A cost-effective mesh design for extraperitoneal inguinal hernia repair using lightweight mesh

Abstract

Dear Editor, Akolekar et al. [1] are to be commended for their wellconducted study documenting that the use of non-Wxated lightweight mesh sheet for the preperitoneal repair of inguinal hernias was associated with a higher recurrence rate compared to heavyweight mesh using the same operative technique (4.3% vs. 2.8%). The authors rightly make a case for improvement in mesh adhesion to prevent early mesh displacement, and, thus, recurrence, if one continues to use lightweight mesh to reap the beneWt of increased patient comfort. Indeed, it has been shown in a concurrent article that meshes tend to migrate and/or contract superiorly, thereby, exposing the deep inguinal ring for indirect recurrence [2]. My concern is that, while the use of staples, as suggested by the authors, has been well known to have the potential for vascular injuries, nerve entrapment and inguinodynia, Wxation by staples, tacks or Wbrin glue adds considerably to the overall operating cost, which is already quite high, as lightweight mesh is over Wve times more expensive than its conventional counterpart. Hernia repair is one of the most frequently performed operations in most parts of the world; any improvement in cost-eVectiveness has major and widespread implications. I feel, therefore, compelled to introduce to your readers an ingenuous technique of mesh anchorage specially designed to prevent superior displacement. We have used this technique to repair over 50 inguinal hernias without a single recurrence [3]. The lower edge of a lightweight mesh measuring 15£15 cm is Wrst folded up behind the upper part on a horizontal line one-third of the way from the bottom and is then aYxed using two interrupted prolene stitches placed 9 cm from the medial edge (Fig. 1). A tongue-like Xap, about 3 cm wide, is fashioned with scissors from the posterior fold, projecting from its stitched bottom edge and slanting upwards and medially for about 5 cm. A notch is cut near the lateral upper border of the tongue-like Xap to accommodate the spermatic pedicle—this, aided by the two stitches placed just lateral and inferior to the notch, would eVectively prevent not only upward displacement, but also rotation of the mesh. To facilitate orientation and deployment of the mesh within the narrow preperitoneal space, the prosthetic is concertinaed and kept pleated temporarily using a running vertical mattress suture. The slender bundle can then be easily inserted via the optical port. When it is positioned horizontally in front of the inguinal ligament, the free tail of the posterior Xap will be seen projecting upwards; the latter is grasped and tunnelled behind the cord structures from the lateral to the medial side. With the lower edge thus anchored, pulling out the suture thread immediately unleashes the rectangular patch, which will automatically fall into the proper place. The upper edge of the patch is grasped and held aloft, while the telescope is repeatedly advanced to press the patch Xat against the lower abdominal musculature. In this way, the lightweight mesh can be easily, accurately and securely anchored—at no extra cost. W. T. Ng (&) Department of Surgery, Yan Chai Hospital, 7–11 Yan Chai Street, Tsuen Wan, Hong Kong e-mail: houston_n@yahoo.com