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319
IX
Inguinal Hernia Recurrence and Pain
Conclusions
Recurrent inguinal hernias are often asymptomatic but
will usually cause some mild to moderate discomfort
like their primary counterpart. An increase in postop-
erative pain after open sutured repair may be associated
with a higher rate of recurrence.
However, further studies are required in this area.
Finally, although severe chronic pain is probably
more common after repair of a recurrent hernia, the
difference is small and should be discussed pre-op-
eratively with the patient when consenting for oper-
ation.
References
1. Ong KS, Seymour RA. Pain measurement in humans. Surg J
R Coll Surg Edinb Irel. 2004; 2: 15–27
2. Page B, Paterson C, Young D, O’Dwyer PJ. Pain from primary
inguinal hernia and the effect of repair on pain. Br J Surg
2002; 89: 1315–1318
3. Beets GL. Oosterhuis KJ. Go PM. Baeten CG. Kootstra G.
Long-term follow-up (12–15 years) of a randomized con-
trolled trial comparing Bassini-Stetten, Shouldice, and high
ligation with narrowing of the internal ring for primary
inguinal hernia repair. J Am Coll Surg. 1997; 185:352–
357
4. Hair A, Duffy K, McLean J, Taylor S, Smith H, Walker A, Ma-
cintyre IMC, O’Dwyer PJ. Groin hernia repair in Scotland. Br
J Surg 2000; 87:1722–1726
5. Ar vidsson D, Berndsen FH, Larsson LG, Leijonmarck C-E, Rim-
bäck G, Rudberg C, Smedberg S, Spangen L, Montgomery
A. Randomized clinical trial comparing 5-year recurrence
rate after laparoscopic versus Shouldice repair of primary
inguinal hernia. Br J Surg 2005; 92:1085–1091
6. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional im-
pairment 1 year after inguinal herniorrhaphy: a nationwide
questionnaire study. Ann Surg 2001; 233: 1–7
Discussion
O’Dwyer: I think there’s an incredibly wide variation in
what people regard as chronic pain. I suspect one has to
take the definition from pain after the wound has healed.
Whether it is a good definition I really don’t know. Most
people think that is 3 months. But I think probably a
year is better than 3 months because some people will
still have persistent pain because of the persistence of a
haematoma or a complication.
Kingsnorth:
I just think its better a 6- to 3-months period
because it is internationally recognized amongst anaes-
thesiologists. Do you think it is a recommendation we
should stick to?
O’Dwyer:
I think as long as we stick to that we are all
regarding the same thing.
Amid:
I just want to confirm exactly what you said. I have
performed about 350 operations because of pain and these
are patients that have been referred by pain clinic centres.
There is no correlation between pain and recurrence. The
incidence of pain after open versus laparoscopic repair is
the same. There is no correlation between the pain and a
mesh, and the result of surgery is much more successful
after anterior repair.
Kurzer:
Looking at long-term postoperative pain as a sig-
nificant outcome at least as important as recurrence that
is going to have an effect on how we deal with hernia with
respect to the recent watchful trial results. We are going
to have reconsider who we operate on.
O’Dwyer:
I have not read Bobs trial yet, but certainly in our
trial on symptomatic patients, there was no increase in pain
in those we operated on but there was a slight decrease.
Schumpelick:
If recurrence is not associated with pain,
how does the patient notice that he has a recurrence?
O’Dwyer:
He notices a lump in the groin. If there is no
lump there is probably no hernia.
IX
29 Recurrence and Mesh Material
F. K, C. S-P
Introduction
A meta-analysis of the EU Hernia Trialist Collaboration of
all available prospective randomized trials could prove
a significant lower recurrence rates for techniques with
the use of mesh after primary repair of groin hernias
(
⊡
Table 29.1
) [1, 2]. There was no statistical difference
between the open and the endoscopic techniques in the
recurrence rate after primary repair when a mesh was
used. In the nationwide Danish hernia database as large
prospective observational study of 26,304 herniorrhaphies
the re-operation rates 30 months after anterior mesh repair
and laparoscopic repair were significantly lower than after
sutured posterior wall repairs in primary inguinal hernia
(2.2 and 2.6% vs. 4.4%; p < 0.0001). Re-operation rates were
also lower with anterior mesh repair (6.1%; p < 0.0001)
and laparoscopic repair (3.4%) after recurrent hernia
(
⊡
Table 29. 2) [3].
Mesh and Recurrences
Recurrence after inguinal herniorrhaphy continues to
be a problem, although the mesh techniques are as-
sociated with reduced recurrence rates [4]. Operative
findings in recurrent hernia after a Lichtenstein proce-
dure showed direct recurrences in 62%, whereas the re-
maining recurrences were either indirect (17%), femoral
(13%) or unclassified (8%) [4]. The main reasons for
recurrences after primary mesh repair are technical
faults during the operation and shrinkage of the mesh
(see list below) [5].
A typical technical fault of the endoscopic repair
of primary hernias is the use of too small meshes. The
Neumayer study has shown the significant influence
of the mesh size on the recurrence rate, although the
differences between the mesh sizes were not great
(
⊡
Table 29. 3) [6, 7].
⊡
Table 29.1. Incidence of recurrences after primary
repair [2]
Open non-mesh 4.4% –
Open mesh 1.4% p < 0.001
Endoscopic mesh 2.1% p = 0.026
⊡
Table 29.2. Re-operation rates after repair of recur-
rent hernia [3]
Sutured posterior wall repair 10.6%
–
Anterior mesh repair 16.1%
p < 0.0001
Endoscopic repair 13.4%
p < 0.0001
322 Treatment of Recurrent Inguinal Hernia
29
Reasons for recurrence after primary mesh repair [4]:
▬
The recurrent hernia develops in 99% of all cases at
the free edges of the mesh
▬
Hernias in the area of the mesh seems to be a rare
exception
▬
Technical faults during the operation (mesh size,
fixation, etc.)
▬ Shrinkage of the mesh
▬ Alteration of the extracellular matrix
Mesh Shrinkage
Considering mesh size as an important factor in the
avoidance of recurrences shrinkage of meshes also
has a substantial influence on the concrete choice of a
mesh. Klinge et al. (1998) could show that the amount
of polypropylene influences the extent of inflammatory
response and the corresponding consecutive fibrosis.
Shrinkage might be responsible for secondary folding in
cases of poor elasticity and small pores [8]. Meshes that
contain a lot of polypropylene shrink to about 30–50%
of their original size after 4 weeks (
⊡
Table 29.4). Re-
duction in the polypropylene content decreases both the
inflammatory response and the shrinkage. Meshes with
lower content of polypropylene and larger pores are less
likely to fold and improve compatibility [8].
Light-Weight Polypropylene Meshes –
Experimental Data
The development of light-weight monofilament, large-
pore polypropylene meshes has led to an appreciable
improvement in biocompatibility. This has been shown
in a number of experimental studies [8–14].
Using an experimental model with domestic pigs
(containing 11 pigs in each group) with the endo-
scopic total extraperitoneal approach different meshes
( Atrium, Vypro II, Parietene, TiMesh extralight and
Ultrapro) were placed in the preperitoneal space. After
3 months the animals were sacrificed and a diagnostic
postmortem laparoscopy performed. Specimens com-
prising both mesh and tissue were then removed, and
the dimensions of the meshes measured in the fresh,
tension-free specimens and recorded. Tissue samples
were studied histologically, including immunohisto-
chemistry and electronmicroscopy.
⊡
Table 29.3. Size of the mesh used for endoscopic
repair of a primary hernia [6]
Recur-
rence
No re-
currence
p
Mean vertical
dimension
[cm]
8.1 ± 0.6 8.5 ± 1.3 < 0.001
⊡
Table 29.4. Mesh shrinkage. The amount of poly-
propylene influences the extent of the inflammatory
response and the corresponding consecutive fibrosis.
Shrinking might be responsible for secondary folding
in cases of poor elasticity and small pores [8]
Monofilament, polypropylene, 95 g/m 46%
Multifilament, polypropylene, 55 g/m 34%
percentage
0
mesh shrinkage [%]
20 40 8060 100
atrium
Vypro II
parietene
light
TiMesh
extralight
Ultrapro
87,1
71,2
93,0
94,9
97,2
⊡
Fig. 29.1. Comparison of mesh shrink-
age (% of original size).
323
IX
Recurrence and Mesh Material
Clear differences were found in the shrinkage char-
acteristics of the meshes. In the first experiment Vypro
II mesh shrinkage (28%) was significantly greater in
comparison with Atrium (12%), Parietene (7%) and
TiMesh extralight (5%). The lowest chronic inflam-
matory reaction was seen with TiMesh extralight (13%
PV of inflammatory cells) (
⊡
Table 29. 5). With regard
to cell proliferation, Parietene and TiMesh appeared
to have slight advances. No differences were observed
in the apoptotic rate. In this experiment the TiMesh,
as a light-weight and titanium-coated mesh, proved
to be significantly superior to all the other implanted
meshes. Vypro II as a multifilament mesh with a large
surface and partially absorbable mesh (polyglactic acid)
induced a pronounced inflammatory and fibrotic reac-
tion, which exceeds that of heavy-weight monofilament
polypropylene meshes [9, 15].
In a further study, Ultrapro, another light-weight
polypropylene mesh (technical data in comparison
to TiMesh extralight,
⊡
Table 29.6
) showed an over-
all mean reduction of the surface area of the mesh of
2.8%, which was the least shrinkage rate of all meshes
(see
⊡
Table 29. 5
,
⊡
Fig. 29.1
), even in comparison to
TiMesh extralight (surface area 97.2% vs. 94.9%), but
⊡
Table 29.5. Histological properties of various polypropylene meshes used for endoscopic inguinal hernial repair – im-
pact on their shrinkage rates and inflammatory tissue reaction, cellular reaction
Atrium Vypro II Parietene
light
TiMesh
extralight
Ultrapro
Mesh surface on
explantation [%]
87,1 ± 7,3 71,2 ± 21,6 93,0 ± 12,0 94,9 ± 7,4 97,2 ± 4,9
Partial volume of in-
flammatory cells [%]
21,0 ± 8,2 34,1 ± 13,6 29,0 ± 19,8 13,1 ± 5,3 15,8 ± 7,9
KI67 (proliferation) [%] 17,3 ± 9,4 25,8 ± 10,7 19,2 ± 11,9 12,3 ± 4,3 5,8 ± 4,5
Apoptotic index (cell
death)
7,6 ± 4,0 10,3 ± 5,4 9,5 ± 4,8 8,7 ± 2,8 2,1 ± 2,1
CD 11A (granulocytes,
macrophages, mono-
cytes, lymphocytes)
12,2 ± 5,8 18,0 ± 6,9 11,7 ± 3,0 1,1 ± 0,7 7,4 ± 7,2
CD 68 (macrophages/
monocytes)
7,9 ± 3,7 9,1 ± 6,0 5,1 ± 2,3 0,2 ± 0,4 5,1 ± 3,4
Ultrapro
0.0
0.1
0.2
n
0.3
TiMesh extralight
*8
1
31
shrinkage [%]
10 11
Ultrapro
0
20
30
partial volumes of the
inammatory cells [%]
n
40
TiMesh extralight
10
10 11
4
⊡
Fig. 29.2. Comparison of mesh shrinkage (% of original size)
– lightweight meshes, p = 0.111
⊡
Fig. 29.3. Comparison of the partial volumes (%) of the inflam-
matory cells – lightweight meshes, p = 0.376
324 Treatment of Recurrent Inguinal Hernia
29
without significance (p = 0.111) (
⊡
Fig. 29.2
). The par-
tial volumes of inflammatory cells measured for TiMesh
extralight showed only slightly lower, but not significant
figures in comparison with Ultrapro (13.1% vs. 15.8%,
p = 0.374) (
⊡
Fig. 29.3
). By the addition of the Monocryl
supplementation (resorbable), in contrast to TiMesh
extralight a large proportion of the inflammatory cells
comprised macrophages or monocytes.
Conclusion
The development of light-weight monofilament, large-
pore polypropylene meshes has led to an appreciable
improvement in biocompatibility. As a result of its good
biocompatibility and elastic properties, the light-weight
large-pore meshes as TiMesh extralight and Ultrapro
showed a very low foreign-body reaction and therefore
only a very slight tendency to “shrink”. This renders
these meshes extremely well suited for clinical utiliza-
tion in hernia repair surgery.
In the daily clinical routine situation, this is usually
underscored by a reduction in the foreign-body sensa-
tion, and the less frequent development of seromas,
which are also more minor. Reduced rates of chronic
pain have also been reported [16, 17]. It is possible that
the elastic properties of meshes also play a role, but
this has yet to be confirmed clinically over the long
term. As a result of the only slight tendency of these
meshes to shrink, the risk of a recurrence following an
endoscopic hernial repair is likely to be small, provided
that the mesh was initially appropriately dimensioned
and accurately placed.
References
1. EU Hernia Trialist Collaboration (2000) Laparoscopic com-
pared with open methods of groin hernia repair: system-
atic review of randomized controlled trials. Br J Surg 87:
860–867
2.
EU Hernia Trialist Collaboration (2000) Mesh compared with
non-mesh methods of open groin hernia repair: systematic re-
view of randomized controlled trials. Br J Surg 87: 854–859
3. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen
FH, Wara P, Juul P, Callesen T; Danish Hernia Database Col-
laboration (2001) Quality assessment of 26.304 herniorrha-
phies in Denmark: a prospective nationwide study. Lancet
358: 1124–1128
4. Bay-Nielsen M, Nordin P, Nilsson E, Kehlet H; Danish Hernia
Database Collaboration (2001) Operative findings in recur-
rent hernia after a Lichtenstein procedure. Am J Surg 182:
134–136
5. Klosterhalfen B, Klinge U, Rosch, Junge K (2004) Long-term
inertness of meshes. In: Schumpelick V, Nyhus LM (eds)
Meshes: benefits and risks. Springer, Berlin Heidelberg New
York, pp 170–178
6. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. (2004)
Open mesh versus laparoscopic mesh repair of inguinal
hernia. N Engl J Med 350: 1819–27
7. Neumayer L (2004) Open mesh versus laparoscopic mesh
hernia repair. N Engl J Med 350: 1463–1465; comment on:
N Engl J Med 350: 1819–1827
8. Klinge U, Klosterhalfen B, Müller M, Öttinger AP, Schumpelick
V (1998) Shrinking of polypropylene mesh in vivo. An experi-
mental study in dogs. Eur J Surg 164: 965–969
9. Scheidbach H, Tamme C, Tannapfel A, Lippert H, Köckerling
F (2004) In vivo studies comparing the biocompatibility of
various polypropylene meshes and their handling properties
during endoscopic total extraperitoneal (TEP) patchplasty.
Surg Endosc 18: 211–220
10. Cobb WS, Kercher KW, Heniford BT (2005) The argument for
lightweight polypropylene mesh in hernia repair. Surg Innov
12: 63–69
11. Greca FH, de Paula JB, Biondo-Simmoes ML, da Costa FD, da
Silva AP, Times S, Mansur A (2001) The influence of differing
pore sizes on biocompatibility of two polypropylene meshes
in the repair of abdominal defects – experimental study in
dogs. Hernia 5: 59–64
12. Junge K, Rosch R, Bialasinski L, Klinge U, Klosterhalfen B,
Schumpelick V (2003) Persistent extracellular matrix remod-
elling at the interface to polymers used for hernia repair. Eur
Surg Res 35: 497–504
⊡
Table 29.7. Technical data of light-weight meshes
Ultrapro TiMesh
extralight
Material PP + Poliglecaprone
(absorption within
90–120 days)
PP +
titanium
coating
Weight 28 g/m
2
16 g/m
2
Pore size ~3–4 mm ~ 1.0 mm
Filament
thickness
0.09 mm 0.065 mm
Mesh thick-
ness
0.5 mm 0.2 mm
Elasticity
(max. abd.
pressure)
17.5%
16 N/cm
Max. tensile
strength
(manufac-
turer’s data)
650 mmHg
(~ 69 N/cm)
> 8.5 N/cm
325
IX
Recurrence and Mesh Material
13. Klinge U, Klosterhalfen B, Birkenhauer V, Junge K, Conze J,
Schumpelick V (2002) Impact of polymer pore size on inter-
face scar formation in a rat model. J Surg Res 103: 208–214
14. Schumpelick V, Klinge U, Welty G, Klosterhalfen B (2000)
[Meshes within the abdominal wall]. Chirurg 70: 876–887
15. Knook MTT, van Rosmalen AC, Yoder BE, Kleinrensink GJ,
Snijders CJ, Looman CWN, van Steensel CJ (2001) Optimal
mesh size for endoscopic inguinal hernia repair: a study in
a porcine model. Surg Endosc 15: 1471–1477
16. O´Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers
B, Horeyseck G (2005) Randomized clinical trial assessing
impact of lightweight or heavyweight mesh on chronic pain
after inguinal hernia repair. Br J Surg 92: 166–170
17. Tamme C, Garde N, Klingler A, Hampe C, Wunder R, Köcker-
ling F (2005) Totally extraperitoneal inguinal hernioplasty
with titanium-coated lightweight polypropylene mesh: early
results. Surg Endosc 19: 1125–1129
Discussion
Miserez:
You said that the light-weight meshes potentially
cause less recurrences and a better quality of life because of
better biocompatibility. We have seen with the Vypro so far
that this is not the case. Could you comment on that?
Köckerling: I think the problem with the Vypro concept
is that the pore size was so large that, especially in our
model where we don’t fix the meshes, probably this was
a mechanical problem. The shrinkage was not due to the
heavy reaction. The reaction was more due to the fact
that it was a multifilament.
Read:
I don’t have any scientific comment but I just want
to tell you that your presentation was a model. It was a
work of art.
Kingsnorth: I do appreciate the scientific content of this
and its very nice preclinical data. You did begin to tell us
a bit about the clinical data but we made mistakes with
the early light-weight meshes we used in terms of the
technical details, of not fixing the mesh with open repair.
So do you have any technical tips for using the meshes for
laparoscopic repair or are they equally amenable for use
in laparoscopic and open hernia repair?
Köckerling:
I can tell you from my clinical experience
that you can use this mesh in any type of hernia repair.
So we use it for endoscopic hernia repair, open hernia
repair, especially Lichtenstein, and I also use it for inci-
sional hernia repair where we perform a specific open
technique. You have seen the video in Turin. We always
use this type of a mesh – it is strong enough, it is excel-
lently biocompatible, the ingrowth is for me more than
enough and the surgical handling is excellent.
Duh:
I also want to congratulate you, it was a wonder-
ful talk. In fact you may have convinced me that we
can fight it in San Francisco if we start trying it. I have
some question about whether you have studied meshes
that have different shapes, which are, for example, three-
dimensional. Do they prevent shrinkage?
Köckerling:
My personal opinion is that I would prefer any
type of two-dimensional reconstruction, not a three-dimen-
sional one. Hopefully, I could show you what would happen
if you use a three-dimensional material. It ends up in more
reaction, more connective tissue. It’s more material and this
is not necessary. In this manner I would say less is more.
Kukleta: I can agree to that exactly. Since we use Ultrapro
it seems that it doesn’t shrink at all, Vypro II did, and that
is a big difference.
IX
30 Mesh Explantation in the Groin
G.D. A
Introduction
The use of prosthetic mesh in inguinal hernia surgery is a
well-accepted practice. Adverse effects of mesh implanta-
tion in the long term seem to be seldom and mesh removal
is still a rare procedure today. Nevertheless, several case
reports have been published about severe complications
following mesh repair.
Most of these deal with the phenomenon of mesh
migration. Mesh plugs have been found in the scrotum
mimicking a third testicle (Dieter 1997; Novak 2005) or
dislocated in the preperitoneal space causing severe and
disabling pain (Moorman 2004). Flat meshes are more
likely to migrate into the bladder (Hume 1996; Boden-
bach 2002; Riaz 2004) or into the colon (DeGuzman 1995;
Hamy 1997). The patients suffer from persistent infec-
tions or recurrent bleeding and there is an urgent indica-
tion for the surgical or endoscopic removal of the mesh
material.
Besides mesh migration, other adverse effects of mesh
placement are infection and chronic groin pain. Mesh re-
moval may be necessary under these conditions (Avtan
1997; Schumpelick 1997; Taylor 1999; Athanasakis 2000)
but indication and timing of revisional surgery is debat-
able. Our own experience of indication, operative tech-
nique and results of mesh removal after mesh repair of
inguinal hernia are presented here.
Patients and Methods
Patients
From October 1998 to October 2005, 25 patients with
with a mesh were identified for mesh removal at the
Surgical Department of the Park-Klinik in Berlin-Weis-
sensee. Several attempts of conservative treatment on
an outpatient basis had been done in all of the patients.
Most of them had been treated with chronic intake of
analgesic drugs. In some cases a psychosomatic therapy
had been recommended. Since the TAPP repair is the
most popular mesh procedure in Berlin to date, most
cases had a TAPP repair in their history. Patients with
mild or moderate symptoms responding to a conserva-
tive therapy are not included in this series.
All patients underwent a standardized program of
examinations, including a careful history with special
attention to the characteristics of inguinal pain, clini-
cal examination and ultrasound. Local anaesthesia of
the ilioinguinal nerve with 10 ml of Xylocain 1% at the
SPA (spina iliaca anterior superior) was performed in
all patients except two cases with a mesh infection. The
data of the patients, postoperative interval until presen-
tation at the Park-Klinik and type of the last repair are
given in
⊡
Table 30.1.
328 Treatment of Recurrent Inguinal Hernia
30
Indication for Operation
In patients with an inguinal abscess or sinus due to
an infected mesh a revision of the groin through an
inguinal incision was done. Removal of the mesh was
intended in only two cases of a mesh “swimming” in an
abscess. The wound was left open for secondary healing.
The hernia was fixed later by a Shouldice repair.
In nine patients with chronic inguinal pain not re-
sponding to a blockade of the ilioinguinal nerve with
local anaesthesia ( ilioinguinalis syndrome) at the SPA,
a transinguinal revision was performed. When a small
clinical inapparente recurrence was ruled out intra-
operatively and the genital nerve could not be visual-
ized, the removal of the mesh was recommended. The
defect of the posterior wall was repaired either with a
two-layer Shouldice procedure or a Lichtenstein repair
using a light-weight mesh.
In 14 patients with severe groin pain not related to
the ilioinguinal nerve and a clinical apparent recur-
rence, a re-operation with removal of the mesh was
done. The defect was closed by a Shouldice repair, a
Lichtenstein mesh repair or a Rives procedure.
Operative Technique of Mesh Removal
and Reconstruction
The inguinal canal is opened through a transinguinal
approach. In cases with a Lichtenstein repair, the crem-
asteric muscle has to be dissected and the spermatic
duct and the vessels are armed with a loop. In a typical
Lichtenstein repair the cremasteric muscle is preserved,
which facilitates the identification and preparation of
the cord. The posterior plane of the cremasteric fascia
is taken together with the underlying mesh and excised
from the internal oblique muscle. Mostly the caudal
margin of the mesh cannot be dissected from the basis
of the inguinal ligament without destroying this struc-
ture. A small strip of the mesh (about 3 mm) could be
left in place in these cases. Later, the caudal stitches
of the Shouldice repair can be anchored to this mesh-
ligament strip. After total or nearly total excision of the
muscle mesh component the defect of the posterior
wall is closed with a two-layer Shouldice repair of the
untouched cranial transversalis fascia.
In patients with a preperitoneal mesh position, the
deep epigastric vessels must be divided caudal near the
femoral vessels. Then the posterior wall is opened from
the lateral side and the incision is completed medially to
the pubic bone. The exact position of the mesh must be
explored by digital palpation and an edge of the mesh
is armed with a sharp clamp. Under light tension lat-
erally and caudally the medial and cranial part of the
mesh is excised from the preperitoneal tissue by sharp
dissection. The epigastrics are ligated and divided also
at the cranial margin of the mesh. At the internal in-
guinal ring, the dissection of the testicular vessels, the
spermatic duct and the femoral vessels from the mesh
is the most challenging part of the procedure. Depend-
ing on the individual situation, it might be necessary
to leave small strips of the mesh on these structures.
Vascular defects occur most likely at the femoral vein.
After complete or near-total removal of the mesh, the
defect is closed by a two-layer Shouldice procedure. In
cases of a large destruction of the transversalis fascia, a
Lichtenstein repair or a Rives procedure using a light-
weight mesh (Vypro II) is performed.
Peri-Operative Care and Follow-Up
Informed consent was taken from all patients regarding
an increased risk of intra- and postoperative complica-
tions (estimated percentage of ischemic orchitis about
5%, vascular injury about 5%, and recurrent hernia
about 10%).
A single-shot antibiotic prophylaxis was used in all
operations. All patients were mobilised within 4–6 h
postoperatively. Suction drains were removed between
the 2nd and 5th postoperative day. Patients were dis-
charged due to their own wish between day 3 and 10.
Physical activity was restricted for 2 weeks after dis-
charge from hospital.
In October 2005 all patients were examined clinically
and by ultrasound. The follow-up interval ranged from 12
to 86 months. Due to the small number of patients with
different complaints, no statistical analyses were done.
⊡
Table 30.1. 25 patients identified for mesh removal
at the Surg. Dept. in Berlin-Weissensee from 10/1998 to
10/2005 (19 male/6 female, mean age 48 (14–71) years.
Interval from index operation 10–46 months
Mesh procedures Patients [n]
TAPP 18
TEP 12
Lichtenstein 14
Mesh plug 11
329
IX
Mesh Explantation in the Groin
Results
Two patients presented with a late manifestation of a
deep infection. The interval after the index operation
was 23 and 46 months. In both cases the mesh was
found to be “swimming” in an abscess. The mesh could
be easily removed and the hernia was repaired by a
Shouldice procedure 6 and 9 months later. No signs
of a persistent infection were found at follow-up. Both
patients were completely satisfied.
In nine cases the groin pain did not respond to local
anaesthesia of the ilioinguinal nerve. All these had their
meshes removed and got a Shouldice repair. A partial
bladder resection was necessary in one case with mesh
migration into the bladder. Follow-up examination af-
ter 12 to 72 months revealed excellent results in eight
patients. In one case a recurrence was found.
Fourteen patients presented with a clinical appar-
ent recurrence and severe inguinal pain not respond-
ing to a nerve blockade. The meshes were removed to-
tally or nearly totally. Small strips of the mesh material
were left on the spermatic duct in three cases. Suturing
of a large defect of the femoral vein was necessary in
one case. In all but two patients, the reconstruction of
the posterior wall was possible with a two-layer Shoul-
dice procedure. In a 57-year-old female the excision of
the mesh-fascia-muscle specimen resulted in a large
defect of the posterior wall which had to be closed by
a Rives procedure with a Vypro II mesh. In another
male the inguinal floor was augmented with a Vypro
II-Lichtenstein repair.
Early postoperative complications in these 14 pa-
tients were seroma formation and an ischemic orchi-
tis with a consecutive testicular atrophy in each case.
At follow-up after 12 to 86 months no recurrence was
found. Eight patients were totally satisfied, with no
symptoms at all. Mild inguinal pain during physical
exercise was reported by five patients. The 58-year-old
male with the testicular atrophy had no inguinal pain
but was not satisfied with the result (
⊡
Table 30.2).
The explanted meshes showed macroscopically the
shrinkage of 50 to 70% of the surface, and additional
kinking and folding. During histological examination
the mesh material was found to be a heavy (> 90 g/m
2
)
polypropylene mesh in 23 cases and a polyester mesh
in two patients.
Conclusion
In the literature there are only two other series of mesh
removal after groin hernia surgery. In 1998 Heise and
Starling described the transinguinal mesh removal in 20
patients with severe groin pain following Lichtenstein
(n = 17) or laparoscopic mesh repair (n = 3). Outcome
was excellent or good in 12 (60%) of the 20 cases. Be-
sides a tendency of better results after additional neu-
rectomy during mesh removal, they were not able to
identify other factors that could improve postopera-
tive results or help to select better patients for surgery
(Heise 1998).
Recently Rosen and coworkers (Rosen 2006) pre-
sented their experience with mesh explantation on the
basis of ten cases selected from 1998 to 2004. Indica-
tion was chronic groin pain not responding to local
anaesthesia of the inguinal nerves. The index operation
was a Lichtenstein procedure in nine of the ten cases.
In contrast to Heise and Starling and our approach
they used a combined procedure with transinguinal
removal of the mesh and laparoscopic repair of the her-
nia defect. Results were good or excellent in nine of ten
patients.
These data and our results show that transingui-
nal mesh explantation is feasible and may reveal good
long-term results. An important supposition is a care-
ful selection of patients. Indication should be re-
stricted to cases with conservatively intractable symp-
toms. Favourable indications are persistent infection
with abscess formation around the mesh, invasion
into a hollow organ (gut/bladder), severe groin pain
when other reasons had been ruled out (ilioinguina-
lis syndrome, hip degeneration, etc.) and recurrent
hernia with severe pain which is not related to the
recurrence.
The operation is challenging. The surgeon should be
experienced in hernia surgery and vascular surgery as
well. Informed consent from the patient concerning the
increased risk of testicular and vascular complications
is mandatory (Arlt 2003).
⊡
Table 30.2.
Results of mesh removal after inguinal
mesh repair. Data of 25 patients, follow-up 12–86 months
Recurrent hernia 11
No complaints at all 18 (72%)
Mild/moderate pain during physical activity
15 (20%)
Dissatisfied (testicular atrophy) 11
330 Treatment of Recurrent Inguinal Hernia
30
References
1. Arlt G, Lamm T, Klosterhalfen B (2003) Mesh removal in in-
guinal hernia repair. Eur Surg 35:42–44
2. Athanasakis E, Saridaki Z, Kafetzakis A et al. (2000) Surgical
repair of inguinal hernia: tension free technique with pros-
thetic materials (Gore-Tex Mycro Mesh expanded polytet-
rafluoroethylene). Am Surg 66:728–731
3. Avtan L, Avci C, Bulut T, Fourtanier G (1997) Mesh infections
after laparoscopic inguinal hernia repair. Surg Laparosc En-
dosc 7:192–195
4. Bodenbach M, Bschleipfer T, Stoschek M, et al. (2002) Intra-
vesical migration of a polypropylene mesh implant 3 years
after laparoscopic transperitoneal hernioplasty. Urologe-A
41:366–368
5. DeGuzman LJ, Nyhus LM, Yared G, Schlesinger PK (1995)
Colocutaneous fistula formation following polypropylene
mesh placement for repair of a ventral hernia: diagnosis by
colonoscopy. Endoscopy 27:459–461
6. Dieter RA (1999) Mesh plug migration into the scrotum: a
new complication of hernia repair. Int Surg 84:57–59
7. Heise CP, Starling JR (1998) Mesh inguinodynia: A new clini-
cal syndrome after inguinal herniorraphy? J Am Coll Surg
187:514–518
8.
Hume RH, Bour J (1996) Mesh migration following laparoscopic
inguinal hernia repair. J Laparoendosc Surg 6:333–335
9. Moorman ML, Price PD (2004) Migrating mesh plug: com-
plication of a well-established hernia repair technique. Am
Surg 70:298–299
10. Novak DD, Chin AC, Singer MA, Helton WS (2005) Large scro-
tal hernia: a complicated case of mesh migration, ascites,
and bowel strangulation. Hernia 9:96–99
11. Riaz AA, Ismail M, Barsam A, Bunce CJ (2004) Mesh erosion
into the bladder: a late complication of incisional hernia
repair. A case report and review of the literature. Hernia
8:158–159
12.
Rosen MJ, Novitsky YM, Cobb WS, Kercher KW, Heniford BT
(2006) Combined open and laparoscopic approach to chronic
pain following open inguinal hernia repair. Hernia 10:20–24
13. Schumpelick V, Arlt G, Schlachetzki A, Klosterhalfen B
(1997) Chronischer Leistenschmerz nach transperitonealer
Netzimplantation (TAPP) – Kasuistik einer Netzschrumpfung.
Chirurg 68:1297–1300
14. Taylor SG, O´Dwyer PJ (1999) Chronic groin sepsis following
tension-free inguinal hernioplasty. Br J Surg 86:562–565
Discussion
Simons: Very interesting talk and a very difficult problem.
Do you ever do only triple neurectomy and leave the mesh
in place? And another question I would like to attach is:
what I sometimes do is I give a block of the nerve with
Bubivacain and if it works then my idea is the nerve
can be influenced to treat the pain so neurectomy might
work. You’re saying if the anaesthesia doesn’t work you
take out the mesh. So I’d like some more clarification on
these two questions: Do you do triple neurectomy only
without taking out the mesh ever and how do you use the
local anaesthesia to your diagnostic work?
Arlt:
We use local anaesthesia to block the ilioinguinal
nerve and the hypogastric nerve and I think it’s really
impossible to reach the genital branch and the difference
between responder and non-responder is responding to
the block on the ilioinguinal nerve and the hypogastric
nerve. And if we have a responder we do nothing more
than a neurectomy.
Amid: Thank you very much for the great presentation.
I would like to sympathize with you because I have to
remove mesh at least once a month. I know how difficult
and tedious it is. Just a few suggestions: having a CAT
scan before mesh removal gives the surgeon a roadmap
on where to go. Particularly if the CAT scan shows that
what you want to remove is close to the great vessels for
somebody like me who has no experience in vascular
surgery or make sure a vascular surgeon in the house is
available. Also one suggestion for semantic in order to
understand each other: I think it is a good idea to make
a distinction between the term shrinkage and wrinkle. It
is better to lead shrinkage when the mesh becomes smaller
but very uniformly without creating three-dimensionality
or sharp edges and then use wrinkle when we have the
things that you show because if we use shrinkage for both
of them, then people who read or listen to us really don’t
understand what we’re talking about.
Arlt:
I will follow your advice during the next Suvretta
meeting. Thank you. And to your first question:
Amid: It was not a question, I only confirmed your com-
ment that it is very difficult to remove this and your ap-
proach is the best approach.
Fitzgibbons:
I don’t understand your local anaesthesia
test for triple neurectomy because how do you differenti-
ate the physiological effect of local anaesthesia to get rid
of the pain versus some type of therapeutic effect. How do
you know if you inject local anaesthesia and the patient
gets relief how that it is just the physiological effect of
blocking the nerves as it posed to be a neuralgia.
Arlt: No, I think this is not the target. I want to block the
two nerves, not three nerves, the two nerves. And if they
respond I have a concrete target. I can leave the mesh.
The mesh is responsible for fixing the hernia and I’m not
interested in creating another hernia. I’m just interested in
pain relief and if this could be done by simple neurectomy
of ilioinguinal nerve and hypogastric nerve I will do this.
It’s much more simple and much quicker. I don’t know if
I answered your question.
Fitzgibbons:
First thing I do discover from local anaes-
thesia is to block those 2 nerves, that’s a very effective
way to block those nerves but it’s only temporary. I just
don’t understand.
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