Hernia (2000) 4: 316-3zo

Hernia (~) Springer-Verlag 2000

Preperitoneal, minimally invasive, prosthetic groin hernia repair

G.C. Zotti, M. Mancuso, A. Giuliani, S. Navarra, G. Salvo and E. Scalise Department of General Surgery, Medical School Hospital, University "Federico II" - Naples, Italy

Summary: The study describes the advantages of using the positioning of the prosthesis in the pre-peritoneal space by a posterior approach in the repair of inguinal hernia. The research was carried out on 388 patients (372 (96%) men and 16 (4%) women), who had undergone hernioplasties with the insertion of a polypropylene prosthesis by a preperitoneal approach, between lanuary 1994 and December 1996. 216 of these patients (56%) had an indirect inguinal hernia, 94 (24%) a direct inguinal hernia and 78 (20%) a double inguinal hernia (direct and indirect). In 21 cases (6%) it was a recurrent hernia. The following clinical parameters were considered: pain, sensitivity of the inguinal region, testicular pathology, wound pathology and recurrence. 384 patients out of 388 (99%) were discharged at latest one day after the operation. On average the patients went back to work 6 days after the operation. All the patients were checked at least three times out of four, with follow-ups at 3o days, 6 months, 1 year and 2 years after the operation. In 13 patients (1.8%) there was a minor complication, in 3 patients (o.80) we found an early recurrence due to technical error. We consider that positioning the prosthesis in the preperitoneal space using this minimally invasive procedure can be carried out easily and with very good clinical results in terms of typical early and/or late complications, which range from 2% to 20% by the anterior approach.

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Correspondence to: G. Zotti e-mail: [email protected]

Key words: Inguinal hernia - Hernioplasty - Preperitoneal approach - Mesh Tension-free technique Received April 02, 2000 Accepted in final form August 14, 2000

It was Bassini [Bassini 1887] who described the fundamental anatomic and technical principles of the surgical treatment of groin hernia and it is since his studies that research on this issue has gained increasing momentum. Since then, other

procedures have been discovered and used widely, which embody more or less the same principles. New procedures have been used recently which represent true innovations, like the use of synthetic materials [Lichtenstein 1989, Benda-

rid 1992, Corcione 1997]. Thus, the concept of "replacement", ie, of inserting a new layer to withstand the abdominal pressure, has been introduced in the field of hernia surgery, whereas up to now the concept of "repair" by direct

G.C. Zotti, et al.: Preperitoneal, minimally invasive, prosthetic groin hernia repair

suture-plasty of the impaired wall and contained structures has been traditional [Corcione 1997, Rutkow 1993, Shulman 1992]. If the traditional anterior approach is used, without a prosthesis, the literature shows that the percentage of recurrences reaches 25% [Lowham 1997] when the Bassini technique or Cooper's ligament plasties are used. When more recent techniques like the Shouldice procedure are used, the percentage of recurrences falls to about 2-3% [Rutkow 1995, Gramegna 1998, Hay 1995, James 1998]. When a prosthesis is used by an anterior approach the percentage of recurrences can range from 4.5% [Lowham 1997] for fixed prostheses to striking results ranging from o.5% to 2.2% with the tension-free technique [Gilbert 1992, Lafferty 1998, Rulli 1998, Schimitz 1999, Millikan 1996, Morfesis 1996, Wantz 1996] (Table 1). In hernioplasties where a prosthesis has been inserted by a preperitoneal a p p r o a c h , the i n c i d e n c e of relapse ranges from 0.5% to 2% [HernandezRichter 1999, Rignault 1986]. Another important problem is represented by the occurrence, in anterior approaches with or without a prosthesis, of a morbidity made up of a range of events which, though representing only minor pathologies, often prove very annoying and limiting for the patient. This is the case as far as the following complications are concerned: scrotal hematoma and seroma, damage to the nerves, painful syndrome o f the inguinal walls and canal, sensation of a foreign body, inflammation of the cord and testicle (sometimes due to vascular lesions), and also a higher risk of the onset of femoral hernia [ L o w h a m 1997, T a s c h i e r i 1998, Emmanoulidis 1993, Bower 1996, Nahabedian 1997]. The treatment of inguinal hernia is currently under review and there is a real therapeutic anarchy, with dozens of personal approaches, each with its own variations on the theme. In this study we have data and experience gathered from 388 cases of inguinal hernia where a polypropylene prosthesis was inserted by a preperitoneal approach, following a

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Table 1. Complications and recurrence rates in different hernia repair techniques Technique

Authors

Suture hernia repair, no prosthesis Bassini Hay, 1995 Emmanoulidis, 1993 Shouldice Hay, 1995 Kingsnorth, 1992 Anterior prosthetic approach Liechtenstein Wantz, 1996 Trabucco Campanelli, 1993 Preperitoneal prosthetic approach Stoppa Stoppa, 1989 Topla, 1997 Rignault Rignault, 1986

minimally invasive technique [Nyhus 196o, Rives 1968, Wantz 1996]. All these cases date back to the period between 1994-96 so that data are available for a group of patients monitored adequately with a z-year follow-up, since it is in this period that 8o% of relapses occur [James 1998]. We still use the Shouldice procedure, however, for all cases where we prefer not to use a foreign material, ie, patients younger than 13, ntflliparous young women, septic and immunologic disorders, and neoplastic patients in poor condition, since we agree completely with the principles of Wantz and Nyhus [James 1998]. We began to use this method in 199z after experience in successive periods of traditional and prosthetic surgical procedures - for the treatment of bilateral hernia via a subumbilical incision, and for the treatment of unilateral recurrent hernia via an incision above the groin [Zotti 1991]. Since 1994, given the good results and the ease and rapidity of this technique, we have used it in all kinds of hernia, especially after noting the anomalously high rate of early femoral hernia a few months after treatment by anterior inguinal hernioplasty. We believe that the former were already present at the time of the first operation and that they had not been recognised at that time. Therefore, we decided to use a technique to avoid this risk and which would also protect the entire wall of the inguinal canal with a bigger prosthesis, above and below the ligament. Such a

Complications

Recurrence

27%

8,6%

19%

6,1%

12% lZ%

0,5% 0%

3,5%

1,1%

2%

2%

prosthesis could obviously be inserted only via a posterior approach [Gramegna 1998, Amid 1992].

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Materialandmethods Our series is made up of 267o patients who were operated between 1972 and 1999 for groin hernia. The operations, mostly carried out at the Department of General Surgery, "Federico II" University Hospital,Naples, were always carried out by one of the authors, as shown in Table 2. [Zotti 1991, Zotti 19921. In this s t u d y we c o n s i d e r only the adult patients operated between 1994 and 1996, since they are sufficiently homogeneous and were monitored with a follow-up program by a medical examination at our Surgical Service. This was completed this year for 334 (86%) of the patients who have undergone all the four checks that had been programmed. All the patients of this group have undergone at least three checks out of four. From January 1994 to December 1996 we operated 473 hernias (446 inguinal, 27 femoral) in 388 adult patients, 362 men (96%) and 26 women (7%) with an average age of 62.7 years (range z9-88), inserting the prosthesis via a prep e r i t o n e a l a p p r o a c h . A m o n g these patients, z16 cases (56%) had an indirect hernia, in 94 (24%) a direct hernia and in 78 cases (20%) the hernia was both direct and indirect. In 85 cases (22%) the hernia was multiple: in (58 (15%) it was bilateral and in z7 (7%) it was a multiple

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G.C. Zotti, et el.: Preperitoneal, minimally invasive, prosthetic groin hernia repair

Table 2. Experience over the years with different procedures Period

Procedure

1976~1981 1982-1988 1989 -1993 1994-1999

Bassini Shouldice Trabucco Preperitoneal

Table 3. Causes and time of the recurrences Patient

Time from the operation

Recurrence due to

1 z 3

z weeks 1 month 6 months

Badly positioned prosthesis Sliding of the prosthesis Incomplete dissection

Patien ts 315 too7 639 7o9

Fig. 1 The shapeof the preperitoneal mesh

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Fig. 2

The placement of the mesh in the pelvis surrounding the spermatic cord

homolateral hernia (inguinal and femoral). None of the patients had only a primary femoral hernia. In 31 cases (8%) it was a recurrent hernia, either inguinal or femoral. The prosthesis used was polypropylene, molded into different shapes, but always more or less in a quadrangular shape with rounded edges and with the lateral edge slightly inclined when compared with the medial. The transverse length (major diameter) ranged from 12 to 16 c m , according to the structure of

the patient's pelvis; the height (minor d i a m e t e r ) r a n g e d f r o m 7 to 11 cm (Fig. 1). The operation was carried out with a transverse incision 5-6 cm long about 1 or 2 fingerbreadths below the a n t e r i o r s u p e r i o r iliac spine. After r e t r a c t i n g the lateral a b d o m i n a l muscles, the peritoneal sac was "unstuck" from the inguinal ring and the cord was isolated down to the femoral ring,where the iliac a. and v. were identified. Then the hernial sac was reduced, together with those associated with direct and/or femoral hernias, if any; The sac was separated with smoothly from the cord and the preperitoneal fat of the posterior wall of the inguinal canal up to the pubic tubercle. It is necessary to pay particular attention to the small and frequent inflammatory lipomas that can be found at the femoral ring and are normally adherent to the iliac v., since they play an important role in the possible genesis of a recurrence [Lowham 1997, Kunge11999]. Then, the prosthesis was molded, a vertical 2-3 cm incision was made along the superior edge, through which the cord was passed, and the prosthesis inserted to cover the whole internal aspect of the posterior inguinal wall until it reached only a short tract in the inferior region on the iliac vessels at a juxtafemoral level (Fig. 2). In women we did not slit the mesh but just stitched the center of the prosthesis to the round ligament at the inguinal ligament where this enters the inguinal ring, so that it was parietalized. We n e v e r used drainage. For 39 patients (lO%) we used general anesthesia, usually at their own request. For 349 patients (9o%) we used loco-regional anaesthesia (330 with spinal and 19 with local infiltration) The operation lasted 40 minutes on average (range 30 to 7o mins). The patients were treated, if

they requested it, with analgesics, mainly Ketorolac 30 mg, usually 4-6 hours after the operation and in 384 cases (98%) were discharged one day after operation. They were monitored after 30 days, 6 months, i year and a years at an outpatient check-up and were all included in this research, after being checked at least 3 out of the planned 4 times. During these surveys some clinical parameters were evaluated, such as pain, sensitivity of the inguinal region, testicular pathologies, wound pathology, and recurrence.

I Results No cases of sepsis of the prosthesis were found. 7 patients (1.8%) suffered from complications. One patient suffered from sepsis of the wound with onlay collection but recovered within a fortnight by aspiration and daffy wound care. No testicular complications were registered. Six patients suffered from ecchymosis of the scrotum region. 54 (14%) patients are lost to follow-up for several reasons: 31 (8%) did not attend on the assigned date twice or more; 19 (5%) not found for the latest checks; 4 (1%) died from unrelated causes. During the check-ups no patient reported hyperesthesia of the inguinal region, sensation of a foreign body, sensitivity changing with the weather, hyperesthesia of the wound, or inguinal syndrome. The patients went back to work on average 6 days after the operation (range 2 to lO days). Three patients (o.8%) showed a recurrence (Table 3). The type of anesthesia used was unrelated to the recurrence [Hay 1995]. Two patients already had obvious recurrences at the first examination made 30 days after the operation and one stated that it had appeared after about two weeks. These patients were reoperated a few days in the same way:

G.C. Zotti, eta!.: Preperitoneal, minimally invasive, prosthetic groin hernia repair

the previous prosthesis was found displaced from the internal abdominal wall with the hernial sac under the mesh into the inguinal ring. We removed the mesh and inserted another similar to the first, but larger, with successful recovery in two days. These were clearly surgical errors due to incorrect positioning of the prosthesis at the moment of relaxing the peritoneal sac. The third recurrence appeared later after six months and was not operated.

Discussion The insertion of a prosthesis via a preperitoneal approach when treating an inguinal hernia is often considered a more aggressive procedure than the anterior approach and it is generally thought that the former has a higher rate of complications, though the recurrence rate for the latter technique is higher [Taschieri 1998]. Possibly, the pre-peritoneal approach prevents injury to the iliohypogastric and ilioinguinal nn., which, though they are normally isolated when they are m a c r o s c o p i c a l l y identified, can be damaged. Some of their branches can also be cut if they cannot be identified during the operation [Bower 1996]. With our technique any damage to these nerves would be avoided, together with any damage to the genitofemoral n., since the incision does not reach the projection on the abdomen wall of the iliac and femoral vessels where the branch of the genitofemoral n. passes under the inguinal ligament. However, inguinal incisions and transverse incisions like the Pfannenstiel often reach this region, damaging the nerve [Nahabedian 1997]. In cases of recurrence of groin hernia it is necessary to distinguish between two different causes from a physiopathologic point of view [Lowham 1997, Zotti 1992 ]. In the case of an immediate or very early recurrence, it is easy to identify the reason, which may lie in technical mistakes regarding the positioning of the mesh, the separation of the elements and of the sac, no matter what technique is used in the operation. The reasons for a late recurrence, however,

relate to more numerous and complex causes, connected wth the performance of the surgical plasties or to insufficiency of the wall or of the suture. While trying to obtain better results, and bearing in mind the necessity to make this technique easier, we thought that its positioning in the preperitoneal region was a good option, instead of the usual operations where a prosthesis is used. This technique allows a complete evaluation of the whole anatomy of the inguinal canal and also enables us to correct adequately any multiple or bilateral defects at one time and with a single incision. Furthermore, this approach allow us to carry out combined operations such as the treatment of varicocele and similar pathologies in the retro- and pro-peritoneal region, and in some cases also in the intra-peritoneal region in the iliac fossae. There are several causes of recurrence in these cases and they are all related to the surgical approach. All our three relapses were early ones, due to technical mistakes. Much is said about the "ideal" dimensions of the prosthesis and about its shape-square, rectangular, rhomboidal, diamond, etc. It is also debated whether it is better to suture its inferior and lateral edges, and if the cord is to be parietalized or s u r r o u n d e d [Wantz 1996]. We think that the most important things are the basics of surgery, ie, good hemostasis, accurate isolation of the structures, and generous calculation of the mesh dimensions, paying particular attention to ensure that it unfolds really smoothly during insertion, without any turn, wave or pleat, and that it is reduced if need be by the particular anatomy of the patient[Wantz 1996, Amid 1992, Zotti 1994, Kungel 1999]. We paid particular attention to hemostasis; hematomas are one cause of relapse, since they can displace the prosthesis. Wantz [Taschieri 1998] advocates drainage if hemostasis proves incomplete or if there is a sac of huge dimensions where blood can accumulate. When the prosthesis is not fixed, Wantz [Wantz 1996] suggests using Mersilene| which is well-suited to the complex curves of the pelvis, thanks to its physical characteristics, and remains

319

fixed. We prefer the polypropylene prosthesis, of medium thickness, whose rigidity can be modified according to the peculiar needs at the time, using several layers. This material is reliable enough, after being used widely all over the world [Barnes 1987], thanks to the fibroblastic reaction [Tascheri 1998] it causes, which contributes to its fixation. Its reliability owes much to the fact that its constituent, the monofilament of polypropylene, has a high biologic and physico-chemicaI compatibility with several structures of the tissues, including the vascular ones [Lowham 1997]. Another issue is the shape to be given to the prosthesis, considering that recurrence in these patients takes place following a path starting from the inferior and lateral edge of the mesh. Therefore, shaping that is well developed in the inferior and lateral region seems to be the best option, compared with an elliptic or low rectangular shape, which tends to be displaced medially, thus furthering the onset of recurrence of indirect hernia. The dimensions of the prosthesis used are also important: in fact the recurrence rate in those who had small prosthesis was different from those with bigger ones, which showed better results [Lowham 1997]. It is very important that the inferior and lateral edge of the prosthesis adheres to the underlying layers, to prevent steps, p r o m i n e n c e s or waves. This is less important as far as the superior edge is concerned, since the prosthesis follows the curve formed by the abdominal wall, thus remaining fixed. When the prosthesis is inserted great care must be taken to isolate accurately all the structures of the spermatic cord, which, once found, can be surrounded by the prosthesis with an incisure; it can also be covered so that it is parietalized to the inferior abdominal wall [Stoppa 1989]. In the latter cases we fix the prosthesis with a central stitch, shaped like a U, between the mesh and the inguinal ligament. One of the advantages of the preperitoneal approach is the possibility of correcting some pathologies related to the extra-peritoneal region, such as varicocele (9 cases), the possibility to carry out a ganglionectomy (2 cases), and even to treat intra-abdominal pathologies such

320

as appendicitis (4 cases) and ovarian cyst (3 cases); all these cases formed 5% of our series. Another positive aspect was that no secondary hernias were found; this refers particularly to the

G.C. Zotti, et al.: Preperitoneal, minimally invasive, prosthetic groin hernia repair

onset of femoral hernia after herniorraphy for inguinal hernia by an anterior approach [Gramegna 1998, Zotti 1991]. In short, after analysing the carefully conducted follow-up (2 years at least) of

about 400 cases of groin hernia, the technique used appears to give satisfactory results as regards r e c u r r e n c e (o.8%), with a morbidity rate lower than the traditional techniques (1.8%).

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