Kugel Patch Research Articles

Laparoscopic Spigelian and Inguinal Hernia Repair With the Kugel Patch

Spigelian hernia is a ventral abdominal hernia that only rarely causes incarceration or strangulation of the bowel. Few reports of laparoscopic treatment for Spigelian hernia have been published. Here we report a case of laparoscopic Spigelian and inguinal hernia repair using the Kugel Patch-a shape memory prosthesis. The patient experienced severe intermittent lower abdominal pain, which was difficult to diagnose until repeated computed tomography scans were performed. The patient also had inguinal swelling, which had not been confirmed preoperatively; therefore, we repaired an inguinal hernia and a Spigelian hernia simultaneously by laparoscopic operation using the Kugel Patch. The surgery was completed without bleeding complications or converting to open operation. The patient was discharged from the hospital on postoperative day 4 with no complications. An accurate preoperative diagnosis of Spigelian hernia led to the successful laparoscopic repair with the Kugel Patch.

Amyand's Hernia: A Case Report and Review of Japanese Literature

Amyand′s hernia is an extremely rare type of inguinal hernia that involves herniation of the appendix. Here, we report a case of Amyand′s hernia in a 77–year–old man. The patient had developed a painful swelling in the right inguinal region 3 years ago; the swelling could be manually reduced but became increasingly painful over time. The hernia was intraoperatively identified as an external inguinal hernia containing the ileocecum and an uninflamed appendix. Only weak adhesions were present between the appendix and hernial sac; therefore, the appendix could be easily separated and was replaced within the abdominal cavity. The mesoappendix was not involved, and an appendectomy was not required. The inguinal hernia was repaired in a radical operation using a direct Kugel patch. The patient′s postoperative course was favorable, and he was discharged 3 days after the surgery. Postoperative infection of the surgical site did not occur.

Impacted obturator hernia treated successfully with a Kugel repair: Report of two cases

Obturator hernia repair has traditionally been performed via an intra-abdominal approach, although laparoscopy is also emerging as a feasible alternative. On the other hand, the Kugel method is a minimally invasive and effective form of repair of groin hernia, but there have been few reports on its use for an incarcerated obturator hernia. We describe how we used the Kugel method to repair an obturator hernia in two patients. Both patients presented with acute intestinal obstruction, necessitating emergency surgery. Via a preperitoneal approach, the impacted obturator hernia was carefully released and the obturator canal defect was repaired with a Kugel patch. One patient recommenced oral intake on postoperative day (POD) 1, and was discharged on POD 5. The other patient's postoperative course was complicated by ileus, prolonging the hospital stay to 14 days. There has been no sign of recurrent disease for 6 and 21 months, respectively. The Kugel method offers several advantages, such as a short operative time (76-82 min), small scar (3 cm), and early postoperative ambulation (POD 1), thus minimizing the hospital stay. Further study is needed to confirm the usefulness of this procedure for an incarcerated obturator hernia.

Perineal hernia as a rare complication after laparoscopic abdominoperineal resection: Report of a case

We report what seems to be the second documented case of perineal hernia after laparoscopic abdominoperineal resection (APR) and describe its successful repair with transperineal intraperitoneal mesh. An 89-year-old woman complained of a large, painful perineal swelling 4 months after APR for rectal cancer. Computed tomography (CT) showed small intestine protruding through the pelvic floor into the perineal area. However, opening of the hernia sac revealed no intra-abdominal adhesions. An oval, 8 x 12 cm Bard Composix Kugel Patch (Davol, Cranston, RI, USA) was inserted into the intraperitoneal space and secured over the defect in the pelvic floor; then firmly attached to the pelvic wall with 16 interrupted nonabsorbable sutures. There has been no sign of hernia recurrence in 10 months of follow-up. We speculate that because laparoscopic surgery is minimally invasive, fewer postoperative adhesions in the abdominal cavity can result in the small bowel sliding more readily into the perineal area. Based on our experience, perineal hernia after laparoscopic APR can be repaired easily and effectively with a Composix Kugel Patch.

Mini-incision technique for repair of inguinal hernias: an alternative to laparoscopy?

Minimally invasive, open-access surgical techniques are being increasingly applied to facilitate recovery and reduce post-operative complications, such as pain, which are inherently associated with large incisions. These techniques aim to combine the beneWts of small incisions with threedimensional appreciation of the anatomy. We describe a mini-open modiWcation of anterior, open-approach hernioplasty for repair of small-to-medium reducible inguinal hernias. A 3- to 4-cm skin crease incision is placed extending medially from the mid-inguinal point. Subsequently, wider surgical exposure is obtained by use of targeted retraction, which also stretches the wound (Fig. 1a), providing excellent views of the free edge of the inguinal ligament, spermatic cord, posterior wall and pubic tubercle. Mesh/meshplug hernioplasty is subsequently performed with ease through this incision as normal, with stapled Wxation of the mesh and/or plug using the MultiWre VersaTack stapler (Covidien, MansWeld, MA, USA; previously Autosuture). The wound is closed with a subcuticular suture, with consequent noticeable shrinkage of the incision (Fig. 1b). A mini-incision retroparietal hernia repair technique using the Kugel patch has been described [1]. Our method combines technical ease with good anatomical views for repairing small-to-medium inguinal hernias in selected individuals. It can also be used for bilateral hernias, though we accept most will be treated laparoscopically. It has a shorter learning curve, does not require new equipment and is ideal for units not oVering the latter. It therefore still has applicability in training junior surgeons. The incision can also be enlarged as necessary, our equivalent to an ‘open conversion’, making it applicable for repair of larger hernias.

Experience with Direct Kugel Patch Method for Repair of Adult Inguinal Hernia

The direct Kugel Patch method is a minimally invasive but nonlaparoscopic preperitoneal method of hernia repair which has various ideal characteristics including all the benefits of laparoscopic hernia repair without the risks of complications. In this retrospective study, we report our experience with this method for adult inguinal hernia repair. Forty-four hernias, including 35 indirect, 7 direct inguinal hernias, and 1 recurrent indirect inguinal hernia, in 41 patients were surgically repaired using the direct Kugel patch method. The average operation time was 45.6 +/- 11.3 min, and the average hospitalization time was 6.2 +/- 5.0 days. There were 5 complications of seroma and only 1 recurrence of hernia which were successfully managed. We concluded that the direct Kugel patch method provides an ideal approach to adult inguinal hernia repair with short operation time and hospital stay and a very low risk of complications or recurrence.

Experience with Porcine Acellular Dermis…

This editor is compelled to add a comment. It would be reasonable to contend that these novel, rather expensive biomaterials—with thus far unproven longterm results—should be employed only in selected cases, where and when conventional nonbiologic meshes (which are less expensive and of proven long-term durability and results) are contraindicated. A classic situation in which a bio-patch would be a preferable option is the contaminated or infected abdominal wall defect of whatever etiology. Thus, it is difficult to understand why the authors of this article decided to use the patch made of porcine acellular dermis in patients with uncontaminated chronic ventral hernias amenable to conventional repair with well proven synthetic materials. Clearly, no data are available to prove that biologic prostheses are strong enough to bridge abdominal wall defects in the long term. Cross-linking of such materials increases fibroblast encapsulation and the resistance of the implant to degradation but decreases the rate of its cellular infiltration. However, the optimum crosslinking pattern and density to balance the durability of the biomaterial with cellular ingrowth and remodeling is unclear because of the lack of long-term clinical data [1]. We have to resist pressures from the aggressive industry that wants us to rush and implant experimental materials into human tissues for marginal indications. Remember the Kugel Patch? It was a wunderherniaprosthesis—until its recent recall [http://www.medscape. com/viewarticle/529032].

GS01 INGUINAL HERNIORRHAPHY USING KUGEL PATCH

Purpose Inguinal hernia repair is one of the most frequently performed operations in general surgical practice. A variety of techniques have been used in the past with different results. The aim of the present study is to report our experience of inguinal hernia repair using the Kugel patch and to measure the frequency of postoperative recurrence and chronic groin pain.Methodology Data were recorded prospectively from a series of 333 inguinal hernia repairs performed between January 2004 to December 2006 using the Kugel patch technique. Wound infection, seroma, haematoma urinary retention, 6‐month recurrence and chronic groin pain were the outcome measures.Results The Kugel patch hernia repairs were performed in 284 patients during the 3‐year period. There were no recurrences or chronic groin pain within 6 months of the 333 repairs. There was only one reported wound infection. The average operating time for bilateral hernia repair was 40.5 minutes (SD 8.8). Recurrent hernias took an average of 26 minutes (SD6.2) to repair whilst unilateral hernias took an average of 23 minutes (SD 6.8). 5 (1.8%) of the 284 patients had urinary retention. The average operating time for 136 direct procedures was 27 minutes compared with 25 minutes for the 148 indirect procedures (p = 0.096, t‐test).Conclusion In this prospective series the Kugel hernia repair is associated with no post hernia repair groin pain and no recurrence within 6 months of the procedure. It is inexpensive compared with laparoscopic repair, and allows the surgeon to cover all potential defects with one piece of mesh.

Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs

The Kugel patch inguinal hernia repair is a relatively new, open, minimally invasive procedure using a preperitoneal approach. Prospective multicentre case series of 450 consecutive Kugel patch repairs. Recurrence rates and persistent inguinal pain after at least 1 year as well as short-term outcomes were studied. After a follow-up of 18 months, eight recurrences (1.9%) were found, and persisting inguinal pain was reported in 15 patients (3.5%). The mean operation time and hospital stay were 20 +/- 9 min and 19 +/- 1.3 h respectively. Less than 1% of patients planned for an ambulatory treatment needed prolonged hospitalisation. Analgesics were used for 3 +/- 2 days. Paracetamol was the only painkiller used in 69% of patients, and 13% did not take any painkiller at all. Half of all patients returned to their daily activities after 9 days and half of the employed patients returned to work after 14 days. The Kugel patch repair is a quick technique with a low recurrence rate and good patient comfort. It offers the advantages of a preperitoneal inguinal hernia repair without the need for general anaesthesia or expensive laparoscopic equipment.

Femoral hernia repair

Plug insertion for primary femoral hernia repair may cause p.o. discomfort. The Kugel technique may avoid this problem. Patients' satisfaction to the Kugel and the plug techniques is compared in the present study. Demographics, surgical, outcome and analgesic consumption data of 26 patients treated for with the plug technique (P group) are compared with 24 operated with the Kugel patch (K group). Patients' p.o. discomfort to the two procedures was measured with quantitative (VAS score) and a qualitative (the short form of McGill pain questionnaire, SF-MPQ) methods, and compared. P group presented higher early p.o. pain (P<0.001), higher analgesic consumption and a significative delay in the return to physical activity (P<0.001). SF-MPQ scores at p.o. day 8, day 30 and month 6 were significantly lower for K group (P<0.001, P<0.001, P<0.005). The Kugel technique for femoral hernia treatment seems to cause less p.o. discomfort to patients than the plug technique.

Comparison of Kugel and Lichtenstein Operations for Inguinal Hernia Repair: Results of a Prospective Randomized Study

The aim of this prospective randomized clinical study was to compare the Lichtenstein hernia repair with Kugel's patch hernia repair. From September 1999 to August 2002, adult patients with inguinal hernia were randomized into two groups. Group I included patients with the Lichtenstein hernioplasty, and group II included patients with the Kugel hernioplasty. The duration of the operation, surgical findings, and postoperative complications were recorded for the patients in both groups. A total of 139 patients (134 men, 5 women) were randomized to either group I or group II. No significant differences were observed for the duration of the operation or the complication rates between the groups during the same follow-up time (53.06 +/- 5.6 months vs. 53.41 +/- 7.11 months in groups I and II, respectively). Kugel herniorraphy is a minimally invasive method and as safe as the Lichtenstein hernia repair technique, with similar complication rates.

Tension-free herniorrhaphy using Kugel patch in groin hernia

目的 总结聚丙烯补片(Kugel补片)行腹股沟疝修补术的近期临床效果.方法采用Kugel补片对58例62侧腹股沟疝患者行无张力疝修补术.结果每侧手术时间25 min,术后平均15 h下床活动,术后5 d恢复正常日常活动.无一例伤口感染、阴囊血肿、阴囊积液.术后随访1～36个月,无复发,无髂腹股沟神经综合征.结论 Kugel补片微创腹股沟疝修补术具有创伤小、患者恢复正常活动早等特点,同时其学习曲线为10例,容易掌握。

A Large Abdominal Incisional Hernia Treated with Laparoscopic Surgery

We present a case of abdominal incisional hernia that was successfully treated with laparascopic surgery. An 81-year-old woman presented with symptoms of abdominal pain and discomfort. In the past history, she had distal gastrectomy for gastric carcinoma in 1995 and total gastrectomy for the remnant of gastric carcinoma combined with a cholecystectomy in 2003. Subsequently, she developed a swelling in the abdominal region. She had consulted a local hospital and surgery was suggested, but she rejected. Finally, she visited Keihin General Hospital with the hope for a treatment by endoscopic surgery. On medical examination, longitudinal and horizontal surgical scars were observed on the upper abdominal region and an incisional hernia measuring 14×15 cm in diameters was found. Laparoscopic repair operation was performed under general anesthesia using a 19.6×24.6 cm Bard Composix Kugel Patch (Bard, Inc.), inserting through three ports of about 11 mm in diameter in the lower abdomen. At present, the patient is under follow up with no pain or recurrence. In conclusion, we report a better prognosis of a case with huge incisional hernia under laparoscopic repair operation.

Early Belgian Experience with the Kugel Patch Inguinal Hernia Repair

The Kugel hernia repair is an open but minimally invasive, tension free repair, offering the advantages of a preperitoneal repair without the need for general anaesthesia. We report our initial experience with this technique in 25 inguinal hernia repairs. Operating time averaged 40 ± 16 min, and one complication, a bladder tear, occurred intra-operatively. Patients were discharged after a median of 2 days and were then seen after 3 weeks and after at least one year. Three weeks postoperatively, there were two superficial skin inflammations and one haematoma. One year postoperatively no recurrences occurred but two patients complained of persistent inguinodynia. The Kugel hernia repair is a relatively new technique with a short operating time and minimal postoperative pain, but a learning curve, comparable to that of TEP has to be overcome in order to reproduce the results of its inventor.

Inguinal hernia repair with the Kugel patch

The Kugel hernia patch (Davol, Cranston, RI, USA) for treatment of inguinal hernias is a minimal access technique of inguinal herniorrhaphy, which aims to combine the utility of the open operation with the advantages of the laparoscopic procedures. The aim of the present study is to report an initial experience of a cohort of patients with inguinal hernias undergoing repair using this technique. A prospective series of 107 inguinal hernia repairs performed between January 2000 and October 2003 in 96 patients, using the Bard Kugel hernia patch were entered into the study. Patient comfort, complications, activity levels postoperations and early recurrence were evaluated. The median age was 76 years (range 23-88 years). There were 107 inguinal hernias repaired. There were 11 bilateral, 39 left and 46 right sided hernias, 12 were recurrent. There were no major complications. There were no early recurrences. At 6 and 12 months there were one and two hernia recurrences, respectively. A further recurrence was noted at 2 years. There was no consistent relationship between having hernia surgery and loss of mobility. There was no difference in straight leg raising noted following surgery compared to the patients' preoperative score. Ability to shower, dress, reach the toilet or perform housework by day 7 returned to normal. Shopping activities were resumed by day 30 in all patients. The Kugel hernia operation is associated with minimal postoperative pain and rapid return to normal activity. There is a modest hernia recurrence rate, which needs to be addressed.

An Abdominal Incisional Hernia Repair using the Composix Kugel Patch: Two Cases Reports

We describe two patients with abdominal incisional hernias, which occurred after appendectomy and replacement of an artificial blood vessel. Both were treated by operative hernial repair with the Composix Kugel Patch (C.R. Bard Inc.), a composite mesh that combines polypropylene mesh and expanded polytetrafluoroethylene (Gore-Tex). The mesh has various beneficial characteristics. It is a reinforcing material for the abdominal wall; even when in direct contact with the intestinal tract it is minimally adherent to the intestinal tract. The mesh expands readily and is easily fixed to the abdominal wall because it has a shape-memory ring. The long-term results of operative repair with this mesh have not yet been reported, but it is hoped that the aforementioned characteristics will yield favorable outcomes.

The open preperitoneal approach to recurrent inguinal hernias in high-risk patients.

Whether it is an open anterior, laparoscopic, or open preperitoneal approach, we have no general consensus on the preferred approach to recurrent inguinal hernia repairs. Recent reevaluations of the previously described open preperitoneal approach have shown promising results. We critically evaluate our experience with this procedure in our high-risk patient population and compare the results to other useful techniques. We present a retrospective study of 48 consecutive patients with 49 recurrent inguinal hernias. All patients underwent an open preperitoneal approach using a Bard Kugel Patch supervised by the senior author. Complications and recurrences were evaluated with all patients returning to the clinic postoperatively. Among the 49 (6%) hernia repairs, there were three recurrences. The overall complication rate was 8%, including postoperative hematoma requiring drainage (1), pain leading to the patch being removed (1), and postoperative urinary retention (2). The open preperitoneal approach using the Bard Kugel Patch for recurrent inguinal hernias results in a low recurrence rate and an acceptable complication rate. It is the preferred approach at our institution.

Inguinal Hernia Recurrence following Preperitoneal Kugel Patch Repair

Three hundred eighty-six preperitoneal inguinal herniorrhaphies using a polypropylene Kugel patch (Davol) were performed in 355 consecutive patients by six surgeons. Variables for recurrence evaluated included age, gender, hernia type, whether the Kugel patch was placed for a primary or recurrent hernia, and the experience of the surgeon. Of 336 patients with long-term follow-up available (18 months to 63 months, median 42 months) 28 recurrences developed 1 to 48 months (mean 16 months) after 366 Kugel patch repairs (7.7%). Recurrence was highest (27.8%) in the subset of patients who had a Kugel patch placed for recurrent inguinal hernias (P < 0.05). Patients with direct primary hernias involving the entire floor had a recurrence rate of 22.7 per cent (P < 0.05). Patient age and gender had no bearing on recurrence. Surgeon experience did play a role, as the recurrence rate was 18.2 per cent during each surgeon's first 36 cases and 2.9 per cent thereafter (P < 0.0005). Surgeons using a preperitoneal Kugel patch for inguinal herniorraphy had a recurrence rate that was unacceptably high. The technique may not be suitable for repair of recurrent inguinal hernias or primary large direct inguinal hernias. Surgeons in this study saw a learning curve of 36 cases.

Inguinal hernia repair: where to next?

Hernia repair is one of the most frequently performed operations in general surgery - a total of 39 000 elective inguinal hernia repairs were performed in public and private hospitals in Australia between July 1998 and June 1999 - and, as such, even minor alterations in outcome and resource use have appreciable impact. However, decisions regarding choice of operation for hernia repair remain controversial. The purpose of the present paper is to critically evaluate the evidence available regarding recently introduced open mesh repair techniques and to try to identify meaningful directions for future hernia research. A thorough search of all published surgical literature was undertaken. Medline, EMBASE and the Cochrane databases were searched by title, by key words and by author. References in review articles and in textbooks were pursued. The manufacturing companies were contacted for trials evaluating their product. Eight original articles evaluating either the Kugel Patch, the PerFix Plug or the Prolene Hernia System were located. None of these trials directly compared two or more of these repair systems. To date, there has been no published review of the evidence regarding the newer mesh repair techniques. With one exception, all of these articles qualify as Level IV evidence. Highlighted is the lack of evidence regarding chronic significant posthernioplasty pain - this has an incidence of 6-12%. This complication is 3-5 times more common than recurrence after open repair, is clinically relevant, is poorly understood and has been poorly studied. Arguably it is a more important end point than recurrence. Only one study comparing the newer techniques of open hernia repair (PerFix Plug) constitutes level II evidence. The PerFix Plug appears to be quicker to insert and uses a smaller incision. Chronic significant posthernioplasty pain is a more important endpoint in hernia research than is recurrence, and this review concludes with a proposal for a multicentre, randomized, controlled trial evaluating the incidence of chronic significant posthernioplasty pain following elective mesh repair of primary, unilateral -hernias.