Page 44 - World Journal of Laparoscopic Surgery

Snehal Fegade

Open Suture Repair of Inguinal Hernia a. Giant prosthetic reinforcement of the visceral sac (GPRVS),
Following methods of suture repair of inguinal hernia is Reni Stoppa
practiced: b. Lichtenstein onlay patch repair
• Bassini’s repair c. Patch and plug repair
• Halsted repair d. Kugel patch
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• Tanner (relaxing incision to reduce suture line tension) e. The PROLENE polypropylene hernia system
• McVay repair
• Shouldice’s repair Laparoscopic Hernia Repair
Ger in 1982 attempted minimal access groin hernia repair by
Open Mesh Repair of Inguinal Hernia
closing the opening of an indirect inguinal hernial sac using
Materials from native tissues like strips of external oblique Michel clips. Bogojavlensky in 1989 modified the technique by
aponeurosis, fascia lata grafts from thigh and even skin from intra-corporeal suture of the deep ring after plugging a PPM
the edges of the incision to metal and silk were tried in hernia into the sac. Toy and Smoot in 1991 described a technique of
repair. intraperitoneal onlay mesh (IPOM) placement, where an intra-
The concept of hernia repair underwent evolution with the abdominal piece of polypropylene or e-PTFE was stapled over
introduction of monofilament knitted polyethylene plastic mesh. the myopectineal orifice without dissection of the peritoneum.
PPM remains most popular both in open and laparoscopic The present day techniques of laparoscopic hernia repair
surgery. However, Dacron a machine knitted polyester polymer evolved from Stoppa’s concept of pre-peritoneal reinforcement
was the first popular nonmetallic mesh. In 1976, Gore developed of fascia transversalis over the myopectineal orifice with its
the expanded PTFE or e-PTFE. Recently some of the prosthetic multiple openings by a prosthetic mesh. In the early 1990’s
biomaterials have been combined together to form various Arregui and Doin described the transabdominal pre-peritoneal
composite mesh in an attempt to minimize the undesirable side repair (TAPP), where the abdominal cavity is first entered,
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effects. Composix meshes (polypropylene with a thin coat of peritoneum over the posterior wall of the inguinal canal is incised
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e-PTFE on one side). Vypro mesh {light, large pore to enter into the avascular preperitoneal plane which is
multifilament mesh composed of 50% polyglactin 910 adequately dissected to place a large (15 × 10 cm) mesh over the
(absorbable) and 50% polypropylene}. Ingrowths of fibrous hernial orifices. After fixation of the mesh, the peritoneum is
tissue and collagen provide strength to the repair. 2 carefully sutured or stapled. TAPP approach has the advantage
Significantly less pain on exercise after 6 months and fewer of identifying missed additional direct or femoral hernia during
patients reported the feeling of a foreign body after repair with the first operation itself.
use of lightweight composite mesh. Around the same time Phillips and McKernan described
Cumberland and Scales criteria for an ideal prosthetic mesh: the totally extraperitoneal (TEP) technique of endoscopic
it should be chemically inert, noncarcinogenic, capable of hernioplasty where the peritoneal cavity is not breached and
resisting mechanical strain and resist bursting by the maximum the entire dissection is performed bluntly in the extraperitoneal
forces created by the intra-abdominal pressure, easy to handle space with a balloon device or the tip of the laparoscope itself.
and fabricate as per requirement, allow tissue ingrowth within it An advanced knowledge of the posterior anatomy of the
resulting in normal pattern of tissue healing and repair without inguinal region is imperative. Once the dissection is complete, a
inciting adhesion formation if placed intra-abdominally. The 15 × 10 cm mesh is stapled in place over the myopectineal orifice.
tissue fluids should not physically modify it or incite It appears to be the most common endoscopic repair today.
inflammatory, foreign body or allergic reaction and it should In both these repairs, the mesh is in direct contact with the
resist infection. It must conform easily to the abdominal/inguinal fascia of the transversalis muscle in the pre-peritoneal space,
wall and be seen-through for accurate placement over the defect. allows tissue ingrowths leading to the fixation of the mesh (as
Finally; it should not be too costly. opposed to being in contact to the peritoneum as in IPOM
A perfect prosthesis in addition to above should be repair where it is prone to migrate).
impregnated with antibiotic material to resist infection, allow
fibrous tissue ingrowths on one side for proper fixation and Relative Contraindication for
anti-adhesive properties on the other to avoid adhesions to the Laparoscopic Approach
abdominal viscera and finally should respond like autologous
tissue in vivo. A. Obesity with BMI >30
B. Significant chest disease
Tension-free Repair of Inguinal Hernia C. Patient on anticoagulants
Tension free repair requires a mesh. Placement is either by open D. Adhesions
anterior, open posterior approach or by laparoscopic means. E. Massive hernias

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