Home Print this page Email this page
Users Online: 2182
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 177-179

Preperitoneal sutureless mesh repair of inguinal hernia by open inguinal approach using inferior epigastric vessel complex as landmark: A tertiary care centre experience


Department of General Surgery, Government Medical College, Rajindra Hospital, Patiala, Punjab, India

Date of Web Publication13-Aug-2014

Correspondence Address:
Bhupinder Singla
Department of General Surgery, Government Medical College, Rajindra Hospital, Patiala, Punjab - 147 001
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.138601

Rights and Permissions
  Abstract 

Introduction: The study is a clinical trial done on patients with inguinal hernia, who were treated by open preperitoneal sutureless mesh repair, using inferior epigastric vessel complex as landmark. Aim: To study the postoperative complications and recurrence rates associated with the open preperitoneal sutureless mesh repair. Materials and Methods: Total 100 patients of inguinal hernia were recruited in this clinical trial from January 2009 to December 2012. Those with bilateral inguinal hernia or recurrent hernias were excluded from the study. Results: The average time taken to complete the surgery was 42.2 minutes and the average hospital stay was 2.5 days. Post-surgery, at a median follow-up period of 2 years, only 2 patients had seroma formation. Visual analog scale pain scores of 4 and 6 were seen in 60% and 40% cases, respectively. No recurrences were encountered post-surgery in any of the case till the last follow-up. Conclusion: This procedure was found to have fewer complications and was less time-consuming as compared to the other conventional open hernia repairs.

Keywords: Inguinal hernia, mesh repair, preperitoneal, sutureless


How to cite this article:
Chawla I, Singla B, Gupta S, Singh V, Singh M. Preperitoneal sutureless mesh repair of inguinal hernia by open inguinal approach using inferior epigastric vessel complex as landmark: A tertiary care centre experience. Int J Health Allied Sci 2014;3:177-9

How to cite this URL:
Chawla I, Singla B, Gupta S, Singh V, Singh M. Preperitoneal sutureless mesh repair of inguinal hernia by open inguinal approach using inferior epigastric vessel complex as landmark: A tertiary care centre experience. Int J Health Allied Sci [serial online] 2014 [cited 2024 Mar 28];3:177-9. Available from: https://www.ijhas.in/text.asp?2014/3/3/177/138601


  Introduction Top


The surgical history of inguinal hernias dates back to ancient Egypt. From Bassini's heralding of the modern era to today's mesh-based open and laparoscopic repairs, this history parallels closely the evolution in anatomical understanding and development of the techniques of general surgery. [1] While numerous surgical approaches exist to treat inguinal hernias like Bassini's, Shouldice and Lichtenstein repair, we present a clinical trial of 100 patients in which open preperitoneal sutureless mesh repair of inguinal hernias was done using inferior epigastric vessels as landmark.


  Materials and methods Top


This is a prospective clinical trial, conducted in 100 patients of inguinal hernia, in the department of surgery of our institute, from January 2009 to December 2012. Patients in the age group 20-70 years were included in this trial. Those with bilateral inguinal hernia or recurrent hernias were excluded from the study.

Under spinal anesthesia, an incision was made half an inch above and parallel to the medial two-third of inguinal ligament. The external oblique aponeurosis was cut up to the superficial inguinal ring, so as to expose the whole of the inguinal canal. The ilioinguinal and iliohypogastric nerves were identified and preserved. The investing layers of internal spermatic fascia and cremastric fascia surrounding the cord were split opened. Cremastric branches supplying the cremaster muscle and other coverings of the cord could bleed, when cremastric layer is dissected off the spermatic cord. Bleeding points were picked up and coagulated with diathermy. In the cases of indirect hernias, the sac was identified and isolated from the rest of the cord. Then the sac was opened, the contents were reduced and the sac was transfixed. The proximal part of the hernial sac was dissected up to its neck, where the inferior epigastric vessels were identified, lifted up by Lahey's forceps and an umbilical tape was passed [Figure 1]. Space was created below the inferior epigastric vessels by blunt dissection using roll gauze or finger dissection medially up to the midline, laterally up to the anterior superior iliac spine, and 6 to 8 cm above the pubic symphysis.
Figure 1: Inferior epigastric artery lifted up to create preperitoneal space

Click here to view


We encountered pubic branch of inferior epigastric artery in two cases, which was injured in 1 case unintentionally, and in the other case it was identified and secured safely. Mesh of size 11 × 7 cm and 15 × 8 cm were used and depending upon the patient's built, it was tailored and a slit was created in the lateral part of the mesh, which encircled the spermatic cord snuggly at the level of the internal ring. Mesh was placed behind inferior epigastric vessels in the preperitoneal space [Figure 2]a and b.
Figure 2: (a and b) Mesh placed in preperitoneal space behind inferior epigastric artery

Click here to view


In the cases of indirect hernia, we never sutured the mesh; instead, it was placed properly in the extraperitoneal space. In the cases of direct hernia, after pushing back the sac and creating good space in the extraperitoneal space, we anchored mesh with cooper ligament with one or two interrupted nonabsorbable sutures. Internal ring was narrowed wherever it was wide. Spermatic cord was placed over it and external oblique aponeurosis was closed with interrupted nonabsorbable sutures. The subcutaneous and subcuticular closure was done with absorbable sutures and the skin was stitched with nonabsorbable sutures.


  Results Top


Out of 100 patients, 80 had indirect hernia and 20 had direct hernia. The mean age of the patients was 45 years (range: 20 to 70 years) [Table 1]. The average time taken to complete surgery was 42.2 minutes and the average hospital stay was 2.5 days. There were no adverse effects of the spinal anesthesia in these 100 patients. At a median follow-up period of 2 years, only 2 patients had seroma formation, of which one resolved spontaneously and, in the other, it was large and was aspirated. No other postoperative complication occurred in the patients [Table 2]. For postoperative pain, visual analog scale (VAS) pain score of 4 was seen in 60% cases and 6 in 40% cases. No recurrences were encountered post-surgery in any of the case till the last follow-up.
Table 1: Patient's profile

Click here to view
Table 2: Postoperative complications

Click here to view



  Discussion Top


Eighty percent of hernias are inguinal and 92% are in men, 18% of which occurs below 15 years of age. The pathophysiology behind an indirect hernia is a patent or partially patent processus vaginalis (lateral to the inferior epigastric vessels). Direct hernias begin medial to the inferior epigastric vessels, within Hesselbach's triangle; therefore, they do not pass through the deep inguinal ring. They are thought to occur secondary to a deficient posterior inguinal wall. [2]

There are many ways of repairing an inguinal hernia, with over 80 operative techniques described so far, the most common being, the meshless repairs (modified Shouldice and Bassini's) and the mesh technique (modified Lichtenstein). [3]

Open mesh repair is associated with reduction in the risk of recurrence by 50% to 75%. There is also some evidence of quicker recovery with reduced rehabilitation period and lower rates of persisting pain as compared to sutured repairs. [4] Large case series indicate recurrence rates for mesh repairs as low as 0.2%, with similar results reported for recurrent hernias. [5]

Pain in the postoperative period is always expected and requires appropriate analgesia. The degree of pain and neuralgia varied among different studies. In a study by Campanelli et al. complete absence of pain was seen in 81.5%, a pain score of 2 was seen in 15.8% and only 2.7% patients reported a pain score of 3. [6] Pain score of more than 3 was not seen in any of the registered patients. Pain control was seen within 2 months in all the patients. In our study, VAS pain scores of 4 and 6 were seen in 60% and 40% patients, respectively.

This technique of open preperitoneal sutureless mesh repair is better than other methods of hernia repair. Inferior epigastric vessel complex was chosen as the landmark for this approach because this vessel complex runs in the transversalis fascia, i.e., above the peritoneum, which makes it easy for an operating surgeon to make the preperitoneal space, so as to place the mesh in that space, and also, very minimal dissection is needed in this procedure. Compared to prolene mesh hernia system, single mesh is used in this system, patients encounter less stiffness and pain, and postoperative recovery is quick. The advantages of this system over laparoscopic repair is that it is cost-effective, can be done at a facility where laparoscopic setup is not present, is easy to learn, operating time is less and no general anesthesia is needed for this type of inguinal hernia repair.

In the literature, the incidence of neuralgic pain is 1.9% and 3.5% in laparoscopic and open repairs, respectively. [7] In our study, there was no neuralgic pain in a follow-up period of 2 years. The approach used in this study requires little expertise to demonstrate the anatomy and methodology of placing the mesh. Great care must be taken to precisely place the preperitoneal mesh to achieve remarkably low recurrence rates. If the surgeon has no experience in opening the posterior wall of inguinal canal and dissecting the preperitoneal space, then additional training is required before attempting this repair.


  Conclusion Top


Inferior epigastric vessel complex is a good landmark to approach the preperitoneal space. Mesh can be kept in this space without sutures. In this approach, a policy of selective mesh fixation was followed. Avoiding routine fixation of the mesh helps in decreasing the complication rate and operative cost.

 
  References Top

1.Sherwinter DA, Lavotshkin S, Macura JM, Adler HL. Hernia Inguinal Repair, Open. Updated: Jul 24, 2009.  Back to cited text no. 1
    
2.Ali M, Habiba U, Hussain A, Hadi G. The outcome of darning method of inguinal hernia repair using polypropylene in a district general hospital. JPMI 2003;17:42-5.  Back to cited text no. 2
    
3.Ali N, Israr M, Usman M. Recurrence after primary inguinal hernia repair: Mesh versus Darn. Pak J Surg 2008;24:153-5.  Back to cited text no. 3
    
4.Grant AM. EU Hernia Trialists Collaboration. Open mesh versus non-mesh repair of groin hernia meta-analysis of randomized trials leased on individual patient data [corrected]. Hernia 2002;6:130-6.  Back to cited text no. 4
    
5.Atkinson HD, Nicol SG, Purkayastha S, Paterson-Brown S. Surgical management of inguinal hernia: Retrospective cohort study in southeastern Scotland, 1985-2001. BMJ 2004;329:1315-6.  Back to cited text no. 5
    
6.Campanelli G, Pettinari D, Cavalli M, Avesani EC. A modified Lichtenstein hernia repair using fibrin glue. J Minim Access Surg 2006;2:129-33.  Back to cited text no. 6
    
7.Poobalan AS, Bruce J, Smith WC, King PM, Krukowski ZH, Chambers WA. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 2003;19:48-54.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed3184    
    Printed145    
    Emailed0    
    PDF Downloaded228    
    Comments [Add]    

Recommend this journal