Mesh versus non mesh for repair of indirect inguinal hernia by cremasteric apparatus

Mesh versus non mesh for repair  of indirect  inguinal hernia

by cremasteric apparatus

Wael  EIShelfa, MD

Department of Surgery, Zagazig University Hospitals, Sharkiya, Egypt.

Abstract

Background: Open mesh repairs are commonly used ,but the incidence of mesh infection is

still recorded, the goal of this work is to evaluate using cremasteric muscles and fascia instead of the mesh (as foreign body) to strengthen the inguinal canal and to avoid the intractable infected mesh which may be incurred.

Patients and method: In this randomized prospective study, n=80 patients with unilateral inguinal hernia, 40 patients were repaired with this technique, (group B), and the other (group A), 40 patients were repaired with Lichtenstein technique. Operative time, hospital stay, overall complication rates, and cost-effectiveness were investigated. A time period of 1-2 years was determined for patient follow up.

Results: All the patients were followed up ranges (12 to 24 months). There was one case of

recurrence in group B versus one case of recurrence in group A. Time of wound healing was significantly longer in group A versus group B. The deep wound infection and groin pain was more and significantly longer in group A, and work off time ranged from 14-23 days in group B versus 12-33 in group A.

Conclusion: The results of this new repair technique using cremasteric apparatus as an auto meshing  appear promising  especially  after  more studies  with more  number of patients.

Introduction:

Inguinal hernia repair is one of the most common surgical  procedures  performed worldwide. Improved surgical techniques and a better  understanding of the anatomy  and physiology of the  inguinal canal have significantly improved outcomes for many patients.I These improvements have occurred most notably in centers specialized in hernia surgery, with some institutions reporting failure rates ofless than 1%.1,2

General surgeons today have access to a wider and more sophisticated range of synthetic biomaterials for use in hernia repair than ever before. The advantages and disadvantages  of each of these  devices must be understood, however, before surgeons select any of these implants.The surgeon's choice of the prosthesis used in hernia repair is based on a combination of factors, including:  patient characteristics,

clinical experience, training, interest,  skills, understanding of the range of products available and the clinical studies that may have been performed on each, and    the  surgeon's familiarity with a particular product  and/or surgical  approach.3

Ideal mesh characteristics include a porous material that would allow tissue ingrowth. The material must be reactive enough to stimulate fibroblast ingrowth, yet  inert  enough to minimize foreign body  reaction, allergic reaction, and to reduce infection. The mesh must have enough strength to protect the groin and prevent early recurrence. Finally, it must have flexibility to accommodate the forces applied to the groin as a result of activity, and it  must   avoid fragmentation. The  most commonly used  material for mesh  repairs currently  uses  polypropylene  mesh.4

In contrast, failure rates for general surgeons

without expertise in hernia surgery  remain significantly higher (up to 10% for primary hernias, and 5-35% for recurrent hernias).5

The search for a method that accomplishes all the above goals perfectly, preferably without the insertion of any foreign body such as mesh, continues.

This study aims to report a new method of

inguinal hernia repair with cremasteric muscle apparatus as a method instead of a prosthetic mesh.

Patients and methods:

This is a prospective and retrospective study of 80 consecutive patients with 80 inguinal hernias, n=12 female, and n=68 male from June 2009 to June 2011, they were divided into two groups; group (B), 40 patients were operated on using the cremasteric apparatus as an auto meshing to strengthen the floor of the inguinal canal and for narrowing the internal ring. The muscle layer was fixed with non absorbable sutures. And group (A), 40 patients were operated on with Lichtenstein repair.

The mean age of the patients was 44.54 years (range: 23-67 years). All were operated on under regional or general anesthesia. There were no intraoperative  complications. One injection ofDiclofenac 50 mg once a day was given  to all the patients. Patients were encouraged to ambulate after 8 h of surgery.

The patients  were  evaluated, and data collected included duration of hospital stay, pain, ambulation and complications recorded during the operations or the hospital stay.Pain was measured using the visual analog scale (VAS) with 0-3 signifying mild pain, 3 to 6 moderate pain, and >6 severe pain. "Limited ambulation" indicated movements inside the room, "free movements" were movements outside the room, and ''no movements" mean that bed rest was advised. The follow-up schedule was explained to the patient at the time of discharge and was scheduled after 10 days for suture removal, then, after I month,

6 months, and then, yearly. The patients were evaluated in detail and the data recorded at each assessment.

The entire data were collated and analyzed at the end of the study. Patients were followed up for a mean period of 12.2 months (range:

7-18 months).

Surgical technique:

Skin and fascia are incised using a regular, oblique inguinal incision to expose and incise the external oblique aponeurosis (EOA). The cord was mobilized gently and hanged then incised longitudinally to be skeletonised, after excision of the sac and closure of the ring, Figures(1,2).

All the cremasteric apparatus {muscle and

fascia}was dissected and incised at the distal end,  Figure(3). This  bulky structure [Cremasteric apparatus] was deviated around the cord for narrowing the internal ring, Figure(4). Then it is introduced superficial to the transversalis fascia to be fixed with non absorbable prolene sutures, one to the lacuner ligament, others to the inguinal ligament below and finally to the conjoint tendon above and one stitch to narrow the internal ring Figures(4,5) This is followed by routine closure of  the  superficial fascia    and  the  skin.

Statistical analysis:

Data are expressed as mean±standard deviation unless indicated otherwise. The student t-test was used to compare the overall series ofboth groups. A p-value less than 0.05 was  considered statistically significant.

Results:

The series was made up of 68 men and 12 women, a median age of 35 (23-67) years. Four patients had a pantaloon hernia and excluded from the study. Table(l) summarized the  patients' clinical  characteristics, and medical-surgical history. Mean operating time in Lichtenstein repair (group A) was 48 minutes (range 35 to 90), versus 45 (35-65) minutes. The median hospital stay was 24 hours versus

12 hours respectively.  Ligation  of inferior

epigastric vessels was performed in  (12) patients, versus (4) patients in the group B. Postoperative complications appeared in 11 and 5 patients in both groups respectively. Neuralgia developed in the early postoperative period in 15 versus 2 cases in both groups respectively, mostly located in the inguinoscrotal region. 6 patients complained of scrotal edema versus 3 patients, and in 2

developed a pseudohemia versus 3 in group B (transient serohemorragic accumulation  into the  distal hernial sac). One  case  of  late recurrence was seen in the patients in group A after extraction of the mesh versus one in group  B. One long-term complication was detected in group (A) as there was deep seated mesh infection  which resisted the treatment

and was cured after mesh extraction. Return to work and/or  their usual previous  activity occurred after  an average  of 24±3  (18-30) versus14±1.2 (10-20) days, although the vast majority of  the  patients reported to  have unrestricted  activity  within a week after the operation in group B.

Table (1): Preoperative and postoperative characteristic.

Figure (1): Inguinal canal exposure before skeletonization of the cord.

Figure  (2): After excision  of the sac and closure of the ring.

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Discussion:

Hernia repair is currently the  most commonly performed general surgical operation; it occurs with a greater frequency in men than women (12:1 ratio). The ratio in our study was 6:1.

Success of groin hernia repair depends largely on the surgeon's understanding of the functional  anatomy  and pathophysiology of the abdominal wall and groin.  Bassini, 7 is considered today to be the "father of modem herniorrhaphy", he repaired the transversalis fascia defect by reinforcing the canal's posterior wall using a 3-layer technique, with suturing oflocal tissues in multiple layers by imbricating the full thickness of the transversalis fascia to the inguinal  ligament in a ''vest-over-pants" fashion, followed by further reinforcement of the transversus muscle to the undersurface of the  external  oblique  aponeurosis.8

In our work we do suturing the cremasteric

muscle apparatus   from  around the cord, as local tissues in multiple layers to be administrated superficial to the fascia transversalis, and to the inguinal ligament, followed by  further reinforcement of  the transversus muscle to the undersurface of the external oblique aponeurosis like Shouldice procedure.

Since Shouldice introduction, more than

280,000 repairs have been performed, mainly under local anesthesia,7,8 and the recurrence rate was decreased to reach about  1% to 2% nearly the same recurrence  rate in our study (2.5%).

Other studies published that  although the Shouldice technique, was considered the gold standard in open no-mesh techniques, it has recurrence rates of 1-4% in specialized centers, and the long-learning curve, the risky dissection of the inguinal floor and a lack of experience make these figures unattainable for the general surgeon practicing outside these specialized centers.9,10

Versus our work, where we hada significant difference in both procedures when compared to each other in favor of the non mesh repair.

In spite that Lichtenstein tension-free mesh repair opened a new era in groin hernia repair with superior  results,  it is still considered a foreign material, and  deep   infection is

catastrophic  for the patient, which happened in our work  with one case of infection that resisted treatment until we  removed it.

Results from 3,019 repairs from 5 sites have

demonstrated  a 0.5% recurrence rate, and an overall 0.6%  infection rate.6 The slightest movement of the mesh from the sutured area is a leading cause of failure of mesh repair of inguinal hernias.

Agreeing with our work, there was a high incidence of chronic groin pain following mesh hernia repair, reportedly in the range of28.7-

43.3%. by some stdies.11,12

Chronic groin sepsis  after mesh repair requires complete removal of mesh to treat the sepsis. Possible damage to the spermatic cord, and nerve entrapment  following mesh repair due to extensive fibrosis are also raised by this technique.13

Discarda has already published the results of two series based on his new technique of inguinal hernia repair,4,5,6 they used interrupted sutures made of a non-absorbable material for repairs in both series. In a third study, the author described the results  of repairs done with  continuous absorbable sutures.

All open non-mesh repairs are done by using interrupted sutures made from non-absorbable material. Interrupted sutures are used in open repairs to distribute the tension equally on all the sutures, to avoid recurrence of the hernia due to splitting of the tissue by the pull of the displaced  muscles. Non-absorbable material is used to keep those structures together  for unlimited lengths of time to make them blend properly and gain full strength.

We also believed that, the well vascularized cremasteric muscle and fascia was a sufficient bulky  structure that  made  the floor  of  the inguinal canal well  formed and  strong.

Strong  cremasteric structures around the cord, and its administration above the fascia transversalis, usually give protection to prevent herniation in such individuals. This protection is lost if those muscles are weak, and this is only observed in some individuals who had developed the hernia early, as we believe that its bulk  and strength is related  to the long standing hernia.

Hence, this technique will prove to be very effective, even in the hand of junior surgeons.