Abstract
Dear Professor Schumpelick, We were glad to see that the results of this complete and thorough prospective audit are those that any general surgeon can attain. We too have had similar gratifying results with simple modiWcations of the original description of the “plug and patch” inguinal hernioplasty [1]. The important issue is that the dissection is “high” into the preperitoneal space, which is easily identiWed as having been reached by the glistening bright yellow preperitoneal fat, something that is rarely made enough fuss of. Indeed, we have often thought that the “PERFIX plug” would have been better named the “PREFIX plug” to remind surgeons that correct placement is the crucial step in this technique of repair. Furthermore, to attain a good preperitoneal placement of the plug, its outer petals are best stretched and Xattened, as illustrated in Fig. 1. Only then are the inner petals sutured to the margins of the hernial defect. This simple modiWcation allows the outer layer of the plug to sit astride the defect in the perperitoneal plane as a “sublay” patch. Since 1997, we have used this repair in 1,255 patients with very satisfying results and a paucity of complications in both the short and long term. We have had three cases of urinary retention and nine haematomas, of which, four needed draining. In the original description [1], it was suggested that the mesh patch was placed without sutures, as it was only there to augment the beneWt of the “plug.” Although we believe this still to be true, we now anchor the patch medially with one stitch just short of the pubic tubercle. This simple single suture keeps the patch in close proximity to the back wall of the canal. With these simple modiWcations, we have not seen a case of migration or sepsis, and have had to excise only one plug (in a butcher) at a median follow up of 7 years. Our recurrence rates are similar to that of these authors, but they do vary as to the aetiology of the hernial defect; primary indirect 2/789 (0.25%), primary direct 3/360 (0.83%) and 1/87 (1.1%) when a plug repair is used to manage a recurrence following a previously sutured repair. As stated some time ago, the “plug and patch approach” has caught on [2, 3], but its simplicity should not be an excuse for a poor anatomical dissection. At this point, it would be prudent to recall the words of Wakely, quoted by Glassow, well before the widespread use of mesh, who said “a surgeon can do more for his community by operating on hernia cases and seeing that his results are good, than by operating on cases of malignant disease” [4, 5]. In other words, if we do it well, we can all get good results and, with this technique, the anatomy is familiar to us all and the learning curve short.
Published Version
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