Open Tension-free Hernioplasty Research Articles

An Observational Analysis of Mesh Fixation with Minimum Sutures and Its Postoperative Outcomes

Background The history of hernia repair is the history of the surgery itself. The surgical management of inguinal hernia has continuously evolved for 200 years. Aim This article determines the incidence of recurrence, chronic pain, and complications following open, tension-free Lichtenstein hernioplasty using a minimal stitch approach. Material and Methods This was a single-center, hospital-based, prospective observational study. A total of 197 participants with uncomplicated hernias were enrolled. All participants were operated following open, tension-free, minimal stitch Lichtenstein hernioplasty. The duration of follow-up was 6 months. Results Thirty-one (15.7%) participants were lost to follow-up, and 154 (78.2%) participants completed the follow-up. Making total of 166 cases (of which 142 were unilateral and 12 were bilateral, counted as 24 individually). Overall, right-sided direct inguinal hernia (30%) was the most common type, followed by right-sided indirect hernia (26%). Most participants (85%) were given three sutures to fix the mesh during open tension-free hernioplasty. The incidence of postoperative complications, including wound infection, hematoma, and seroma, was zero among participants in each group. The incidence of chronic pain and recurrence at 3 and 6 months after the surgery was zero among all participants. Conclusion Most patients in this study required three stitches to fix the mesh during hernioplasty. There were zero incidences of chronic pain, recurrence of the hernia, or any postoperative complication among participants. Thus, hernioplasty can be safely and effectively performed with minimal sutures among male patients with either unilateral or bilateral uncomplicated hernia.

Nigam’s inverted curtain hernioplasty: a modified lichtenstein tension free hernioplasty for inguinal hernia

Background: It is an open tension-free hernioplasty for primary inguinal hernias using minimal dissection and only 3 sutures to fix the mesh.Methods: A description of operative technique and patient’s demographics are presented.Results: 362 repairs were done with this technique over a period 18 years (March 2000 to March 2018). All were primary uncomplicated inguinal hernias.Conclusions: NICH tackles the both known aetiological factors for recurrence i.e., weakness in inguinal floor and tension at the suture line. It involves minimal tissue dissection and least number of sutures. Two sutures are used to fix the mesh with inguinal ligament. Third suture is used to make an artificial deep inguinal ring in the mesh as well as used to narrow the natural deep inguinal ring to further avoid recurrence. No suture is applied in main body of mesh which remains free like an inverted curtain covering the whole hernia susceptible region of groin. Prolene mesh is used which completely covers the potentially weak area on the floor of inguinal region irrespective of the size of the area in small or big frame persons. Semi double breasting of external oblique aponeurosis avoids displacement of mesh. NICH is associated with least recurrence, less post-operative pain, less post-operative complications and short learning curve.

Comparative Study of TAPP Repair Vs Open Tension Free Inguinal Hernioplasty

Aims and Objective: Present study was conducted with objective to compare laparoscopic TAPP (Transabdominal preperitoneal) repair with open tension free repair with respect to operative time, complications, postoperative recovery. Materials and Methods: A comparative study was conducted in tertiary health care center from May 2012 to November 2014 and cases fulfilling inclusion criteria were included in study. 38 cases were operated in laparoscopic TAPP repair while 68 cases with open tension free repair and assessed for complications and postoperative recovery. Result: In the study operative time was higher for Laparoscopic TAPP repair (50 min Vs 30 min, p value <0.05), while post op complication were lower for TAPP repair (15.8 % Vs 16.2 %, p value <0.48) but difference was insignificant, chronic pain at 6 month is less for TAPP repair (0.18 Vs 1.48, p value <0.5) and time to return to normal activity was also lower for laparoscopic group (9.3 days Vs 13.8 days, p value< 0.5). Conclusion: Laparoscopic TAPP repair offers a significant advantage over open tension free hernioplasty. It was associated with less post operative pain, faster recovery and higher operative time due to learning curve with insignificant difference in early post operative complication. Thus, Laparoscopic TAPP repair should be considered for primary hernioplasty in view of lesser post operative pain and faster recovery.

Application of tension-free hernioplasty with hernia meshes of different materials and the postoperative effects on the reproductive function of male rats

This study aimed to compare the effects of polypropylene (PP), lightweight PP (UP) and expanded polytetrafluorethylene (e-PTFE) hernia mesh on the reproductive function of adult male Sprague-Dawley (SD) rats following open tension-free hernioplasty. Forty adult SD rats were obtained and divided into five groups: A sham-operated (FO) group, an e-PTFE mesh group, a PP mesh group, the UP mesh group and a normal control (NC) group (without any surgical manipulation). Ninety days following open tension-free hernioplasty, hematoxylin and eosin staining and immunhistochemistry were used to observe the pathological changes of the testicular tissue and to compare the expression of hypoxia-inducible factor-1α (HIF‑1α) in the rat testis, respectively. ELISA was used to analyze the serum concentration of antisperm antibodies (AsAbs) and routine semen testing was conducted to measure the percentage of grade a+b sperm from the epididymis. More than 50% of mesh adherence to the spermatic cord was observed in the PP and UP groups, and mild or no adhesion was observed in the NC, FO and e-PTFE groups. In the UP and PP groups, marked congestion of necrotic tissue was observed in the seminiferous tubule cavity, a significant reduction in the percentage of grade a+b sperm and a significant increase in the expression levels of AsAbs and HIF-α. It was concluded that the e-PTFE mesh exhibited a marginal effect on the reproductive function of rats compared with that of the PP and UP mesh and is more suitable for tension-free hernioplasty. The clinical significance of these results requires further elucidation with a multi-centered prospective study.

Partial removal of infected parietal meshes is a safe procedure

Open tension-free hernioplasty using prosthetic meshes dramatically reduced recurrence rates after hernia or incisional hernia repair and has become the rule. Mesh infections (MI) are the major complication of prosthetic material. The aim of this study was to assess the efficacy of partial removal of mesh (PRM) therapy in the treatment of MI. From January 2000 to April 2010, from a prospective database, we retrospectively selected patients who underwent surgery for MI. We studied the epidemiological data (sex, age, obesity, diabetes, smoking), the operating time of the initial intervention, the presence of intestinal injuries during the first intervention, the average interval between initial surgical procedure and MI, the location of the hernia, the average size of the hernia, type of mesh used, the position of the mesh, type of surgery performed, the number through interventions required to achieve a cure, the cumulative duration of hospital stay and hernia recurrence rates. Twenty-five patients were supported for a MI in our institution. There were 9 women (36 %) and 16 men (64 %). The median age was 59 years (range 37-78). There were 4 inguinal hernias (16 %), 15 incisional hernias (60 %) and 6 multirecurrent incisional hernias (24 %). It was performed a PRM in 92 % of cases (n = 23), a total excision of the prosthesis in 4 % of cases (n = 1) and no removal of prosthesis in 4 % of cases (n = 1). The average number of reoperations before healing was 1 (range 1-5). The mean cumulative duration of hospitalization until healing was 9.5 days (range 2-43). No visceral resection was performed. PRM is feasible in most cases allowing first to spare the capital parietal patients and secondly to avoid major surgery. In case of failure, total removal of the mesh can be discussed.

Open tension-free hernioplasty using a novel lightweight self-gripping mesh: medium-term experience from two institutions

The process of mesh fixation and the potential risk of associated chronic pain are always surgeon's main concerns in hernia surgery. A wide variety of lightweight mesh models are currently available on the market to overcome some of these problems showing good preliminary results, but no data representing the medium- or long-term results. The present study aims to report the clinical outcomes of two institutional series of patients who underwent hernia repair using a partially absorbable auto adherent mesh (Parietene™ Progrip™--PP). A prospective analysis was performed including unselected patients with primary groin hernia who underwent a standardized Lichtenstein procedure using the PP mesh at two tertiary institutions. During the 2-year study period, 181 patients (167 males; 14 females) with a median age of 63 years (19-85 years) were operated on at both centers. Short-term complications occurred in 27 patients (15%), the most commonly seen being urinary retention (6%) followed by hematoma (5%) and acute orchitis (2%). With a median follow-up of 17 months (12-29 months), 4 patients (2%) had a feeling of a foreign body in the groin, and 7 (4%) developed chronic pain. A total of four patients (2%) developed recurrence. In our experience, the use of the PP mesh for hernioplasties offers a potential benefit not only in the short-term period but also in a medium-term follow-up with low recurrence and late chronic pain rates. However, this particular mesh does not fully prevent all complications and chronic pain and recurrent hernias have been reported for the first time.

Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial

The open tension-free mesh-plug hernia technique, transabdominal preperitoneal (TAPP) technique, and totally extraperitoneal (TEP) laparoscopic technique all are common surgical procedures for primary unilateral inguinal hernia repair. However, the choice of the right surgical procedure still is controversial in China. This study aimed to compare open tension-free hernioplasty with two laparoscopic hernia repairs. In this study, 164 male patients with primary unilateral inguinal hernia were randomized to undergo an open operation with mesh-plug and patch, TAPP, or TEP. Completion of the study required 3 years, from February 2006 to February 2009. Of the 164 patients, 62 underwent open repair, 50 had TAPP, and 52 had TEP. The patients then were followed up for 15.6 ± 8.5 months. The average operating time for the open repair group was significantly shorter than for the other two groups (p < 0.001). The cost for the open repair group also was significantly less than for the other two groups (p < 0.001). By contrast, the pain scores in the open mesh group were significantly higher than in the other two groups (p < 0.001). The hospital stay and the recovery time both were significantly longer in open repair group than in the other two groups (p < 0.001). No major complications or recurrence was found in any of the groups. The findings show that open tension-free mesh-plug hernia repair, TAPP, and TEP are safe and effective for patients with primary unilateral inguinal hernia. Both TAPP and TEP are superior to open repair in terms of less postoperative pain and faster recovery time. The authors therefore recommend laparoscopic repair techniques as the preferable choice of surgical procedure. However, they think open repair will remain a practical solution in China because of its lower cost, short learning period, and need for no special equipment.

The outcomes of open tension-free hernioplasty in elderly patients

The outcomes of open tension-free hernioplasty have been evaluated for elderly patients and compared with other techniques without prosthesis or analyzed in elderly patients without a control group constituted by younger patients. Our aim was to compare the outcomes of open tension-free hernioplasty between elderly patients and younger patients applying the recently developed Quantitative and Qualitative Measurement Instrument (QQMI). From January 1997 to December 2003, 731 male patients were electively operated on for inguinal hernia at our institution. We studied 688 patients (94%). Forty-three (6%) were excluded: 12 died of causes unrelated to inguinal surgery and 31 were lost to follow-up. The follow-up period ranged from 22 to 106 months, mean 87 +/- 8.5 months. Recurrence developed in seven patients (1%): six were patients younger than 70 years old. The final mean QQMI score for patients younger than 70 years old was 10.4, significantly higher than the score of 8.9 for elderly patients. The outcomes of open tension-free hernioplasty were better in patients younger than 70 years old than the outcomes for elderly patients.

Fate of the inguinal hernia following removal of infected prosthetic mesh

Open tension-free hernioplasty using a prosthetic mesh is a common operation for inguinal hernia repair because of the relative ease of the operation and low recurrence rate. Wound infection is a potential complication of all hernia repairs and deep-seated infection involving an inserted mesh may result in chronic groin sepsis which usually necessitates complete removal of mesh to produce resolution. Removal of mesh would potentially result in a weakness of the repair and subsequent hernia recurrence. We reviewed the outcome of all our patients who had mesh removal for sepsis over an 8-year period, particularly examining for hernia recurrence and chronic groin pain. This was a retrospective review of the database of patients who had mesh repair of inguinal hernias over an 8-year period. There were 2,139 inguinal hernias repaired using prosthetic mesh. All patients who had mesh removal for infection were identified and followed up. Fourteen patients had deep-seated wound infection which required mesh removal for resolution of sepsis. No peri-operative complications occurred during mesh removal. After a median follow-up of 44 months (range 5-91 months), there were two asymptomatic recurrences and none of the patients had chronic groin pain. Hernia recurrence is uncommon following mesh removal for chronic groin sepsis, suggesting that the strength of a mesh repair lies in the fibrous reaction evoked within the transversalis fascia by the prosthetic material rather than in the physical presence of the mesh itself. When there is established deep infection, there should be no unnecessary delay in removing an infected mesh in order to allow resolution of chronic groin sepsis.

Hernioplasty and simultaneous laparoscopic cholecystectomy: A prospective randomized study of open tension-free versus laparoscopic inguinal hernia repair

Background. The laparoscopic repair of unilateral primary groin hernia remains controversial. This randomized study evaluates the outcome of the laparoscopic technique in hernia repair in patients undergoing simultaneous laparoscopic cholecystectomy (LC) and compares laparoscopic repair with tension-free open groin hernia repair. Methods. Sixty-four low-risk patients with symptomatic chronic calculous cholecystitis and synchronous unilateral primary inguinal hernia were randomized to undergo either laparoscopic transabdominal preperitoneal mesh hernia repair (TAPP) and LC or LC and open tension-free hernia repair. Results. The operating time was longer in the TAPP and LC group (mean ± SD = 121 ± 32 minutes) than in the LC and open group (95 ± 27 minutes) (P <.01). The mean operating costs were higher in the TAPP and LC group ($1235 versus $1080) (P <.03). The intensity of postoperative pain at rest was greater in the LC and open group at 24 hours (P <.01) and 48 hours (P <.05), with a greater consumption of pain medication (P <.01). No differences between the 2 groups were found in terms of postoperative complications, disability period before return to work, or hernia recurrences. Conclusions. The totally laparoscopic procedure does not result in a significant benefit other than improved comfort in the first 2 postoperative days. However, laparoscopic hernia repair is considerably more difficult to perform than open tension-free hernioplasty. Thus, the totally laparoscopic approach should be performed only by experienced laparoscopic surgeons with special expertise in hernia surgery. (Surgery 2001;129:530-6.)

Recurrent inguinal hernia after anterior open tension-free hernioplasty: the efficacy of preoperative herniography

This study is an analysis of recurrent inguinal hernias in an attempt to determine the cause of recurrence based on the findings of herniography. Ten recurrent inguinal hernias in 10 patients, who had previously undergone anterior open tension-free repair, were examined by herniography preoperatively, and the anatomy of the recurrent hernias was confirmed by surgery. It was found that preoperative herniography could uniformly predict the type of recur rent hernia, location of the hernia neck and size of the sac in nine cases, leaving one exception. However, herniography could not indicate the cause of failure or visualize the dislodged mesh or plug.

Study of recurrences after anterior open tension-free hernioplasty

The anterior open tension-free hernioplasty popularized by the Lichtenstein group has gained world-wide acceptance and popularity. As described by the same group, utilization of a small sheet of mesh and failure to overlap the mesh with the pubic tubercle can lead to recurrence of the hernia. However, recurrence through the internal ring has not been reported. We report three recurrences from the internal ring area after open tension-free hernioplasty. The cause is discussed and the importance of making a mesh shutter mechanism at the internal ring in order to prevent indirect recurrence, is emphasized.

The Learning Curve for Laparoscopic Hernia Repair

As with other laparoscopic procedures, the learning curve for laparoscopic inguinal hernia repair is longer than most surgeons anticipated. This, combined with a lack of familiarity with the preperitoneal anatomy and the simultaneous adoption of open tension-free hernioplasty, has made it difficult for surgeons to sustain enthusiasm for the laparoscopic hernia repair.

Long-term result and current status of the Lichtenstein open tension-free hernioplasty

The tension-free hernioplasty project began in 1984 at the Lichtenstein Hernia Institute. The method consists of complete reinforcement of the inguinal floor with a large sheet of mesh, with adequate mesh tissue interface beyond the boundary of the inguinal floor and creation of a new internal ring made of prosthesis. The preliminary report of this operation was published in 1989, with no recurrence at that point in time. Shortly after the submission of the report, several recurrences were encountered. Based on the lesson learned from those recurrences, the operation was slightly modified and reported in 1991 [Amid 1993]. Since then, the Lichtenstein technique has gained world-wide popularity. Outcome measures identical to ours and other authors have been achieved by even those surgeons who have no special interest or expertise in herniology. The purpose of this article is to report the current state of the open tension-free hernioplasty for the repair of primary and recurrent inguinal hernias.

The Inflammatory Response to Open Tension-free Inguinal Hernioplasty Versus Conventional Repairs

Background: The tension-free inguinal hernioplasty is now a popular method because of less postoperative disability and low recurrence rate. The laboratory evaluation of the inflammatory response to the injury is an objective approach to determine the stress status of a surgical procedure. The aim of this study is to evaluate and to compare inflammatory responses to open tension-free and conventional repairs of inguinal hernias. Methods: Forty-eight male patients with primary indirect inguinal hernias were treated with elective operations, and separated into three groups according to surgical procedure: 12 pediatric patients treated with dissection of hernia sac in group 1, 16 adult patients with open tension-free hernioplasty in group 2, and 20 adult patients with conventional repairs in group 3. Ten healthy adult volunteers formed group 4 as control. The repair was performed with polypropylene mesh and suture as the Lichtenstein technique in group 2, and with polypropylene suture as one of Bassini, McVay, or Shouldice techniques in group 3. The inflammatory response was evaluated with serum interleukin-6 (IL-6) levels at 12 hours and serum C-reactive protein (CRP) levels at 48 hours postoperatively. Serum levels of IL-6 and CRP were measured in group 4 as control. Patient characteristics, operating time, and IL-6 and CRP levels were compared among the four groups. Results: There were no significant differences in mean age and operating time between the two groups of adult patients with hernia repair. Mean serum IL-6 levels of 12.1 ± 5.2 and 8.2 ± 2.7 pg/mL, and CRP levels of 34.3 ± 13.8 and 7.5 ± 4 mg/L in pediatric and control groups, respectively, were significantly lower than in the other two hernia groups. Mean serum IL-6 levels were 58.9 ± 25.4 pg/mL in group 2 (tension-free repair) and 44.3 ± 18.1 pg/mL in group 3 (conventional repair) ( P >0.05). Mean serum CRP levels were 111.3 ± 41.3 and 83 ± 43.2 mg/L in groups 2 and 3, respectively ( P >0.05). The differences not being statistically significant, a similar and considerable inflammatory response was noted in patients with either prosthetic mesh repair or with conventional repairs of indirect inguinal hernias. Conclusions: The reinforcement of the posterior wall of the inguinal canal induces significant cytokine response regardless of tension-free or conventional repair. Open tension-free hernioplasty offered no advantages over conventional repairs from the standpoint of the inflammatory and acute phase response.

Current assessment of Lichtenstein tension-free hernia repair

The tension-free hernioplasty project began in 1984 at the Lichtenstein Hernia Institute. The method consists of complete reinforcement of the inguinal floor with a large sheet of mesh, with adequate mesh tissue interface beyond the boundary of the inguinal floor, and creation of a new internal ring made of prosthesis. The preliminary report on this operation was published in 1989, with no recurrence at that point in time. Shortly after submission of the report, several recurrences were encountered. Based on the lesson learned from those recurrences, the operation was slightly modified and reported in 1991. Since then, the Lichtenstein technique has gained world-wide popularity. Outcome measures identical to ours and other authors have been achieved by even those surgeons who have no special interest or expertise in herniology. The purpose of this article is to report the current state of the open tension-free hernioplasty for the repair of primary and recurrent inguinal hernias.

Simultaneous Repair of Bilateral Inguinal Hernias Under Local Anesthesia

The authors confirm the advantages of simultaneous repair of bilateral inguinal hernias, indicate that it is feasible to perform the procedure under local anesthesia, and suggest that when an open tension-free technique is used, the results are superior to those of laparoscopic repair of bilateral inguinal hernias. Between 1971 and 1995, simultaneous repair of bilateral inguinal hernias were performed in 2953 men. Initially, between 1971 and 1984, patients with indirect hernias underwent the traditional tissue approximation repair. Those with direct hernias had the same procedure, with the repair additionally buttressed by a sheet of Marlex mesh (Davol, Inc., Cronston, RI). Between 1984 and 1995, both direct and indirect hernias were repaired using the open tension-free hernioplasty procedure. The 2953 patients underwent simultaneous repair of bilateral inguinal hernias under local anesthesia in a private practice setting in general hospitals. In those cases in which the "tension free" technique was used, patients experienced minimal to mild postoperative pain and had a short recovery period, with a recurrence rate of 0.1%. Uncomplicated bilateral inguinal hernias in adults are best treated simultaneously. It is feasible to perform the operation under local anesthesia, and when an open tension-free repair is used, postoperative pain and recovery periods are equally comparable with those of laparoscopic repair, although the complication and the recurrence rates are significantly less.