The Kugel repair for groin hernias

Transabdominal preperitoneal repair for a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament: A case report

The Kugel procedure resulted in extensive adhesion in the preperitoneal space. Performing a transabdominal preperitoneal repair (TAPP) for recurrent hernia after Kugel procedure is extremely difficult. In this case report, we present the case of a 81-year-old male who presented with recurrent inguinal hernia after Kugel procedure 8 years ago. Transabdominal laparoscopy was performed first. Indirect hernia formed inferior to the lateral edge of the previous mesh was diagnosed under laparoscopy. The patient's medial umbilical ligament (MUL) was big enough and could be completely released by separating the Retzius space. Finally, TAPP was successfully performed by using the MUL to create and close the preperitoneal space. No perioperative complications or hernia recurrence was observed 1 year after the surgery. Using the MUL to deal with preperitoneal problems was practical and feasible.

Prosthetic meshes for hernia repair: State of art, classification, biomaterials, antimicrobial approaches, and fabrication methods

Worldwide, hernia repair represents one of the most frequent surgical procedures encompassing a global market valued at several billion dollars. This type of surgery usually requires the implantation of a mesh that needs the appropriate chemical, physical and biological properties for the type of repair. This review thus presents a description of the types of hernias, current hernia repair methods, and the state of the art of prosthetic meshes for hernia repair providing the most important meshes used in clinical practice by surgeons working in this area classified according to their biological or chemical nature, morphology and whether bioabsorbable or not. We emphasise the importance of surgical site infection in herniatology, how to deal with this microbial problem, and we go further into the future research lines on the production of advanced antimicrobial meshes to improve hernia repair and prevent microbial infections, including multidrug-resistant strains. A great deal of progress has been made in this biomedical field in the last decade. However, we are still far from an ideal antimicrobial mesh that can also provide excellent integration to the abdominal wall, mechanical performance, low visceral adhesion and minimal inflammatory or foreign body reactions, among many other problems.

A registry-based 2-year follow-up comparative study of two meshes used in transinguinal preperitoneal (TIPP) groin hernia repair

PURPOSE

Onflex™ mesh has replaced Polysoft™ patch on the market, without being clinically evaluated thus far in the transinguinal preperitoneal (TIPP) technique.

METHODS

All consecutive TIPP registered in our registry during the overlap period of availability of both meshes were included and studied with the chronic postoperative inguinal pain (CPIP) as primary endpoint, assessed with a verbal rating scale (VRS), and included in a patient-related outcome measurement (PROM) phone questionnaire.

RESULTS

A total of 181 Onflex cases vs 182 Polysoft cases were studied with a 2-year follow-up rate of 92% vs 88%. The overall rate of pain or discomfort was not statistically different in the 2 studied subgroups (16.5% vs 17.6%; p = 0.71), while moderate or severe pain were significantly more frequent in the Polysoft subgroup (5.5% vs 11.6%; p = 0.01). These symptoms did not interfere with the patient daily life in 16% vs 16.5% of cases, and they were self-assessed as more bothersome than the hernia in only 0.5% vs 0.5% of cases, suggesting an overestimation of the pain by the VRS. Patients assessed the result of their hernia repair as excellent or good in 97.8% vs 96.7% and medium or bad in 2.2% vs 3.3% (p = 0.53). The cumulative recurrence rate was 0% vs 2.2%. Two reoperations (one for early and one for late recurrence) were reported in the Polysoft subgroup (1%), none related to the non-absorbable memory ring.

CONCLUSIONS

These results suggest that TIPP with Onflex provides results at least similar than those with Polysoft.

Mini-mesh and Lichtenstein repair compared with a modified Kugel technique for femoral hernia: a randomised controlled trial

INTRODUCTION

A modified Kugel patch is more expensive than ordinary mesh and demands a wide dissection of the preperitoneal space in femoral hernia repair. We therefore adopted a novel method using mini-mesh and a Lichtenstein repair. This study compared mini-mesh and Lichtenstein repair with a modified Kugel technique in patients with a primary unilateral femoral hernia.

METHODS

Patients with unilateral femoral hernia were assigned randomly to undergo mini-mesh and Lichtenstein repair (M group) or modified Kugel repair (K group), followed-up at one week, three months, one year and two years. Demographics, hernia characteristics and operative outcomes of two groups were analysed.

RESULTS

A total of 48 patients in the K group and 49 participants in the M group completed follow-up. The operation time for the M group (68.6 ± 13.4 minutes) was significantly shorter than that of the K group (80.6 ± 10.1 minutes; p=0.030). There was no significant difference between the two groups for chronic pain, foreign body feeling and quality of life, and no recurrence occurred.

CONCLUSIONS

Mini-mesh and Lichtenstein repairs have reasonable results in the patients with femoral hernia in this study, with a reduced operation time compared with a modified Kugel repair. The trial was registered with the Chinese Clinical Trials Registry: ChiCTR1900022264.

Recurrent groin hernia surgery after primary open inguinal procedures: a reappraisal of the open preperitoneal (Ugahary) technique

PURPOSE

There are several methods for repairing recurrent inguinal hernia, depending on the type of initial repair. Our aim was to analyze our long follow-up results on the open preperitoneal repair for patients with recurrent inguinal hernia.

METHODS

Our retrospective survey included 135 consecutive recurrent inguinal hernia patients, operated on during 1999-2010, with a mean follow-up time of 8.7 years.

RESULTS

During the mean follow-up time of 8.7 years, only four (3%) patients developed a re-recurrence. Two of these patients were asymptomatic, and the two other were operated on. Early postoperative complications occurred in four (3%) patients. The complications comprised one hematoma, one seroma, and two infections. Chronic pain was diagnosed in five (3.7%) patients, but their symptoms disappeared spontaneously within a few years.

CONCLUSIONS

We conclude that in competent hands, the open preperitoneal repair (Ugahary) is a good surgical option in operating recurrent inguinal hernias.

Anterior transversalis fascia approach versus preperitoneal space approach for inguinal hernia repair in residents in northern China: study protocol for a prospective, multicentre, randomised, controlled trial

INTRODUCTION

Many surgical techniques have been used to repair abdominal wall defects in the inguinal region based on the anatomic characteristics of this region and can be categorised as 'tension' repair or 'tension-free' repair. Tension-free repair is the preferred technique for inguinal hernia repair. Tension-free repair of inguinal hernia can be performed through either the anterior transversalis fascia approach or the preperitoneal space approach. There are few large sample, randomised controlled trials investigating the curative effects of the anterior transversalis fascia approach versus the preperitoneal space approach for inguinal hernia repair in patients in northern China.

METHODS AND ANALYSIS

This will be a prospective, large sample, multicentre, randomised, controlled trial. Registration date is 1 December 2016. Actual study start date is 6 February 2017. Estimated study completion date is June 2020. A cohort of over 720 patients with inguinal hernias will be recruited from nine institutions in Liaoning Province, China. Patient randomisation will be stratified by centre to undergo inguinal hernia repair via the anterior transversalis fascia approach or the preperitoneal approach. Primary and secondary outcome assessments will be performed at baseline (prior to surgery), predischarge and at postoperative 1 week, 1 month, 3 months, 1 year and 2 years. The primary outcome is the incidence of postoperative chronic inguinal pain. The secondary outcome is postoperative complications (including rates of wound infection, haematoma, seroma and hernia recurrence).

ETHICS AND DISSEMINATION

This trial will be conducted in accordance with the Declaration of Helsinki and supervised by the institutional review board of the Fourth Affiliated Hospital of China Medical University (approval number 2015-027). All patients will receive information about the trial in verbal and written forms and will give informed consent before enrolment. The results will be published in peer-reviewed journals or disseminated through conference presentations.

TRIAL REGISTRATION NUMBER

NCT02984917; preresults.

Initial experience with application of single layer modified Kugel mesh for inguinal hernia repair: Case series of 72 consecutive patients

OBJECTIVE

This is an initial review of the safety and efficacy of anterior preperitoneal modified Kugel (MK) mesh herniorrhaphy application without using optional onlay mesh.

METHODS

We retrospectively reviewed patients who underwent herniorrhaphy by a single surgeon from July 1^st, 2009 to December 31^st, 2010. During these 18 months, a total of 72 patients underwent single-layer MK mesh herniorrhaphy. Anterior preperitoneal approach was used to place the mesh. If the patient's inguinal hernia defect did not exceed the memory ring of MK mesh, the onlay mesh was omitted. Postoperative results (wound infection, recurrence, and chronic pain/discomfort) were recorded and analyzed.

RESULTS

A total of 72 patients underwent anterior preperitoneal single layer MK mesh herniorrhaphy. One patient had recurrent hernia after 1 year and was treated with a laparoscopic transabdominal preperitoneal operation. The most common postoperative complaint was mild soreness which was self-resolving after 1 month. Mean total operative time (skin to skin) was 73 minutes. The average hospital stay was 2 days. Most of the postoperative complications including soreness (14%), pain for > 3 months (1.4%), and scrotal hematoma (1.4%) were self-resolving. One patient experienced wound infection, which was treated with oral antibiotics. One patient had recurrence 1 year after the operation.

CONCLUSION

The postoperative complication and recurrence rates of single-layer MK mesh herniorrhaphy was comparable with previously reported tension-free repair. Single-layer application is safe and feasible. A longer follow-up period and larger study group with a control group are needed to verify our method.

Comparative Study of Prolene Hernia System and Lichtenstein Method for Open Inguinal Hernia Repair

BACKGROUND

Prolene Hernia System (PHS) is a bi-layered polypropylene mesh with a connector that combines the anterior and posterior inguinal hernia repair, but still not very popular in this part of the country. Hence a prospective & randomized comparative study was undertaken to compare PHS with the already popular Lichtenstein Hernia Repair (LHR) and determine the post-operative outcome.

MATERIALS AND METHODS

Total 67 inguinal hernia repairs were randomly assigned to either PHS or LHR method, and data was collected regarding various outcome measures like duration of surgery, post-operative pain, requirement of analgesia, return to normal activity, and early and late complications.

RESULTS

Mean duration of surgery was significantly higher for PHS group than LHR group (65.4 min vs 51.26 min, p-value <0.0001). Significant difference was noted between the PHS and LHR group in terms of moderate to severe post-operative pain (15.15% vs 41.18%,p-value 0.018), time of requirement of analgesia (3.7 vs 4.6 days, p-value 0.024), and time to return to normal activity (2.7 vs 3.4 days, p-value 0.023), all in favour of the former technique. No intra-operative complication was noted in either of the groups. 5 patients had early complications in PHS group and 6 in LHR group, but this was statistically not significant. The average time of follow-up for the study was 7.8 month, ranging from 1 to 18 months. Chronic inguinal pain was noted in 1 and 2 patients respectively in PHS and LHR group, again statistically not significant. No recurrence was noted in both the groups till the time of follow-up.

CONCLUSION

PHS is a safe and better alternative to the time honored Lichtenstein hernia repair with the added advantage of strengthening whole of myopectineal orifice, and virtually eliminating any risk of recurrence.

Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia: the first 1,000 patients

INTRODUCTION

After the introduction of mesh in inguinal hernia repair, the focus to improve surgical technique has changed from recurrence to chronic postoperative inguinal pain. At present, the most common surgical techniques are the Lichtenstein hernioplasty and total extraperitoneal procedure. Both techniques have their own specific disadvantages, with regard to potential nerve damage and the necessity of general anesthesia, respectively.

OBJECTIVE

The goal of this study was to evaluate the results of a new technique in which the inguinal nerves are not at risk, and in which general anesthesia is not needed: trans rectus sheath extraperitoneal procedure (TREPP).

MATERIAL AND METHODS

Between 2006 and 2010, a total of 1,000 patients were treated for inguinal hernia with TREPP. A questionnaire concerning pain, sensibility changes, patient satisfaction, and recurrence was sent to all patients.

RESULTS

The questionnaire was completed by 932 patients. Almost 90% of patients had not experienced any pain since the surgical procedure; 8% of patients reported experiencing some pain, but less than preoperatively; and 2% of patients reported an increase in pain postoperatively. Recurrence occurred in 1 and 3% were unsure about this. Reduced sensibility of the scar, scrotum, and upper leg was reported by 12.4, 1.4, and 1.5%, respectively. Overall, 97.4% of patients were satisfied with the results of the surgical procedure. The time period in which TREPP was performed was not associated with any of the outcome measures.

CONCLUSION

TREPP has proven to be a feasible new technique for inguinal hernia repair, with excellent results, justifying a randomized controlled trial in which TREPP should be compared with standard techniques.

Surgical approach to abdominal wall defects: history and new trends

We briefly outline the history of hernia surgery development from the Ebers Papyrus to modern prosthetic repairs. The rapid evolution of anatomical, physiological and pathogenetic concepts has involved the rapid evolution of surgical treatments. From hernia sack cauterization to sack ligation, posterior wall repair (Bassini), and prosthetic reinforcement there has been an evident improvement in surgical treatment results that has stimulated surgeons to find new technical solutions over time. The introduction of prosthetic repair, the laparoscopic revolution, the impact of local anesthesia and the diffusion of day surgery have been the main advances of the last 50 years. Searching for new gold standards, the introduction of new devices has also led to new complications and problems. Research of the last 10 years has been directed to overcome prosthetic repair complications, introducing every year new meshes and materials. Lightweight meshes, composite meshes and biologic meshes are novelties of the last few years. We also take a look at future trends.

Transinguinal Preperitoneal Patch (TIPP) under Local Anesthesia with Sedation

Transinguinal preperitoneal placement of the patch (TIPP) combines the advantages of the preperitoneal patch and the simplicity of the inguinal approach. The aim of the study was to evaluate the feasibility of TIPP under local anesthesia (LA) with sedation on a series of unselected patients. All 161 patients referred to one of us for inguinal hernia repair were included in a prospective evaluation; they were operated on for 169 inguinal hernias, in LA with sedation. TIPP was the routine method and was used in all but a few particular cases. TIPP was performed in 139 cases out of 169 (82.2%). In 21 cases (12.4%) another method was chosen, due to the patient's age, the patient's request, or the type of the hernia. In nine cases (5.3%) another technique was used because preperitoneal dissection was not possible, due to a previous preperitoneal surgery. In the 139 cases where a TIPP was performed, general anesthesia was used in four cases at the patient's request and spinal anesthesia in two cases of large irreducible scrotal hernias in old, frail patients. TIPP was begun under LA in 133 cases and conversion to general anesthesia was necessary in one case only. Therefore, TIPP under LA was possible in 132 cases out of 139 (95%). These results suggest that TIPP can be performed under LA in most cases. The expected advantages of combining preperitoneal patch repair and local anesthesia are worth being confirmed by comparative studies.

Colovesical fistula following an open preperitoneal "Kugel" mesh repair of an inguinal hernia

Erosion of the "Kugel" mesh into intraperitoneal organs has not been previously reported in the medical literature. We report such an occurrence in a 54-year-old male, 4 years following a "Kugel" preperitoneal repair of a left-sided inguinal hernia. The patient presented with septicaemia, pneumaturia and left iliac fossa pain. His computed tomography (CT) scan indicated the presence of gas in the bladder and a thickened loop of sigmoid colon attached to the region of the dome of the bladder. Colonoscopy showed some scattered diverticula in the sigmoid colon but no tumour. On surgical exploration, the "Kugel" mesh was found to erode the sigmoid colon and the bladder wall, leading to a colovesical fistula. An anterior resection of the rectum with removal of the mesh with closure of the bladder wall defect was performed.

Preperitoneal groin hernia repair with Kugel patch through an anterior approach

Kugel hernia repair is classically carried out through the posterior approach; in this study we investigated the effectiveness and invasiveness of a Modified Kugel (Bard-Davol Inc., RI, USA) hernia repair procedure carried out through an anterior approach. A prospective series covering a 2-year period, including 122 patients (142 hernias) were carried out using the anterior approach. Patient comfort, complications and recurrence were evaluated. A total of 142 inguinal hernias were repaired, median age was 67 years, the mean operation time was 51 +/- 23 min and the average incision was 4.5 cm. There was one case recurrence 5 months after repair. Other complications were few and not severe, only slight groin discomfort was observed in two patients during follow up. This Modified Kugel hernia through anterior approach is effective, mini-invasive and easy to learn with fewer complications.

Enterocutaneous fistula associated with ePTFE mesh: case report and review of the literature

A case of enterocutaneous fistula secondary to the erosion of an expanded polytetrafluoroethylene (ePTFE) prosthesis into the jejunum is described. This case is unusual secondary to the long experience with ePTFE and the lack of published cases similar to this one. The technical details of this case reveal extenuating circumstances associated with the fistula formation, and it is concluded that this particular case does not provide sufficient evidence to implicate ePTFE, by itself, as an etiologic agent for gastrointestinal fistulization. In addition, the published safety record of ePTFE in abdominal wall surgery is reviewed.

Prosthetic material in inguinal hernia repair: how do I choose?

With numerous prosthetic options and a changing landscape of prosthetic development, a systematic approach to choosing a prosthetic is more sensible than trying to memorize all the details of each prosthetic. The surgeon should hone a single technique for the vast majority of inguinal hernia repairs to maximize proficiency. This limits the number of prosthetics to those suitable for that technique. Narrowing the choice further should be based on the likelihood that a given prosthetic will achieve the preoperative goals of the hernia repair. For alternative clinical scenarios, the surgeon should know one to two additional techniques, which may require a different prosthetic. The surgeon should use existing experimental and clinical data to estimate long-term benefits of any new prosthetic.

Open repair of inguinal hernia: an evidence-based review

This article provides an evidence-based review of open hernia repair. Technical considerations in general, including perioperative management of the patient, and the most currently used open repairs are addressed. Outcomes after repair are reviewed using the latest available literature. Current recommendations from this review include the routine use of mesh in primary repair of inguinal hernia and the need to counsel patients preoperatively about the risk of chronic postoperative groin pain.

Experience with direct Kugel patch method for repair of adult inguinal hernia

The direct Kugel Patch method is a minimally invasive but nonlaparoscopic preperitoneal method of hernia repair which has various ideal characteristics including all the benefits of laparoscopic hernia repair without the risks of complications. In this retrospective study, we report our experience with this method for adult inguinal hernia repair. Forty-four hernias, including 35 indirect, 7 direct inguinal hernias, and 1 recurrent indirect inguinal hernia, in 41 patients were surgically repaired using the direct Kugel patch method. The average operation time was 45.6 +/- 11.3 min, and the average hospitalization time was 6.2 +/- 5.0 days. There were 5 complications of seroma and only 1 recurrence of hernia which were successfully managed. We concluded that the direct Kugel patch method provides an ideal approach to adult inguinal hernia repair with short operation time and hospital stay and a very low risk of complications or recurrence.

Stab anterior preperitoneal hernioplasty in groin hernias: a new technique

With laparoscopic hernia repair still not qualifying as the ideal method, the search is still on for the optimal method of intervention combining the advantages of both open mesh repair and laparoscopic repair for groin hernias. Eighty-five patients with uncomplicated inguinal hernias classified as Nyhus type 2 or higher were operated on by the modified anterior preperitoneal (APP) repair. The peroperative parameters were studied and compared with those of totally extraperitoneal (TEP) repair to determine the efficacy of the modified approach. Eighty-eight anterior preperitoneal repairs were carried out on these 85 patients. Twenty-one patients were Nyhus type 2, 17 were type 3a (direct), 41 were type 3b (indirect), and nine were type 4 (recurrent). The results were compared with TEP parameters done by the same surgeon. The incision size was 2.8 cm (2.3-4.5 cm). The operating time was 15.7 min (11-26 min) compared with 31.2 min for the TEP repair. Discharge time was 2.3 days (range 2-4 days) compared with 2.2 days in TEP repair. Complications included seroma in eight patients, pain radiating to the scrotum even at 6 months in one patient, and superficial wound infection in one patient. Return to work in patients with stab APP was 12.6 days ( 7-15 days ), whereas it was 10.4 days in TEP repair. The overall recurrence rate was 1.66% at the end of 2 years. The results with stab APP repair were comparable with those with TEP repair. The stab APP in addition had the advantage of being easier to learn and can be done faster.

Surgical management of inguinal hernia

The Lichtenstein repair is now the gold standard for open hernia repairs. This repair is easier to learn and easy to implement for the average general surgeon. Open mesh repairs are not the end-all in hernia operations, however, and surgeons must retain the knowledge for open tissue-based procedures. Laparoscopic inguinal hernia repair is a safe alternative to open repair for inguinal hernias but is much more operator dependent. Open mesh repair has a lower recurrence rate when compared with TEP or TAPP repairs for less experienced laparoscopists. Laparoscopic repair has a quicker return to work, is associated with less postoperative pain, and has a better cosmetic result. It is more difficult to learn, however, and hospital costs are higher. Surgeons need to look at their own numbers and experience to decide which approach is better given the clinical situation based on their proficiency with the various techniques.

Femoral hernia repair

Plug insertion for primary femoral hernia repair may cause p.o. discomfort. The Kugel technique may avoid this problem. Patients' satisfaction to the Kugel and the plug techniques is compared in the present study. Demographics, surgical, outcome and analgesic consumption data of 26 patients treated for with the plug technique (P group) are compared with 24 operated with the Kugel patch (K group). Patients' p.o. discomfort to the two procedures was measured with quantitative (VAS score) and a qualitative (the short form of McGill pain questionnaire, SF-MPQ) methods, and compared. P group presented higher early p.o. pain (P<0.001), higher analgesic consumption and a significative delay in the return to physical activity (P<0.001). SF-MPQ scores at p.o. day 8, day 30 and month 6 were significantly lower for K group (P<0.001, P<0.001, P<0.005). The Kugel technique for femoral hernia treatment seems to cause less p.o. discomfort to patients than the plug technique.

Closer to an ideal solution for inguinal hernia repair: comparison between general surgeons and hernia specialists

BACKGROUND

It is accepted a priori that specialists of hernia surgery have better results than general surgeons who use the same or different techniques as part of their complete surgical repertoire.

METHODS

Results of general surgeons trained in the technique of hernia repair using a bilayer connected mesh device (BCMD) was compared to results of specialists and other general surgeons who used other techniques.

RESULTS

One report from hernia specialists and three additional reports from trained general surgeons showed similar results using a BCMD. These results were better than results of all other mesh repairs.

DISCUSSION

This study shows the value of surgeon-training as well as the value in the design of a particular mesh device for hernia repair. The three components of this device offer three separate, yet connected, barriers to the formation of a recurrent hernia.

CONCLUSION

General surgeons trained to use a bilayer mesh device repeatedly duplicated the results of specialists who used it.

Kugel hernia repair: open “mini-invasive” technique. Personal experience on 620 patients

A large monoinstitutional series adopting the Kugel retroparietal technique for inguinal hernia surgery is analysed. Our aim is to assess the "mini-invasiveness" of this technique. Six hundred and twenty patients (pts) affected by monolateral inguinal hernia were treated with a preperitoneal alloplasty with a posterior approach (Kugel hernia repair, KHR) between January 2002 and September 2004. The surgical incision extension was 3.5 cm on average (range 2-4.5). The mean operation time was 33 min (range 20-45). Spinal anaesthesia and ambulatory procedure were applied in 595 cases (96%). Postoperative complications affected 20 pts (3%). The postoperative pain was well controlled. No chronic neuropathic pain was registered at follow-up. Patients resumed work after an average of 9 days (range 7-12) from operation. Recurrence rate was 0.8%. Conclusions. The Kugel hernia repair satisfies the standards to be awarded as a "mini-invasive" technique.

Current approaches to inguinal hernia repair

The repair of a simple inguinal hernia or a complicated incisional hernia no longer involves just the sewing together of a defect in the musculature. Present-day hernia operations require that the surgeon more fully understand the functional anatomy and pathophysiology of the abdominal wall and groin. Hernia surgeons must be familiar with a myriad of surgical techniques, ranging from the traditional tissue repairs with suture to the mesh-based "tension-free" open and laparoscopic techniques. Furthermore, the surgeon must comprehend outcome analysis in evaluating differing therapies. Several approaches have been used for repair of groin hernias and have included tissue repairs (later termed "tension" repairs), as well as mesh or tension-free repairs and laparoscopy. Although each of these repairs boasts its successes, there are advantages and disadvantages to each approach. This article highlights each of these repairs through review of the literature.