Inguinal hernia recurrence: classification and approach

We reviewed case reports, updated to January 2005, of 2,468 operations for groin hernia in 2,350 patients, including 277 recurrent hernias. The data obtained, following a simple anatomo-clinical classification into three types that could be used to orient surgical strategy, were: type R1--first recurrence of "high" oblique external reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; type R2--first recurrence of "low" direct reducible hernia with small (<2 cm) defect in non-obese patients after pure tissue or mesh repair; and type R3--all other recurrences, including femoral recurrences, recurrent groin hernia with large defect (inguinal eventration), multi-recurrent hernias, non-reducible contralateral primary or recurrent hernia, and situations compromised by aggravating factors (e.g. obesity) or otherwise not easily included in R1 or R2 after pure tissue or mesh repair.

Spigelian Hernia

We report on the evolution in concept and techniques that allowed us to improve the treatment of spigelian hernia, operable in day surgery in 90% of cases and through a preperitoneal and recently a preperitoneal and subfascial prosthetic repair (PHS).

BACKGROUND DATA

We propose an innovative use of the PHS mesh for spigelian hernia repair. With this new implementation, we confront the standard surgical technique and its postoperative period.

METHODS

From January 1992 to March 2004, we performed 2,500 hernia surgical operations, including 32 spigelian hernia repairs (1.3% of total case series). The first surgical approach used for 20 of these 32 patients (62.5% of total spigelian hernias), all electively operated on, was a classical preperitoneal repair (Wantz), performed when possible by size of defect and weight (Body Mass Index) of the patient, under local anesthesia and on a day-surgery basis. Our new modified technique takes place through the insertion of a PHS large-type mesh, whose bottom underlay portion lies flat in the preperitoneal space with the connector obliterating the hernial orifice and with the overlay portion lying on the internal oblique muscle, covered by the aponeurosis of the external oblique muscle.

RESULTS

Our modification to the classical technique consisted only in the application of a product, such as the PHS, in a hernia defect, which presented with an orifice of the size of the connector and, therefore, was easily repairable with the use of the PHS device. This approach is easier than the preperitoneal approach, it's always suitable for local anaesthesia, and it gives a more comfortable postoperative period. The surgical approach may be performed completely in day surgery.

CONCLUSIONS

We believe that spigelian hernia surgical repair should always be performed by means of a preperitoneal prosthesis under local anaesthesia when the patient's clinical and physical conditions allow for it, always in day surgery, and using the PHS mesh when the hernia defect size fits with the connector diameter. This last possibility seems to be easier and more comfortable for the patient in the postoperative period.

Prosthetic repair, intestinal resection, and potentially contaminated areas: Safe and feasible?

INTRODUCTION

Prosthetic repair for abdominal wall hernia currently represents the gold standard. However, it is still difficult to identify the correct indication for prosthetic implant in borderline cases. The authors propose evaluating whether a prosthetic implant is absolutely contraindicated in potentially infected operating fields through the review of literature and personal experience.

MATERIALS AND METHODS

The authors performed ten prosthetic hernia repairs in potentially contaminated areas, with a preliminary preparation of the retromuscular-preperitoneal space hosting the prosthesis implant, and subsequent performance of the major operation.

RESULTS

There were neither major nor minor complications with a 21-month follow-up (mean period).

DISCUSSION

It is certain that both in noncomplicated inguinal hernia and in abdominal wall hernia repairs, the use of antibiotics can significantly reduce the number of infections. It is very important to underline that the success of the described procedure can be guaranteed only by an accurate preparation of the preperitoneal space: perfect haemostasis, temporary closure of the space with the insertion of iodine gauzes and suturing the edges, local antibiotic treatment, washing of the cavity, and accurate drainage.

CONCLUSIONS

Prosthetic repair is the gold standard for inguinal, incisional, and all abdominal wall hernias and should be used, with the method described, even in potentially contaminated areas. The use of a prosthesis has to be avoided in clearly infected cases.

Difficult hernia repair in the elderly. A particular case

A particular clinical case personally observed is described. On the basis of this case it is evaluated if it can be correct to implant a mesh in potentially contaminated areas, if preperitoneal repair is the best approach in recurrent or difficult hernia repair and if there are specific contraindications in operating elderly patients.