Kugel Patch Research Articles

HERNIA MESH EXPLANTATION FOR MESH INGUINODYNIA AND ALLODYNIA. WHY IS HERNIA MESH SO PAINFUL?

Abstract Introduction Chronic pain after mesh repair for abdominal wall hernia is an indication for the removal of mesh and reconstruction by a non-mesh technique. Materials and Methods In a consecutive series over 19 years, 128 patients had mesh removed to relieve chronic pain. This open method of mesh removal relies on confirming normal anatomical landmarks. The superior and inferior leaf of the External oblique aponeurosis are raised, the spermatic cord is identified and retracted. The mesh is gently dissected off the Internal oblique from lateral to medial, taking care in preserving the vas, and accompanying vessels. Adherent ilio-inguinal, iliohypogastric and genitofemoral nerves are removed with the mesh. The resultant recurrent hernia is repaired by Moloney darn, a tension-free tissue repair. Results 128 consecutive patients have been treated by mesh explantation and immediate reconstruction on average 6 years after implantation. Resolution of symptoms was experienced very shortly after the mesh removed. Preperitoneal mesh particularly Kugel patch has been the most difficult to remove. Meshes have been submitted for histological examination and the findings are usually chronic granulomatous foreign body reaction. Few complications have been encountered with a follow-up period ranging from 6 months to 15 years, the most common being the failure of explantation to alleviate inguinal pain in the long-term. Conclusion All hernia patients should be afforded informed consent including discussing the potential long-term consequences of chronic groin and abdominal pain.

Treatment outcomes of Kugel repair for obturator hernias: a retrospective study

BackgroundWe examined the validity and applicability of the Kugel repair approach for obturator hernias, whereby we placed a Kugel patch through the preperitoneal space after placing a short 5-cm skin incision just medial to the anterior iliac spine and 2 cm cranial to the expected origin of the internal inguinal ring.MethodsWe studied patients who underwent surgical Kugel repair for obturator hernias at the Department of General Surgery, Saitama Medical University between 2007 and 2017. We examined the operating time, length of hospital stay, postoperative complications, and mortality rate.ResultsFifty-eight patients with obturator hernias presented with symptoms of small bowel obstruction. A Kugel approach was used in 53 patients and a midline approach was used in 5 patients with preoperative peritonitis. Of the 53 patients managed using the Kugel approach, 39 did not require intestinal resection; a mesh was used in all these patients. In the remaining 14 patients, intestinal resection was required and performed using the same approach; subsequently, a mesh was used successfully in 6 of these 14 patients. The overall median operating time was 47 min; the corresponding values for procedures with and without intestinal resection were 39 and 68 min, respectively. In terms of postoperative complications, operative mortality was not noted among patients without intestinal perforation; however, superficial surgical site infection developed in 2 patients. Among the 5 patients with preoperative peritonitis who underwent exploratory laparotomy via a midline incision, intestinal perforation was detected during surgery, and all patients required intestinal resection; none of the patients had received a mesh, and 2 patients died after surgery.ConclusionsThe Kugel repair approach was possible even in patients with obturator hernia requiring intestinal resection. However, for patients with perforations, open surgery should be performed after securing the surgical field through a midline incision.

Sublay repair for primary superior lumbar hernia with the Kugel patch.

BackgroundA superior lumbar hernia is a posterior ventral hernia that is rarely encountered in the clinical setting. However, no standard operative strategy exists for superior lumbar hernia repair at present.MethodsTwelve patients with primary superior lumbar hernia who underwent sublay repair via the retroperitoneal space with the Kugel patch between December 2008 and June 2019 were included in this study. The demographic, peri‐operative and post‐operative data of the patients were collected to analyse the effectiveness of this technique.ResultsAll patients underwent an uneventful operation. The median operative time was 60 min, and the median blood loss was 35 mL. The median hernia defect area was 16 cm2. Five medium‐sized Kugel patches (11 cm × 14 cm) and seven large‐sized Kugel patches (14 cm × 17 cm) were used for the repairs. The median visual analogue scale score on post‐operative day 1 was 3. The median time to removal of drainage was 3 days. The median duration of the hospital stay was 3 days. No serious post‐operative complications, including seroma, haematoma, incision or mesh infection, recurrence and chronic pain, occurred during the follow‐up period.ConclusionSublay repair for primary superior lumbar hernia with the Kugel patch shows benefits including a reliable repair, minimal invasiveness and few post‐operative complications.

Grynfeltt hernia repair using a Kugel patch.

To introduce a surgical technique for repairing Grynfeltt hernia using a Bard Kugel patch mesh. After incision and dissection, hernia was found behind the latissimus dorsi muscle. The retroperitoneal fat or sac was isolated from surrounding tissues and the retro muscular preperitoneal space was developed using blunt dissection at least 5cm beyond the margins of defect in all directions. A proper size Kugel patch was placed into the place at least 3cm beyond the muscular or rib edges. The defect was reduced and the mesh was fixed by interrupted sutures. Then the fibers of the latissimus dorsi muscle were reapproximated by loose absorbable suture. The skin was closed by continuous absorbable suture without any drainage. The patients had a mean hospital stay of 3.22days. The follow-up ranged from 4months to 2years and there were no recurrences or any other significant postoperative complications. Repairing Grynfeltt hernias using a Kugel patch can be successfully performed with the posterior approach. This method of repair is easy, safe, and effective.

Effective Treatment for Incarcerated Obturator Hernia With Bowel Dilatation by Combined Laparoscopy and Preperitoneal Approach: A Case Report

Background: We report a case of a 90-year-old woman with intestinal obstruction due to left-sided incarcerated obturator hernia, which was revealed using computed tomography. Methods: Emergency surgerywas performed using laparoscopy, which showed a dilated small intestine and bilateral obturator hernia in the intraperitoneal space. After reducing incarceration of the small intestine using laparoscopy, we approached the bilateral preperitoneal space and inserted a Kugel patch via a small lower abdominal median incision (approximately 4 cm). Results: The patient was discharged on postoperative day 10 and showed no recurrence at the 18-month follow-up. Although relatively rare, obturator hernia can significantly cause intestinal obstruction. It has no specific clinical symptoms and is thus often difficult to diagnose. Treating obturator hernia is essential; however, mesh infection, recurrence, and opposite side of the obturator hernia should be carefully monitored. Conclusions: Although laparoscopy is used for treating obturator hernia, it may be difficult in patients with intestinal obstruction. In this case, a surgical technique combining laparoscopy and preperitoneal space approach via a small lower abdominal median incision was used to effectively treat an incarcerated occult bilateral obturator hernia.

Diagnosis of a Case of Colonic Perforation Caused by a Kugel Patch Using Fiberoptic Endoscopy

Diagnosis of a Case of Colonic Perforation Caused by a Kugel Patch Using Fiberoptic Endoscopy

Efficacy of single-incision laparoscopic totally extraperitoneal repair for irreducible or incarcerated inguinal hernia.

The aim of this study was to evaluate the efficacy of single-incision laparoscopic surgery for totally extraperitoneal repair (SILS-TEP) of irreducible inguinal hernias and incarcerated inguinal hernias. We performed a retrospective analysis of 194 patients, including 16 with irreducible or incarcerated hernia, who had undergone SILS-TEP from May 2016 to December 2017 at Kinki Central Hospital. The outcomes of patients with irreducible or incarcerated hernia and those with reducible hernia were compared. For irreducible or incarcerated hernia, laparoscopic exploration with hernia reduction through an intraumbilical incision was performed. If no bowel resection was needed, one-stage SILS-TEP was performed. If bowel resection was required, two-stage SILS-TEP was performed 2-3 months after the bowel resection. Of the 16 patients, 8 had an irreducible hernia, and 8 had an incarcerated hernia. The eight patients with an incarcerated hernia underwent emergency surgery, and among these patients, two needed single-incision laparoscopic partial resection of the ileum followed by two-stage SILS-TEP. Fourteen patients, excluding the two patients who required single-incision laparoscopic partial resection of the ileum, underwent laparoscopic exploration with hernia reduction followed by one-stage SILS-TEP. Among these 14 patients, one with an irreducible hernia required conversion to Kugel patch repair. The operative outcomes were generally comparable between the two groups. However, the operative time was longer for unilateral hernia, and more seromas were seen in the irreducible or incarcerated group. No other major complications or cases of hernia recurrence were noted in this study. SILS-TEP, which offers good cosmetic results, can be safely performed for irreducible or incarcerated inguinal hernia.

Assessment of the incidence of chronic pain and discomfort after primary inguinal hernia repair

BackgroundChronic pain and discomfort is a notable complication after inguinal hernia repair. This study assesses the incidence and degree of chronic pain and discomfort after primary inguinal hernia repair performed in our hospital and aims to clarify its relationship to the type of mesh placement. Materials and methodsA retrospective analysis was conducted of 334 patients (378 lesions) who underwent primary inguinal hernia using the Lichtenstein (onlay mesh), Ultrapro Plug (UPP; onlay plus plug mesh), modified Kugel Patch (onlay and underlay mesh), or laparoscopic transabdominal preperitoneal (TAPP; underlay mesh) procedure. Postoperative pain was assessed using a numerical rating scale at postoperative 2-3 wk, 3 mo, and 6 mo. Postoperative discomfort was assessed 6 mo afterward. ResultsQuestionnaire responses were received for 378 lesions (100%) after 2-3 wk, 229 (60.6%) after 3 mo, and 249 (65.9%) after 6 mo. The majority of chronic pain experienced was mild, and no patient suffered from severe pain. The level of pain tended to be less for the TAPP procedure than for other methods. Discomfort at rest was significantly less for TAPP versus Ultrapro Plug (P < 0.01), and discomfort with movement was significantly less for TAPP versus modified Kugel (P < 0.05). ConclusionsOnlay mesh appears to be a risk factor in chronic pain and discomfort. The lower level of chronic pain and discomfort with underlay mesh placement is considered to result from the reduced risk of nerve damage in this procedure than in the onlay mesh placement procedure.

Long-term follow-up of anterior approach preperitoneal hernia repair using the Kugel patch

BackgroundDespite many advantages of original Kugel hernia repair over other procedures, there exist certain disadvantages of technical difficulty, long learning curve, and high early recurrence. The aim of this study was to explore the outcomes of long-term follow-up using anterior approach preperitoneal hernia repair with the Kugel patch and determine its safety and efficacy. MethodsFive hundred eighty-one inguinal hernias were performed in 560 patients, using anterior approach preperitoneal repair. Patients' age and sex, type of hernias, operative time, hospital stay, complications, and recurrence were evaluated. ResultsWe included 581 hernias, with 354 on right side, 162 on left side, and 65 bilateral sides. All hernias were primary. There were 443 indirect hernias, 115 direct hernias, and 23 femoral hernias. Mean operative time was 50 minutes; local anesthesia was applied in 530 cases (91.2%). Postoperative complications affected 50 patients (8.9%). The patients were discharged from 4 to 8 days (with average of 6 days). The averaged follow-up time was 70 months (12 to 120 months). There were 3 recurrences in the period (.5%). ConclusionsThe results of long-term follow-up with this procedure are safe and effective, easy to learn. We believe that this procedure should be adopted as an alternative method for Chinese patients with inguinal hernias.

Kugel法術後1年8カ月に遅発性メッシュ感染を呈した1例

鼠径部ヘルニアに対するtension-free hernioplastyの増加に伴い，メッシュ感染例が報告されるようになってきた．今回，Kugel法術後の遅発性感染に対するメッシュ摘出術を行った症例を経験したが，その術後に一過性の股関節内転筋麻痺をきたしたので，それも併せて報告する．症例は77歳の女性で，右外鼠径ヘルニアに対してKugel法による鼠径ヘルニア修復術を受けたが，その1年8カ月後に鼠径部の違和感で来院した．CTで右鼠径部に膿瘍形成を認めたため，遅発性メッシュ感染と診断した．切開排膿・ドレナージを行い，洗浄を継続したが改善せず，初回手術から3年10カ月後にメッシュ除去術を施行した．メッシュ除去第3病日に右股関節内転筋麻痺症状が出現したが，リハビリによって歩行機能は改善し退院となった．メッシュ除去後2年で感染兆候やヘルニア再発は認めず，右股関節内転筋の筋力も完全に回復していた．

A randomized clinical study on postoperative pain comparing the Polysoft patch to the modified Kugel patch for transinguinal preperitoneal inguinal hernia repair

The transinguinal preperitoneal approach is a relatively new technique for inguinal hernia repair. Two types of memory-ring mesh are available in Japan: the modified Kugel patch (MK) and the Polysoft patch (PP). We tested the hypothesis that the PP is noninferior to the MK with respect to chronic postoperative pain. An unblinded randomized controlled trial was conducted to assess the noninferiority of PP compared to MK with a 5% noninferiority margin. A total of 442 inguinal hernia patients operated on from November 2010 to December 2012 were included in this study. The primary endpoint was the pain score assessed by the visual analog scale (VAS) (0-1 vs. 2-10) 1year after surgery. The patients were randomized to the PP and MK groups (n=221 each). One year after surgery, 206 patients (95.4%) in the PP group and 182 patients (89.6%) in the MK group rated pain at 0-1 on the VAS scale. According to this rating, the PP group appeared not to be inferior to the MK group (95% confidence interval, 0.7-10.7%, P<0.05). Furthermore, crude superiority tests, adjusting for 1month of pain, denoted that the outcomes were significantly improved with the PP compared to the MK. The use of the PP was noninferior to the MK with respect to the severity of postoperative chronic pain scores 12months after surgery.

鼠径ヘルニア術後にKugel patchの癒着により生じた絞扼性イレウスの１例

鼠径ヘルニア術後にKugel patchの癒着により生じた絞扼性イレウスの１例

Inguinal hernia repair outcomes that utilized the modified Kugel patch without the optional onlay patch: a case series of 163 consecutive patients.

The purpose of this study was to evaluate the efficacy and safety of the anterior Kugel herniorrhaphy approach when the onlay patch is omitted. The study population comprised patients who underwent anterior Kugel herniorrhaphy without the onlay patch from 1 May 2009, to 31 June 2012. The onlay patch was omitted if the posterior wall defect did not exceed the inner Posiflex(®) ring diameter. After reviewing the clinical follow-up records and conducting telephone interviews, the postoperative results were recorded and analyzed. A total of 163 patients underwent 175 hernia repairs. One patient developed recurrence after undergoing our herniorrhaphy method. The most common postoperative complaints were mild soreness, indescribable discomfort, and foreign body sensations (11 patients). The mean operative time and hospital stay were 67 min and 2 days, respectively. More serious complications included one scrotal hematoma, one hydrocele, and one wound infection that resulted in epididymitis. The onlay patch can be omitted with low recurrence and complication rates if the posterior wall defects do not exceed the inner Posiflex(®) ring diameter.

The Kugel patch method prevents the development of a femoral hernia after inguinal herniorrhaphy

A femoral hernia is a relatively rare condition, and no standard surgical methods have so far been established. In this study, we investigated the development of a femoral hernia after inguinal herniorrhaphy. A total of 1,969 patients who underwent surgery for an inguinal hernia from April 1992 to March 2012 were enrolled in this study. The patients were composed of 1,934 (98.2 %) inguinal hernia and 35 (1.8 %) femoral hernia patients. Of these, we retrospectively studied the femoral hernia cases with reference to the use of inguinal herniorrhaphy. Of all 35 femoral hernia cases, six cases (17.1 %) were femoral type recurrences after inguinal herniorrhaphy performed by the conventional or mesh plug methods. The surgical methods used for the 35 cases were mesh plug repair in 15 cases (42.9 %), the Kugel patch method in seven (20.0 %) and conventional repair in 13 patients (37.2 %). Inguinal type recurrences developed in three cases (8.6 %) that were re-repaired by mesh plug repair or sac resection. There were no femoral or inguinal type recurrences after Kugel patch repair for a femoral hernia. The results of this study suggested the importance of repairing all hernia orifices when repairing a groin hernia. The Kugel patch repair method is available for all inguinal region hernias by the same approach, and it seems to be useful for preventing the development of recurrence after surgery.

Composix Kugel Patch®を用いた腹壁瘢痕ヘルニア修復術後に小腸穿通をきたした1例

Composix Kugel Patch®を用いた腹壁瘢痕ヘルニア修復術後に小腸穿通をきたした1例

Kugel patch repair of superior lumbar hernias

In 1866, Grynfeltt was the first to report a hernia through the superior lumbar triangle, which now bears his name [1]. The superior lumbar triangle is an inverted triangle bounded by the internal oblique muscle anteriorly, the erector spinae muscle posteriorly, and the 12th rib and serratus posterior inferior muscle superiorly, which forms the base of the triangle. The roof is formed by the latissimus dorsi muscle. The floor is consisted of transversalis fascia and the aponeurosis of the transverse abdominis muscle [2]. Of primary lumbar hernia, about 24 % become incarcerated [3] and 18 % will actually be strangulated [4]; therefore, it is recommended that both primary and secondary lumbar hernias be repaired early [5]. Nowadays, there are two main surgical approaches for lumbar hernia repair: the traditional approach, with direct suture or with prosthetic mesh repair, and the laparoscopic (transperitoneal or extraperitoneal) approach. Each approach has advantages and disadvantages [6]. We describe an open repair of primary superior lumbar hernia in three patients with the Kugel patch. The results demonstrate that this procedure is easy and safe and presents good recovery after long-term follow-up. Case reports

A Case of Recurrent Obturator Hernia Repaired with a Kugel Patch

A Case of Recurrent Obturator Hernia Repaired with a Kugel Patch

Surgical Repair of the Abdominal Bulge Using Composix Kugel Patch with the Intraperitoneal Onlay Mesh Technique

Surgical Repair of the Abdominal Bulge Using Composix Kugel Patch with the Intraperitoneal Onlay Mesh Technique

Composix Kugel Patch®を用いた腹壁瘢痕

Composix Kugel Patch®を用いた腹壁瘢痕

A Case of Late Mesh Infection after Repair of Abdominal Incisional Hernia with Composix Kugel Patch

腹壁瘢痕ヘルニア修復術後の遅発性メッシュ感染の報告は少ない．今回，Composix Kugel patch（以下，CKPと略記）の癒着が原因と考えられた遅発性メッシュ感染を経験したのでその原因と予防法について考察を加え報告する．症例は75歳の女性で，他院で腹壁瘢痕ヘルニアに対しCKPで修復術を受け術後3年経過して遅発性メッシュ感染を発症した．保存的治療に抵抗性であったためメッシュ除去手術を施行した．腹腔内に留置されたCKPはPolytetrafluoroethyleneの辺縁が全周性に腹腔側に折れ曲がり外側のポリプロピレンが腹腔内に露出し全周性に小腸が癒着していた．腸管とメッシュに囲まれた間隙に膿瘍を認めた．メッシュを除去して欠損した腹壁を直接縫合閉鎖し術後は合併症なく退院となった．本例はCKPの固定法に何らかの問題があったと考えられCKPを使用する際には固定法に注意すべきだと思われた．