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62
C. Doerhoff
For surgeons who believed that heavyweight mesh was linked to
inguinodynia, Bard introduced the PerFix Light Plug in 2010 (Fig. 5.4 ).
Bard fashioned the macroporous PerFix Light Plug from polypropylene
mesh weighing 59 g/m
2
with a pore size of 0.48 mm
2
. The overlay
measures 5.8 cm × 14 cm. The original PerFix plug is made from
polypropylene, weighing 115 g/m
2
with a pore size of 0.4 mm
2
. Its
overlay is 4.6 cm by 8.9 cm.
Millikan Modi fi ed Mesh-Plug Hernioplasty
In 1997, Dr. Keith Millikan modi fi ed the PerFix plug hernioplasty
[ 32 ] . Millikan noted that Rutkow and Robbins positioned the fl uted
portion of the plug to the edge of the defect, causing the plug to protrude
further than necessary toward the abdominal cavity. Millikan inserted the
entire plug through the defect, but instead of suturing the fl uted edge to
the defect allowed the fl uted portion to lay much fl atter in the preperitoneal
space extending away from the defect. The plug was secured by its petals.
This method of fl attening the plug appeared to have several bene fi ts:
wider overlap of the defect and less protrusion of the tip toward the
abdominal cavity.
In 2003, Millikan reported results of 1,056 patients who underwent
primary unilateral herniorrhaphy. For type I and type II indirect hernias,
the inside petals of a large plug were sutured to the internal oblique
Fig. 5.4. For surgeons who believed that heavyweight mesh was linked to
inguinodynia, Bard introduced the PerFix Light Plug in 2010.
63
5. Technique: Plug and Patch
portion of the internal ring. For type III indirect and type IV and V direct
hernias, an extra-large plug was used. Petals were sutured to the conjoined
tendon, Cooper’s ligament, and the shelving edge of the inguinal
ligament. Mono fi lament permanent sutures were used for plug fi xation
for types III, IV, and V. The onlay mesh was placed around the cord and
the tails secured with a stitch. The mesh itself is not suture fi xated. At
1 year, recurrence rate was 0.1%. 95.9% of patients had returned to
normal activities by the third postoperative day. The incidence of
postoperative groin pain was only 0.5%. There were no reports of erosion
or migration.
Atrium ProLite Mesh and ProLoop
In 1997, Atrium provided the plug-patch surgeon another alternative.
The ProLite self-forming plug consists of three circular layers of ProLite
mesh made from polypropylene mesh weighing 85 g/m
2
(Fig. 5.5 ). The
three layers are welded at 3, 6, 9, and 12 o’clock. A central tab has been
added that can be grasped, facilitating insertion. The circular mesh forms
a conical plug as it is introduced through a hernia defect. Dr. Goldstein
recommended suturing the plug in place with interrupted mono fi lament
sutures [ 33, 34 ] .
In 2001, Atrium introduced the ProLoop plug (Fig. 5.6 ). ProLoop is
a preformed polypropylene plug that has 30% less polypropylene than
the PerFix plug. The ProLoop plug has multiple protruding mono fi lament
loops that reportedly keep the plug from deforming as it is inserted
through the defect. The loops reduce contact of the plug with surrounding
tissue—in hopes of reducing mesh/plug shrinkage, hardening, and
contracture. The intent is to decrease the incidence of long-term groin
pain. Two overlay patches are available: One is an oval pointed patch
measuring 4.6 cm × 8.9 cm with a lateral slit, and the other is a blunted
5.0 cm × 8.9 cm overlay with a caudal slit.
A study by Sanders [ 35 ] randomized 239 patients between Lichtenstein
repair, PerFix plug and patch, and ProLoop plug-and-patch repair of
primary inguinal hernias. No signi fi cant statistical differences in
recurrence rates, complications, or inguinodynia were noted. Recurrence
rate for the ProLoop plug was 2.1%, for the PerFix plug 1%, and 2% for
Lichtenstein repair. All procedures were performed under local anesthesia
with 100 mg diclofenac suppository given 1 h preoperatively. Operative
times were comparable: 32.9 min for the ProLoop plug, 31.1 min for the
64
C. Doerhoff
PerFix plug, and 32.8 min for the Lichtenstein tension-free mesh repair.
By comparison to the Rutkow study of 2,060 patients that had a 1%
recurrence for primary hernia repair and 2% for recurrent hernia repair at
6 years, Sanders suggested that surgery in a highly specialized center for
inguinal hernia repair by higher volume surgeons would have a lower
recurrence rate.
Ethicon Ultrapro Plug and Patch
In 2007, Ethicon introduced a double-sided low-pro fi le plug that
works well for hernia defects that are 3 cm and smaller. The plug looks
like a circular plate (anchor) connected to a shallow bowl (rim) (Fig. 5.7 ).
For a large plug, the preperitoneal portion or “anchor,” measures 5 cm in
Fig. 5.5. The Atrium
ProLite self-forming plug
consists of three circular
layers of ProLite mesh made
from polypropylene mesh
weighing 85 g/m
2
.
Fig. 5.6. In 2001, Atrium
introduced the ProLoop
plug.
65
5. Technique: Plug and Patch
diameter. Once inserted, the anchor lies fl at in the preperitoneal space.
The fl at and fl exible anchor is unlikely to erode through peritoneum. The
inguinal fl oor portion or “rim” measures 5 cm in diameter. The rim lies
on top of the inguinal fl oor. For indirect hernias, if a wedge of the rim is
removed, it keeps the rim from lying on top of the cord and tilting the
position of the rim.
The plug is 25% PROLENE
*
(polypropylene) and 75% MONOCRYL
*
(poliglecaprone 25). The prolene portion of the plug is lightweight mesh
28 g/m
2
. The weight of the large plug before absorption is 2.82 g. The
absorbable component improves handling characteristics and absorbs in
120 days. The weight of the large plug postabsorption is only 0.26 g.
The overlay patch is 25% ULTRAPRO
*
(31 g/m² and intertwined
with MONOCRYL
*
) and measures 7.5 cm × 12 cm. Usually, the patch
can be placed without trimming. A slit for the cord can be fashioned
lateral or caudal.
Three or four absorbable sutures are used to “position” the overlay
patch. The fi rst stitch attaches the patch to the rectus fascia, assuring a
1.5–2 cm overlap medially. Lateral to that, two of the stitches will
incorporate the overlay patch, the rim of the plug, and together are af fi xed
to the iliopubic tract (Fig. 5.8 ).
Holzheimer, RG reported about early outcomes for outpatient inguinal
hernia repair among 16 specialized hernia centers in Germany. A register
was introduced on October 1, 2009, with an online hernia database (www.
qs-leistenhernie.de) [ 36 ] . By poster at the International Ambulatory
Surgery conference, Koch reported early results of 1,322 cases. 57% had
UHS (UltraPro Hernia System) and 43% UPP. At 12 weeks, the recurrence
rate was 0.7%, inguinal pain 2.3%, and testicular pain 0.7%. Their early
conclusion was that the “incidence of pain” was comparable or less than
other repairs. The ongoing database will provide continuous documentation
and quality control in hernia surgery. Since introduction of UPP, more
than 200,000 procedures have been performed worldwide.
Fig. 5.7. In 2007, Ethicon
introduced a double-sided
low-pro fi le plug, the Ethicon
Ultrapro Plug, that works
well for hernia defects that
are 3 cm and smaller.
66
C. Doerhoff
Gore Bioabsorbable Hernia Plug
In 2004, W. L. Gore introduced a synthetic, completely absorbable
hernia plug (Fig. 5.9 ). It is made of 67% polyglycolic acid (PGA) and
33% trimethylene carbonate (TMC)—the same material composition as
Maxon suture. After implantation, the plug retains 70% tensile strength
at 3 weeks, 0% tensile strength at 6 weeks, and is completely absorbed
by 6 months. Following repair with the Gore plug and overlay patch, four
studies show an impressively low incidence of long-term groin pain
[
37– 40 ] . For implantation, the plug is placed entirely within the
preperitoneal space and allowed to lay as fl at as possible. The porous
surface of the material “sticks” to surrounding tissue. The plug requires
Fig. 5.8. Three or four
absorbable sutures are used
to “position” the overlay
patch of the Ultrapro Plug.
The fi rst stitch attaches the
patch to the rectus fascia
assuring a 1.5–2 cm overlap
medially. Lateral to that, two
of the stitches will
incorporate the overlay
patch, the rim of the plug,
and together are af fi xed to
the iliopubic tract.
Fig. 5.9. In 2004, Gore
introduced the Gore
Bioabsorbable Hernia Plug .
67
5. Technique: Plug and Patch
no fi xation. Since the plug completely absorbs, there is absolutely no risk
of migration or erosion. The plug keeps the hernia reduced as the overlay
mesh incorporates. In doing so, less fi xation is needed for the overlay
patch. For the overlay patch, good selections are macroporous
polypropylene, hydrophilic polyester, or self-adhesing polyester.
Lessons Learned and Opinions
The 3D plug and patches available to the surgeon allow the surgeon
to tailor the plug and patch to best fi t the needs for initial inguinal
hernia repair. Patients with a defect of 3 cm or smaller are excellent
candidates for plug-and-patch repair. Poor candidates for plug and
patch are patients with giant hernias, large recurrent hernias, multiply
recurrent hernias, and obese patients where subcutaneous fat is greater
than 5–6 cm.
LeBlanc stated, “Simplicity should not be confused with complacency.”
Some are quick to correlate the plug with pain. A surgeon should understand
the plug-and-patch repair in its entirety. Components of the procedure are
a combination of mesh and technique. Inguinodynia seemingly must come
from one of four sources: Dissection, the plug, overlay patch, or fi xation.
It is a surgeon’s responsibility/obligation to properly identify and not injure
nerves. However, if a nerve interferes with fl at placement of the overlay,
the nerve should be transected and ligated. Whatever plug material is used,
its preperitoneal deployment should be larger than the defect it traverses.
Cone-shaped mesh plugs require suture fi xation. For cone mesh plugs,
migration might be a concern. A single nonabsorbable loose stitch between
the overlay patch and plug should prevent any risk of plug migration.
When covering the myopectineal ori fi ce, the bigger the patch, the better.
The overlay patch should extend 1.5–2 cm medial to the pubis and 3–4 cm
lateral to the internal ring. Since the plug reduces the hernia immediately
with implantation, the overlay need only be positioned correctly—not
fi xated. Surgeons have the option of using loose stitches, fi brin sealant, or
nothing at all.
Plug and patch has a short learning curve and a proven track record
for low recurrence. As a result of modi fi cations of plug-and-patch
materials and techniques, this durable procedure has culminated in fewer
and fewer complications with a decreasing incidence of inguinodynia.
The plug-patch will remain a popular choice for inguinal hernia repair
for years to come.
68
C. Doerhoff
References
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hernias. Arch Surg. 1990;125:265–7.
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14. Rutkow IM, Robbins AW. The mesh plug technique for recurrent groin herniorrhaphy:
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15. Goyal S, Abbasakoor F, Stephenson BM. Experience with the preperitoneal ‘plug and
patch’ inguinal hernia repair. Br J Surg. 1999;86:1284–5.
16. Bringman S, Ramel S, Nyberg B, Anderberg B. Introduction of herniorrhaphy with
mesh plug and patch. Eur J Surg. 2000;166:310–2.
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primary and recurrent inguinal hernias-a prospective study. Surg Technol Int.
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18. Huang CS, Huang CC, Lien HH. Prolene hernia system compared with mesh plug
technique: a prospective study of short- to mid-term outcomes in primary groin hernia
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69
5. Technique: Plug and Patch
19. van Nienhuijis SW, Oort I, Keemers-Gels ME, Strobbe JA, Rosman C. Randomized
clinical trial comparing the prolene hernia system, mesh plug repair and Lichtenstein
method for open inguinal hernia repair. Br J Surg. 2005;92:33–8.
20. Dalenback J, Anderson C, Anesten B, Bjorck S, Eklund S, Magnusson O, Rimback G,
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for primary inguinal hernia repair: 3 year outcome of a prospective randomized
controlled trial. Hernia. 2009;13:121–9.
21. Cristaldi M, Pisacreta M, Elli M, Valgo GL, Danelli PG, Sampietro GM, Taschieri
AM. Femoro-popliteal by-pass occlusion following mesh-plug for prevascular femoral
hernia repair. Hernia. 1997;1:197–9.
22. Dieter RA. Mesh plug migration into scrotum: a new complication of hernia repair. Int
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23. Chuback JA, Singh RS, Sills C, Dick LS. Small bowel obstruction resulting from mesh
plug migration after open inguinal hernia repair. Surgery. 2000;127:475–6.
24. Tokunaga Y, Tokuka A, Ohsumi K. Sigmoid colon diverticulosis adherent to mesh
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25. Moorman ML, Price PD. Migrating mesh plug: complication of a well established
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hernioplasty: a review of the literature. Am Surg. 2007;73:207–9.
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70
C. Doerhoff
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71
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_6,
© Springer Science+Business Media New York 2013
6. Technique: Laparoscopic TEP
Guy Voeller and Benjamin S. Powell
Indications
Open inguinal hernia repair is one of the most common surgical
procedures performed. Laparoscopic repair of inguinal hernia gives
excellent results when performed by surgeons expert in the technique
and is estimated to make up between 15 and 30% of inguinal hernia
repairs in the USA. We believe, however, a good herniologist should
have multiple options to offer his/her patients. Most hernia repair
methods, both open and laparoscopic, have literature supporting a very
low recurrence rate when using mesh. The majority of data does show
that the laparoscopic repair leads to less acute pain and quicker recovery,
but most importantly, when done correctly, the risk of chronic pain is
lower for the laparoscopic repair. Most patients referred for repair are
symptomatic, and we advocate fi xing all symptomatic inguinal hernias if
the patient can tolerate surgery. If the patient is asymptomatic, then we
will discuss watchful waiting realizing that many will eventually become
symptomatic. We perform both laparoscopic and open repairs for inguinal
hernia in the range of 250 per year. For a surgeon to become comfortable
with the laparoscopic repair, it requires a signi fi cant amount of repetition
to become pro fi cient enough to have almost no morbidity and to have
low long-term recurrence rates. We believe TEP inguinal hernia repair
can be used in the following instances:
1. Unilateral hernias: Some believe only recurrent or bilateral hernias
should be done with the laparoscope. We disagree. We believe that
the only way to become pro fi cient at lap repair is to learn the
technique on the unilateral, virgin inguinal hernia. The recurrent
hernia can have scar tissue that distorts anatomy and makes the
case more dif fi cult. Bilateral repairs will take a long time until the
learning curve is shortened, and thus, it can be very frustrating for