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The Role of Laparoscopy in the Repair of Pediatric Inguinal Hernias
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 7
MANAGEMENT OF ADULT INGUINAL HERNIAS:
THE OPEN PREPERITONEAL APPROACHES
Junsheng Li
*
and Zhenling Ji
Center of Hernia Repair, Department of General Surgery,
Affiliated Zhongda Hospital, Southeast University, Nanjing, P. R. China
ABSTRACT
Adult inguinal hernia is a common surgical problem. Many procedures have been
used in the repair of this disease, including open and laparoscopic techniques. Among
them, open preperitoneal approaches have the advantages of putting the mesh in the
preperitoneal space, being performed even under local anesthesia, and avoiding the need
for general anesthesia. Several different types of open preperitoneal procedures have been
introduced, with some differences in the techniques and the types of meshes used, such
as, the Stoppa and Wantz techniques, the Kugel patch, the modified Kugel patch repairs,
the polypropylene hernia system (PHS), and the Nyhus techniques. In this chapter, we
review the history of open preperitoneal repair and the applied surgical anatomy of the
preperitoneal space and several commonly used open preperitoneal procedures. We also
report our own experience and results of performing this preperitoneal repair technique,
especially of the Modified Kugel technique and PHS. Finally, the comparative results of
the open preperitoneal repair technique, as compared with other techniques and the
results of meta-analysis as compared with Lichtenstein are presented.
Keywords: Inguinal hernia repair, treatment, open procedure, preperitoneal, Kugel, PHS
*
Corresponding author: Email:Lijunshenghd@126.com.
Junsheng Li and Zhenling Ji
96
INTRODUCTION
Brief History of Open Preperitoneal Approaches in Groin Hernia Repair
Preperitoneal approaches are becoming more and more popular for the repair of primary,
bilateral, recurrent, inguinal, and femoral hernias. The preperitoneal approach to the groin
began a century ago with a new operation to manage aneurysm of the external iliac artery.
Crucial steps eventually resulted in the extraperitoneal groin hernia repair and the
preperitoneal approaches becoming preferred techniques [Read, 2011]. This has led to a
greater appreciation for the mechanical advantage of a posterior or preperitoneal hernia repair
[Rives, 1967; Gilbert, 1992]. This applies to both inguinal and ventral hernias [Knight and
Fenoglio, 2002]. By applying the prosthesis to the same side of the abdominal wall as the
higher pressure, the intra-abdominal pressure actually contributes to the integrity of the repair
instead of being the constant enemy, as it is with an anterior repair.
In contrast to the anterior mesh repair, which typically requires careful fixation, the
posterior approach involves placement of a large piece of mesh in the preperitoneal space
covering the whole myopectinal orifice of Fruchaud with wide overlap of all possible hernia
defects, and works according to the principle of Pascal [Stoppa and Quintyn, 1969; Stoppa et
al., 1984]. The posterior repair allows the pressure of the abdomen to keep the mesh pressed
against the defect and, due to the overlap of mesh around the defect, recurrence is prevented.
According to this mechanism, it is understandable that the posterior repair is perfectly tension
free, even under physical stress, thus there is need for very little or no fixation.
The procedure of anterior prosthetic preperitoneal repair was first introduced by Usher et
al. [1958]. Using polyethylene mesh (later polypropylene), the mesh was not slit since the
spermatic cord was lateralized. Rives carried out both anterior and posterior preperitoneal
prosthetic repairs of groin hernias using polyester mesh in France [Rives, 1967].
Nyhus became interested in the posterior approach to inguinal hernia when he visited the
University of Southern California Department of Surgery in 1954. Instead of taking the
Cheatle-Henry posterior approach via a midline, Nyhus applied a transverse incision lateral to
the rectus [Nyhus, 2003].
Beginning in 1969, the outstanding French herniologist, Rene Stoppa, championed
Usher’s concepts regarding prosthetic repair by inserting large overlapping prostheses
preperitoneally from the midline to posterior using the Cheatle-Henry approach so as to cover
Fruchaud’smyopectineal orifices and parietalizing the spermatic cords [Stoppa and Quintyn,
1969]. He further let the mesh hang without pelvic sutures, relying on intra-abdominal
pressure for fixation. The spacious, easily cleaved, avascular extraperitoneal space was
recognized as the proper plane for the prosthesis, which encased the peritoneum, thereby
preventing protrusion and he noted “The prosthesis was like a gaiter between the inner tube
and the tire” [Stoppa, 2003]. His recurrence rate following repair of many “complicated”
examples was remarkably low. The importance of Stoppa’s work was shown in the early
1990s, when laparoscopists adopted the principles of Giant Prosthetic Reinforcement of the
Visceral Sac (GPRVS) in their repair of inguinal hernia. Wantz [1989] proposed a unilateral
version in which repair involved the preperitoneal spaces of Bogros and Retzius using a
transverse incision extending laterally from the linea alba, 3 cm below the anterior superior
iliac spine.
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
97
Gilbert et al. [1999] employed a two-layered prosthesis, the upper layer resting on the
transversalis fascia, the lower in the space of Bogros. The layers were connected by a plug
passed through the internal inguinal ring. Kugel [1999; 2003] described a posterior
preperitoneal mesh repair technique for inguinal hernia using an abdominal gridiron incision.
More recently, modifications using anterior preperitoneal approaches to the Kugel technique
have been introduced.
APPLIED SURGICAL ANATOMY TO PREPERITONEAL
INGUINAL HERNIA REPAIR
A proper understanding of the anatomy is important to any hernia repair, but is especially
important for both open and laparoscopic preperitoneal repairs. The preperitoneal space
includes both the Bogros space, and the space of Retzius, which goes into the suprapubic
space.
Retzius' space, first described in 1858 by the Swedish anatomist Retzius, is situated
between the transversalis fascia and the pubic bone inferiorly and the bladder posteriorly
[Retzius, 1858]. This space can be dissected free of the pubovesical ligament of the pelvic
floor. Bogros' space was described in 1823 by Bogros, a French anatomist and surgeon, in his
thesis “Anatomy of the iliac region: Description of a new procedure for the ligation of
epigastric and external iliac arteries” [Bogros, 1823]. It is a triangular space limited laterally
by the iliac fascia, inferiorly by the transversalis fascia, and medially by the parietal
peritoneum. It is a lateral extension of the retropubic space of Retzius, clearly seen on sagittal
cross-sections of the inguinal region
The preperitoneal space is a well-defined space that is relatively avascular and, in open
procedures, can be entered either anteriorly or posteriorly, depending on the techniques
applied. In the posterior approach, the inguinal canal is never opened or entered during
routine repair, which is especially beneficial when repairing recurrent inguinal hernias.
Figure 1. Anatomy of the preperitoneal space (right side).
Junsheng Li and Zhenling Ji
98
Frequently, the best identifier of the preperitoneal space is the typical appearance of the
preperitoneal fat, which distinguishes it from other fat; however, this identification requires a
little experience, and it may not be present in sufficient quantities in very thin patients. The
most important anatomic structures in this procedure are the inferior epigastric vessels.
Identification of these vessels during the course of the repair will help to orient the surgeon to
every other important landmark.
The following landmarks are important, and the position of these landmarks will also
closely correlate to the center position of the mesh prosthesis when it is properly placed. As
seen from inside (Figure 1) these landmarks are:
1. Pubic tubercle and Cooper’s ligament.
2. External iliac vein and artery.
3. The inferior epigastric vessels as they come off the external iliac vessels.
4. Vas deferens and cord vessels.
Along with the iliopubic tract, these landmarks define the three spaces associated with
inguinal hernias:
1. Indirect inguinal hernia: lateral to the inferior epigastric vessels.
2. Direct inguinal hernia: medial to the inferior epigastric vessels and lateral to the
border of the rectus abdominus muscle within the triangle of Hesselbach.
3. Femoral hernia: under the iliopubic tract, medial to the iliac vein, and lateral to
Cooper’s ligament.
All three spaces should be covered by an appropriate size mesh as part of inguinal hernia
repair.
Generally, the cord structures (round ligament in the female) pass through the internal
ring into the preperitoneal space. They are totally preperitoneal structures and not intra-
abdominal, and therefore do not have to be encircled by the prosthesis. The spermatic cord
travels superiorly through the internal ring. As the gonadal vessels continue in a superior
direction, the vas deferens branches off toward the prostate. This generally occurs at the
internal ring, or as much as 2 cm to 3 cm superior to the internal ring. The round ligament in
the female tends to be enveloped by the peritoneum and does not usually dissect easily away
from the peritoneum without tearing the peritoneum. For this reason, the round ligament
usually has to be divided to separate it from the peritoneum.
ANESTHESIA CONSIDERATIONS
The open preperitoneal approaches can be performed using a variety of anesthetics,
according to the surgeon’s preference. In general, the anesthetic is best selected after
considering each patient’s specific needs and wishes, as well as the skill and experience of the
anesthesiologist. General anesthesia has the advantage of simplicity and may be the
anesthesiologist’s preference. It may be necessary in patients who have a limited ability to
cooperate with the surgeon, such as elderly patients with Alzheimer’s disease or dementia, or
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
99
younger patients with extreme anxiety. General anesthesia is almost always the backup option
if one of the other methods proves to be insufficient. Regional anesthesia (spinal or epidural)
may be very effective and is particularly useful with bilateral and recurrent hernias or in
obese patients. Local anesthesia is an excellent option for open preperitoneal inguinal hernia
repair. It is particularly effective in elderly patients who may be at higher risk with other
anesthetics. In these patients, very little sedation may be necessary. In younger patients,
however, it may be more difficult to achieve adequate anesthesia without significant sedation.
METHODS FOR OPEN PREPERITONEAL APPROACHES
Implantation of mesh behind the transversalis fascia via an open approach can be
achieved through 1) a transinguinal method such as the Rives operation or Modified Kugel
technique; 2) a slit made in the broad abdominal muscles (e.g., the Wantz and Kugel repairs);
or 3) a lower midline abdominal incision (e.g., the Stoppa GPRVS method).
Stoppa and Wantz Procedures
Stoppa et al. [1975] first described their use of a large, unsutured Dacron prosthesis for
repair of difficult groin hernias using a preperitoneal approach via a low midline incision.
General anesthesia or spinal anesthesia is typically used for the Stoppa procedure, though
uncomplicated one-side Stoppa procedures or Wantz procedures, can be performed using
local anesthesia.
The procedure begins with a midline hypogastric incision. Briefly, after making an
infraumbilical median incision, the preperitoneal space of the inguinal regions are dissected
bilaterally. The dissection is easy and bloodless in the preperitoneal spaces of Retzius and
Bogros, and the excellent exposure of the “musculopectineal orifice” allows the opportunity
to repair several inguinal floor defects by a single approach. During parietalization of the cord
elements, the hernia sac is reduced. If not reduced instantly, it can be amputated at its neck,
and its distal part left in situ. A large piece of mesh is then implanted into the preperitoneal
space, tailoring the mesh to each patient's anatomic measurements. The mesh used can be
either polyester or polypropylene and is either fixed to the pubis, or not fixed, relying on
initial fixation by intraabdominal pressure on the muscular layers; and later fixation is
achieved by tissue adhesion and ingrowth into the prosthesis [DeBord, 1998]. Some authors
prefer to fix the mesh to the Cooper’s ligament [Fernández-Lobato et al., 2006].
The Stoppa procedure is suitable for the treatment of bilateral hernia via a sub-umbilical
incision. For the treatment of unilateral hernia, the Wantz procedure is the best choice. During
the Wantz approach, the surgery is carried out with a transverse incision 5-6 cm long,
extending laterally from the linea alba, 3 cm below the anterior superior iliac spine [Wantz,
1989]. After retracting the lateral abdominal muscles, the peritoneal sac is "unstuck" from the
inguinal ring and the cord is isolated down to the femoral ring, where the iliac artery and vein
were identified. The the hernia sac is then reduced, together with those associated with direct
and/or femoral hernias, if any. The sac is smoothly separated from the cord and the
preperitoneal fat of the posterior wall of the inguinal canal up to the pubic tubercle.
Junsheng Li and Zhenling Ji
100
The Results of Stoppa and Wantz Approaches
Stoppa emphasized the value of prosthetic repair with polyester mesh for huge and
recurrent hernias. Using this method of repair, Stoppa and Warlaumont [1989] reported a
long-term recurrence rate of 1.4% among 604 repairs. Fernández-Lobato et al. [2006]
reported 210 patients with bilateral inguinal hernia (420 hernias) that were repaired with the
Stoppa procedure, including emergency surgery for incarcerated hernia in six cases (2.8%).
Operative time decreased from 100 min to 61 min-66 min with increased experience, hospital
stay decreased from 5.1 days to 1.2 days; and morbidity from 50% (1995) to 12-16%
(P<0.0001). There were three recurrences, two in the first 30 cases (6.6%), and one in the
remaining 180 (0.5%) (4-92 months follow-up). Koc et al. [2004] reported their results of
using the Stoppa procedure compared with the Lichtenstein procedure in surgery for repair of
bilateral inguinal hernias. Although there was no difference between the two groups in the
early postoperative period, three of eight parameters measured (physical functioning, role
limitation-physical, general health perception) showed significant improvement in long-term
health status. The authors concluded that long-term quality of life following the Stoppa
procedure is superior to that following bilateral Lichtenstein hernia repair in bilateral inguinal
hernias. However, Malazgirt et al. [2000] reported that the only marked difference observed
was a decrease in surgery time. The Stoppa repair took significantly less time than the
Lichtenstein repairs (51 min vs. 65 min, P< 0.0l). In that study, there was no clearly superior
technique or type of anesthesia used in the repair of bilateral hernias. Both techniques were
capable of producing favorable postoperative results, and were well accepted by most of the
patients. Similar good results were achieved Wantz [1989], who used a technique similar to
that of Stoppa. That technique has now become known as giant prosthetic reinforcement of
the visceral sac (GPRVS) [Wantz, 1989; DeBord, 1998]. The Stoppa procedure is a very safe
repair of bilateral inguinal hernia, but it requires a learning period to achieve optimal results.
Matthews and Neumayer [2008] pointed out that, although the Stoppa procedure is very
good at preventing recurrence, the big midline incision and the large amount of dissection
required, the associated pain, and the time needed to complete the repair have kept this
technique from being routinely used in the typical hernia patient.
The Nyhus Technique
The surgical procedure originally described by Nyhus [2003] involves a low transverse
incision two cm above the pubis which is then deepened through the skin, the aponeurosis of
the external oblique and transversus muscles; the anterior rectus sheath is incised and the
muscle reflected medially. The preperitoneal space is widened in all directions with blunt
dissection, exposing the myopectineal orifice. The prosthesis is then placed in the
preperitoneal space accordingly.
The Read-Rives Technique
The Read-Rives procedure can be performed under general, spinal anesthesia or local
anesthesia. Using standard groin incision, the canal is opened and the hernia assessed [Read et