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Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
101
al., 1993]. If an indirect hernia is present, it is treated the same way as in the Lichtenstein
repair, with resection and ligation. The transversalis fascia is divided and the internal ring
exposed to allow high ligation flush with the peritoneum. The epigastric vessels are
identified, the floor of the canal is opened, and the preperitoneal plane is developed. The
spermatic duct and vessels are separated to parietalize the cord. An appropriate size section of
polypropylene mesh is placed in the preperitoneal position, deep to the inferior epigastric
vessels, and secured with three sutures at the pubic tubercle, Cooper’s ligament, and the psoas
muscle laterally. The transversalis fascia is then closed, followed by closure of the external
oblique, Scarpa’s fascia, and skin. Following surgery, the patients are encouraged to walk and
resume unrestricted activity as soon as possible. Early return to work was encouraged.
Muldoon et al. [2004] reported comparative results between the Lichtenstein and Read-
Rives procedures involving 247 male patients with unilateral primary inguinal hernia. There
were few complications in both groups. The operative time of the Read-Rives repair was 9
minutes longer than for the Lichtenstein repair; and six patients developed hernia recurrence,
five in the Lichtenstein group (4.3%), and one in the Read-Rives group (<1%).
The Gilbert/Prolene Hernia System® (PHS) Approach
The Prolene Hernia System® (Ethicon Endo-Surgery, Cincinnati, OH USA) (PHS) is a
bilayer mesh that combines the Lichtenstein and the preperitoneal repair approaches. The
system comprises two layers: a superficial layer for placement in front of the transversalis
fascia and a deep layer for placement behind the transversalis fascia. The PHS technique of
Gilbert et al. [1999] combines the benefits of a posterior and anterior repair from an open
approach. The Ultrapro Hernia System® (UHS) (Ethicon Endo-Surgery, Cincinnati, OH
USA) is a partially absorbable, lightweight mesh composed of monocryl-prolene-composite
and is an alternative material for use with this method (Figure 2).
Figure 2. The UHS patch as viewed from above (left) and from the side (right).
The procedure can be performed under general, spinal anesthesia or local anesthesia. A
groin incision is made in the side of the hernia, with the first part of the procedure being
similar to Lichtenstein technique, and the hernia sac is dissected beyond its neck to reduce it
into the abdominal cavity. In the second part of the procedure, a preperitoneal space is entered
either through the internal ring (indirect hernia) or by circumscribing the transversalis fascia
Junsheng Li and Zhenling Ji
102
around the hernia neck (direct hernia). The preperitoneal space is then created behind the
transversalis fascia for the placement of the deep layer of the PHS mesh. The dissection is
done bluntly using either the index finger or gauze. Care should be taken to spread the deep
layer behind the fascia transversalis (Figure 3). The connecting cylinder of the PHS mesh is
fixed to the internal ring by one or two prolene sutures, and the superficial layer of the PHS
mesh is spread onto the floor of the inguinal canal using several 2/0 prolene sutures. Care is
taken to avoid entraping nerves in the stitches. While repair of the fascia transversalis is not a
routine part of our repair technique, tightening of a wide internal ring with few prolene
stitches around the cylindrical layer is done whenever required. The superficial layer of the
mesh is slit laterally to accommodate the spermatic cord and its two flaps were then
approximated with a stitch that is used to fix the mesh to the inguinal ligament.
Awad et al. [2007] reported 623 cases of inguinal hernia repair of which 321 were
repaired using the PHS method and 302 were repaired with the Lichtenstein onlay mesh
repair (LMR) technique. Those authors noted a trend toward decreased complications in the
PHS group (17%) compared with the LMR group (23%). Further, there was a significant
decrease in the recurrence rate for patients treated with the PHS method (0.6%) when
compared to those treated with the LMR method (2.7%). A five-year long-term follow-up
study [Pierides and Vironen, 2011] showed comparable rates of recurrence and long-term
chronic postoperative pain in PHS-treated patients compared to those who underwent LMR
repair. The LMR patch repair caused significantly more frequent long-term sensory
dysfunction of the skin in the operated groin. A meta-analysis comparing six trials involving
1313 patients, demonstrated that the use of PHS mesh was associated with an increased risk
of peri-operative complications compared to LMR mesh repair. Both mesh repair techniques
have comparable short- and long-term outcomes [Sanjay et al., 2012].
Kugel Repair Technique
The idea behind the Kugel repair method was to develop a technique that could be
performed through a relatively small incision, with little or no suturing and a minimum of
postoperative discomfort [Kugel, 1999]. The special design of the Kugel patch was to
facilitate performance of this repair, and the self-expanding patch allows this to happen.
The Kugel patch is composed of two overlapping layers of a knitted monofilament
polypropylene mesh material (Figure 4). These two layers are bonded together by a narrow
ultrasonic weld placed approximately 1 cm from the outer edge of the patch. This outer apron
is able to bend and fold, and therefore conforms to irregular surfaces like the iliac vessels
over which the patch will lay. The top layer of mesh has a single transverse slit that allows the
introduction of a finger or instrument by the surgeon to facilitate patch insertion and
positioning. The polyester ring makes the patch easier to insert, because after folding the
patch for insertion it has a natural tendency to open up when released.
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
103
Figure 3. Placement of the deep layer of the patch beneath the transversalis fascia (indirect hernia).
Figure 4. The Kugel patch.
There are two primary sizes of patch used for repair of inguinal hernias. The small, oval
patch measures 8 cm by 12 cm, and the medium, oval patch measures 11 cm by 14 cm. The
small oval patch is usually adequate, but it must be precisely placed. The larger patch does
provide a little greater margin for error, and its use should be considered for repair of very
large direct hernias, and it may be a good idea in more obese patients.
General anesthesia, regional anesthesia (spinal or epidural), and local anesthesia are all
appropriate for the Kugel repair technique. A 3 cm to 4 cm incision is made one-third lateral
and two-thirds medial to an imaginary line drawn between the anterior superior iliac spine
and the pubic tubercle. The abdominal wall incision is made using the muscle-splitting
approach until the peritoneum is seen following dissection of the aponeurosis of the external
oblique muscle. The preperitoneal space is entered after dissecting the transversalis fascia.
Blunt dissection is performed to liberate the peritoneum from the adjacent structures. The
indirect sac is liberated easily. A pseudosac is completely separated from the peritoneum and
preperitoneally located fat tissue in direct hernia patients. The cord structures are carefully
dissected from the adjacent peritoneum and the hernia sac in men. After dissection is
performed far enough posteriorly to create an adequate space between the cord structures and
the peritoneum, Kugel mesh is introduced into that space to cover Hesselbach’s triangle, the
internal inguinal ring, and the femoral ring and also to cover the obturator foramen.
When in proper position, the patch should roughly parallel the inguinal ligament, with
about three-fifths of the patch above the level of the inguinal ligament and about two fifths of
the patch below the level of the inguinal ligament (Figure 5). When properly placed, the
posterior edge of the patch will lie back over the iliac vessels a short distance. The medial
corner of the patch will extend to the symphysis pubis and the lateral corner will extend up
Junsheng Li and Zhenling Ji
104
under the incision made in the transversalis fascia, to protect against incisional hernia through
the incision. In this position, the patch will be sandwiched between the peritoneum on one
side and the transversalis fascia, cord structures (or round ligament), Cooper’s ligament, the
femoral canal, and the internal ring on the other [Kugel, 2003].
Van Nieuwenhove et al. [2007] reported 450 cases of inguinal hernias, with 1.9%
recurrence rate after Kugel repair; and the mean surgery time and hospital stay were 20 +/- 9
minutes and 19 +/- 1.3 hours, respectively. Ceriani et al. [2005] reported 620 patients who
underwent repair with the Kugel posterior approach, with a small incision of 3.5 cm on
average. Those authors reported a mean surgery time of 33 minutes, and postoperative
complications in 3% of patients, and found that patients resumed work after an average of 9
days (range 7–12) following surgery. The recurrence rate was 0.8%, and the authors regarded
this method as a ‘‘mini-invasive’’ technique. Nienhuijs et al. [2007] compared the
postoperative pain at three months following Kugel repair with Lichtenstein mesh repair, and
found the Kugel procedure to be a feasible alternative for the standard Lichtenstein procedure
since Kugel repair is associated with less chronic pain at three months.
In contrast, unacceptably high recurrence rates following Kugel repair have been
described [Schroeder et al., 2004]. Recurrence was highest (27.8%) in the subset of patients
who had a Kugel patch placed for recurrent inguinal hernias. Patients with direct primary
hernias involving the entire floor had a recurrence rate of 22.7%. Surgeon experience played a
role, as the recurrence rate was 18.2% during surgeons’ first 36 cases and 2.9% thereafter. As
suggested by Kugel, typical of any new procedure, there is a learning curve with the Kugel
procedure. The number of cases required to develop proficiency depends on the background
and experience of the surgeon [Kugel, 2003].
A special consideration for the Kugel technique is that there be adequate dissection to
allow enough room to accommodate the patch in a completely flat position. Inadequate
dissection can lead to folding of the mesh, which can result in a sharp kink in the expanding
ring of the patch that may erode through the transversalis fascia into the inguinal canal and
cause chronic post-herniorrhaphy inguinodynia, and may also result in hernia recurrence.
Thus, proper and adequate preperitoneal dissection is a key step to successful repair.
Figure 5. Kugel patch position in the preperitoneal space.
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
105
Figure 6. The modified Kugel patch.
Anterior Modified Kugel (MK) Technique
The patch used in the MK technique is quite similar to the classical patch, and it contains
both round and oval shaped materials, with an optional onlay patch (Figure 6). In our
experience, we seldom use the upper layer in the modified kugel technique.
Open preperitoneal repair can be performed through either anterior or posterior
approaches (e.g., Stoppa, Wantz, or Nyhus methods); however, most surgeons are not familiar
with the posterior approach, since they likely learned inguinal hernia repair using anterior
approach procedures (e.g., Bassini or Lichtenstein methods). Further, posterior approaches
require a long learning curve, as in Kugel repairs. This is in spite of several researchers
having found that the Kugel herniorrhaphy is minimally invasive and as safe as the
Lichtenstein hernia repair technique, with similar complication rates [Ceriani et al.,2005;
Dogru et al., 2006; Van Nieuwenhove et al., 2007]. The MK technique may shorten the
learning curve, since it is performed through an anterior approach with an equally small
incision [Li et al.,2008
a
]. Further, this procedure could be performed under local anesthesia,
even in incarcerated inguinal or femoral hernias [Li et al.,2008
a
].
At the authors’ institution, some patients underwent the MK procedure under local
anesthesia, depending on the patient’s condition and desire. All patients were monitored with
pulse oximetry, as well as with a cardiac monitor if they had a history of cardiac disease or if
they were over 70 years old. Local anesthesia consisted of 1% lidocaine with adrenaline 1 :
200 000, administered by local layer infiltration, supplemented with intravenous
benzodiazepine sedation. To block the ilioinguinal nerve, the anesthesia agent was injected
medial to the anterior superior iliac spine, with additional infiltration lateral to the pubic
tubercle for further blocking. A transverse skin crease incision 4–5 cm long was made down
to the external oblique aponeurosis. Before incising through these layers, 5–10 ml of
anesthetic solution was injected to “flood” the space below the external oblique muscle. After
opening the external oblique muscle, more anesthetic agent was infiltrated into the mesentery
of the cord, the area of the deep ring.
Dissection during the MK Procedure
Indirect sacs are dissected from the cord up to the extraperitoneal fat, and then inverted
into the deep ring, to create the preperitoneal space, elevating the inferior epigastric vessels to
Junsheng Li and Zhenling Ji
106
keep them anterior and medial. Laterally, the peritoneal sac should be dissected bluntly from
the iliac vessels. In this step, gauze is inserted to keep the peritoneal sac in a cranial position,
keeping the spermatic cord and testicular vessels lateral (peritonealization) (Figure 7). The
direct sac is then isolated and the transversalis fascia around the direct sac neck circumcised,
after which the preperitoneal space can be reached directly. The femoral hernia sac should be
reduced completely. If the incarcerated sacs are particularly large, the inguinal ligaments may
be divided. The preperitoneal space is entered 1–2 cm above the inguinal ligament by incising
the transversalis fascia. The dissection of the preperitoneal space can be done with gauze
swabs. The dissection of the preperitoneal space must include the following landmarks:
medially, the pubic tubercle; laterally, the iliac vessels; and caudally, Cooper’s ligament.
When this space is slightly larger than the oval MK patch, the patch is inserted into the
preperitoneal space (Figure 8), covering the entire groin region, including the direct, indirect,
and femoral space. The slit in the superficial layer allows the insertion of an index finger and
correct placement of the mesh. Once the patch is placed, its position can be checked by
inserting the index finger into the preperitoneal space between the mesh and the inguinal
ligament, keeping the mesh in a cranial position, and making sure the mesh is flat (Figure 9),
with the mesh boundaries covering the following landmarks: the rectus abdominis medially;
Cooper’s ligament caudally; and the iliac vessels laterally. Straps of the patch are then fixed
to the transverse fascia and inguinal ligament with one suture (Figure 10). We seldom use the
onlay patch when performing this procedure.
Figure 7. Using the gauze to keep the preperitoneal sac in a cranial position.
Figure 8. Inserting the patch into the preperitoneal space.
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
107
Figure 9. The mesh should be flat when placed in the preperitoneal space.
Figure 10. Fix the straps of the mesh to the transverse fascia and inguinal ligament.
Crucial Steps and Keys to Success of the MK Procedure
1. The preperitoneal space must be created adequately.
2. The dissection progresses posterior to the inferior epigastric vessels.
3. The cord structure should be separated from the peritoneum (and indirect hernia sac)
for a distance that extends at least 3 cm.
4. The patch must be precisely placed, otherwise recurrence may happen from the
border of the patch.
Postoperatively, there are no specific restrictions that need be placed on patients. The
patients are encouraged to resume their normal activities within one week after discharge.
They can resume all regular activities, including lifting, as tolerated.
There are several advantages to the MK procedure. For example, the MK procedure can
be performed with local anesthesia, even for bilateral hernias and for incarcerated and/or
femoral hernias. Since the onlay patch is not routinely used, a small incision of 3-4 cm is
sufficient in most patients. Although the MK repair method is carried out through an anterior
approach, the spermatic cord structure is not mobilized, thus not only avoiding complications,
such as orchititis and testis atrophy, but also avoiding the incidence of nerve injury. The mesh
is properly sandwiched between the peritoneum and the transversalis fascia and also uses the
Junsheng Li and Zhenling Ji
108
pressure of the abdominal cavity to hold the mesh in place, thereby reducing the need for
aggressive fixation and subsequently decreasing pain and the risk for nerve entrapment.
We reported satisfactory results with the MK inguinal hernia repair, and even in the
learning curve period, the recurrence rate was 0.7%. To date, we have repaired over 500
inguinal hernias using the MK technique. The recurrence rate is approximately 1%, and
postoperative complication rates are low (9.1%) [Li et al., 2008
b
]. Others have described
using a similar anterior direct Kugel technique with the Modified Kugel patch, except for
entering the preperitoneal via an incision in the transversalis fascia; and they concluded that
the direct Kugel patch method provides an ideal approach to adult inguinal hernia repair with
short surgery time and hospital stay and a very low risk of complications or recurrence
[Kurihara et al., 2008].
Evaluation and Meta-Analysis of the Open Preperitoneal Tension-Free
Inguinal Repair
Meta-analyses have the practical advantage of combining and summarizing the results of
numerous pertinent investigations into one paper, so the readers do not have to retrieve,
evaluate and synthesize the results of all studies on the topic. If done well, they can provide
data for accurate conclusions due to the increased statistical power of the analysis as well as
the precision of the estimate of the treatment effects. Only a few meta-analyses were reported
to compare the open preperitoneal inguinal hernia repair and Lichtenstein repair. In our meta-
analysis on this topic [Li et al., 2012], we identified 12 eligible trials, including 2860 patients,
and we combined data on the incidence of chronic pain, hematoma, wound infection,
testicular complications, urinary complications, numbness, inguinal parenthesis, and surgery
time, as well as postoperative recurrence. This analysis included data from several different
open preperitoneal techniques, such as Nyhus, Kugel, PHS, TIPP (transinguinal preperitoneal
hernia repair) and Read-Rives. Results favored open preperitoneal techniques, since the
preperitoneal technique was associated with a reduced incidence of recurrence. However,
there was no difference with respect to all the other endpoints and the surgery time.
The meta-analysis by Sanjay et al. [2012] compared only the UHS and Lichtenstein
techniques. Their study included six randomized trials and 1313 patients. Their conclusions
were that the use of PHS mesh was associated with an increased risk of perioperative
complications compared to Lichtenstein. Both mesh repair techniques have comparable short-
and long-term outcomes.
Willaert et al. [2012] reported their analysis in an aim to compare elective open
preperitoneal mesh techniques with Lichtenstein mesh repair in terms of pain; and three
eligible trials involving 569 patients were identified. However, due to methodological
limitations in the included studies, there was considerable variation in the results of acute
(risk range 38.67% to 96.51%) and chronic pain (risk range 7.83% to 40.47%) across the
control groups. The meta-analysis was not performed but the results of the outcomes in the
individual trials were compared. They drew a conclusion that both techniques are valid as
they result in similar low recurrence rates. Evaluation of pain data in the individual trials
showed some evidence that preperitoneal repair caused less or comparable acute and chronic
pain compared to the Lichtenstein procedure.
Management of Adult Inguinal Hernias: The Open Preperitoneal Approaches
109
Special Considerations of Open Preperitoneal Inguinal Hernia Approaches
Although a sound concept, there still are some concerns with open approaches, such as
unnecessary dissection behind the transversalis fascia in the preperitoneal space leading to the
possibility of injury to pelvic structures such as major blood vessels, bowel, and the bladder.
In addition, according to the meta-analysis results, the outcome and recurrence rates of mesh
implantation in front of the transversalis fascia versus behind the transversalis are similar.
However, placing mesh in front of the transversalis fascia is easier to perform and to learn
and teach [Muldoon et al., 2004]. Regardless of the technique or approach, mesh placement
behind the transversalis fascia in the preperitoneal space (spaces of Retzius and Bogros), as
described earlier, has led to growing concern among urologists and vascular surgeons.
However, with experience, the open preperitoneal inguinal hernia repair methods have proved
to be as safe and effective as the Lichtenstein procedure. Furthermore, for large and
complicated inguinal and femoral hernias, the open preperitoneal approaches provide unique
and effective methods for treatment.
CONCLUSION
Many different types of open preperitoneal approaches have been developed using either
an anterior approach or a posterior approach. Many randomized trials and meta-analyses have
revealed that these procedures are as safe and effective as the Lichtenstein procedure, and
they also have particular merits, that the Lichtenstein procedure does not provide.
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