospective
trial comparing IPOM with ePTFE to an open repair reported an even
higher recurrence rate of 43% [ 23 ] . It is likely that these recurrence rates
contributed to the decline in the use of PTFE for laparoscopic inguinal
hernia repair.
In addition to the concern for hernia recurrence is the risk of infection
associated with the use of PTFE. When the pore size of a prosthetic is
less than 10 m m, macrophages and neutrophils are too large to enter and
cannot eliminate bacteria [ 24 ] . When PTFE does become colonized,
removal is mandatory in order to manage the infection. The small pore
size of PTFE also impacts the formation of postoperative seromas. There
is insuf fi cient molecular permeability for fi brinous and proteinaceous
materials to be cleared [ 24 ] .
Barrier Prosthetics and Composite Prosthetics
In addition to prosthetics that are pure synthetic material or pure
biologic material, there are a variety of prosthetics that combine various
materials. One example is beta-glucan-coated polypropylene prosthetics.
Fig. 3.3. Polytetra fl uoroethylene.
32
E.L. Albright and J.S. Roth
Beta-glucan is a plant product that is used to promote healing and also
has an immunomodulatory effect. In published series, using beta-glucan-
coated polypropylene resulted in a decrease in the incidence of chronic
pain compared to polypropylene alone and a low incidence of recurrence
at 2 years (1.9%) [ 25, 26 ] .
Other prosthetics combine permanent material with a barrier layer to
prevent adhesions to one side. This type of prosthetic is particularly useful
if the peritoneum has been violated and is not available to separate the
prosthetic from intra-abdominal contents. Barriers can be placed on one
side or both sides of the mesh. Typically, the barrier layer is designed to
allow adequate time for a neo-peritoneum to develop prior to their
degradation. The previously mentioned prosthetics, including
polypropylene, polyester, lightweight and heavyweight, all have an
alternative with a barrier layer. The majority of the data regarding
prosthetics with a barrier layer focuses on their use in ventral hernia repair
where they are more likely to be intact with intra-abdominal contents.
In an effort to decrease the amount of permanent foreign material,
composite materials have been developed that combine polypropylene
with absorbable materials. One example is a composite mesh of
polypropylene with polyglactine. While the polypropylene is permanent,
the polyglactine fi bers are resorbed in approximately 60 days. In studies
comparing polyglactine-polypropylene composite with polypropylene
alone in open inguinal hernia repair, there was no difference in
perioperative complications, postoperative pain, or recurrence [ 27– 29 ] .
These results were similar when polyglactine-polypropylene was
compared to polypropylene alone in laparoscopic inguinal hernia repair
with no difference in pain, return to normal daily activities, and recurrence
[ 7, 30– 32 ] . Polyglactine-polypropylene is smoother than polypropylene
and thus has different handling characteristics. However, this does not
translate into a difference in operating times or subjective assessment of
dif fi culty of mesh placement [ 31 ] .
In addition to polyglactine, there are other alternatives to an absorbable
component combined with polypropylene. One such example is
polyglecaprone 25. When polypropylene was compared to a
polyglecaprone 25-polypropylene composite in an animal model, there
was a decrease in the in fl ammatory and fi brotic reaction; however, it was
not statistically signi fi cant [ 33 ] . As we search for the optimal mesh, there
are likely to be more combined prosthetics developed in addition to those
mentioned here.
Prosthetics have also been altered to decrease the need for fi xation.
One example is a polypropylene mesh with a nitinol frame [ 34 ] . Another
33
3. Prosthetic Choice in Laparoscopic Inguinal Hernia Repair
example is a titanium-coated mono fi lament polypropylene mesh that has
been shown to have a recurrence rate of 0.4%, persistent inguinal pain in
3.8%, and groin stiffness in 1.7% after a 7-week follow-up [ 35 ] .
As humans are two-dimensional structures, there has been an effort to
manufacture prosthetics that conform to the contours of the human body
and avoid the need for fi xation. One study looking at mesh fi xation showed
it to be associated with a longer hospital stay and more narcotic analgesia
requirements [ 36 ] . In a retrospective review of 212 transabdominal
pre-peritoneal herniaplasties using a three-dimensional mesh, 94% of
patients had returned to normal activities by 3 weeks. Mesh fi xation was
used in 19% of the cases in this series. They did not fi nd that bilateral
repair or fi xation altered recovery. Only four patients in the series had
minor pain or numbness. With a mean follow-up of 23 months, there was
only one recurrence. They concluded that an anatomically contoured
prosthetic had minimal risk of neuropathy, had a low recurrence rate, and
often does not require fi xation [ 37 ] . A second series looking at an
anatomically contoured prosthetic in 390 patients had similar results [ 38 ] .
At 2 years, there were three recurrences, and 43 patients reported minor
parietal pain.
Biologic Prosthetics
Biologic prosthetics are designed as either allografts (from human
tissue) or as xenografts (from animal tissue). Available animal products are
porcine and bovine. In addition to what species a biologic material is from,
they also differ on what part is harvested, including dermis, small intestinal
submucosa, and pericardium. The role of biologic materials in any hernia
repair has mainly been limited to infected surgical fi elds. For laparoscopic
inguinal hernia repair, there exists limited data examining the role of biologic
prosthetics, and research examining their role is ongoing. Recently, the
design of a study comparing the use of lightweight polypropylene to cross-
linked porcine dermis was published [ 39 ] . Currently, 172 men are enrolled
in the study, and data are being collected. Other studies have focused on the
feasibility of using biologic prosthetics for inguinal hernia repair [ 40– 42 ] .
There are concerns regarding the use of biologic prosthetics for
laparoscopic inguinal hernia repair, namely, the risk of recurrence. For
laparoscopic inguinal hernia repair, all prosthetics are placed in a bridging
manner. In incisional hernia repair, when biologic prosthetics are used in
a bridging manner, there is an 80% recurrence rate [ 43 ] . In this study,
34
E.L. Albright and J.S. Roth
there is no comment on size of hernia defect, but generally incisional
hernias have a larger defect size than inguinal hernias. The risk of
recurrence with a bridging biologic prosthetic in laparoscopic inguinal
hernia repair would not be expected to be as high as in incisional hernia
repair but still expected higher than a synthetic material. In a prospective
series of 11 patients undergoing laparoscopic inguinal hernia repair using
a biologic prosthetic, there was one recurrence (9%) with a mean
follow-up of 14.5 months [ 40 ] .
Advantages of biologic materials for inguinal hernia repair are mainly
focused on postoperative pain. In a randomized trial comparing
polypropylene to a biologic prosthetic derived from small intestine
submucosa, while there was no difference to the incidence in postsurgical
pain, there was a signi fi cant decrease in the degree of pain and a lower
proportion of patients that took pain medications [ 44 ] .
Summary
There exists a multitude of options available to surgeons today. While
there are multiple prosthetics that have proven their longevity over the
years, multiple new prosthetics enter the market each year. The choice of
prosthetic used for laparoscopic hernia repair must be tailored to the
individual patient. Clearly there is not one prosthetic that fi ts all patients
or situations.
References
1. Vrijland WW, van den Tol MP, Luijendijk RW, Hop WCJ, et al. Randomized clinical
trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg.
2002;89:293–7.
2. Johansson B, Hallerback B, Glise H, Anesten B, et al. Laparoscopic mesh versus
open preperitoneal mesh versus conventional technique for inguinal hernia repair: a
randomized multicenter trial (SCUR hernia repair study). Ann Surg.
1999;230:225–31.
3. Karthikesalingam A, Markar SR, Holt PJE, Praseedom RK. Meta-analysis of
randomized controlled trials comparing laparoscopic with open mesh repair of
recurrent inguinal hernia. Br J Surg. 2010;97:4–11.
4. Langeveld HR, van’t Reit M, Weidema WF, Stassen LP, et al. Total extraperitoneal
inguinal hernia repair compared with Lichtenstein (the LEVEL-Trial). Ann Surg.
2010;251:819–24.
35
3. Prosthetic Choice in Laparoscopic Inguinal Hernia Repair
5. Wolstenholme JT. Use of commercial Dacron fabric in the repair of inguinal hernias
and abdominal wall defects. Arch Surg. 1956;73:1004–8.
6. DeBord JR. The historical development of prosthetics in hernia surgery. Surg Clin
North Am. 1998;78:973–1006.
7. Langenbach MR, Schmidt J, Zirngibl H. Comparison of biomaterials: three meshes
and TAPP for inguinal hernia. Surg Endosc. 2006;20:1511–7.
8. Cobb WS, Peindl RM, Zerey M, Carbonell AM, Heniford BT. Mesh terminology
101. Hernia. 2009;13:1–6.
9. Weyhe D, Belyaev O, Muller C, Meurer K, Bauer KH, et al. Improving outcomes in
hernia repair by the use of light meshes – a comparison of different implant
constructions based on a critical appraisal of the literature. World J Surg.
2007;31:234–44.
10. Cobb WS, Burns JM, Kercher KW, Matthews BD, et al. Normal intraabdominal
pressure in healthy adults. J Surg Res. 2005;129:231–5.
11. Junge K, Klinge U, Prescher A, Giboni P, et al. Elasticity of the anterior abdominal
wall and impact for reparation of incisional hernias using mesh implants. Hernia.
2001;5:113–8.
12. Agarwal BB, Agarwal KA, Mahajan KC. Prospective double-blind randomized
controlled study comparing heavy- and lightweight polypropylene mesh in totally
extraperitoneal repair of inguinal hernia: early results. Surg Endosc. 2009;23:242–7.
13. Khan LR, Liong S, de Beaux AC, Kumar S, Nixon SJ. Lightweight mesh improves
functional outcome in laparoscopic totally extra-peritoneal inguinal hernia repair.
Hernia. 2010;14:39–45.
14. Bringman S, Wollert S, Osterberg J, Smedberg S, et al. Three-year results of a
randomized clinical trial of lightweight or standard polypropylene mesh in
Lichtenstein repair of primary inguinal hernia. Br J Surg. 2006;93:1056–9.
15. Nikkolo C, Lepner U, Murruste M, Vaasna T, Seepter H, Tikk T. Randomized clinical
trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty.
Hernia. 2010;14:253–8.
16. O’Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, et al. Randomized clinical trial
assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal
hernia repair. Br J Surg. 2005;92:166–70.
17. Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of
lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg.
2004;91:44–8.
18. Khan LR, Kumar S, Nixon SJ. Early results for new lightweight mesh in laparoscopic
totally extra-peritoneal inguinal hernia repair. Hernia. 2006;10:303–8.
19. Shah BC, Goede MR, Bayer R, Buettner SL, et al. Does type of mesh used have an
impact on outcomes in laparoscopic inguinal hernia? Am J Surg. 2009;198:759–64.
20. Ramshaw B, Abiad F, Voeller G, Wilson R, Mason E. Polyester (Parietex) mesh for
total extraperitoneal laparoscopic inguinal hernia repair. Surg Endosc.
2003;17:498–501.
21. Riepe G, Loos J, Imig H, Schroder A, et al. Long-term in vivo alterations of polyester
vascular grafts in humans. Eur J Vasc Endovasc Surg. 1997;13:540–8.
36
E.L. Albright and J.S. Roth
22. Toy FK, Moskowitz M, Smott RT, Pleatman M, et al. Results of a prospective
multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal
hernioplasty. J Laparoendosc Surg. 1996;6:375–86.
23. Kingsley D, Vogt DM, Nelson T, Curet MJ, Pitcher DE. Laparoscopic intraperitoneal
onlay inguinal herniorrhaphy. Am J Surg. 1998;176:548–53.
24. Amid PK. Classi fi cation of biomaterials and their related complications in abdominal
wall hernia surgery. Hernia. 1997;1:15–21.
25. Champault G, Barrat C. Inguinal hernia repair with beta glucan coated mesh: results
at two-year follow up. Hernia. 2005;9:125–30.
26. Champault G, Bernard C, Rizk N, Polliand C. Inguinal hernia repair: the choice of
prosthesis outweighs that of technique. Hernia. 2007;11:125–8.
27. Bringman S, Heikkinen TJ, Wollert S, Osterberg J, et al. Early results of a single-
blinded, randomized, controlled Internet-based multicenter trial comparing Prolene
and Vypro II mesh in Lichtenstein hernioplasty. Hernia. 2004;8:127–34.
28. Bringman S, Wollert S, Osterberg J, Smedberg S, et al. One year results of
randomized controlled multi-centre study comparing Prolene and Vypro II-mesh in
Lichtenstein hernioplasty. Hernia. 2005;9:223–7.
29. Khan N, Bangash A, Sadiq M, Hadi AU, Hamid H. Polyglactine/polypropylene mesh
vs. propylene mesh: Is there a need fo newer prosthesis in inguinal hernia? Saudi J.
Gastroenterology. 2010;16:8–13.
30. Bringman S, Wollert S, Osterberg J, Heikkinen T. Early results of a randomized
multicenter trial comparing Prolene and VyproII mesh in bilateral endoscopic
extraperitoneal hernioplasty (TEP). Surg Endosc. 2005;19:536–40.
31. Heikkinen T, Wollert S, Osterberg J, Smedberg S, Bringman S. Early results of a
randomized trial comparing Prolene and VyproII-mesh in endoscopic extraperitoneal
inguinal hernia repair (TEP) of recurrent unilateral hernias. Hernia. 2006;10:34–40.
32. Junge K, Rosch R, Krones CJ, Klinge U, Mertens PR, et al. In fl uence of
polyglecaprone 25 (Monocryl) supplementation on the biocompatibility of a
polypropylene mesh for hernia repair. Hernia. 2005;9:212–7.
33. Torres-Villalobos G, Sorcic L, Ruth GR, Andrade R, et al. Evaluation of the rebound
hernia repair device for laparoscopic hernia repair. JSLS. 2010;14:95–102.
34. Tamme C, Garde N, Klingler A, Hampe C, Wunder R, Kockerling F. Totally
extraperitoneal inguinal hernioplasty with titanium-coated lightweight polypropylene
mesh. Surg Endosc. 2005;19:1125–9.
35. Koch CA, Greenlee SM, Larsan DR, Harrington JR, Farley DR. Randomized
prospective study of totally extraperitoneal inguinal hernia repair: Fixation versus no
fi xation of mesh. JSLS. 2006;10:457–60.
36. Bell RCW, Price JG. Laparoscopic inguinal hernia repair using an anatomically
contoured three-dimensional mesh. Surg Endosc. 2003;17:1784–8.
37. Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis without fi xation.
Le Journal de Celio-Chirurgie. 1998;28:64–8.
38. Bellows CF, Shadduck PP, Helton WS, Fitzgibbons RJ. The design of an Industry-
sponsored randomized controlled trial to compare synthetic mesh versus biologic
mesh for inguinal hernia repair. Hernia. 2011;15:325–32.
37
3. Prosthetic Choice in Laparoscopic Inguinal Hernia Repair
39. Agresta F, Bedin N. Transabdominal laparoscopic inguinal hernia repair: is there a
place for biologic mesh? Hernia. 2008;12:609–12.
40. Ansaloni L, Catena F, Gagliardi S, Gazzotti F, et al. Hernia repair with porcine
small-intestinal submucosa. Hernia. 2007;11:321–6.
41. Fine A. Laparoscopic repair of inguinal hernia using Surgisis mesh and fi brin sealant.
JSLS. 2006;10:461–5.
42. Jin J, Rosen MJ, Blatnik J, McGee MF, et al. Use of acellular dermal matrix for
complicated ventral hernia repair: does technique affect outcome. J Am Coll Surg.
2007;205:654–60.
43. Ansaloni L, Catena F, Coccolini F, Gazzotti F, et al. Inguinal hernia repair with
porcine small intestine submucosa: 3-year follow-up results of a randomized
controlled trial of Lichtenstein’s repair with polypropylene mesh versus Surgisis
Inguinal Hernia Matrix. Am J Surg. 2009;198:303–12.
Part II
Techniques for Inguinal Hernia Repair
41
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_4,
© Springer Science+Business Media New York 2013
4. Technique: Lichtenstein
David C. Chen and Parviz K. Amid
Lichtenstein Tension-Free Operation for the Repair
of Unilateral and Bilateral Inguinal Hernias
Lichtenstein “tension-free” hernia repair, a term coined by our group,
began as a protocol-driven project in 1985 and evolved to its current
standard procedure in the late 1980s [ 1, 2 ] . Standard tissue repair to close
the abdominal wall defect had changed little in the hundred years since
Bassini introduced the modern era of herniorrhaphy in 1887. Several
modi fi cations of tissue repair introduced by Shouldice, McVay, and
others helped to re fi ne this method, but overall recurrence rates remained
in the range of 10–15%. In the “tension-free” method, synthetic mesh is
placed between the external and internal oblique layers eliminating the
need to pull the tissues together under tension. The advantages of this
method have been extensively de fi ned and resulted in a paradigm shift in
hernia repair with “tension-free” repair accepted as the standard of care.
In the 1990s, variations on this concept of “tension-free” repair led to
several different preperitoneal open and laparoscopic approaches. Some
have demonstrated relative equivalency, but none have proven to be
superior. While “tension-free” repair using mesh has markedly reduced
the recurrence rate, chronic pain after all varieties of both open and
laparoscopic hernia repair is a continuing concern. This chapter describes
the sequential steps of the Lichtenstein “tension-free” operation for the
repair of unilateral and bilateral [ 3 ] inguinal hernias. Special attention is
given to groin neuroanatomy and correct nerve handling to minimizing
the risk of chronic postoperative pain.