Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1601_Библиотеки_им_академика_М_И_Перельмана
.pdf
331
IX
Mesh Explantation in the Groin
Arlt: No, no this test is only to make the diagnosis.
Young: I backed up having done vascular surgery be-
fore hernia surgery. I do feel comfortable having that
knowledge going into doing this. I have one comment
or a specific question: they are extremely difficult to do
particularly if you are going into remove laparoscopically
placed mesh entirely. The question I have is if you have
a patient with a recurrence and chronic pain, obviously
what we would suggest – and I guess you do – is a neu-
rectomy: when you repair the hernia do you also take
that mesh out or do you leave it in?
Arlt: I take only those meshes from which I suppose that
they are responsible for the chronic pain and if somebody
has a recurrence it’s one thing, if he has groin pain it’s
another. There were 14 patients where both things came
together and we removed the mesh but to make it quite
clear: we didn’t remove the mesh because of the recurrence
but because of the pain caused by the mesh.
Ma:
I think this topic is very interesting for me. In China
now some very difficult cases come to me especially for
the infection. The question is after you removed the mesh
how to treat it. Your say give the Shouldice procedure
immediately or put in a mesh. That is correct?
Arlt: Yes, that’s correct.
Ma: You don’t wait for some time for the second wound
healing? But I think if there is infection when you put in
a mesh that’s indication or contra-indication?
Arlt:
Yes, you’re quite right. So we were happy that in
these two cases where we got a swimming mesh in the
abscess and a groin sepsis we were able to do a Shouldice
repair and it was not necessary to place another mesh in
this situation.
Ma:
According to my experience if you take out the mesh
and immediately give a hernia repair it is very difficult
so my experience is to wait. But so far I have maybe 12
cases so I know recurrence. I don’t know why, maybe skin
do no repair the hernia I think.
Miserez: If you have a mesh in the preperitoneal space
will it sometimes be safer to go through a small midline
incision and do a kind of a Stoppa approach to get it
out? Secondly, is there a place for a partial remove of the
mesh? If you have a hard rim which you can feel which
is very painful to the patient, is there a place just to get
this hard rim out or not?
Arlt:
I think it depends on the concrete case and to my
experience it’s wiser to leave small parts of the mesh in
place especially near the vessels near the duct and I think
by doing this you can save the testicle and even can save
the limb and doing another approach than transinguinal
may be a possible way – I don’t have any experience in
this. I think there has to be a plan before you go to the
operation theatre. You have to have a concrete plan. This
can be done by CT, it can be done by ultrasound – I’m
much more familiar with ultrasound – so for me it’s much
easier to do such an examination.
Kehlet: We published a review of the literature on surgi-
cal treatment for chronic pain in the British Journal of
Surgery last year and the overall conclusion was that the
literature is chaotic regarding pre-operative assessment,
characterization of the pain and the patients, intra-opera-
tive handling and especially postoperative follow-up are
so variable and without any details that it is impossible
to make any conclusion on this important topic. I’m re-
ally afraid that the number of patients operated for this
is increasing. Even Amid, you never saw a patient with
chronic pain in a meeting in Sweden on pain 10 years ago
or 12 years ago. But now you’re saying you’re operating
more and more and more and you are operating and
several other people are operating. I think we need to work
together and have exactly the same detailed assessment
of the pain and the patient pre-operatively, intra-opera-
tively, diagnostic tests and the follow-up, most important
the follow-up because if you talk to a neurologist on this
topic with a neurectomy and all the others they will say:
You’re crazy? What I simply say it’s not true? So I really
plea for this and I also say that we – Clifford Woolfe
and I – have a major review on this topic in the Lancet
on chronic postoperative pain and the pathophysiology
behind it and please in the future collaborate. We have
to do this; otherwise it will just be a disaster in the fu-
ture. More patients will be operated and they will not be
pain-free, I’m sure.
Arlt:
Thank you. I think this is a very important remark.
Since your paper was published in 2005 it was – and I
can’t rely on this and I can’t use this for the patients I have
already operated upon – but for the future I think it’s good
advice to have standards and to collect the patients.
Kukleta:
I have a question regarding the immediate repair
of the hernia. I had the chance to explant several infected
plaques and anterior meshes and these patients never had
hernia afterwards. Is that because they did not have any
before or does it apply to somebody’s knowledge that there
are less recurrences than expected after explantation even
if you don’t do anything more than explant?
Arlt: I can’t answer this question.
Deysine:
I had several patients who deposited enough
collagen after an infection in the area to prevent a recur-
rence. I even have one that had a large ventral in which
we remove Marlex for about a year and than we didn’t
have to do anything else.
Ferzli:
A comment on the infection and mesh in the
preperitonal space on the person on experience bases.
Number one is quite hard to diagnose on clinical ground.
Often the diagnosis is made on CAT-scan when the nerve
332 Treatment of Recurrent Inguinal Hernia
30
fluid level is seen above the bladder and that is how the
diagnosis is made. Quite often the approach they do is
midline and sometimes the mesh is just floating as some-
one just described and they remove it.
Schumpelick: I would like to confirm the comment of Dr.
Kehlet. I think the patients come with pain and say: I have
a mesh, can you remove it? We had many of these cases
in the – I would say 5 years ago. This story is down now
and you have seen the figures of Arlt decreasing the risk
and I agree with you don’t remove a mesh because there
is some pain. Many pains will stay after mesh removal.
But there are some cases, which we must define, where a
mesh removal makes sense, but some do not – don’t rely
on the pain of patients only.
IX
31 The Mesh and the Spermatic Cord
R.J. F J.
Introduction
The fibrotic reaction of polypropylene mesh after tension-
free (TFR) inguinal herniorrhaphy causing vasal obstruc-
tion has been implicated as the reason for infertility in
a group of patients presented in a recent paper by Shin
and colleagues [1]. The purpose of this presentation is to
examine the controversial subject of infertility and inguinal
hernia repair and analyze some of the currently available
evidence.
Discussion
Can prosthetic material actually cause infertility by
virtue of the dense fibroblastic reaction which it is de-
signed to produce? The manuscript referred to above
by Shin and colleagues incriminating the polypropylene
mesh fibrotic reaction as a cause of infertility would
seem to provide evidence of this [1]. Fourteen patients
with infertility secondary to obstructive azoospermia
(normal sperm in a testicular biopsy yet no sperm in the
ejaculate) felt to be related to the fibroplastic involve-
ment of the vas deferens after a heterogeneous group
of mesh repairs (conventional, laparoscopic, unilateral,
bilateral) are presented. All patients underwent surgi-
cal exploration with intra-operative vasography. The
vasogram determined the site of the obstruction in the
inguinal region and the surgical exploration identified
the cause of the obstruction to be the mesh.
But could there be another explanation for these
findings? Experienced surgeons who perform re-op-
erative groin explorations after mesh inguinal hernia
repairs for reasons other than fertility such as recur-
rence or postherniorrhaphy groin pain know that the
intense fibrotic response described in the manuscript
is invariably present. Polypropylene and the other mesh
materials used in hernia surgery are supposed to incite
a dense fibroplastic tissue response for the purpose of
creating a strong mesh-aponeurotic complex to re-
place weakened native tissue. Eight hundred thousand
groin hernia repairs are performed in the US per year,
of which approximately 90% are now mesh repairs [2].
Given the fact that inguinal hernias occur at all ages
of life and inguinal herniorrhaphies are performed in
sizable numbers of patients who are still planning to
bear children, why then are we not seeing an epidemic
of infertility? Do these 14 patients represent a subset
that is exquisitely sensitive to the normal fibroblastic
response to mesh? Or was the real cause of the vasal
obstruction described in this manuscript the result of
a more traditional injury (see list below) followed by
scarification to the most convenient structure, which
in this case would be the mesh?
Causes of vasal obstruction related to inguinal her-
niorrhaphy:
▬ Division
▬ Ligation
▬ Clipping
▬ Stapling
334 Treatment of Recurrent Inguinal Hernia
31
▬ Electrocauterization
▬ Devascularization
▬ Scarification.
▬ Traction injuries [3]
Infertility caused by inguinal hernia surgery can be
related to either the vas deferens or the testicle. The
incidence of injury to the vas deferens during inguinal
herniorrhaphy has been estimated at 0.3% for adults
and between 0.8 to 2.0% for children [4]. Injury to the
testicle which eventually leads to atrophy is estimated
to occur in about 0.5% for primary hernia repairs but
increases tenfold to 5% for recurrent hernia repair [5,
6]. The routine use of prosthetic material for inguinal
hernia repair has resulted in a marked decrease in the
historical recurrence rate when compared to popula-
tion-based studies of non-tension-free herniorrhaphies
[7]. The irony of this discussion of polypropylene mesh
causing infertility is the theoretical effect of decreas-
ing the recurrence rate in the general population from
10–15% seen with Bassini and its variants to less than
5% with the mesh tension-free approach. One should
expect a parallel decrease in infertility because of the de-
creased need for re-operative surgery for recurrence.
We know that the overall incidence of infertility after
inguinal herniorrhaphy is higher than the general popu-
lation. Yavetz et al. looked at 8500 infertile patients and
found that 565 or 6.65% gave a history of an inguinal
hernia repair [8]. However, this does not shed light on
the incidence of the infertility caused by the operation.
The issue is clouded by the fact that that many hernior-
rhaphy patients have no intention of conceiving a child,
so fertility status cannot be known; the fertility status of
the patient prior to herniorrhaphy is usually not known
and the time period between the herniorrhaphy and
the diagnosis of infertility introduces the variable of
intervening causation. We must look to investigators
like Shin and colleagues who conduct specialty infertil-
ity clinics to try to extrapolate the incidence. But that
literature is dominated by case reports or small series
calling into question the quality of the estimates [9]. It
is possible that the incidence is so low that the fertility
advantages of mesh repair as the result of the avoidance
re-operation for recurrence outweighs it.
If one were to assume that polypropylene mesh does
indeed cause obstruction of the vas, then one logically
must consider the mechanism. Is it caused by an exag-
gerated fibroblastic response in some patients? If so,
why is not the entire structure obliterated? Or does
it have only to do with sites where the vas comes in
contact with edges of the mesh? It should then occur
only at the external and internal rings where the cord
rides over these edges. Would the modified Lichten-
stein operation in which the tails of the split mesh are
simply approximated lateral to the cord at the inter-
nal ring put the patient at greater risk than the classic
operation in which the inferior surface of the supe-
rior tail is sutured to the inferior surface of the in-
ferior tail and the inguinal ligament which creates a
shutter valve effect?
Additional Clinical Papers
This is not the first report of abnormality of the vas def-
erens after mesh inguinal herniorrhaphy. For example,
an often-quoted case report by Silich et al. describes a
patient who presented 4 years after an inguinal herni-
orrhaphy with a painful subcutaneous nodule in the
repair site [10]. At groin exploration the patient was
found to have a spermatic granuloma “imbedded in
surrounding fibroareolar tissue and mesh”. The authors
concluded that cut edges of the mesh where the tails had
been wrapped around the cord eroded into the cord,
and even provided a diagram depicting this, despite
the fact that the original operation was performed at
“an ambulatory surgery centre” and no details of that
operation were available. One might speculate that an
isolated injury to the vas deferens was the more likely
explanation, as a spermatic granuloma is by definition
an immunological response to extravasated sperm. A
direct injury to the vas resulting in a sperm leak might
be a more plausible explanation than the gradual ero-
sion by the edge of the mesh. Similarly, a case report
published by Seifman et al is often purported to show
unequivocal evidence that mesh can cause obstruction
of the vas [11]. The 32-year-old patient was diagnosed
with secondary infertility (infertility which develops af-
ter a successful conception) 1 year after a right inguinal
hernia repair with mesh. The patient underwent a groin
exploration after he was determined to have obstruc-
tive azoospermia on the right based on the absence of
viable sperm in a seminal vesical aspirate compared
to a right testicle aspirate showing many sperm. An
isolated segment of vas was resected that was “incor-
porated into a scarification process involving the mesh
and the vas was totally obstructed” and a reconstruction
performed. The patient successfully conceived a child
6 weeks later. It seems pretty clear: the site of blockage
was identified precisely, the problem corrected surgi-
cally, and the patient was almost immediately able to
conceive a child. However, what is commonly omitted
when this article is referenced is that the patient also
underwent a simultaneous varicocelectomy on the op-
335
IX
The Mesh and the Spermatic Cord
posite side. The authors felt that the short time interval
between the varicocelectomy and the conception was
too brief to have any effect. It must be left to the reader
whether the correction of a known cause of infertility, a
varicocele, or a technically challenging reconstruction
was responsible for the pregnancy.
There is literature other than case reports useful for
the purposes of a discussion concerning infertility that
addresses not only vasal obstruction but other potential
causes. Aydede and colleagues looked at a group of 60
patients who had undergone TFR herniorrhaphies, 30
of whom were preperitoneal and 30 conventional ante-
rior [12]. The study parameters included spermiograms
and testicular perfusion with color Doppler ultrasonog-
raphy. The spermiograms were identical pre-operatively
and postoperatively in both groups. The testicular per-
fusion studies showed a significant difference between
pre-operative and early postoperative values but not late
postoperative values in either group. The authors con-
cluded that the results “supported the idea that inguinal
mesh application is still a safe procedure in patients with
no children or who are undergoing infertility treatment,
where testicular function is important.”
Color Doppler ultrasonography was used to assess
testicular perfusion in another study by Dilek et al. [13].
Twenty-six patients were randomly assigned to undergo
a totally extraperitoneal preperitoneal or a standard
Lichtenstein TFR hernia repair. The specific blood
flow indexes of the spermatic artery studied included
end diastolic velocity, peak systolic velocity, and the
resistive index. Studies were performed immediately
pre-operatively and then 3 months after surgery. No
differences were found between the pre-operative and
postoperative measurements.
Laboratory Models
Several experimental studies in varying animal mod-
els have been published with mixed conclusions. The
more widely referenced are summarized to illustrate this
point. One of the studies was published in the Journal of
Urology in 1999 by Uzzo and others [14]. Twelve male
beagle dogs had inguinal hernia defects surgically cre-
ated on one side of each animal. Six were repaired using
a polypropylene TFR and the other six with a Shoul-
dice technique. Study parameters included testicular
temperature and volume, peripheral and testicular vein
testosterone levels, testicular blood flow, vasography,
testicular and cord histology, and sperm motility and
morphology. The side without a hernia defect acted as
a control. Postoperative testicular temperature, blood
flow, and volume were similar to controls from both
the mesh and Shouldice groups although there was a
trend toward decreased volume in the TFR group(17.8
cc pre vs. 12.6 cc post, p = 0.17). Contralateral (con-
trol) testicular vein testosterone levels were higher in
animals repaired with mesh than by Shouldice. There
was a significant decrease in cross-sectional vasal lumi-
nal diameter in both repair groups compared to their
respective contralateral controls. Microscopic examina-
tion disclosed a marked foreign-body reaction in the
soft tissues surrounding the vas in the TFR group. All
vasograms demonstrated patency. Three of the six TFR
dogs had grossly abnormal pathology (two hydroceles
and one ischemic testis). None of the Shouldice dogs
demonstrated such findings. Sperm morphology and
motility did not differ between the two groups.
Our group conducted a study to determine whether
congenital indirect inguinal hernias in male pigs could
be repaired by placing a polypropylene mesh prosthesis
over the defect intra-abdominally [15]. The study de-
sign called for an assessment of the effect on fertility.
The project differed from other mesh fertility studies in
that the prosthesis was placed using an intraperitoneal
onlay mesh technique (IPOM) meaning that perito-
neum separated the prosthesis from the cord structures.
Twenty-six healthy Yorkshire cross feeder male pigs
weighing between 23 and 30 kg with congenital unilat-
eral or bilateral indirect inguinal hernias were divided
into two groups. In group 1, 13 pigs had a total of 19 in-
direct inguinal IPOM herniorrhaphies performed at the
time of a laparotomy. Thirteen pigs in group 2 under-
went the same operation laparoscopically and a total of
16 indirect inguinal hernias were repaired. All pigs were
followed for 6 weeks postoperatively and allowed unre-
stricted physical activity and then sacrificed. There were
no signs of erosion or damage to cord structures in any
pig. There was normal flow of methylene blue without
obstruction or extravasation (
⊡
Fig. 31.1). A standard
electrical transrectal ejaculation protocol employed in
the livestock industry for artificial insemination was
used to harvest sperm before sacrifice. Spermiograms
were then performed and were normal.
Another evaluation of fertility was conducted by the
respected group from Aachen, Germany, in pigs and
rats [16]. Fifteen pigs underwent a TFR-type proce-
dure on one side and a control operation Shouldice on
the other. Three animals were sacrificed weekly until
35 days. On the TFR side, foreign-body reaction with
diffuse infiltrating inflammatory cells was found in all.
Five pigs were noted to have venous thrombosis of their
spermatic veins and one animal was shown to have focal
fibrinoid necrosis of the wall of the vas. On the control
336 Treatment of Recurrent Inguinal Hernia
31
operated side, only minor postoperative changes were
observed. The same operative scheme was used in eight
chinchilla rabbits, but the study parameters in these
animals included in addition to histological evaluation
of the foreign-body reaction, testicular size, testicular
temperature, testicular and spermatic cord perfusion,
and spermatogenesis using the Johnsen scoring system.
Just as in the pigs, there was much more foreign-body
reaction on the mesh side than the Shouldice. In addi-
tion, there was decreased arterial perfusion and lower
testicular temperature on the mesh side when compared
to Shouldice. The TFR operation appeared to have ad-
versely effected the Johnsen scale, which measures the
rate of seminiferus tubules with regular spermatogen-
esis (TFR: 48.1%, Shouldice: 63.8%, controls: 65.8%).
The authors voiced concern about this potential influ-
ence on spermatogenesis.
A study from Brazil included 18 dogs divided into
three groups: group 1 (n = 7) underwent bilateral groin
exploration with mesh being placed on the left side
while the right had a non TFR repair [17]. In group
2 (n = 7), the sides were reversed (left side without
mesh versus right side with mesh. Group 3 (n = 4) had
no surgical manipulation (control group). The results
were that there was increased chronic inflammatory
reaction in all operated groups compared to controls,
increased chronic inflammatory reaction on the mesh
side compared to nonmesh, and decreased vas deferens
diameter size on mesh side.
Taneli et al. examined testicular function, testicu-
lar nitric oxide metabolism, and germ cell-specific
apoptosis in 40 rats who were divided into two groups
consisting of a study group in whom a 0.5×1-cm poly-
propylene mesh patch was implanted behind the left
inguinal spermatic cord and a sham-operated control
group [18]. They concluded that long-term polypro-
pylene mesh implantation has no effect on testicular
hormonal function and only a limited effect on nitric
oxide levels, and this effect is not sufficient to cause
apoptosis in testis that could lead to infertility.
Another experimental study in rats evaluating how
different types of mesh affect the spermatic cord was pub-
lished in European Surgical Research by Berndsen and
colleagues [19]. They divided 30 rats into 3 groups:
1. Conventional non-TFR repair,
2. TFR repair with a heavy-weight polypropylene mesh,
and
3. TFR repair with large-pore, light-weight poly-
propylene/polyglactin composite.
Vasography was performed after 90 days. Study end-
points included cross-sectional area of the vas deferens
and S-testosterone measured from the spermatic vein
using the contralateral side as control. Light microscopy
of the inguinal canal was performed and inflammation
and fibrosis were graded. The vasography revealed pat-
ent vas deferens in all animals. In group III, there was a
lower S-testosterone in the spermatic vein and a reduced
cross-sectional area of the vas deferens on the operated
compared to the control side. However, there was no dif-
ference in the other groups and there was no significant
difference in S-testosterone levels between the groups.
There was significantly more inflammation and fibrosis
after mesh repair compared to suture repair, but there
was no difference between the two mesh groups. The
authors had no reason to believe that fertility would have
been affected by any of these findings.
Conclusion
Infertility is a known complication of inguinal her-
nia surgery with or without mesh, and can be caused
by a variety of mechanisms. The findings in the Shin
manuscript which were the reason this review was un-
dertaken are provocative and certainly provide an in-
vitation for further study. However, careful analysis of
the patients reported in that paper, as well as review
of other pertinent literature, fails to unequivocally
prove that polypropylene mesh can cause vasal ob-
struction as an independent aetiology. It seems logical
that there might be a subset of patients in whom vasal
obstruction will occur because of exquisite sensitivity to
the fibroplastic response intended with the use of mesh
material in hernia surgery. However, this subset must
be quite small given that larger numbers of infertile pa-
tients are not being identified despite the fact that many
patients having mesh hernia repairs are in an age group
⊡
Fig. 31.1. Patency of the vas deferens was assessed with
methylene blue injection
337
IX
The Mesh and the Spermatic Cord
still intending to father children. This is not just a matter
of staunch TFR enthusiasts turning their backs and hiding
their collective heads in the sand rather than face this
“new revelation”. On the contrary, the concern is overre-
action to these level-4–5 evidenced based findings result-
ing in a return to the routine use of the Bassini operation
or one of its nonprosthetic variants, which will inevitably
lead to the need for more re-operative surgery for recur-
rence, which places the patient at the greatest risk of loss
of fertility as a consequence of testicular atrophy.
References
1. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with
polypropylene mesh causing inguinal vasal obstruction: A
preventable cause of obstructive azoospermia. Ann Surg.
2005; 241: 553–558
2. Rutkow IM. Demographic and socioeconomic aspects of
hernia repair in the United States in 2003. Surg Clin North
Am 2003; 83: 1045–51, v–vi
3. Ceylan H, Karakok M, Guldur E, Cengiz B, Bagci C, Mir E. Tem-
porary stretch of the testicular pedicle may damage the vas
deferens and the testis. J Pediatr Surg 2003; 38: 1530–1533
4. Sheynkin YR, Hendin BN, Schlegel PN, Goldstein M. Micro-
surgical repair of iatrogenic injury to the vas deferens. J Urol
1998; 159: 139–141
5. Iles J. Specialisation in elective herniorrhaphy. Lancet 1965;
17: 751–755
6. Wantz GE. Testicular atrophy and chronic residual neuralgia
as risks of inguinal hernioplasty. Surg Clin North Am 1993;
73: 571–581
7. Amid PK. Groin hernia repair: Open techniques. World J Surg
2005; 29: 1046–1051
8. Yavetz H, Harash B, Yogev L, Homonnai ZT, Paz G. Fertility of
men following inguinal hernia repair. Andrologia 1991; 23:
443–446
9. Ridgway PF, Shah J, Darzi AW. Male genital tract injuries af-
ter contemporary inguinal hernia repair. BJU Int. 2002; 90:
272–276
10. Silich RC, McSherr y CK. Spermatic granuloma. an uncommon
complication of the tension-free hernia repair. Surg Endosc
1996; 10: 537–539
11. Seifman BD, Ohl DA, Jarow JP, Menge AC. Unilateral obstruc-
tion of the vas deferens diagnosed by seminal vesicle aspira-
tion. Tech Urol. 1999;5:113–115.
12. Aydede H, Erhan Y, Sakarya A, Kara E, Ilkgul O, Can M. Effect
of mesh and its localisation on testicular flow and spermato-
genesis in patients with groin hernia. Acta Chir Belg. 2003;
103: 607–610
13. Dilek ON, Yucel A, Akbulut G, Degirmenci B. Are there adverse
effects of herniorrhaphy techniques on testicular perfusion?
evaluation by color doppler ultrasonography. Urol Int 2005;
75: 167–169
14. Uzzo RG, Lemack GE, Morrissey KP, Goldstein M. The effects
of mesh bioprosthesis on the spermatic cord structures:
A preliminary report in a canine model. J Urol. 1999; 161:
1344–1349
15. Fitzgibbons RJ,Jr, Salerno GM, Filipi CJ, Hunter WJ, Watson
P. A laparoscopic intraperitoneal onlay mesh technique for
the repair of an indirect inguinal hernia. Ann Surg 1994; 219:
144–156
16. Peiper C, Junge K, Klinge U, Strehlau E, Ottinger A, Schum-
pelick V. Is there a risk of infertility after inguinal mesh re-
pair? Experimental studies in the pig and the rabbit. Hernia.
2006; 10: 7–12
17. Goldenberg A, Paula JF. Effects of the polypropylene mesh
implanted through inguinotomy in the spermatic funicu-
lus, epididium and testis of dogs. Acta Cir Bras. 2005; 20:
461–467
18. Taneli F, Aydede H, Vatansever S, Ulman C, Ari Z, Uyanik BS.
The long-term effect of mesh bioprosthesis in inguinal hernia
repair on testicular nitric oxide metabolism and apoptosis in
rat testis. Cell Biochem Funct 2005; 23: 213–220
19. Berndsen FH, Bjursten LM, Simanaitis M, Montgomery A.
Does mesh implantation affect the spermatic cord structures
after inguinal hernia surgery? An experimental study in rats.
Eur Surg Res 2004; 36: 318–322
Supported by a Grant from the United States Agency for
Healthcare Research and Quality (5 R01 HS09860–03)
and the Department of Veterans Affairs Cooperative
Studies Research and Development Program (CSP
#456).
Discussion
Deysine: I would like to start the discussion by telling the
audience that when this paper arrived I lost some sleep.
But I also read a commentary that Dr. Fitzgibbons wrote
on the same issue of Annals of Surgery and that cleared
the air completely. It was extremely well written to the
point and with all the information necessary to take away
the initial panic that people may have had and I have to
congratulate you for that. Thank you!
Kingsnorth: I agree completely with the way you have
analyzed this very difficult topic and the literature review
you have done on the animals and so on. Thinking a
bit laterally, because you know we are in a chronic pain
session as well: do you think that damage to the vas def-
erens done either by the surgeon or by stenosis caused by
the mesh is a source of chronic pain? It is something we
don’t consider. But do you think there are some patients
in whom a transscrotal vasogramm may be beneficial in
helping us to diagnose the cause of chronic pain?
Fitzgibbons:
That’s a very interesting question. As you
know, Dr. Bendavid has described the dysejaculation syn-
drome, which is a specific syndrome obviously related
to the vas. Whether there’ll be patients that have just
generalized pain not associated with the ejaculation is
interesting. I suppose it’s a possibility, but a speculation
for me, though.
IX
32 Principle Actions for Re-Recurrences
R. S, U. K
Introduction
Since the use of meshes for inguinal hernia repair has be-
come increasingly popular, hernia surgery has undergone
major changes in the past 15 years. Approximately 200,000
inguinal hernia operations are performed annually in Ger-
many. Whereas synthetic meshes were used in less than 10%
of cases in 1995, they are today applied in about every sec-
ond patient using either a conventional or endoscopic ap-
proach. In England, Scotland and the United States, the per-
centage of mesh repairs is even between 70 and 86% [1, 2].
The main argument for a wide expansion of mesh tech-
niques is an expected lower recurrence rate compared
to suture techniques. A model for calculating the recur-
rence rates with the assumption of meta-analysis leads to
expected 15% recurrent hernias following suture repairs
and a total of 5% after mesh techniques. But the use of
meshes did not eliminate the recurrence. In spite of the
wider application of meshes, the rate of operations for
recurrent inguinal hernias in Germany continues to be
8–15% [2, 5, 10]. Mesh material that was introduced dur-
ing a previous operation is currently detected in about
10% of recurrences or an annual number of approximately
2500 patients in Germany [5, 10]. With an increasing use
of meshes, we have to face more recurrences following
previous mesh repair in the future (
⊡
Fig. 32.1).
The implantation of a mesh leads not only to excessive
scarring and thus to the desired stabilization of the hernia
site but also to massive adhesions in many cases. For this
reason, the surgical revision of a previous mesh repair is
a major technical challenge for every surgeon. In the case
of multiple recurrences, the degree of difficulty of a revi-
sion operation increases drastically with the number of
previous operations.
How to Treat the Re-Recurrence?
To debate this problem, multiple factors have to be con-
sidered. There is a huge variety of previous techniques
performed for inguinal hernia repair. None of these
procedures is suitable as a standard for all types of re-
currences. Furthermore, the indication to explant the
former mesh has to be clarified. Therefore an individual
approach considering the previously applied technique
has to be performed. This requires an extended experi-
ence in various techniques.
In order to assess the situation in the management
of recurrent hernia, we analyzed the medical records
of 672 patients who underwent recurrent inguinal her-
nia repair in Aachen (n = 438) and Koblenz (n = 234)
between January 2000 and September 2004. In 92 of
these cases (13.7%), a mesh had been used in a previ-
ous repair (Aachen: n = 63 or 14.4%; Koblenz: n = 29
or 12.4%). Altogether 44 patients presented with a first
recurrence, 26 patients with a second recurrence, 10
patients with a third recurrence and 12 patients with
multiple recurrences (4 to 11). Of the 92 included pa-
tients 47.8% had a first and 52.2% had multiple recur-
rences after previous mesh repair.
340 Treatment of Recurrent Inguinal Hernia
32
In the previous operation, the mesh had been placed
anterior to the posterior wall of the inguinal canal in
55 cases (59.8%) and in a preperitoneal position using
a posterior approach in 37 cases (40.2%). A Lichten-
stein repair as anterior onlay mesh had been carried
out in the majority of previous operations (56.5% or
n = 52). A previous endoscopic technique (13 TEP and
19 TAPP procedures) had been used in 34.8% of the
patients (n = 32).
There was a wide variety of reasons why a particular
operative procedure was chosen for the repair of a re-
current hernia. The ultimate decision as to which tech-
nique to use was made as late as during surgery in 71
cases (77.2%). In a mere 21 cases (22.8%), the surgeons
decided before surgery to perform either an endoscopic
procedure or a conventional ( Stoppa, Wantz) approach
(
⊡
Table 32.1).
After a previous anterior approach (Lichtenstein:
n = 52, plug and patch: n = 3), an anterior repair tech-
nique was again chosen in 24 cases. In 12 of these cases,
the surgeons used a Shouldice procedure or a direct
suture for the closure of small defects. The mesh was
removed in 8 of these cases. A Lichtenstein repair was
performed for the repair of both the previous and re-
current hernias in 10 cases (a larger medial overlap was
created in the majority of these cases). In one case, the
Lichtenstein technique was chosen after a previous
plug and patch repair. A total of 31 of the 55 patients
who had undergone a previous anterior repair had a
preperitoneal repair for a recurrent hernia. An endo-
scopic (TEP) approach was used in 7 of these cases
and a conventional TIPP repair was chosen in 15 cases
(6 meshes were removed). Last but not least, a Wantz
repair was performed in 5 cases and a Stoppa repair in
the remaining 4 cases
(
⊡
Table 32.1).
After a previous preperitoneal repair (32 endoscopic
TAPP or TEP procedures, 5 conventional Stoppa, Wantz
or TIPP procedures), the technique was changed and
an anterior placement of the mesh was chosen in 30
patients. A Lichtenstein repair (TAPP or TEP) was per-
formed in 15 of these cases, a Tipp repair in one case
and a direct suture or a Shouldice repair in another 15
cases. In six cases with a previous posterior repair, a
preperitoneal mesh was implanted again using a Stoppa
repair after a Wantz procedure in two cases, a TIPP
repair after a TEP procedure in one case, a Wantz repair
after a TAPP procedure in another case, a TAPP repair
after a Stoppa procedure in one case and a TAPP repair
was repeated in one case (
⊡
Table 32.1).
An analysis of the records showed that the decision
as to which repair technique to use was mostly made
on the basis of each individual case. In the majority of
cases, it is not possible to identify a definitive algorithm
for the selection of a technique. The following state-
ments can be made:
▬ There is a huge variety of previous techniques per-
formed for inguinal hernia repair.
▬
A transinguinal repair technique was usually used
for revision in patients presenting with pain and a
recurrent hernia.
▬ Where multiple recurrences could not be managed
using the commonly employed technique, a mini-
mal direct suture repair (either with or without the
placement of an additional small mesh) was used
0
year
10
8
14
18
2004
2000
2002
operation for recurrence [%]
0
20
40
100
mesh repair [%]
70
60
50
30
10
16
12
6
4
2
1998
1996
1994
1992
80
90
2006
2008
2010
operations for recurrent hernia (D)
to be expected
hernia repair with mesh
⊡
Fig. 32.1. In Germany, the mesh did
not eliminate recurrence as should be
expected
341
IX
Principle Actions for Re-Recurrences
for small defects or a preperitoneal (Wantz, Stoppa
or TAPP) approach was used for inserting a new
large mesh.
To follow up the patients, telephone interviews were
performed on the basis of a questionnaire in order to as-
sess the outcome of revision operations for recurrences
after previous mesh repairs (
⊡
Table 32. 2). The mean
follow-up was 36.3 months (13 to 68 months; median:
33) or, in other words, slightly more than 3 years. It
was possible to conduct interviews with 87 of the 92
patients. One patient had died of another cause, but
had had no recurrence. Another 4 patients could not be
contacted. Accordingly, a follow-up rate of 94.6% was
achieved. Whereas 9 patients (10.3%) had undergone
surgery for a re-recurrence by the time of follow-up, all
other patients had had no recurrence. The re-operations
had been performed after an average of 19.9 months
(9–38 months) after the last repair. Only patients with
previous multiple recurrences were affected. Of the 26
patients who had undergone a non-mesh repair, 6 had
a recurrence. This group of patients showed the highest
re-operation rate (23.1%).
The surgical management of recurrent inguinal
hernia after a previous mesh repair is a technically
demanding challenge for a surgeon. Compared with
a suture repair, the mesh technique leads to consider-
ably more scarring, thereby making it usually much
⊡
Table 32.1. Repair techniques used in the previous and revision operations
Previous
operation
Revision operation Total
Shouldice
or suture
Lichten-
stein
TIPP TAPP TEP Wantz Stoppa
Lichten-
stein
12 10150744 52
TEP 14 18 110000 13
TAPP 10 17 101010 19
Want z 11 10 100002 13
Stoppa 10 10 101000 11
Plug and
patch
11 11 100010 13
TIPP 10 11 100000 11
Total 28 27 16 2766 92
⊡
Table 32.2. High rate of re-recurrences following non-mesh repair after previous mesh repair
a
Re-recur-
rence
Suture Lichten-
stein
TEP TIPP TAPP Wantz Stoppa
No 20 25 7 14 2 5 5
Yes 16 (23%) 110 11001
a
Follow-up of 87 Patients (94.6%) after 36.3 months (13–68); re-recurrence rate 10.3% (n = 9)
Соседние файлы в папке Библиотека им академика М.И. Перельмана