MINIMALLY INVASIVE OPEN REPAIRS
PHILLIP P. SHADDUCK, MD
Groin hernias and their treatment remain a significant healthcare problem. They occur with an incidence of 1 in 350 to 500 men/year and have a lifetime prevalence in men of 6% to 27% [1-4]. Approximately 800000 inguinal/femoral hernia repairs are performed annually in the United States [1,4]. The socioeconomic impact of groin hernias on the US healthcare system is estimated to be several billion dollars annually. As one of the “most frequently performed operations in general surgery…even minor alterations in outcome and resource use have appreciable impact,” . Fortunately, during the last 15 years, tremendous progress has been realized in herniorrhaphy techniques and outcomes. This article will review the historical background and summarize the latest techniques in this ongoing evolution.
EVOLUTION OF TECHNIQUES
Bassini made the critical observation that the successful treatment of hernias depends not on manipulation of the hernia sac but rather on repair of the underlying defect. Prior to Bassini’s observation in the 1880s, recurrence rates were essentially 100%. The repairs developed by Bassini, Halsted, and McVay addressed the myofascial defect and thereby reduced recurrence rates to 10% to 15%. These sutured repairs remained the mainstays of Shouldice’s multilayer repair reduced recurrence rates even further, to approximately 1% to 2%, and gained popularity by the 1980s. However, all of these sutured repairs resulted in tissue tension, postoperative pain, and temporary disability. Mesh techniques were developed to reduce tension, postoperative pain, disability, and recurrence rates. Though several mesh techniques were described through the mid to late 1900s (Cheatle, Nyhus, Condon, Stoppa, Rives, Wantz, and others), widespread acceptance of mesh repairs was not achieved until Lichtenstein’s “tension-free hernioplasty” in 1989. With the acceptance of open mesh repairs, and the laparoscopic cholecystectomy revolution at that same time, laparoscopic mesh repairs followed. By the early 1990s, the transabdominal preperitoneal placement (TAPP) and totally extraperitoneal placement (TEP) of mesh were being touted as minimally invasive techniques. Though the TAPP/TEP repairs did have the advantages of minimal pain and rapid postoperative recovery, they had the disadvantages of longer learning curves, higher operative costs, and rare but serious complications. Over the last decade, several investigators have endeavored to develop techniques that combine the best of both worlds–achieving the advantages of open mesh repairs (simplicity, safety, low recurrence, low cost) and of laparoscopic repairs (minimal pain and rapid recovery). Thus were born the “minimally invasive open repairs.”
THE “MINIMALLY INVASIVE OPEN REPAIRS”
The author considers the following to be “minimally invasive open repairs”: (1) the plug and patch repair (Rutkow, 1993); (2) the Prolene Hernia System (PHS) repair (Gilbert, 1999); and (3) the Kugel repair (Kugel, 1999). Taken together, these 3 new techniques already account for about 40% of hernia repairs performed in the United States (plug and patch >30%, Kugel 8% to 9%, PHS 1% to 2%). They approximate the Lichtenstein tension-free hernioplasty (approximately 40%) and exceed the laparoscopic repairs (approximately 10% to 15%) and sutured repairs (<10%) (Figure 1).
Several variations exist on the theme of a plug and patch repair. The best studied and most widely practiced technique is that developed by Dr Ira Rutkow [6,7]. This technique involves placement of a polypropylene plug through the hernia defect into the preperitoneal space, and then placement of a flat polypropylene patch on the inguinal floor, with little or no suture fixation (Figure 2).
The Prolene Hernia System (PHS) repair was developed by Dr Arthur Gilbert . The PHS patch is also made of polypropylene and is described as a “3-in-1” device, incorporating an “underlay patch” that is positioned in the preperitoneal space, a “connector” that is placed thru the hernia defect, and an “onlay patch” that is placed on the inguinal floor, also with minimal fixation (Figure 3).
The Kugel technique was developed by Dr Robert Kugel . The Kugel patch is a bilayer polypropylene patch with a self-retaining outer memory recoil ring. Through a 3-cm to 4-cm muscle splitting incision, the preperitoneal space is entered and a pocket developed, and the mesh is positioned in the preperitoneal space. This results in a repair that is anatomically very similar to the laparoscopic TAPP/TEP repairs (Figure 4).
All 3 of these techniques are accomplished in an ambulatory setting, with the patient under local or regional anesthesia, with operative times of about 30 minutes, minimal postoperative pain, and rapid recovery with little or no work restrictions. What are the results of these new techniques, and how do the results compare with those of other more established techniques?
A literature search of all published results for these minimally invasive, open repairs reveals about 20 randomized clinical trials (RCT) and prospective studies [10-30]. Most of these studies address the Rutkow plug and patch technique [10-24]; few published RCT and prospective studies exist for the Kugel and PHS repairs [25-27,29]. The available results from these publications are summarized and presented, in simplified form, alongside outcomes for more established mesh repairs (Lichtenstein and laparoscopic TAPP/TEP) (Table 1). Data from nonmesh, sutured repairs are not presented here. The interested reader is referred to the Cochrane metaanalysis for data demonstrating that open mesh techniques have fewer recurrences, allow quicker return to work, and cause less persistent pain than do nonmesh, sutured repairs. Each of the 5 mesh repairs presented in the table has advantages and disadvantages. The differences among the mesh techniques are, in many parameters, subtle. Based on available data, it appears that the minimally invasive open techniques have comparable perioperative and short-term results when compared with those of more established techniques and therefore merit additional study, particularly in randomized trials and prospective registries.
Groin hernias remain a significant healthcare problem. Herniorrhaphy is one of the most frequently performed general surgery operations. The cost of hernia treatment runs into the billions of dollars annually. In the last 2 decades, hernia repair techniques have undergone an evolution, almost revolution. The minimally invasive open repairs are the newest entries in this ongoing process. Though most would probably agree that we have not yet achieved an ideal hernia repair, it appears that we may be closer now than ever before.
Figure 1. Utilization of groin hernia repair techniques in the United States, 1970-2002. Adapted from Rutkow I. Surg Clin North Am. 1998;78:941.
Figures 2a, 2b, 2c. The plug and patch repair as described by Dr Rutkow [6,7]. The polypropylene mesh plugs and preformed onlay patch (Bard PerFix Plug, Davol, Cranston, RI, USA/Bard, Murray Hill, NJ, USA) are shown. The procedure is accomplished with the patient under epidural anesthesia, without routine antibiotics. A 4-cm to 6-cm oblique incision is made, and standard dissection is performed with cautery. No specific effort is made to identify or mobilize the nerves. For indirect hernias, the sac is mobilized high, not opened or ligated, and dropped back through the internal ring. The mesh plug is positioned into the internal ring, tapered end first, as shown here, and sutured to the crura with absorbable sutures. The onlay patch is then positioned in the inguinal canal as shown, with little or no suture fixation. For direct hernias, the sac is circumscribed circumferentially with electrocautery, invaginated, and then the mesh plug and onlay patch placed in a similar fashion.
Figure 3. The Prolene Polypropylene Hernia System (PHS) repair . The “3-in-1” PHS prosthesis (Ethicon/Johnson & Johnson, Somerville, NJ, USA) incorporating the underlay patch, connector, and onlay patch. Standard incision and exposure are accomplished. For indirect hernias, high dissection of the sac is performed and the sac invaginated through the internal ring. The preperitoneal space is “actualized” with forefinger and sponge dissection. The onlay patch and connector are grasped with a sponge forceps, and the underlay patch is deployed into the preperitoneal space, inferior to the cord structures. The connector is positioned in the defect at the internal ring. The onlay patch is positioned along the inguinal floor, with overlap of the pubic tubercle and transverse aponeurotic arch. A slit is created in the onlay patch to accommodate the cord structures. The onlay patch is suture fixated to the pubic tubercle, the mid portion of transversus aponeurotic arch, and the mid portion of inguinal ligament.
Figures 4a, 4b. The Kugel repair . The Kugel Hernia Patch (Davol, Cranston, RI, USA/Bard, Murray Hill, NJ, USA) is a bilayer polypropylene patch with a self-retaining outer “memory recoil ring.” Local, regional, or general anesthesia is used. A 3-cm to 4-cm transverse incision is made superior to the mid point between the pubic tubercle and anterior superior iliac spine. The external oblique is incised, the internal oblique and transversus abdominus split bluntly, and the transversalis fascia incised vertically. The preperitoneal space is entered and a pocket developed. For direct hernias, the hernia contents are reduced fully. For indirect hernias, the cord structures are delivered through the incision, and the indirect sac and/or “cord lipoma” mobilized high and invaginated into the preperitoneal space. Dissection can be blunt (by palpation), sharp, or both, under direct visualization (facilitated by headlight and 1” malleable retractor). An 8 x 12-cm (or 11 x 14-cm) Kugel patch is introduced into the preperitoneal pocket and positioned as shown, resulting in coverage of the pubis, Cooper’s ligament, rectus abdominus, transversus abdominus, and all direct inguinal/indirect inguinal/femoral defects and potential defects.
Address reprint requests to: Phillip Shadduck, MD, 4301 Ben Franklin Blvd, PO Box 15698, Durham, NC 27704, USA. Tel: 919 479 4400, Fax: 919 620 8212.
Dr Shadduck is Chief of General Surgery, Durham Regional Hospital; Attending Surgeon, Durham Veterans Administration Medical Center; and Assistant Consulting Professor of Surgery, Duke University Medical Center, Durham, NC. He received his undergraduate degree from the University of California, Riverside, and his medical degree from the University of California, Los Angeles. His surgical internship, residency, and research fellowship were completed at Duke University Medical Center.
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