Hernia Repair

Inguinal Hernia Repair Update
Bambang Suprapto
SURGERY DEPARTMENT / DIGESTIVE SURGERY

ABDUL WAHAB SJAHRANIE HOSPITAL / FACULTY OF MEDICINE MULAWARMAN UNIVERSITY
SAMARINDA
Outline
• Epidemiology
• Anatomy
• Guidelines
• Inguinal Hernia repair technique
• Video operation
Anterior view
Posterior view
Laparoscopic view
Myopectineal orifice
Nerves of the inguinal area
Nerves of the inguinal area
• The experts decided to focus mainly on technical aspects of open
repair, which is the most common surgery for hernia in our region.
• Mesh should be used in patients age 18 years and older
• For primary unilateral hernia, tension-free mesh repair is the
treatment of choice.
• However, tissue/suture repair is still widely used in many Asian
countries, and depending on a country’s socioeconomic conditions, it
should be considered as an option.
• Suture repair remains an acceptable option for indirect hernias
smaller than 2 cm, young patients, and when surrounding tissue
quality is good.
Asian J Endosc Surg 8 (2015) 16–23

• In cases of recurrent hernia, the suggested approach depends on
whether the primary procedure is an anterior or posterior operation;
the hernia should be approached from the opposite site of the
previous surgical repair
• For bilateral and recurrent hernias, endo-laparoscopic repair is
suggested, but open anterior mesh repair is an acceptable option.
• In a grossly contaminated surgical field, the use of mesh should be
avoided.
Mesh size
• the mesh should allow for a large coverage and overlap the pubic
bone by at least 1–2 cm.
• cover the hernia defects and overlap the surrounding area by more
than 3 cm in all directions.
• recommended that a minimum of 8 × 12 cm coverage be used for
anterior repair and 10 × 15 cm for posterior repair.
Mesh type
• The use of a synthetic mesh with large pores is recommended to
reduce the shrinkage rate (20% up to 90%)
Mesh fixation
• The fixation of flat mesh should be over the pubic tubercle with 1–2
cm overlap. Non-absorbable sutures should be used.
• For lateral fixation, either a running or interrupted suture is
suggested. If the mesh is slit around the spermatic cord, it should be
closed adequately around it to avoid recurrence and/or ischemia of
the testicular vessels
• Self-gripping mesh should be fixed only to the pubic tubercle.
• Either glue or sealant is an acceptable choice for fixation.
After Surgery
• Patients may resume normal activities a few days after surgery.
However, they should wait 3–4 weeks to resume participation in
intensive sports.
• In case of mesh infection, the following steps should be taken as
needed:
• adequate drainage and culture
• targeted antibiotic therapy
• staged repair
• mesh removal if necessary.
International guidelines for groin hernia
management (The HerniaSurge Group)
• The main goal of these guidelines is to improve patient outcomes,
specifically to decrease recurrence rates and reduce chronic pain, the
most frequent problems following groin hernia repair.
• Mesh repair is recommended as first choice, either by an open
procedure or a laparo-endoscopic repair technique.
• Standardizing groin hernia repairs  relatively easy to learn, fast
recovery, reproducible results, and cost effectiveness
Hernia (2018) 22:1–165

• Occurrence of groin hernia — viscera or adipose tissue protrusions
through the inguinal or femoral canal is 27–43% in men and 3–6% in
women.
• Inguinal hernias are almost always symptomatic; and the only cure is
surgery
Problem After surgery
• Recurrences necessitate reoperations in 10–15%
• Long-term disability due to chronic pain (pain lasting longer than 3
months) occurs in 10–12%
How to improve
• Incorrect surgical technique is likely the most important reason for
recurrence after primary IH repair.
• lack of mesh overlap,
• improper mesh choice,
• lack of proper mesh fixation
Diagnostic
• History
• Clinical examination
• Imaging  vague groin swelling and diagnostic uncertainty, poor
localization of swelling, intermittent swelling not present at time of
physical examination, and other groin complaints without swelling.
• Ultrasonography (US)
• Magnetic resonance imaging (MRI),
• Computed tomography (CT)
• Herniography
Hernia (2007) 11:113–116
What is best operative technique ?
• Low risk of complications (pain and recurrence), (relatively) easy to
learn, fast recovery, reproducible results and cost effectiveness.
• The decision is also dependent upon many factors like: hernia
characteristics, anesthesia type, the surgeon’s preference, the
patient’s wishes, cultural differences between surgeons, countries
and regions.
Non Mesh
• The Shouldice is best tissue repair although in general practice the
recurrence rate is higher than mesh repair and risks of pain are
comparable.
Mesh vs Non Mesh
Self Gripping mesh PARIETEX PROGRIP
-Makes possible not to fix the
mesh* with suture or stapple.
- Self-Fixation of the mesh on
its entire underside
(vs fixation points with regular
meshes)
-Fit perfectly to groin anatomy
-Less chance of entrapping

nerve = low post-op pain
-Time saving (less suture = less

operative time)
* The mesh fixation is done according to the surgeon’s preference. The textile’s self-gripping feature makes
possible not to fix the mesh according to the size of the defect, the hernia position and the quality of the
anatomical structures.
Lap vs Open?
TAPP vs TEP
Bilateral
Ideal Meshes
• Sufficient strength to reinforce the repair,
• The ability to stretch, elasticity,
• The ability to integrate into tissues without forming blocking scars,
• A low risk of precipitating chronic inflammation, and
• A low risk of bacterial adherence.
Prosthetic / Mesh materials
• Heavyweight
• Lightweight
• Porosity
• Absorbable and
partially absorbable
mesh
Mesh Recommendations
• Guidelines support the use of lightweight meshes for most open
inguinal hernias but add a word of caution for large direct hernias
where there may be a role for heavier prosthetics
Hernia. 2014;18:151–63.
Parietene TM Lightweight mesh (PPL)
 Open worked stitches & Unique knitting

o Easy handling and positioning
 Multidirectional Elasticity
o Designed for Patient comfort
 High Porosity
o Designed for tissue integration and reduce encapsulation
 Transparency
o Easy to use in Laparoscopic procedure
Mesh fixation
• Consideration of the strength of fixation versus the risk of trauma to
local tissues and nerve damage through entrapment.
• Sutured
• Absorbable vs nonabsorbable
• Sutureless (self gripping mesh)
• Glue PROTACK & ABSOBATACK
• Tackers
V-LOCTM KNOTLESS SUTURES
Suture vs Non suture Mesh fixation
• Six RCTs reported on pain in the first postoperative week. Three
studies noted significantly lower mean VAS scores at one or more
assessment times within week one, with FS, NB2C glue, or self-fixing
mesh compared with suture fixation.
• Five RCTs reported significantly shorter operative times with non-
suture mesh fixation.
Chronic Postoperative Inguinal Pain
Recurrent inguinal hernias
Recurrence rates in this same population can be as high as 15%.
Algorithm for management of the primary inguinal hernia
M. P. LaPinska, J. A. Blatnik (eds.), Surgical Principles in Inguinal Hernia Repair

Tissue Approximation Repairs
• More than 70 types of different tissue repairs have been reported
• Commonly in use today are the Bassini, Shouldice, McVay, and
Desarda repairs
• European Hernia Society guidelines recommend the Shouldice
technique as the best option among tissue repairs
• Indications for tissue repairs include operative field contamination,
emergency surgery, and when the viability of hernia contents is
uncertain.
Bassini Repair
Shouldice Repair
Prosthetic Repairs
• Tension-free prosthetic mesh repairs
• The use of a prosthetic mesh reduces recurrence rates in comparison
with suture repairs, from 8 to 3% in inguinal hernia repairs
• The European Hernia Society (EHS) Guidelines state that “The
Lichtenstein technique, introduced in 1984, is currently the best
evaluated and most popular of the different open-mesh techniques: it
is reproducible with minimal perioperative morbidity, it can be per-
formed in day care (under local anesthesia) and has low recurrence
rates (<4%) in the long term.”
Lichtenstein Tension-Free Repair
Take Home Messages
• The fundamental principles hernia repair technique and
understanding of the neuroanatomy of the inguinal canal needs to
avoids both recurrence and chronic pain.
• Currently ’Ideal mesh’ is not discovered, knowledge hernia and mesh
characteristics important to choose prosthetic mesh.
• Tension-free prosthetic mesh repairs is recommended for open or
laparo-endoscopic procedure to reduces recurrence rates.
13 September 2020

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Inguinal Hernia Repair Update

SURGERY DEPARTMENT / DIGESTIVE SURGERY

Asian J Endosc Surg 8 (2015) 16–23

Hernia (2018) 22:1–165

-Fit perfectly to groin anatomy

-Less chance of entrapping

-Time saving (less suture = less

 Open worked stitches & Unique knitting

M. P. LaPinska, J. A. Blatnik (eds.), Surgical Principles in Inguinal Hernia Repair

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