Causes of Recurrence in Laparoscopic Inguinal Hernia Repair
The factors involved in mesh dislocation or failure are insufficient size, wrong/defective material, incorrect placement, immediate or very early displacement by folding, lifting by a hematoma or urinary retention, missed cord lipomas and herniation through the keyhole (mesh slit) late displacement by insufficient scar tissue ingrowth, mesh protrusion, collagen disease or pronounced shrinkage. Despite the correct and stable mesh position, there is still a limited risk of a late sliding of the retroperitoneal fat under/ in front of the mesh into the enlarged inner ring.
Leibl in 2000 advised to avoid slitting of the mesh and increase its size to reduce the recurrence rate. Generous dissection of preperitoneal space is required to eliminate potential herniation through the slit or strangulation of the cord structures completely and reduces the risk of genitofemoral neuropathy.
Mesh Size
The mesh size should be adequate to cover the entire myopectineal orifice. The established size in 2006 is 15 × 10 cm per unilateral hernia, with minor deviations.
Mesh Material
The mechanical strength of available meshes exceeds the intra-abdominal peak pressures and by far even the lightweight meshes are strong enough for inguinal repair. Aachen group made an important contribution to understanding the interaction of the living tissue with the implanted mesh material. The negative impact of pronounced shrinkage of the traditional heavyweight meshes was recognized as an important factor promoting recurrence. Schumpelick introduced the logical trend of the use of lightweight meshes. The new macroporous compound meshes present both the successful reduction of the overall foreign body amount and the preservation of mesh elasticity after the scar tissue ingrowths, due to very limited shrinkage and reduced bridging effect.
Fixation of the Mesh
In the early years of laparoscopic hernia repairs, a strong fixation seemed to be the most important factor in the prevention of recurrence. With the growing size of the mesh and true macroporous materials being used, the belief in strength reduced and gave way to the concern of acute/chronic pain possibly caused by fixation. The controversy of fixing or unfixing the mesh is currently under scrutiny.
Technical Experience
The long learning curve of endoscopic repairs presents the potential risk of technical errors leading to the unacceptable rise of the recurrence rate. This fact highlights the need for structured well-mentored teaching, a high level of standardization of the procedure, and a rigorous adherence to the principles of laparoscopic hernia repair. The impact of experience on the recurrence rate was in both extremes well documented.
Collagen Status
Inborn or acquired abnormalities in collagen synthesis are associated with a higher incidence of hernia formation and recurrences.
Other Factors
The negative effect on healing in hernia repair is often related to malnutrition, obesity, steroids, type II diabetes, chronic lung disease, jaundice, radiotherapy, chemotherapy, oral anticoagulants, smoking, heavy lifting, malignancy, and anemia. Laparoscopic inguinal hernia repair offers excellent results in experienced hands.
Bilateral Assessment and Treatment
Up to 30 percent of patients with a unilateral hernia will subsequently develop a further hernia on the contralateral side. Also, when examined at operation, 10 to 25 percent is found to have an occult hernia on the contralateral side. Both laparoscopic approaches allow assessment and treatment of the contralateral side at the same operation without the need for further surgical incisions, very little further dissection, and minimal additional postoperative pain. In open surgery, a further large incision is required in the opposite groin. This considerably impairs postoperative mobility and increases the likelihood of admission to the hospital. Some surgeons advocate routine repair of the contralateral side during a laparoscopic repair.
Cost-Effectiveness
It is suggested that laparoscopic hernia repair is more expensive to perform than open hernia repair. The primary reason for this relates to the cost of extra equipment used for the laparoscopic repair with secondary costs attributed to perceived increases in operating time for the laparoscopic procedure. From the Indian perspective, various factors come into play when analyzing the cost implications of laparoscopic repair of inguinal hernia. In most hospitals, except for the larger corporate ones, the theater time is charged on a per-case basis rather than by the hour. Thus, an increase in the operating time, particularly during the learning curve, does not necessarily mean additional expense for the patient. If the surgeon were to adopt cost-containment strategies such as the use of reusable laparoscopic instruments (which is more or less the norm in India) as against disposable ones, use of indigenous balloons devices rather than commercially available ones, sparing use of fixation devices and reliance on sutures for fixation of the mesh, the cost of the laparoscopic hernia repair should be comparable to the open repair. It is likely that many surgeons are already practicing these strategies and passing on the benefits of laparoscopic repair to their patients.
Learning Curve
This period represents the developmental and learning curve for the consultant and the senior registrars. There have been some modifications to the technique as difficulties have been recognized. There is a steep learning curve for laparoscopic repair. Initially, everyone used to fix mesh with staples, but nowadays many surgeons are using sutures for it. As experience increases, our ability to recognize finer structures and to keep within the correct tissue planes, improves. This has been associated with lower minor-complication rates and a higher percentage of pain-free recoveries.
Recommendation
The important points to be kept in mind during the surgery are:
• After dissecting the direct sac, all peritoneal adhesions around the margin of the defect should be meticulously lysed.
• Always search for an indirect sac, even if a direct hernia has been reduced.
• Reflect the peritoneum off the cord completely.
• Place an adequate size mesh to cover the myopectineal orifice completely, preferably the size of 15 × 15 cm.
• The lower margin of the mesh must be comfortably placed - medially in the retropubic space and laterally over the psoas muscle.
• Perform a 2-point fixation of the mesh on the medial aspect over the Cooper’s ligament.
• Avoid cutting of the mesh over the cord. This weakens the mesh and provides a potential site for recurrence.
• Ensure adequate hemostasis prior to placing the mesh.
• The most important factor is the adequate training and learning of the right technique.
The factors involved in mesh dislocation or failure are insufficient size, wrong/defective material, incorrect placement, immediate or very early displacement by folding, lifting by a hematoma or urinary retention, missed cord lipomas and herniation through the keyhole (mesh slit) late displacement by insufficient scar tissue ingrowth, mesh protrusion, collagen disease or pronounced shrinkage. Despite the correct and stable mesh position, there is still a limited risk of a late sliding of the retroperitoneal fat under/ in front of the mesh into the enlarged inner ring.
Leibl in 2000 advised to avoid slitting of the mesh and increase its size to reduce the recurrence rate. Generous dissection of preperitoneal space is required to eliminate potential herniation through the slit or strangulation of the cord structures completely and reduces the risk of genitofemoral neuropathy.
Mesh Size
The mesh size should be adequate to cover the entire myopectineal orifice. The established size in 2006 is 15 × 10 cm per unilateral hernia, with minor deviations.
Mesh Material
The mechanical strength of available meshes exceeds the intra-abdominal peak pressures and by far even the lightweight meshes are strong enough for inguinal repair. Aachen group made an important contribution to understanding the interaction of the living tissue with the implanted mesh material. The negative impact of pronounced shrinkage of the traditional heavyweight meshes was recognized as an important factor promoting recurrence. Schumpelick introduced the logical trend of the use of lightweight meshes. The new macroporous compound meshes present both the successful reduction of the overall foreign body amount and the preservation of mesh elasticity after the scar tissue ingrowths, due to very limited shrinkage and reduced bridging effect.
Fixation of the Mesh
In the early years of laparoscopic hernia repairs, a strong fixation seemed to be the most important factor in the prevention of recurrence. With the growing size of the mesh and true macroporous materials being used, the belief in strength reduced and gave way to the concern of acute/chronic pain possibly caused by fixation. The controversy of fixing or unfixing the mesh is currently under scrutiny.
Technical Experience
The long learning curve of endoscopic repairs presents the potential risk of technical errors leading to the unacceptable rise of the recurrence rate. This fact highlights the need for structured well-mentored teaching, a high level of standardization of the procedure, and a rigorous adherence to the principles of laparoscopic hernia repair. The impact of experience on the recurrence rate was in both extremes well documented.
Collagen Status
Inborn or acquired abnormalities in collagen synthesis are associated with a higher incidence of hernia formation and recurrences.
Other Factors
The negative effect on healing in hernia repair is often related to malnutrition, obesity, steroids, type II diabetes, chronic lung disease, jaundice, radiotherapy, chemotherapy, oral anticoagulants, smoking, heavy lifting, malignancy, and anemia. Laparoscopic inguinal hernia repair offers excellent results in experienced hands.
Bilateral Assessment and Treatment
Up to 30 percent of patients with a unilateral hernia will subsequently develop a further hernia on the contralateral side. Also, when examined at operation, 10 to 25 percent is found to have an occult hernia on the contralateral side. Both laparoscopic approaches allow assessment and treatment of the contralateral side at the same operation without the need for further surgical incisions, very little further dissection, and minimal additional postoperative pain. In open surgery, a further large incision is required in the opposite groin. This considerably impairs postoperative mobility and increases the likelihood of admission to the hospital. Some surgeons advocate routine repair of the contralateral side during a laparoscopic repair.
Cost-Effectiveness
It is suggested that laparoscopic hernia repair is more expensive to perform than open hernia repair. The primary reason for this relates to the cost of extra equipment used for the laparoscopic repair with secondary costs attributed to perceived increases in operating time for the laparoscopic procedure. From the Indian perspective, various factors come into play when analyzing the cost implications of laparoscopic repair of inguinal hernia. In most hospitals, except for the larger corporate ones, the theater time is charged on a per-case basis rather than by the hour. Thus, an increase in the operating time, particularly during the learning curve, does not necessarily mean additional expense for the patient. If the surgeon were to adopt cost-containment strategies such as the use of reusable laparoscopic instruments (which is more or less the norm in India) as against disposable ones, use of indigenous balloons devices rather than commercially available ones, sparing use of fixation devices and reliance on sutures for fixation of the mesh, the cost of the laparoscopic hernia repair should be comparable to the open repair. It is likely that many surgeons are already practicing these strategies and passing on the benefits of laparoscopic repair to their patients.
Learning Curve
This period represents the developmental and learning curve for the consultant and the senior registrars. There have been some modifications to the technique as difficulties have been recognized. There is a steep learning curve for laparoscopic repair. Initially, everyone used to fix mesh with staples, but nowadays many surgeons are using sutures for it. As experience increases, our ability to recognize finer structures and to keep within the correct tissue planes, improves. This has been associated with lower minor-complication rates and a higher percentage of pain-free recoveries.
Recommendation
The important points to be kept in mind during the surgery are:
• After dissecting the direct sac, all peritoneal adhesions around the margin of the defect should be meticulously lysed.
• Always search for an indirect sac, even if a direct hernia has been reduced.
• Reflect the peritoneum off the cord completely.
• Place an adequate size mesh to cover the myopectineal orifice completely, preferably the size of 15 × 15 cm.
• The lower margin of the mesh must be comfortably placed - medially in the retropubic space and laterally over the psoas muscle.
• Perform a 2-point fixation of the mesh on the medial aspect over the Cooper’s ligament.
• Avoid cutting of the mesh over the cord. This weakens the mesh and provides a potential site for recurrence.
• Ensure adequate hemostasis prior to placing the mesh.
• The most important factor is the adequate training and learning of the right technique.
