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342 Treatment of Recurrent Inguinal Hernia
32
more difficult for the surgeon to identify anatomical
landmarks and in most cases impossible to preserve
selective nerves (
⊡
Fig. 32.2
). Especially the traditional
heavyweight small-pore meshes are often associated
with the formation of massive scar and fibrous tissue
[1, 6, 12].
Altogether 22 of 92 meshes were explanted in our
patient population. All Rutkow plugs were removed
during the revision operation. In the absence of pain
or signs of infection, meshes were left in situ during the
revision operation. Meshes were removed only if the
patient reported a relevant foreign-body sensation or
pain. Our approach is according to the literature. The
removal of a previously introduced mesh is indicated
if the patient complains of chronic pain that cannot be
managed by neurolysis, if the foreign material causes
discomfort or if a massive infection with abscess for-
mation develops around the mesh [1]. In addition, it is
postulated that there should be very strict indications
for the removal of mesh material and that the surgeon
must have extensive experience in hernia surgery and
experience in vascular surgery. Especially in the pres-
ence of massive adhesions in the region of the major
vessels, it is better to leave mesh material in situ than to
risk vascular or spermatic cord damage. A mesh that is
not causing a problem can usually be left in place.
There are no generally accepted guidelines and only
a paucity of data on the choice of repair technique for
recurrences after a previous mesh repair. Whereas some
authors recommend repeating the primary procedure
and the placement of an additional mesh [4, 9], others
advocate changing the procedure and using an anterior
approach after a posterior procedure and vice versa [3,
7, 8, 11].
In our experience, the choice of technique depends
on the previous repair technique and on the need for
removing the foreign material that was inserted before-
hand (
⊡
Fig. 32.3
). The mesh must be removed if there
⊡
Fig. 32.2. Difficult dissection in scarry tissue with increased
risk for spermatic cord and nerves
⊡
Fig. 32.3. Algorithm for selecting the most appropriate type of revision operation for the management of recurrent hernia
after a previous mesh repair
recurrence
following
mesh repair
yes
access for
revision
transingiunal
anterior or posterior
posterior
open: Wantz, Stoppa
previous
approach
anteriour
Lichtenstein
posterior
Tapp, TEP
posterior
endoscopic or open
anterior
Lichtenstein
anterior
Lichtenstein
posterior
TAPP, TEP
mesh-related
complications?
no
343
IX
Principle Actions for Re-Recurrences
are complications such as a foreign-body sensation and
pain. The presence of these symptoms appears to re-
quire a conventional transinguinal approach for the
revision operation. The use of a posterior technique
for reconstructing the posterior wall of the inguinal
canal after a previous anterior procedure or vice versa
makes it easier for the surgeon to perform the operation
since mesh is placed in a non-operated area. Likewise, a
change of surgical approach in patients where the mesh
causes no complications has the main advantages that
the trauma of access is minimized and the surgeon can
operate through intact tissue.
An algorithm (
⊡
Fig. 32.3) is provided to advice on
the selection of the most appropriate repair technique.
Depending on local expertise, it is also possible to repeat
previous TAPP or TEP procedures, which, however, are
highly demanding and much more difficult to perform
than a repair after a change in technique. Patients with
multiple recurrences after a previous Stoppa repair
(GPRVS) present a particular challenge for the surgeon.
In our opinion, the best repair approach in these cases
appears to be a transabdominal reinforcement of the
abdominal wall using a TAPP approach. Both a lapa-
roscopic and an open repair are possible.
Conclusions
There is currently neither an algorithm for selecting
the most appropriate type of revision operation in the
management of recurrent hernia after a previous mesh
repair, nor is there general agreement on how to choose
a technique. The increasing use of mesh techniques
requires that we address this problem in a construc-
tive and effective way. As a general rule, re-operations
after mesh repairs are technically more demanding than
re-operations after previous Shouldice repairs and re-
quire a high level of professional skill on the part of the
surgeon. A change of technique from an anterior to a
posterior approach and vice versa enables the surgeon
to operate through intact tissue. The mesh should be
removed in patients presenting with complications
such as pain and a foreign-body sensation. Multiple
recurrences require a mesh repair and a preperitoneal
placement of the new mesh. This is emphasized by
our follow-up data, suggesting a high rate of failure for
the suture repair of recurrent hernias after a previous
mesh repair. The best way to minimize the number of
revision operations after mesh placement is a thorough
knowledge of potential weaknesses and limitations of
the primary operations and thus to avoid recurrences
due to technical failures.
References
1. Arlt G (2004) Explantation of meshes as a routine in future?
In: Schumpelick V, Nyhus LM (eds) Meshes: benefits and risks.
Springer, Berlin Heidelberg New York, pp 413–426
2. Atkinson H, Nicol S, Purkayastha S, Paterson-Brown S (2004)
Surgical management of inguinal hernia: retrospective co-
hort study in southeastern Scotland, 1985–2001. BMJ 329
(7478): 1315–1316
3. Barrat C, Surlin V, Bordea A, Champault G (2003) Manage-
ment of recurrent inguinal hernias: a prospective study of
163 cases. Hernia 7(3): 125–129
4. Ferzli GS, Shapiro K, DeTurris SV, Sayad P, Patel S, Graham A,
Chaudry G (2004) Totally extraperitoneal (TEP) hernia repair
after an original TEP. Is it safe, and is it even possible? Surg
Endosc 18(3): 526–528
5. Hermanek P (2004) Qualitätssicherung der Leistenhernien-
operation. Viszeralchirurgie 39:8–12
6. Klinge U, Zheng H, Si Z, Schumpelick V, Bhardwaj RS, Muys L,
Klosterhalfen B (1999) Expression of the extracellular matrix
proteins collagen I, collagen III and fibronectin and matric
metalloproteinase-1 and -13 in the skin of patients with in-
guinal hernia. Eur Surg Res 31: 480–490
7. Kurzer M, Kark AE, Belsham PA (2005) Open preperitoneal
mesh repair for recurrent inguinal hernias. Hernia 9(1): 105
8. Kurzer M, Belsham PA, Kark AE (2002) Prospective study of
open preperitoneal mesh repair for recurrent inguinal hernia.
Br J Surg 89(1): 90–93
9 . Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R (2000) Recur-
rence after endoscopic transperitoneal hernia repair (TAPP):
causes, reparative techniques, and results of the reoperation.
J Am Coll Surg 190(6): 651–655
10. Mohr D, Bauer J, Döbler K, Fischer B, Woldenga C (2003)
BQS-Qualitätsbericht 2002- Modul 12/3: Hernienoperation.
Bundesgeschäftsstelle Qualitätssicherung gGmbH, Düssel-
dorf
11. Richards SK, Vipond MN, Earnshaw JJ (2004) Review of the
management of recurrent inguinal hernia. Hernia 8(2):
144–148
12. Schumpelick V, Klinge U (2003) Prosthetic implants for hernia
repair. Br J Surg 90(12): 1457–1458
Discussion
Miserez: I agree with the lower parts of your slide com-
pletely. With the upper parts I would just like to say what
has been stressed by the previous speakers. If you have to
take out the mesh which is probably the case in infection,
even if it’s difficult then there is no problem in taking
out the mesh entirely and doing an endoscopical repair
posteriorly to place a new mesh if necessary, so there is,
I think, definitely place in those difficult cases for a com-
bined approach.
Schwab:
Combined approach was exactly what I also
made possible and it also depends on the skill of the sur-
geon who performs it. If you are an absolute expert in
TEP or in TAPP, you will have probably an easier ap-
344 Treatment of Recurrent Inguinal Hernia
32
proach to the posterial wall than Prof. Flament with his
anterior method and his expertise, so it’s not a question
of this council here, it’s a question for the surgeons out
on the field performing 99.9% of the hernia repairs not
the 0.1% we perform here.
Amid:
Many surgeons are afraid of doing anterior repair
after an original mesh repair because it’s more scar tissue.
If I’m given a choice of doing a recurrent hernia repair I
will pick a patient who had a previous mesh repair and
this is, at least in my mind, for a very logical reason.
When there is mesh in the groin, that mesh for me is a
point of reference. I can stay on the mesh, shave off every-
thing else the mesh and then do the rest of the operation.
Whereas when there is no mesh in the inguinal canal it
is all scar tissue. My reference point is gone. If I go too
deep I may end up in the bladder. If I go too superficially
I may end up in the spermatic cord and cause testicular
problems. But when the mesh is there at least in one direc-
tion I’m safe and I have repeatedly mentioned that, but
it seems that it is only my preference. Nobody else agrees
with me. People are afraid of that extra scar tissue when
there is a mesh there, but the presence of mesh, as I said,
is good for me, it is a point of reference for me that makes
my operation safer at least in one direction.
Schwab:
While writing the paper on our patients and on
our results I looked in the literature and find that most
surgeons suggest doing the redo in an untouched layer. It’s
easier for most surgeons, but might not be true for you.
Amid:
I know. As I said, this is surgeon-dependent. I’m
more comfortable with the anterior approach and I men-
tioned the reason, but recurrent hernias are difficult, no
matter what you do.
Young:
Dr Amid, I would agree with you. However, there
are many situations where I do refer these patients to
laparoscopists, even though I don’t do this procedure
myself.
X
Treatment of the Other Hernia
33 Laparoscopic Repair of Recurrent Childhood
Inguinal Hernias After Open Herniotomy 347
34 The Femoral Hernia – the Bête Noire of Hernias!
353
35 The Umbilical Hernia
359
36 Parastomal Hernia: Prevention and Treatment 365
37 Central Mesh Rupture – Myth or Real Concern? 371
X
33 Laparoscopic Repair of Recurrent Childhood
Inguinal Hernias After Open Herniotomy
K.L. C
Introduction
Repair of inguinal hernia (IH) is one of the most common
operations in paediatric surgical practice [1]. The incidence
of IH ranges from 0.8 to 4.4% in children of all ages. It is
particularly common in the first year of life.
Open repair is still the popular method of treatment for
paediatric IH [2, 3] which is the result of a patent processus
vaginalis only. There is no need for muscle strengthening
procedure after the division and ligation of the hernia
sac. However, the recurrence rate still ranged from 1.76
to 6.3% [4–6]. The high recurrence rate was attributed to
the setting of a general department, where several sur-
geons and residents operated upon a limited number of
paediatric patients [6], the other reasons suggested being
junior surgeons or surgeons without specific paediatric
surgical training performing the operations.
In boys, re-operations are difficult and required tedious
and careful dissection of dense fibrous tissue resulting
from the previous surgery. There is a definite risk of dam-
aging the vas deferens and testicular vessels, which are
situated in the midst of the dense fibrous tissue.
Our centre reported a safe laparoscopic method for
paediatric IH repair [7–9]. The operative site is above the
previous operative field if it is a recurrent hernia after an
open operation. The laparoscopic method should have
less chance of damaging the vas deferens and testicular
vessels.
The present study was to evaluate our laparoscopic
repair for paediatric recurrent inguinal hernia after open
repair. The results were also compared with the historic
data of the same laparoscopic method used as the first
attempt at IH repair
Materials and Methods
The medical records of all paediatric patients who were
treated laparoscopically in our institution for recurrent
IH after open surgery were reviewed retrospectively.
The parameters of sex, age, follow-up duration, opera-
tion time, success rate and complications of the patients
were noted. The data were compared with the historic
data from our previously reported IH patients who
were treated laparoscopically as the first initial hernia
operation [9].
Continuous data were expressed as mean +/- stan-
dard deviation (SD) and statistical significance with
two-tail t test or Mann-Whitney test. For proportion
data, Chi-square or Fisher’s exact test was used. Statisti-
cal significance was set at p < 0.05.
Surgical Technique
The detailed technique has been reported elsewhere
previously [7–9]. Briefly, after the induction of general
endotracheal anaesthesia, the patient was placed in the
Trendelenburg position. A 5-mm port was then inserted
through the umbilicus. Pneumoperitoneum of pres-
348 Treatment of the Other Hernia
33
sure between 8 and 10 mmHg was created with carbon
dioxide. The internal opening of the hernia was first
confirmed and then the opposite side was inspected.
Two more 3-mm ports were placed under telescopic
vision via the abdominal wall medial to the anterior
superior iliac spine. Contents of the hernia, such as
omentum or bowel loop were gently dissected from
the hernia sac (
⊡
Fig. 33.1
). For girls, 3/0 prolene stitch
was placed into the peritoneal cavity through the ab-
dominal wall. A purse-string suture was placed around
the internal hernia opening and tied using intraperi-
toneal knotting. The ends of the stitches were then cut
after the needle was passed out through the abdominal
wall.
For boys, to separate the important structures of vas
deferens and testicular vessels from the peritoneum,
normal saline injection was given at the extraperitoneal
space with the injector (6F, 155 mm, NM-3k injector,
Olympus, Tokyo, Japan) which was guided by a metal
cannula (Stryker, Santa Clara,LA) (
⊡
Fig. 33.2
). On plac-
ing the needle for the purse-string stitch, “needle sign”
was emphasized. “ Needle sign” is the sign in which the
⊡
Fig. 33.1. Laparoscopic photo showing the right internal in-
guinal opening of the recurrent hernia. O omentum; TV testicular
vessels; VAS Vas deferens
⊡
Fig. 33.2. a Appearance of the internal inguinal opening after the portion of omentum dissected from the opening. There was
not much fibrous tissue around the opening. b Extraperitoneal saline injection easily separated the testicular vessels and vas
deferens from the peritoneum. c Purse string stitch was put around the internal inguinal opening. d An intracorporal knot tightly
closed the internal inguinal opening.
ab
cd
VAS
O
TV
349
X
Laparoscopic Repair of Recurrent Childhood Inguinal Hernias After Open Herniotomy
needle could be seen clearly underneath the peritoneum
without the vas and the testicular vessel in between. The
sign further protected these important structures to be
included in the stitch.
The stitch ends were pulled and tightened slightly
before they were tied together. A complete ring of peri-
toneum without the presence of visible significant por-
tion of raw stitch was named the complete ring sign.
Only then were the ends tied and the opening closed
completely. The complete ring sign was used to prevent
recurrence.
After the pneumoperitoneum was released, the ports
were removed. The umbilical wound was closed with
absorbable stitches and the lateral ones with sterile
strips.
Results
From September, 2002, to October, 2005, four boys and
one girl were treated in our institution for recurrent IH
after open operation. Their mean age was 58.8 months
(
⊡
Table 33.1). One patient had bilateral hernias after an
open operation on one side in another institution. Both
hernias of the patient were treated laparoscopically in
one operative setting.
All patients were treated successfully with our lapa-
roscopic technique. There was no recurrence detected
in the group of patients with the mean follow-up period
of 21 months. There was no testicular atrophy nor other
possible complications detected on follow up.
The present data such as operative time, complica-
tions, when compared with our previous reported data
from a series of patients who had laparoscopic hernia
repair as the first operation and their data were collected
prospectively [9] and showed no statistical significance
(
⊡
Table 33.1).
Discussion
After reviewing 71 recurrent IH after open repair in 62
children, Grosfeld et al. [10] suggested adequate high
ligation at the internal ring, snugging of a large internal
ring, avoidance of injury to the canal floor and closure
of the internal ring in girls to prevent indirect hernia
recurrence. From the above technical considerations,
the laparoscopic method theoretically can avoid recur-
rence. However, the recurrence rate was reported to
be 3.4% in a three-centre experience with 933 repairs
[11]. The main reason may be due to the presence of
testicular vessels and vas deferens in close proximity to
the peritoneum at the expected site of closure near the
internal ring (see
⊡
Fig. 33.1
). Our technical refinement
in the use of saline injection to separate these structures
from the peritoneum (see
⊡
Fig. 33.2
) and the emphasis
of the complete ring sign during surgery has reduced
the recurrence rate to 1% [8].
⊡
Table 33.1. Comparison between laparoscopic repair of recurrent childhood hernias with historic data for first laparo-
scopic attempt repair of childhood hernias
Recurrent lap hernias (n = 5) Historic lap hernias (n = 41) P value
a
Sex (male:female) 4:1 34:7 0.634
Age [months] 58.8 +/– 68 56+/– 45.67 0.91
Follow-up [months] 21 +/– 13 12.2 +/– 2.83 0.121
OT time(unilateral) 25 +/– 5.58 min 23.25 +/– 6.26 min 0.842
OT time(bilateral) 35 min 34.0 +/– 6.26 min 0.642
Successful rate [%] 100 100 > 0.05
Testis atrophy [%] 0 0 > 0.05
Recurrence [%] 0 0 > 0.05
a
Statistic significance is p < 0.05; data expressed as mean +/– SD
350 Treatment of the Other Hernia
33
In a first initial operation for IH, laparoscopic repair
is also found to be superior to open operation with
regard to postoperative pain, recovery and cosmesis.
It can also allow detection of contralateral hernias and
have them repaired at the same operation [9]. The
findings were based on our prospective randomized
single-blinded control study to compare the two forms
of operation for paediatric IH.
For recurrent hernias after open operation, re-op-
eration with the open method needs to go through the
old operation site which in boys almost always has the
vas deferens and testicular vessels embedded in dense
fibrous tissue. The operation is always tedious and pos-
sesses the danger of damaging these important struc-
tures. From the present retrospective study, the laparo-
scopic method is the preferred operation for recurrent
hernias after open hernia repair. It has all the superior
aspects of laparoscopic method and can also avoid the
previous operation site. Thus, it can avoid damaging the
vas deferens and testicular vessels. Further, it is as simple
as a fresh hernia repair because the time taken for the
repair of recurrent hernia laparoscopically was the same
as the fresh laparoscopic repair (see
⊡
Table 33.1
). There
was no added complication nor was it less successful as
compared with the initial laparoscopic operations. There
was no recurrence in the present group of patients after
a mean follow-up of 21 months.
In conclusion, laparoscopic repair is the preferred
operation for recurrent childhood IH after open opera-
tion. With refinements in the technique in laparoscopic
repair, recurrence can be prevented even in this group
of patients.
References
1. Cheung TT, Chan KL (2003) Laparoscopic inguinal hernia
repair in children. Ann Coll Surg HK 7: 94–96
2. Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty
MG, Glick PL (2002) Variability of inguinal hernia surgical
technique: A survey of North American pediatric surgeons.
J Pediatr Surg 37: 745–751
3. Antonoff MB, Kreykes NS, Saltzman DA, Acton RD. (2005)
American academy of pediatric section on surgery hernia
survey revisited. J Pediatr Surg 40: 1009–1014
4. Carneiro PM (1990) Inguinal herniotomy in children. East Afr
Med J 67: 359–364
5. Har vey MH, Johnstone MJ, Fossard DP. (1985) Inguinal herni-
otomy in children: a five-year survey. Br J Surg 72: 485–487
6. Nazir M, Saebo A (1996) Contralateral inguinal hernial devel-
opment and ipsilateral recurrence following unilateral hernia
repair in infants and children. Acta Chir Belg 96:28–30
7. Chan KL, Tam PK (2003) A safe laparoscopic technique for
the repair of inguinal hernias in boys. J Am Coll Surg 196:
987–989
8. Chan KL, Tam PK. (2004) Technical refinements in laparo-
scopic repair of childhood inguinal hernias. Surg Endosc
18: 957–960
9.
Chan KL, Hui WC, Tam PK (2005) Prospective randomized
single-center, single-blinded comparison of laparoscopic vs
repair of pediatric inguinal hernia. Surg Endosc 19: 927–932
10. Grosfeld JL, Minnick K, Shedd F, West KW, Rescorla FJ, Vane
DW. (1991) Inguinal hernia in children: factors affecting re-
currence in 62 cases. J Pediatr Surg 26: 283–287
11. Schier F, Montupet P, Espostito C (2002) Laparoscopic ingui-
nal herniorrhaphy in children: A three-center experience
with 933 repairs. J Pediatr Surg 37: 395–397
Discussion
Ceydeli:
Thanks, Dr. Chan, for this great presentation
and I think that as pediatric surgeon I have to say that
this is really a revolution in how we’re doing hernia sur-
gery on children. I just have one quick comment and
then a couple of questions for you. Firstly I’m doing this
operation laparoscopically as well but I do not put the
sutures in place intracorporally. I find that managing a
suture, especially in a premature infant, and a needle is
not necessarily an easy task and so what we’re doing is
replacing a 2-mm incision – just a stab incision – over
the internal ring and then passing the suture circumfer-
entially around the neck of the hernia sac and tying it
down in the subcutaneous tissues. This we find is faster
than trying to place the suture inside. I agree with you
that the recurrent hernia – I’ve had one recurrent hernia
in a child who was constipated in straining and the suture
released – and the recurrent hernia is as easy as doing the
initial hernia operation. A couple of questions: How do
you decide whether you should close the opposite side or
not, given the high chance of spontaneous closure of the
pin processes? The next question is how young are these
patients and also what about patients who have ascites,
or are you using laparoscopy for these patients?
Chan:
Thank you for the comment and also for your ques-
tions. There are a number of ways to kill a cat and you
have mentioned one and then I mention mine. I think I
can do the knotting. I find no problem. You found that
there is a problem in diagnosis. I think you just continue
the operation and there is a contralateral repair. I think if
we are doing a laparoscopic method we find holes in the
other side because is a sign to put stitches with minimal
or no chance of damaging anything. So whenever we see
something, we close it if we are doing the laparoscopic
repair; for closure I think there is no prospective study
proof that the patent process will definitely close. So there
is no evidence of this kind. So I think at operation you
have to close the other side as well if you find the holes
open on the other side.
351
X
Laparoscopic Repair of Recurrent Childhood Inguinal Hernias After Open Herniotomy
Ceydeli: The patients that may have ascites – are you
using laparoscopy on them?
Chan:
At the present moment we do not. Maybe later
we’ll try, but the thing is that we don’t know the cause
of ascites.
Read:
Dr. Chan, in your first statement regarding the
cause of these hernias in infants you mentioned a patent
processus vaginalis. We know that the patent processus
vaginalis can persist through life without any hernia de-
velopment. My own son, who is now 54 years of age, as
a neonate had a communicating hydrocele of the cord.
That went away. He has never had a hernia. But we do
know he did have a real patent processus vaginalis. I’d
like you to comment on that.
Chan:
If it’s a hernia it means there is a big patent
processus vaginalis, then I think at the present mo-
ment there is no definition as to how or why the patent
processus vaginalis is a hernia. I suppose if it is more
than half a centimetre, then the bowel can get in and
it can become a hernia. There was a paper published
in the Asian Journal of Surgery in the recent issue.
They will close a patent processus vaginalis that is half
a centimetre in diameter – but the thing is that is no
data.
X
34 The Femoral Hernia –
the Bête Noire of Hernias!
R. B
Introduction
“An error made on your own is safer than ten truths accepted
on faith” (Ayn Rand, Atlas Shrugged 1957). Rand’s aphorism
summarizes all the fears one must experience to become
familiar with the difficult clinical diagnosis and surgical
treatment of femoral hernias. And more than one error
it will be! The cause of this all too common fear is the
lack of familiarity with the problem. Femoral hernias are
less frequently seen than inguinal hernias and make up
only 2 to 5% of all groin hernia series. If the average gen-
eral surgeon treats 50 hernias a year, this means that he
may handle from one to perhaps two femoral hernias a
year [1].
Femoral Laws
At the risk of sounding repetitive and trite and to
hammer a point home (is it not what Madison Avenue
advertising agencies do with publicity spots?), some
platitudes about femoral hernias must be enshrined as
“ Femoral Laws”.
First Law of Femoral Hernias.
Remember that the first
operation is the best chance of a cure. All subsequent
attempts will be attended by danger, fear, failure and
complications [2].
Second Law of Femoral Hernias.
You must search for
and exclude femoral hernias during all surgeries in the
groin. These hernias account for more than 8% of all
recurrences and can be especially difficult [3].
Third Law of Femoral Hernias. Whether surgery is car-
ried out through an open or a laparoscopic technique,
never disturb any fat pad or lymph node present at or
within the femoral ring [4].
Fourth Law of Femoral Hernias.
All femoral hernias must
be repaired with a mesh from, or within, the preperi-
toneal space. Suture repairs, however small the defect,
can no longer be trusted [5].
Fifth Law of Femoral Hernias. Surgery for femoral her-
nias must be done at the earliest convenience if elective.
In emergencies, whether incarcerated of strangulated,
never delay. In strangulation, complications and mortal-
ity vary directly and proportionally with the duration
of the delay [6].
Femoral hernias have been described as the most
treacherous of all hernias and when incarcerated, they
outnumber all other forms of incarcerated abdominal
wall hernias combined [6]. The diagnosis is missed in
25% of cases [7]. Incarceration and strangulation have
been reported in 2–25% [6, 7].
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