The use of mesh in hernia repair, risk management and the advantages of day surgery

Development of laparoscopic hernia repair stimulated I believe what could be termed other competitive open techniques where small incisions were made and mesh has been designed to place between the layers of the abdominal wall and the peritoneum through a muscle splitting incision.

Types of repair:

1. Open technique (from in front) – This can be carried out under local anaesthesia with or without sedation or general anaesthesia.  Local anaesthetic can be infiltrated post operatively for post operative pain relief.

1. Shouldice technique – suturing only. The excellent results at the Shouldice Clinic in Canada have been difficult to replicate at non specialist centers.  The technique has been commented upon as difficult to learn.
2. Bassini repair- suturing only – the oldest technique.  Non-absorbable suturing is essential but high recurrence rates are reported.  Some Surgeons use a relieving incision with this and claim better results.
3. The Lichtenstein repair. This is a mesh reinforcement.  Lichtenstein was the originator of the so called “tension free repair” – uses a flat mesh.  The procedure is carried out under L/A with Neurolept sedation – an essential component of the technique.

B.   Open pre-peritoneal mesh placement – (from behind):

Increasingly especially designed meshes usually polypropylene allow the mesh to be replaced in the deeper plan between the muscles and peritoneum without a large incision.

There are several proponents of these techniques. One example is a kugel repair where a compressible mesh is inserted through a small split in the muscle.  The mesh then regains its shape to form a wide buttress.

Another technique is a Prolene hernia system where a double layer of mesh,  an umbrella where a plug is used.

Various combinations are possible.

There are two main techniques for placing a mesh in the layer between the peritoneum and muscle wall.

1.      TAPP - Trans-Abdominal Pre-Peritoneal mesh – the mesh is
         placed by inflating the abdominal cavity initially with gas and
         opening the peritoneum from within, then placing the mesh and
          repairing the peritoneum.  The mesh is usually stapled into
          position.

BACK  NEXT

Operation showing the sac and the cord

Both these operations are refinements of the open extra-peritoneal repair popularised years ago and for which there are still many proponents.

Direct and indirect inguinal hernia
Inguinal herniae are the commonest by far encountered in practice. They occur at any age. They are at least 20 times as prevalent in males as females.

There are two basic types but they both protrude through the external ring of the inguinal canal.

The INDIRECT descend along the spermatic cord or round ligament.

The DIRECT bulge through the posterior wall of the inguinal canal medial to the inferior epigastria artery, posterior to and separate from the spermatic cord.

The indirect occur at any age, from infancy to the elderly. In children or females the hernia is invariably direct. Direct herniae occur with increasing frequency in males as they age.

The persistence of the processes vaginalis sac at birth following the descent of the testis results in the development of indirect herniae in children. This is the congenital type of the sac.

With incomplete descent of the testis there is usually an associated indirect hernial sac.

Persistence of a patent process vaginalis is also responsible for communicating hydroceles of the testis and encysted hydrococeles of the cord.

There is no conjecture as to whether this congenital type of sac is responsible for the development of indirect herniae in adults or whether the herniae developed as a new event, associated with failure of the muscular shutter mechanism at the internal ring. The ‘congenital sac’ theory assumes there is a congenital sac which only fills with contents in adult life.