Giant prosthesis for reinforcement of visceral sac for complex bilateral and recurrent inguinal hernias: a prospective evaluation.

VV Thapar, PP Rao, RR Prabhu, CC Desai, AS Singh, AN Supe 
 Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India

Correspondence Address:
V V Thapar
Department of Surgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
India

Full Text

Complex bilateral inguinal hernias are defined as bilateral groin defects associated with factors predicting high risk for recurrence such as large size, advancing age, poor muscle tone and other co-morbid conditions like chronic obstructive pulmonary diseases (COPD)[1]. Complex recurrent inguinal hernias are defined as bilateral recurrent inguinal hernias or a recurrent inguinal hernia with a contralateral primary hernia[2]. These hernias are associated with high risk for recurrences[1],[2],[3]. Reasons for these high recurrences include failure to identify the patients and factors affecting recurrence such as large size, weak fascial structures and associated medical conditions like COPD. In addition, the use of the anterior approach to hernia repair for recurrences requires extensive dissection and the use of scarred and devascularised tissues for repair[1],[2].

In order to improve these results Stoppa et al[4] first described a technique aimed at eliminating hernias of the groin and the lower abdomen by reinforcing the peritoneum with a giant polyester mesh. With this giant prosthesis for reinforcement of visceral sac (GPRVS) the mesh acts as an artificial endoabdominal fascia and prevents herniation of the visceral sac through the myopectineal orifice where all the groin hernias begin. Our study is a prospective evaluation of GPRVS for repair of complex bilateral and recurrent inguinal hernias.

::   Subjects and methods

From December 1997 to December 1998, consecutive patients presenting for inguinal hernia repair to a single surgical unit at a tertiary health care centre were selected. The criteria for selection were complex bilateral and recurrent inguinal hernias. Obstructed and strangulated hernias were excluded from the study. Follow up was obtained by examinations at out-patient department.

Technique:

The technique developed by Stoppa et al[4] is used with some minor modifications. The procedure is performed under spinal or general anaesthesia. Amoxycillin 1 gm with clavulanic acid 0.2 gm is given intravenously just prior to taking the incision. A midline incision extending from the umbilicus to the pubic symphysis is taken after placing the patient in a mild Trendelenberg position. The abdominal wall is incised strictly in the midline and the umbilico-prevesical fascia is cut along its entire length. The preperitoneal space is entered with blunt dissection aided by some sharp dissection when the peritoneum is scarred due to previous operations. The dissection includes the retropubic space of Retzius and laterally behind the iliopubic ramus in the space of Bogros. The dissection proceeds laterally under the rectus abdominalis and posterior to the inferior epigastric vessels on the side opposite to the surgeon till the external iliac vessels and the iliopsoas have been identified. Above, the dissection is carried out till the arcuate line of Douglas. The hernia is isolated either distinct from the spermatic cord (in case of direct hernias) or with the spermatic cord (as in indirect hernias). The hernial sacs are treated differently. Direct hernias are reduced, large sacs amputated and ligated with a pursestring suture leading to a smoother visceral sac. Indirect sacs can be reduced by applying traction on the sac or in difficult cases, because of previous adhesions, the sacs are divided, proximal peritoneum is over sewn leaving the distal peritoneum in place undissected and attached to the cord. The spermatic cord and gonadal vessels are parietalised from their peritoneal attachment so that the need to split the mesh is avoided. Now the surgeon changes sides and repeats the same procedure on the opposite side.

The polypropylene mesh (Proline, Ethicon) is fashioned like a chevron and placed in the preperitoneal space with the help of long Kellys artery forceps. The width of the mesh equals the distance between the two anterior superior iliac spines minus two cms and the vertical length equals the distance between the umbilicus and the pubic symphysis. The mesh is spread out by grasping its corners and the centre of each side with the help of Kellys forceps. With the assistant lifting and retracting the parietal wall, the surgeon depresses the peritoneal sac pulling it towards him, so as to open the pre-peritoneal space. First, the forceps holding the inferior middle edge of the mesh is placed between the pubis and the bladder followed successively by the forceps holding the inferior lateral corner, the middle point of the lateral edge and finally the upper lateral corner in that order. The forceps are pushed as far as possible under the abdominal wall, thereby unfolding the mesh and placing it at the inferior, lateral and the posterior limits of the preperitoneal dissection. When the forceps have been pushed as far as possible the assistant immobilises them till the surgeon removes his hand thereby allowing the visceral sac to resume its normal position. The retractor on the abdominal wall is also removed at this time. The Kellys forceps are then gently declamped and are removed by carefully slipping them against the deep surface of the abdominal wall. The surgeon again changes sides and repeats the same procedure on the opposite side.

The midpoint of the superior border is then sutured by a single stitch of non-absorbable suture material to the Richets fascia, the mesh being held in place by virtue of its large size and by the intra-abdominal pressure holding the mesh flat between the peritoneum and the abdominal wall (Pascal’s hydrostatic principle). One or two suction drains are then placed between the mesh and the abdominal wall and the midline incision is closed by non-absorbable suture material.

Liquids are started within six hours of the procedure and advanced to regular diet as tolerated. Drains are removed after 48 hours and the patients discharged if they can void and tolerate liquids. They return to follow up after 10 days for suture removal and a further three monthly follow up at the out patients clinic is advised. All patients are urged to return to their daily routine soon after the procedure.

::   Results

A total of 62 inguinal hernias (31 patients) were repaired. All the patients were men. The mean age was 58 years (range 49-95 years). Risk factors predicting high risk for recurrence included a large hernia size (? 5 cms, 32 %, n=10/31), failure of one or more previous repairs (45%, n=14/31), COPD (25%, n=8/31) and poor tone as graded clinically (70%, n=22/31).



The GPRVS was completed in all the patients and no conversion to other technique was required. General anaesthesia was used in 16 % (5/31) patients and spinal anaesthesia in the remaining 83% (26/31). The mean ? SEM operative time was 65 ? 11 minutes (range 45-115 minutes). There were no major complications and four minor complications (superficial wound infections in two, urinary retention & thrombophlebitis in one each), none requiring re-operation. There were no mesh infections or deaths. At the end of a mean follow up period of 14.6 months (range 12 - 23 months), there were no recurrences. [Table:1]

::   Discussion

Since Bassini first described his technique for repairing inguinal hernias by reinforcing the posterior wall and performing high ligation of the sac multiple approaches have been described in an attempt to improve the results and lower recurrences rates. However, still complex bilateral and recurrent inguinal hernias are associated with high recurrence rates ranging from 5 - 30%[2],[5].

The GPRVS for repair of complex bilateral and recurrent inguinal hernia is a logical extension of the tension free mesh repair principle used for primary or recurrent unilateral inguinal hernias[6]. The posterior approach allows a bilateral approach through a single incision at the same setting, avoids the risk of ischaemic orchitis and nerve injury and the scar tissue from the previous repairs. The abdominal wall reinforcement is achieved by a large pre-peritoneal inlay of prosthetic mesh rather than by approximating already weakened and scarred aponeurotic and fascial structures especially seen in these patients. The mesh is held in its place initially by virtue of its large size and the intraabdominal pressure forcing the mesh to lay flat between the peritoneum and the fascial layers. Later, the fibrous ingrowth prevents the mesh migration and seals the inguinal, femoral and obturator canals as well as other potential sites of weakness in the lower abdomen[2],[4]. This, therefore makes late recurrences unlikely[2],[4].

In our study of repair of complex bilateral and recurrent inguinal hernias in 31 patients with 62 hernias there were no recurrences. Similar low recurrence rates of less than 2% have been reported in other studies[1],[2],[4]. The complication rate of 6% in our study, is comparable with the other reports[1],[2],[4]. Major complications like haematoma formation, mesh infection and mesh extrusion are rare accounting for only 2-5%[1],[2],[4]. In spite of two superficial wound infections in our series, there were no mesh infections. Polypropylene is known to be very resistant to infection and even if infection occurs the infected wounds with exposed mesh heals most often without the need to remove the mesh[7],[8]. For this reason we have used polypropylene as material of choice though other surgeons prefer the polyester mesh[1],[4] . The operative time taken is well within the time taken to repair bilateral inguinal hernias with the anterior approach using two inguinal incisions. The hospital stay is acceptable considering the elderly age group operated upon and the presence of associated co-morbid conditions.

The GPRVS is not a question of a major operation for a simple illness but of an operation correctly adapted to cure certain hernias that have become more serious. This study supports the observations of other surgeons that the GPRVS provides a definitive and a safe cure for repair of complex bilateral and recurrent inguinal hernias because of its simplicity, ease of the procedure, excellent results and low complication rates[1],[2],[4],[5].

References