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Hernias:inguinal and incisional

Andrew Kingsnorth, Karl LeBlanc

In the past decade hernia surgery has been challenged by two new technologies: by laparoscopy, which hasattempted to change the traditional open operative techniques, and by prosthetic mesh, which has achieved muchlowerrecurrence rates. The demand by health care providers for increasingly efficient and cost-effective surgery hasresulted in modifications to pathways of care to encourage more widespread adoption of day case, outpatient surgery,and local anaesthesia. In addition, the UKNational Institute for ClínicalExcellence has recommended strategies forbilateral and recurrent hernias. Here, we discuss these strategies and review some neglected aspects of herniamanagement such as trusses, antibiotic cover, return to work and activity, and emergency surgery. Many of theprincipiesof management apply equally to inguinal and incisional hernias. We recommend that the more difficultandcomplexof the procedures be referred to specialísts.

Inguinal herniaIncidenceInguinal hemia repair consumes a lot of healthcareresources because it has a high lifetime risk; 27% for menand 3% for women.' More than 20 million hemias areestimated to be repaired every year around the world;specific rates vary between countries from around 100 to300 per 100 000 population per year.2 In the UK, about100 000 inguinal hemias are repaired every year; and inthe USA this number reaches 500000. Most inguinalhemias develop for the first time in patients aged youngerthan 1 year (infantil e, congenital hemias-not included inthis repon) and in those aged 55-85 years.' Inguinal hemiasurgery is a multibillion dollar industry that requires adegree of standardisation of practice to contain the costs.

TrussesRepair of an asymptomatic bulge in an elderly untit man isnot mandatory because the risk of strangulation is low" Atruss is an option only if the hemia çan be readily andcompletely reduced and will remain in position despitephysical activity and obesity. For symptomatic hemias inyounger men a truss should allow the patient to continueheavy work with greater comfon while waiting for theoperation. In a survey of general practitioners in 2002 inSwitzerland, 11% of patients with hemias were suppliedwith a truss.'

Patient education about application of trusses is poor.Law and Trapne1l6 assessed 250 consecutive patientsreferred for surgical repair of a hemia, 52 of whom weretitted with a truss before attending an outpatient clinic.Part or complete control of the hemia was achieved in only16 patients (31%), and 33 (64%) found the truss to beuncomfonable. In the UK, 40000 trusses are issued everyyear; this rate of truss supply (700 per million people) ismuch higher than elsewhere in the developed world.7

Lancet2003;362:1561-71

Derriford Hospital, Levei 7, Plymouth, UK (Prof A Kingsnorth FRcs);

Surgical Specialty Group, Medical Plaza I, Baton Rouge, LA, USA

(K LeBlanc FACS)

Correspondence to: Prof Andrew Kingsnorth. Derriford Hospital.

Levei 7. Plymouth PL6 8DH. UK

(e-mail: andrew.kingsnorth@phnt.swest.nhs.uk)

The risksIn a retrospective study, Gallegos and colleagues.investigated the cumulative probability of strangulation inrelation to the length of history for inguinal and femoralhemias independently. Of 476 hemias (439 inguinal,37 femoral) there were 34 strangulations (22 inguinal,12 femora!). After 3 months, the cumulative probability ofstrangulation for inguinal hemias was 2'8%, rising to4,5% after 2 years. For femoral hemias the cumulativeprobability for strangulation was 22% at 3 months and45% at 21 months. 40% were admitted as an emergencywith strangulation or incarceration.. Therefore, femoralhemias should be repaired urgently.

Treatment of patients with groin hemia is sometimesdelayed for several reasons.'O In patients presenting withstrangulation, more than half had noted the presence of ahemia for 1 month, a quaner had not reponed it to theirfamily doctor, and a further quaner were known by familypractitioners or non-surgical medical personnel to have ahemia but had not been referred to a specialist. Statisticaldata from the US National Center For Health Statisticsfrom the decades ending 1968, 1978, and 1988investigated death from hemia." In 1971, Medicaredischarges for inguinal hemia without intestinalobstruction showed that 94% of patients had surgery,with a probability of death of 0,005 (tive per 100000).However, for inguinal hemia with obstruction, 88%underwent surgery with a death rate of 0'05-a ten-foldincreased risk of death. Encouragingly, the death rate

Search strategy and selection criteria

We searched MEDLlNE (1980-2002) and EMBASE using thesearch terms hemia. inguinal, femoral, and incisional alone

and in combination. We selected publications mostly from thepast 5 years but did not exclude commonly referenced andhighly regarded older publications. We also searched the

reference list of articles identified by the search strategy andselected those that were relevant. Selected review articles

and meta-analyses or book chapters were included becausethey provi de comprehensive overviews that would be beyondthe scope of this seminar. The reference list was

subsequently modified during the peer review process on thebasis of comments from the reviewers.

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from hernia with obstruction fell from tive per 100 000 in1968 to three per 100 000 in 1988, indicatingthat electivesurgery had contributed to a lower death rate fromcomplicated hernia.

Elderly peopleEven in elderly patients the surgical option must beconsidered and should be undertaken as a well-plannedprocedure with full medical support for any comorbidconditions. Gilbertl2 reported on 175 patients olderthan 66 years who had had elective repair of inguinalor femoral hernias. Of these patients 50% were AmericanSociety of Anesthesiologists (ASA) grade TIl (severesystemic disease that restricts activity but is notincapacitating), and 22% had undergone coronary arterybypass grafting. Most of the operations were done underlocal or epidural anaesthesia, with no deaths and fewcomplications. Gianetta and colleaguesl3 from Italy andGunnarsson and colleaguesl4 from Sweden have reportedequally good results in a similar population of elderlypatients. Ali studies confirm the safety of the procedure ifconcomitant disease is controlled and if domesticarrangements are made in advance so that the patient'sneed for hospital care can be kept to a minimum or, morecommonly, eliminated.

Classification

These systems allow surgeons to define the anatomicaltypes of inguinal hernia and then match the repair to thedefect found. Examples inelude the Nyhus elassification,which defines the status of the fascia transversalis in theposterior wall of the inguinal and femoral canal;" theGilbert elassification, which is based on anatomical andfunctional defects described at operation and ineludes tivetypes;'6 the Bendavid elassification, which is an elaboratesystem, ineluding typing, staging, and measuring thedimensions of the hernia to elassify them;17 and finally arecommended simpler method devised by Schumpelick ofAachen,'8 which is based on the more traditional Europeananatomical elassitication (direct or indirect inguinal, andfemoral) combined with measurement of the hernia oritice«1'5 cm, 1'5-3.0 cm, >3'0cm).

On the basis of these systems we make the followingrecommendations:

1 If the deep ring has a normal diameter and the fasciatransversalis is of normal strength, only the indirect sacneeds to be excised; arare óccurrence seenoccasionally in adolescent patients.

2 If the deep ring is mildly dilated « 1.5 cm) and theposterior wall is normal, a simple plastic operation totighten the deep ring and resection of the indirecthernia sac is sufficient in a young patient. Usuallyhowever, especially in elderly patients, the posteriorwall is deticient at the internal ring or elsewhere and aLichtenstein operation with prosthetic mesh or theShouldice operation should be undertaken.

3 If the posterior wall is deticient (ie, larger indirect ordirect hernia) the defect should be repaired, withreinforcement by either the Lichtenstein operationwith mesh or the Shouldice operation (see below).

4 With recurrent hernias, especially complex recurrenthernias, an extraperitoneal mesh replacement (open orlaparoscopic) might be necessary. The Lichtensteinrepair or Shouldice repair are indicated in somecircumstances (see below)

Inguinalherniain womenPrimary indirect inguinal hernia is 13 times more commonthan direct hernias. In women, direct inguinal hernias are

very rare, and when they do arlse they usually present in thelateral part of the posterior wall elose to the deep epigastricvessels rather than in the medial canal as they do in men.'9By contrast with femoral hernia, pregnancy and vaginaldelivery are not risk factors for inguinal hernia and obesityseems to be protective.2OThe principies of repair applied tomen are no different in women.

Bilateral herniaIn a large retrospective study from the Mayo Clinic,2Ipatients undergoing simultaneous open repair had greatermorbidity than those undergoing sequential sutured openrepair. 6'1 % of the sequential group and 15% of thesimultaneous repair group had urinary retention. TheLichtenstein operation and laparoscopic inguinal herniarepair both lend themselves more easily to simultaneousrepair of bilateral inguinal hernias.22,2JThere are substantialcost savings when bilateral inguinal hernias are repairedsimultaneously, and the recurrence rate is not affected!4 In2001, the UK National Institute for Clinical Excellence(NICE) published guidance on use of laparoscopic surgeryfor inguinal hernia.25 They recommended laparoscopicsurgery as an option for bilateral inguinal hernia (andrecurrent inguinal hernia).

RecurrentinguinalherniaRepair of recurrent inguinal hernia can be difficulttechnically, and should be undertaken by a skilled surgeon.For a hernia that lias recurred for the first time there areseveral options. Where the first operation was complicatedby haematoma, sepsis, sinus formation, or a complexhernia, the anterior open approach is not recommendedbecause ischaemic orchitis and testicular atrophy is a risk. Inthe absence of these factors an anterior approach with whichthe operator is familiar, such as the Lichtenstein technique,can be recommended.22 If the hernia has recurred morethan once, if there has been much sepsis or scarring, ifanterior mesh was used previously, or if a major tissuedeticit exists, an approach through virgin territory, such asthe extraperitoneal open approach or laparoscopic repair isadvised.2,,26

Radiological diagnosisWhen a swelling in the groin cannot be accurately or easilydiagnosed, ultrasound examination is a very accuratemethod of diagnosing femoral, inguinal, or recurrenthernias with an almost 100% sensitivity and specificity.27MRI is the best valid diagnostic tool for difIerentiating thecauses of uncertain groin pain.28

Antibiotic coverThe efIectiveness of prophylactic antibiotic cover in theform of powder instillation or a single perioperativeintravenous bolus has not been proven. In a co-operativemulticentre prospective study of 2493 inguinal herniarepairs by 65 surgeons, Gilbert and Felton29found a woundinfection rate of less than 1% whether or not biomaterials orantibiotics were used. Several investigators have reportedtrials of antibiotic prophylaxis during elective inguinalhernia surgery.30-34Three of these studies30,31,32were donebefore prosthetic mesh was introduced, tWo of which31,32found no difIerence betWeen patients treated withantibiotics instilled locally into the wound or a single shot ofintravenous antibiotics; the other found in favour ofantibiotics. The other tWo trials",34 found no protectiveefIect of a single perioperative dose of intravenouscefuroxime in laparoscopic surgery, and the onlyprospective, randomised study investigating infection afterthe Lichtenstein technique showed no difference betWeen

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Figure 1: The completed 4-Iayer sutured Shouldice repair

deep infections but reponed a high proponion of superficialinfections possibly caused by the many seroma formations.34These five randomised controlled trials are non-homogeneous, concern different interventions, and theresults are non-conclusive. At present there is insufficientevidence to recommend routine antibiotic prophylaxis forelective inguinal hernia repair."

StrangulatedhemiaUse of mesh is not absolutely contraindicated if the amountof contamination is kept to a minimum and broad-spectrumantibiotics are used during and after the operationfor several days.",37 In 35 patients, nine of whomneeded intestinal resection for necrosis, two developedinfections after surgery: neither of these patients had had anintestinal resection.3. Wysocki and colleagues37investigated16 patients with strangulation in whom one had a bowelresection with no septic complications.

The Shouldice operative technique is recommended totreat a strangulated inguinal hernia, where there is grosscontamination due to necrosis after bowel perforation. Theadditional risk of infection in this situation militates againstuse ofmesh, infection ofwhich could cause morbidity.

Open inguinal hernia repairSutured techniquesSutured techniques remain popular in regions where meshis not affordable. The Shouldice operation is the mosteffective sutured technique. Glassow,'8 in 1984, reviewed10353 Shouldice repairs with a 10-year recurrence rate of1.1%. Meticulous anatomical four-Iayered repair of thefascia transversalis with non-absorbable sutures (figure 1) isapplied. Results in different specialist clinics have alsoyielded uniformly excellent outcomes with a recurrence rateof less than 1%, and justifies adoption of this operation bysurgeons who have been trained adequately.39 However,results from non-specialist units have shown that theShouldice operation cannot be reproduced with the samelow recurrence rates.4<>-44The learning curve for theShouldice operation for the average general surgeon who isdoing fewer than 50 operations a year is too long to learneffectively.

LichtensteinoperationThe trUe tension-free hernioplasty with mesh (figure 2) wasintroduced in 1984 and published by Irving Lichtensteinand colleagues in 1989.45 The perfected tension-freehernioplasty was then reponed by Amid, Shulman, andüchtenstein in 1993... The operation is simple, rapid,almost pain-free, and allows prompt resumption of

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Figure 2: The flat patch Lichtenstein operation

unrestricted physical activity.47Many thousands of patientshave undergone repair under local anaesthesia and patientsare discharged within a few hours of operation with verylittle discomfon.48 A postal survey by Shulman49 of70 surgeons using this technique who did not have a specialinterest in inguinal hernia surgery indicated similar resultsin 22 300 repairs. This operation therefore fulf1ls therequirement of being reproducible in the hands of non-specialist surgeons.

In the UK the üchtenstein technique was first reponedby Kingsnonh's group in üverpool,'o and subsequently by aprivate hernia clinic, The British Hernia Centre.5I The easeof performance, low recurrence rate, and rapid return toactivity was confirmed. A cautionary repon from a group inBrussels" reponing a 4.6% recurrence rate indicated that atechnical fault was failure to overlap the pubic tubercle andthe entire posterior inguinal wall by a wide margin of mesh.

The European Union Hernia Trialists Collaborationinvestigated all randomised and quasi-randomised trialscomparing open mesh (Lichtenstein type operations) withopen non-mesh methods for repair of groin hernia.53Theyidentified 15 eligible trials, including 4005 panicipants.Return to usual activities was quicker in the mesh group forseven of the 15 trials (not significant), and there were fewerreponed recurrences in the mesh groups (1.4% comparedwith 4.4%). Therefore, using the powerful statisticalmethods followed by the Cochrane Collaboration, theavailable published work indicates that mesh repair isassociated with three times fewer recurrences than non-mesh, in the repair of inguinal hernia. Prostheses replace orreinforce the transversalis fascia.54

Plug techniquesThe tension-free hernioplasty has been modified with a plugto block the defect in the posterior inguinal wallsupplemented by a sutureless swatch or patch as an overlayon the posterior inguinal wall.55The plug is a cone-shapedpolypropylene strUcture, supplemented with a small flatmesh. Because of its simplicity, this operation has gainedpopularity since it was first used in 1993. However, the plugis a three-dimensional semi-rigid strUcture, and unaccept-able rates of postoperative pain have been reponed in up to8% ofpatients treated with the plug.'6-59

Operative technique: other mesh hernioplastyproceduresTrabucco.o has developed a single layer mesh with theperceived ideal rigidity and desired characteristics. Thispreshaped mesh can be used in all primary inguinal

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TAPP=transabdominalpreperitoneal repair (Iaparoscopic). TEP=totallyextraperitoneal repair (laparoscopic). IPOM=intraperitonealonlay mesh repair(laparoscopic). .. indicate data were not available.

Table 1: Randomised tria)s comparing laparoscopic and open

inguinal herniorraphy

hernia repairs, fits into the subaponeurotic inguinalspace, and does not have a tendency to wrinkle, curl, orshift.

Corcione6' has adopted a personal modification of thesutureless mesh repair, which is called the held-in meshrepair. An umbrella folded plug is placed through thedeep ring and is held in the preperitoneal space withsuture layers and a fiat mesh is then placed over theposterior wall of the inguinal canal. Excellent results havebeen reported.

Valenti.2 has described the protesi autoregolantesidinamica, which consists of two superimposed layers ofsurgical mesh, placed in the interaponeurotic layers. Eachlayer moves independently where they are superimposed:where the lower layer medially and the upper layerlaterally overlap. More than 500 patients have beenrepaired with a recurrence free follow-up after 5 years andlittle postoperative discomfon.

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The Prolene Hernia System is a double-leaved meshwith a connector. The posterior leaf is placed by the openanterior approach with minimal dissection in thepreperitoneal space, the connector lies in the defect andthe anterior leaf is placed in the interfascial plane similarto the Lichtenstein technique. In a randomised double-blind study"3 this system gave similar results to theclassical Lichtenstein patch with less immediatepostoperative pain, and more patients returning to nonnalactivity by the third postoperative day.

Postoperative careIf social circumstances allow, whether the operation hasbeen done under general or local anaestheic, patientsshould be discharged within a few hours of operation withvery little discomfort for which mild analgesics can beprescribed. Unrestricted activity is encouraged, and mostpatients should resume nonnal activity in 2-10 days."Take it easy" is the wrong advice.47

Integrity of the hernia repair depends on good surgicaltechnique; return to full activity does not increaserecurrences and caution will engender anxiety andperhaps justify the patient's decision to remain off workfor up to 6 weeks........

Laparoscopic repairThe first report of hernia repair with laparoscopy wasmade by Ralph Ger in 1982"7 Since then many surgeonshave contributed' to modifications and improvements insafety but only a few «5% in the UK and USA) haveadopted this technique into routine surgical practice. Atpresent, only the more skilful laparoscopists undertakethis procedure. The most common techniques are thetotally extraperitoneal (TEP) or the transabdominalpreperitoneal procedure (TAPP).

Both methods almost always use general anaesthesia,although some surgeons use an epidural or even localanaesthetic". The TAPP procedure is approachedthrough the peritoneal cavity, whereas the TEP enters thepreperitoneal space. In both procedures the entireinguinal fioor is exposed, which will reveal any direct,indirect, or femoral hernias. The myopectineal orifice anda wide margin is then covered with prosthetic mesh andfixed with tacks, staples, or constructs. Current practice isto reduce the number of fixation points, even to zero.

In Japan and several European countries, few surgeons«5%) are practising laparoscopic hernia repair because ofits complexity, occasional serious complications such asbowel or vascular injury, and the long learning curve,,9.70

ResultsTable I lists the better studies investigating repair ofinguinal hernias. The rate of recurrence and complicationsbetween open and laparoscopic procedures do not differsignificantly. Laparoscopic repair requires a generalanaesthetic in most cases, takes more operative time tocomplete, and the hospital costs are greater. However,earlier return to normal activities and work seems to makethe overall costs of the laparoscopic operation less thanthose of the open procedure. .7.88,90,9'Members of theEuropean consensus conference reinforced theseconclusions with the added caveat that laparoscopy mightincrease the risk of rare complications.92

The trend in most centres is for laparoscopic repair to berestricted to bilateral and recurrent inguinal hernias, forwhich the results are excellent.23,93-9'The choice betweenthe T APP and the TEP is a personal preference of thesurgeon. There is no clinical difference between theconversions to open, the complications seen, or the

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Method Medlan Number Rete of Rete offollow-up of compll- recurrence(years) hemlas catlons (%)-

ReferencePayne" TAPP .. 48 12%

Lichtenstein .. 52 18%Stoker" TAPP 0.6 75 .. O

Lichtenstein 0.6 75 .. OMaddern" TAPP .. 44 400,(,

Doubledarn 42 47%Barkun" TAPP 1.2 43 22% 2.0

Darn/Lichtenstein 1.2 49 12% OLiebl" TAPP 1.3 54 O

Shouldice 1.3 48 .. OLawrence'. TAPP 58 12%

Darn 66 2%Vogt" IPOM 0.7 30 .. O

Mu Itiple types 0.7 31 .. OSchrenk'. TAPP .. 28 .. 5.0

TEP .. 24 .. 16.7Shouldice 34 .. 2.9

Liem" Open 2.0 509 .. 6TEP 2.0 493 .. 3

Johansson80 TEP 1.7 179 .. 1.0Openmesh 1.7 168 .. 3.0Anterior repair 1.7 177 .. O

Champault'l1 TEP 3.0 51 4.0% 6.0Stoppa 3.0 49 29.5% 2.0

Beets'" TAPP 1.75 42 67% 12.5GPRVS 1.75 37 62% 1.9

Wellwood" TAPP 200Tension-free 200

Cohen" TAPP 78 .. 1.85TEP 67 O

Khoury''' TEP 3.0 150 2.5Plug and Patch 3.0 142 3.0

Johansson" TAPP 1.0 604 Notsignificant

Openpreperitoneall.0meshTissue repair 1.0

MRC Laparoscopic 1.0 468 29.9% 1.9LaparoscopicOpen 1.0 433 43.5% OHemiaTrialGroup<'Lorenz"" TAPP 2.0 86 11% 2.3

Shouldice 2.0 90 9% 1.1Sarli" TAPP 2.0 20 34.7% O

Tension-free 2.0 23 35% 4.3Wright'" TEP 5.0 149 2.0

Tension-free 5.0 107 .. OStoppa 5.0 32 .. 9.4Sutured 5.0 12 O

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recurrence rates betWeen these tWo operations in skilledhands.87.95.96However, in assessing the evidence in 2001the UK NICE committee (of which only one of 20members was a surgeon), recommended the TEPoperationas the procedure of choice.25

ConclusionFor primary inguinal hernia in adults the method of repairwill account for the surgeon's training, the type of hernia,and the patient's age"7 Shouldice repair, the Lichtensteinoperation, and laparoscopic techniques conform to theprincipIes of good repair surgery-namely careful andaccurate identification of the anatomy and use ofappositional suture material or implanted mesh to repairthe defect. When combined with good managementpolicies, ali techniques are effective.

The Lichtenstein operation has gained popularitybecause of its simplicity and equally good results in thehands of experts and trainee surgeons; it is therecommended operation of first choice for uncomplicatedunilateral inguinal hernia in men. In countries wheremesh is not affordable, Shouldice repair gives excellentresults in the hands of well-trained surgeons. However,the operation is technically demanding. Variations in theplacement or configuration of mesh have theirprotagonists (usually the designer and patent-holder), butare no more cost effective than the Lichtenstein fIat mesh.The complexity of the laparoscopic repair, the highhospital costs, and the occasional severe complication hasrestricted its use to enthusiasts.

Incisional hemiaDiagnosisAn incisional hernia arising after open or laparoscopicoperation is defmed as a bulge visible and palpable whenthe patient is standing and often requiring support orrepair.98 60% of patients with incisional hernias do nothave any symptoms. Incarceration persisting to acuteintestinal obstruction and strangulation necessitatesemergency surgery. Physical examination of the patientsupine and relaxed usually reveals the hernia. Ultrasoundexamination is a useful diagnostic test and will oftendiscover other impalpable defects, especially in patientswho are obese, but a CT scan is. more efficient andaccurate in defming the defect and the contents of anirreducible sac and for planning the preoperativepreparation of the patient and the chosen operation,,9,100

Prevention and incidence10-15% of laparotomy incisions are estimated toeventually develop hernias.101 In the meta-analysis ofHodgson and colleagues,102 which inc1uded onlyrandomised controlled trials and trials with a JadadQuality score of greater than 3, abdominal fascial c10sureof midline laparotomy wounds with a continuous, non-absorbable suture resulted in a significantly lower (32%risk reduction) rate of incisional hernia than use of eithernon-absorbable or interrupted techniques. Sinuses andwound pain however, were lower with very-slowlyabsorbable sutures. A meta-analysis by van't Riet andcolleagues,103which assessed 15 studies and 6566 patients,reached similar conc1usions. Laparotomy wounds shouldtherefore be c10sed with a non-absorbable or very slowlyabsorbable continuous fascial suture.

ClassificationThe report of an international panel of experts, whichmet under the auspices of the European Hernia Society,has provided a framework for c1assification of incisional

hernia. As a result, guidelines on the choice of surgicaltechnique and its adaptation to the individual patientwere formulated.I04 The classification system useslocalisation, size, recurrence, reducibility, and symptoms(panel). Korenkov and colleagueslO4 also reviewed thepublished work on incisional hernia surgery and judgedpublications according to their scientific quality andrelevance. Techniques using fascial duplication oradaptation with up to 7 years' follow-up had disastrousrecurrence rates of 25-55%. This led the expert panel toconclude that fascial duplication and fascial adaptation(the Mayo technique) should be used only for smallhernias «5 cm) and is of value only in horizontalwounds. A similar conc1usion had been reached by Pauland colleagueslO5after a postal questionnaire to surgicaldepartments in Germany. For the prefascial onlayprosthetic repair (seven studies) recurrence rates were2'5-13'0%; and for the retromuscular prefascial sublaytechnique (lI studies) recurrence rates were 2-23%.'04The European experts concluded that mesh should beused in the repair of ali but small incisional hernias and arandomised controlled trial should be done to decidewhich of the surgical techniques (sublay or onlay) ispreferable. The sublay technique is more complicatedand requires more expertise.

PneumoperitoneumManagement of giant incisional hernia can becompromised by obesity, intrahernial adhesions, andcontraction in the volume of the abdominal cavity. Thissituation however, occurs in no more than 5% of patients(figure 3). Use of pneumoperitoneum before attemptingdefinitive repair of giant hernias was originally suggestedby Moreno in 1940.106The technique is straightforward:under local anaesthetic an epidural catheter is introducedinto the peritoneal cavity. Graduated amounts of gas or airare then injected on successive days, 500 mL at a time

Classlfication for Incislonal hernias104

Localisation1 Vertical

1.1 Midline above or below umbilicus1.2 Midline including umbilicus right or left1.3 Paramedian right or left

2 Transverse2.1 Above or below umbilicus right or left2.2 Crossed midline or not

3 Oblique3.1 Aboveor below umbilicus right or left

4 Combined(midline+oblique; midline+parastomal, etc)

Size (=real fascial gap)1 Small «5 cm in width or length)2 Medium (5-10 cm in width or length)3 Large(>10 cm in width or length)

Recurrence

1 Primary2 Recurrence (1,2,3. etc)

Reducibilityat the hernia gate1 Reducible with or without obstruction2 Irreducible wíth or without obstructíon

Symptoms1 Asymptomatic2 Symptomatic

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Rgure 3: Large ventral hemia with 5ignificant 1055 of domain and 5kin ulceration

onee, tWiee, or three times a day, until a daily volume ofabout 2.5 L is obtained. The patient is ready for surgeryabout 2 weeks after induetion of the pneumoperitoneum,the endpoint being judged by the tension of the abdominalwall, which should feel as tight as a drum, especially inthe flanks.

Principies of technique of open repairPreoperative weight reduetion is desirable. Ali skin lesionsand erosions should be resolved before surgery:pulmonary funCtion should be optimised. Most patientswill require a proeedure that uses a tension-free repairwith prosthetic reinforeement. The following surgiealprincipies should be followed: opening of the peritoneumand excision of the hernia sae is obligatory exeept in smallhernias; negleeted intra-sae adhesions ean cause

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postoperative bowel obstruetion. The length of suturematerial used to dose the faseiallayer should be sueh thatthe suture length is at least four times that of the woundlength.'07

OperativetechniquesOpensutured repaírThe only randomised trial'o. of suture repair eomparedwith mesh repair for ineisional hernia showed that evenwith hernias less than 6 em in length or width, suturedrepair resulted in tWiee as many reeurrenees as meshrepair. Suture repair with or without fascial duplication(Mayo repair) should therefore be used only for small(3 em) ineisional hernias where the tissues are of adequatestrength to hold sutures and the four-to-one ratio ofsuture length to wound length should be applied. '07

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Open prostheticrepairThere are three different approaches for mesh placement:the prosthesis is placed over the defect (onlay) after four-to-one suture closure ofthe fascia;'08the prosthesis is placed inthe prefascial/preperitoneal, retro-muscular space behindthe rectus abdominis muscle (sublay) followed by four-to-one closureof the anterior rectus sheath;109or the prosthesisis placed between the fascial edges to bridge a gap thatcannot be closed with sutures (inlay technique); onlyrequired in fewer than 5% of cases. When the onlay orsublay technique is used, the mesh must overlap eachmargin of the aponeurotic defect by at least 5 cm and mustbe well fixed to the aponeurosis with sutures gap of no morethan 1-2 cm.lnlay techniques are not recommended unlessthere is a substantial defect in the tissue that cannot bebridged with plastic procedures of the natural layers of theabdominal wall. Mesh in contact with bowel will formadhesions and risk obstrUction or strangulation. However,the newer polytetrafluoroethylene based biomaterials havegreatly reduced this risk. Therefore, if these prostheses areused, the inlay technique is acceptable.

ResultsFew centres have published results with a recurrence ratefor incisional hernia repair of less than 10%. However, theintroduction of prosthetic biomaterials and understandingof the correct use of prosthetics in reconstrUction of theabdominal wall should reduce these recurrence rates by atleast half.llo These improvements have not yet beenreflected in population-based clinical outcomes.'1I In somesituations the approach to difficult incisional hernias shouldbe multidisciplinary with the involvement of a respiratoryphysician, skilled anaesthetists and plastic surgeons, andusing techniques such as component separation or slidingdoor for release of the rectus abdominis muscles from theanterior and posterior layers of its sheaths, or tissueexpansion-assisted closure of the abdominal wall.II2-114

LaparoscopicrepairLaparoscopic incisional and ventral herniorraphy was [trstdescribed in 1993.'15 The notions are equivalent to

prosthetic repair of inguinal hernias and adopt thefeatures of the open Rives-Stoppa (sublay) repair ofincisional hernia. The technique should be done bysurgeons adept at complex laparoscopic operations. Theprocedure continues to change as newer prostheticbiomaterials and instrUments are developed. The presenceof incarcerated bowel does not prevent the performance ofthe procedure, but strangulation of bowel usuallynecessitates an open hernioplasry.

Laparoscopicoperative techniqueThe most imponant and potentially fatal complication oflaparoscopic incisional herniorrhaphy is injury to thebowel. Use of any energy source (electrocautery) canresult in an injury to the intestine, if used improperly. Toensure adequate coverage by a 3 cm overlap of theprosthesis, 6 cm is added to the maximum measurementsin all directions. After inspection, tacks are deployed alongthe periphery of the prosthesis by insening them 5-6 mmfrom the edge of the patch, 1,0-1,5 cm apan. Severalauthors"6-120have identified the need to place transfascialsutures to ensure adequate fixation of the prosthesis;without use of these transfascial sutures a high recurrencerate could resulto Rather than placing the additionalsutures around the periphery an additional row of staplescan be placed near the fascial edges (the double-crowntechnique).'J7

ResultsCompared with the open method of repair, operativetimes for laparoscopic repair (about 90 min) are notsignificantly different (table 2). The most frequentcomplications (table 3) after open repair are bowelobstrUction, ileus, seroma, and infections, and the mostcommon complications after laparoscopic repair are ileusand seroma. In all these comparative analyses, theincidence and severiry of the complications were less inthe laparoscopic group than the open repair group, withthe exception of seromas. The most serious complicationin laparoscopic incisional herniorraphy is enterotomy. InRamshaw's series there was an incidence of 2.6%

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Carbajo'" Holzman'" Park'" Ramshaw"" DeMaria120

Open Lap Open Lap Open Lap Open Lap Open Lap

Bowelobstruction 3% 12.5% 0.5% .. .. .. .. 11.0%Cardiac .. .. 4.1%Cellulitis 6.7% .. .. .. .. 3.4% 2.5%Cerebrovascuaraccident .. .. .. .. .. 0.6%Deepveinthrombosis .. .. .. .. .. 5.6%EnterotomyRecognised

.. .. .. .. 1.3%Unrecognised .. .. .. 0.6% 1.3%Fistula .. .. .. .. .. 4.8%Genitourinary 6.1% .. 2.3% 2.5%Haematoma 20.0% 3% .. 10.2%Hypoxia .. 6.3% 0.5%lIeus .. 12.5% .. 5.4% 8.1% 6.3% .. 4.8%Infection01mesh .. 3.6% 2.9%Infection(other) .. .. 4.0% 0.5% .. 33.()O,{, 9.6%Intestinal injury .. .. 4.0%Phlebitis 10%Protractedpain .. .. .. 4.1% 3.6%Pulmonaryembolus .. .. .. .. 0.6%Recurrence rate 6.7% O 12.5% 10.0% 34.7% 11.0% 20.7% 2.5% O 4.8%

Reoperation .. .. .. .. 9.6%Respiratory distress .. .. .. 1.8% 0.6% 1.3%Seroma 67% 13% .. 3.6% 3.6% 6.9% 2.5% 22% 43.0%Serosalinjury .. .. 0.6% 2.3%Skin necrosis 3.3%Woundinlection 6.3% 2.0%

Lap=laparoscopic.

Table 2: Comparison of complications associated with open prosthetic incisional and ventral herniorrhaphy

Table3: Reported large series (>50 patients) of laparoscopic incisionaland ventral hemia repairs (n=1047) comparison of length ofstay between open and laparoscopic incisionaland ventral hemiorrhaphy

compared with 0.6% in the open group. Although notsignificant, it should reinforce the need for vigilance inavoidance of this complication. Mer repair of the injurythe next decision is whether to proceed with repair of thehernia itself. Use of a prosthesis is to be avoided if theinjury involves the large bowel. Ifthere has not been muchcontamination the herniorrhaphy can be completed asplanned. Table 3 lists several other publicationsdescribing this operation, but includes only those thathave recruited 50 or more patients. Complication ratesranged from 5-26%, which is similar or better than that ofthe open repair. Length of admission was a mean of2 days. Recurrences ranged from 0-11 %, which is betterthan the open method.

ConclusionObservational studies indicate that prosthetic mesh hasthe same potential to reduce the unacceptably highrecurrence rates in incisional hernia as has been proven ininguinal hernia. Repair of complex incisional hernias is aprocedure for specialists who have developed an interestand experience in these operations. In skilled handslaparoscopic incisional hernia repair has achievedfavourable early results, with the added benefit ofsignificantly reduced length ofhospital stay.

Prosthetic biomaterialsTo repair abdominal wall hernias prosthetic biomaterialsshould be used as the standard of care. In the USA, morethan 90% of all inguinal and incisional hernias arerepaired with prosthetic material and some places inEurope (eg, the UK) are also beginning to approach thisfigure. There are at least 80 different prostheticbiomaterials that can be used to repair inguinal, incisional,ventral, and other hernias. These materiaIs can bearbitrarily divided into products. that are flat, singlecomponent, preformed, absorbable, or a combination.

Flat prostheses used today are made frompolypropylene, polyester, or expanded polytetrafluo-roethylene. AlI are available in various sizes and can be cutto conform to the dimensions necessary to repair hernias.The main difference betWeen these products is the poresize of the weave, the variation in the weave, and thethickness, suppleness, pliability, and the weight of themesh. Polyester biomaterials have not been used much inthe USA compared with use in Europe, notably France.Expanded polytetrafluoroethylene prostheses are com-monly used in laparoscopic ventral hernioplasty.

There are a few new ideas in use of the flat mesh torepair the inguinal floor. Although each of these productsdiffers in the manner in which they are placed, all use tWoseparate flat meshes placed in different anatomical planesor attempt to plug the defect with an additional flat meshto complete the hernia repair. Preshaped products areavailable to repair the inguinal floor laparoscopically.

Repair of incisional and ventral hernias has resulted inan interest in development of newer prostheses. Thecurrent biomaterials, notably dual sided polytetrafluoro-ethylene, have been used extensively and successfully.

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Other biomaterials have been introduced withabsorbable components incorporated into low weightand heavy weight meshes. These materiaIs attempt toprevent the inelasticity of the abdominal wall or restrictdevelopment of adhesions. Still others are combinationproducts that are bilaminar components of tWo differentbiomaterials, which are designed to encourage ingrowthof collagen into the product on one surface and preventingrowth on the visceral surface. Finally, new collagen-based acellular products are available which are replacedby the patient's native collagen and results in a repair ofthe fascial defect.

Day-case outpatient surgeryHigh quality day-case inguinal hemia surgery has beenpromoted by enthusiasts. These disciplines have beendeveloped mainly in private Hernia Clinics but also includeone within t):le National Health Service (NHS) inPlymouth, UK.'25.126The Plymouth Hernia Service is basedwithin the outpatient unit of Derriford Hospital and wasstarted in 1996. Its introduction involved carefulconstruction of care pathways by surgeons, anaesthetists,director of nursing and quality, day-case manager, localpurchasing groups, and the general practitioner liaisongroup. A 15-step protocol outlining the pathway fromoutpatient clinic to discharge after operation was agreedtogether with a patient information sheet, postoperativeinstructions and an information sheet for generalpractitioners. Compared with outcomes before the HemiaService, the day case rate rose from 28% to 81% and thelocal anaesthesia rate from 7'6% to 90%, resulting in anestimated potential saving of 605 inpatient days per yearwith a large economic benefit. This enhanced patientpathway also encourages early return to normal activity andlow operative morbidity.'27 Overall, development of day-case surgery for adults with groin hernias has been slower inthe UK than in the USA, where most inguinalhernioplasties are done on an outpatient basis.

A nurse assessment clinic can undertake much of theroutine preoperative check of physical status and verify thesocial context and suitability of the patient for daysurgery.'25.126Mer surgery, patient follow-up within 24 hcan also be undertaken by a (hernia) clinical nursespecialist. The Plymouth Hernia Service also incorporates apatient information video, an electronic patient record usingwireless technology and handheld devices to record thepatient history, operation, discharge letter, and follow-up.

Postoperative management and return to activityIn 1993 the Royal College of Surgeons of EnglandClinical Guidelines on the Management of Groin Herniasin Adults recommended patients should be fit to return tooffice work after 2 weeks after an inguinal hernioplastyand back to heavy work after 4 weeks.'28These Guidelineshad a substantial effect on the practice of adult herniasurgery in the UK. A review of such practice several yearsafter publication of the college guidelines was undertakenby postal survey to surgeons in Wales.129Meshes (animportant recommendation by the guidelines) had been

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Park118 Ramshaw'" Franklln'" Tor" LeBlanc118 Kyze.... Henlford124-Number of patients 56 79 112 144 200 53 407Complication rate 18% 19% 5% 24% 18% 11% 13%Hospital stay (days)* 3 2 1-12 (range) 2 1 3 (median) 2Follow-up (months)* 24 21 30 7 36 17 (median) 23Recurrencerate 11% 3% 1% 14% 17%(median) 6.5% 2%

*Meanexceptwherenoted.

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used by only 20% of surgeons in 1993 and had risen to79% in 1997. Although there seemed to be a moreuniform surgical management of adult inguinal hernia by1997, only 10% of surgeons had adopted outpatientsurgery, whereas 80% advocated an inpatient stay of1-2 days. Most surgeons were still advising their patientsto return to activiry at specific times, usually light work at2 weeks and heavy work at 4-6 weeks. A secondquestionnaire study in 2001 sent to patients 6-12 monthsafter their inguinal hernia repair compared therecommendations of the college guidelines with the actualpolicies for hernia repair done in Frirnley Park HospitalNHS Trust, Surrey, UK, including indications,techniques, complications, and outcome.130 This studyalso indicated lengthy times off work but also found anoutpatient rate of 56% and 72'5% of patients beingdischarged within 48 h oftheir surgery. Both these studiesindicate that guidelines need to be updated and reviewedon a regular basis. To illustrate how local practice dictatescare pathways in another region of the UK during thesame time period, only 22% of groin hernia repairs weredone on an outpatient basis in Scotland.13I

The surgical technique used does not affect post-operative pain and return to activity.132 An enthusiasticsurgeon who advises immediate return to unrestrictedactivity is more likely to achieve faster recovery periodsthan would one who does not.133 Other more subtlesocioeconomic and psychological factors also have abearing on outcome such as patient educational levei,income levei, symptoms of depression, anddisposition.134,135

ConclusionDay-case surgery is clinically feasible for at least 75% ofadults with primary inguinal hernias whether theoperation is done by an open or laparoscopic method.Surgery requires technical and organisational excellence ifthe long-term results are going to be worthwhile and ifcomplications are to be avoided. After surgery, earlyreturn to work should be encouraged. Despite the cleardemonstration of the feasibility and clinical excellence ofday-case and short-stay surgery for inguinal hernias, it isthe behavioural attitudes of the surgeons that need to bemodified. Incentives are needed to adopt other adiuncts toefficiency in hernia practice such as nurse assistants, localanaesthesia, patient information videos, and electronicrecords with wireless technology.

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Copyright 2003. Elsevier UK. Reproduced by permission.Further reproduction prohibited without consent ofauthors and publisher.

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