Giant prosthetic reinforcement of the visceral sac. The Stoppa groin hernia repair.

GPRVS is a properitoneal hernioplasty with a prosthesis composed of the polyester Dacron. The repair is anatomic, sutureless, tension-free, and the absolute weapon to eliminate all types of groin hernias. No other technique produces better results for the repair of recurrent and re-recurrent groin hernias. It also is a joy to perform.

Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic.

OBJECTIVE: The authors provide an assessment of mechanisms leading to hernia recurrence after laparoscopic and traditional preperitoneal herniorrhaphy to allow surgeons using either technique to achieve better results. SUMMARY BACKGROUND DATA: The laparoscopic and traditional preperitoneal approaches to hernia repair are analogous in principle and outcome and have experienced a similar evolution over different time frames. The recurrence rate after preperitoneal herniorrhaphy should be low (< 2%) to be considered a viable alternative to the most successful methods of conventional herniorrhaphy. METHODS: Experienced surgeons supply specifics regarding the mechanisms of recurrence and technical measures to avoid hernia recurrence when using the preperitoneal prosthetic repair. Videotapes of laparoscopic herniorrhaphy in 13 patients who subsequently experienced a recurrence also are used to determine technical causes of recurrence. RESULTS: Factors leading to recurrence include surgeon inexperience, inadequate dissection, insufficient prosthesis size, insufficient prosthesis overlap of hernia defects, improper fixation, prosthesis folding or twisting, missed hernias, or mesh lifting secondary to hematoma formation. CONCLUSIONS: The predominant factor in successful preperitoneal hernia repair is adequate dissection with complete exposure and coverage of all potential groin hernia sites. Hematoma mesh lifting and inadequate lateral inferior and medial inferior mesh fixation represent the most common causes of recurrence for surgeons experienced in traditional or laparoscopic preperitoneal hernia repair.

[My experience in repairing, without tension, primary inguinal hernia in men]. / Mon expérience de la réparation sans tension des hernies inguinales primaires chez l'homme.

Beginning in 1990, the tension-free inguinal hernioplasties were adopted for the treatment of primary groin hernias in men. 1252 tension-free hernioplasties were performed in 1,076 men and followed for one to six years. Lichenstein's tension-free hernioplasty and Gilbert's sutureless hernioplasty were used, usually in combination. Anesthesia was local in 97% of the operations. 15 complications occurred (1.2%): one wound infection, one seroma, 12 hematomas, and one ilioinguinal neuralgia, 6 recurrences occurred (0.5%): 4 indirect, one direct and one femoral. No indirect recurrences have occurred since placing Gilbert's cone shaped plug in the deep ring. Tension-free hernioplasties consisting of a patch of polypropylene mesh plus a cone plug of the same material, placed in the deep ring when an indirect hernia is present, produce excellent results and are the preferred methods to manage the majority of primary inguinal hernias in men.

Experience with the tension-free hernioplasty for primary inguinal hernias in men.

BACKGROUND: Tension-free inguinal hernioplasties have been highly touted and aggressively promoted by the initiators of the procedures and manufacturers of the prosthesis. Beginning in 1990, these procedures were adopted for the treatment of primary groin hernias in men. STUDY DESIGN: This experience involved 1,252 tension-free hernioplasties that were performed in 1,076 men who were then followed up for one to six years. Lichtenstein's tension-free hernioplasty and Gilbert's sutureless hernioplasty were the techniques used, usually in combination and tailored to the problem at hand. The mesh was polypropylene. Anesthesia was local in 97 percent of the operations. Antibiotics were not used as prophylaxis for wound infections. RESULTS: Fifteen complications occurred for a rate of 1.2 percent. They were one wound infection, one seroma, 12 hematomas, and one ilioinguinal neuralgia. In none was it necessary to remove the mesh. Six recurrences occurred for a rate of 0.5 percent. Of these, four were indirect, one was direct, and one was femoral. The indirect recurrence followed repair of primary indirect hernias. No indirect recurrences have occurred since the procedure has included placing Gilbert's cone-shaped plug in the deep ring when an indirect hernia was present. CONCLUSIONS: Tension-free hernioplasties consisting of a patch of polypropylene mesh partially fixed to the perimeter of the floor of the inguinal canal, plus a cone-shaped plug of the same material placed in the deep ring when an indirect hernia is present, produce excellent results however they are measured and are the preferred methods to manage most primary inguinal hernias in men.

Management of recurrent and perivascular femoral hernias by giant prosthetic reinforcement of the visceral sac.

BACKGROUND: Classical hernioplasties have been used to manage primary femoral hernias for over a century. In women, infrainguinal repair of the parietal defect is simple and successful. In men, femoral hernias are frequently associated with inguinal hernias and, therefore, a Cooper's ligament repair is indicated. For recurrent femoral hernias, however, the classical hernioplasties are often inadequate just as they are for the repair of recurrent inguinal hernias and a prosthetic repair is indicated. Giant prosthetic reinforcement of the visceral sac (GPRVS) is the descriptive name of a properitoneal groin hernioplasty with a large piece of Mersilene. The repair focuses on retaining the peritoneum rather than repairing the parietal defect and is efficient, anatomic, sutureless, and tension-free. It is the only repair that reliably eliminates all hernias of the groin, including perivascular femoral hernias. STUDY DESIGN: In this study, GPRVS by way of an abdominal incision was used to treat recurrent and perivascular femoral hernias. Also included are a description of and experiences with a new technique of unilateral GPRVS performed through an infrainguinal approach. RESULTS: The data reveal no recurrences in 69 problem femoral hernias of which 15 were primary (two perivascular) and 54 recurrent (four perivascular). CONCLUSIONS: Giant prosthetic reinforcement of the visceral sac performed transabdominally or by way of the newly described infrainguinal method is a useful and reliable method to treat primary, recurrent and perivascular femoral hernias.

[Treatment of recurrent and prevascularized femoral hernias by reinforcement of the visceral sac using a giant prosthesis]. / Traitement des hernies fémorales récidivées et prévasculaires par renforcement du sac viscéral à l'aide d'une prothèse géante (GPRVS).

Giant prosthetic reinforcement of the visceral sac (GPRVS) is the descriptive name of a preperitoneal groin hernioplasty with a large piece of Mersilene. The repair focuses on retaining the peritoneum rather than repairing the parietal defect and is efficient, anatomic, sutureless, and tension-free. Herein, is a discussion of its use to manage recurrent and perivascular femoral hernias and a description of a new technique of unilateral GPRVS done through an infrainguinal approach. The data presented reveal no recurrences in 69 problem femoral hernias of which 13 were primary, 50 recurrent and 6 perivascular.

Testicular atrophy and chronic residual neuralgia as risks of inguinal hernioplasty.

Testicular atrophy can be prevented by limiting dissection trauma to the spermatic cord, specifically, leaving the distal part of the indirect inguinal hernia sacs in situ; never dissecting beyond the pubic tubercle; and using the properitoneal space when it is advisable, as in recurrent hernias, to avoid dissection of the spermatic cord altogether. Chronic residual neuralgia may be debilitating and difficult to manage. The involved nerve may be identified by local anesthetic nerve blocks. Neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerves may cure the neuralgia.

The technique of giant prosthetic reinforcement of the visceral sac performed through an anterior groin incision.

The technique of giant prosthetic reinforcement of the visceral sac performed through an anterior groin incision is described. The procedure, which is usually performed through an abdominal incision, is indicated for all hernias of the groin that are at high risk for recurrence after classical repair and that are encountered unexpectedly during routine primary hernioplasty.

[Technique of properitoneal hernioplasty. Unilateral reinforcement of the visceral sac with Mersilene giant prosthesis]. / Une technique de hernioplastie propéritonéale. Le renforcement unilatéral du sac viscéral par grande prothèse de Mersilène.

358 hernias of the groin (340 patients), predominantly recurrent and re-recurrent, were treated by this procedure, similar to bilateral hernioplasty, specifically developed for ambulatory surgery. There were 16 recurrences of which most were due to flaws in the original procedure. This was overcome by widening and extending the distal lateral corner of the mesh.

Prevention of ischemic orchitis during inguinal hernioplasty.

Ischemic orchitis and testicular atrophy remain the most dreaded complications of inguinal hernioplasties. The current study examines these complications in a series of hernia repairs during a period of 20 years. The incidence of the complications in the ten year period from 1971 to 1981 was compared with the experience since 1981, from which time all distal indirect hernia sacs were left in place and increasing experience was gained in properitoneal repairs of recurrent hernias. The incidence of ischemic orchitis in primary hernia repairs was reduced from 0.65 per cent (11 instances in 1,682 repairs) to 0.03 per cent (one in 3,634 repairs). The incidence in recurrent hernia repairs was reduced from 2.25 per cent (seven in 311 repairs) to 0.97 per cent (eight in 827 repairs). These data have led us to emphasize the importance of minimizing cord dissection by leaving intact all significant distal hernia sacs and not dissecting beyond the pubic tubercle. Additionally, properitoneal repairs should be considered for repairs of recurrent hernias not only to reduce further recurrences but also to avoid testicular complications.

Incisional hernioplasty with Mersilene.

Thirty large incisional abdominal hernias (myoaponeurotic defects greater than 10 centimeters) were successfully repaired by a technique of incisional hernioplasty which implants a large Mersilene (polyester fiber) prosthesis in the space between the abdominal muscles and the peritoneum. The prosthesis extends far beyond the borders of the myoaponeurotic defect, and is solidly held in place by intra-abdominal pressure and later by fibrous ingrowth. The prosthesis protects against recurrence in two ways. First, it prevents peritoneal eventration by adhering to the visceral sac and rendering it indistensible. Second, the prosthesis unites and consolidates the abdominal wall. Consequently, the procedure uniquely exploits the very force which caused the hernia to prevent a recurrence. A prosthesis of Mersilene is essential for success because it is supple and elastic enough to conform freely to the curvatures of the visceral sac, has the necessary grainy texture to grip the peritoneum and prevent slippage and is reactive enough to induce a rapid fibroblastic response to ensure fixation.

[Testicular atrophy. A risk of inguinal hernioplasty]. / L'atrophie testiculaire. Un risque de la hernioplastie inguinale.

Testicular atrophy is a complication of inguinal hernioplasty that angers men of all ages. It is caused by thrombosis of the spermatic cord. Experience with over 6,500 inguinal hernioplasties in men indicates that the thrombosis is induced by direct surgical trauma to the cord. Trauma to the cord can be minimized and the incidence of testicular atrophy can be reduced by 1) not dissecting beyond the pubic tubercle, by 2) leaving distal indirect hernia sacs attached to the cord or by 3) avoiding dissection of the spermatic cord altogether by employing a posterior properitoneal approach.

Giant prosthetic reinforcement of the visceral sac.

One hundred and seventy-nine patients with 237 hernias of the groin who were at high risk for recurrence after classic hernioplasty were operated upon; the procedure of giant prosthetic reinforcement of the visceral sac (GPRVS) was used. The patients in this series had predominantly recurrent and re-recurrent hernias. However, a few were obese with bilateral primary direct hernias and some had associated connective tissue disorders, such as Marfan and Ehlers-Danlos syndromes. GPRVS eliminates hernias of the groin by rendering the peritoneum inextensible by placing, in the preperitoneal space, a large prosthesis that extends far beyond the borders of the myopectineal orifice. The myopectineal orifice is the weak spot at which all hernias of the groin begin and is bounded by the rectus, oblique abdominal and iliopsoas muscles and the pectin of the pubis. In bilateral GPRVS, the peritoneum of both groins is reinforced with a single prosthesis inserted in the preperitoneal space through the midline. In unilateral GPRVS, the mesh envelops the peritoneum of a single groin. This simplifies the operation and makes it suitable for surgical centers that perform outpatient operations. The prosthesis with the best physical characteristics for GPRVS is Mersilene (polyester fiber). Unsutured prostheses of polypropylene and Teflon (polytetrafluoroethylene) may not adhere at the far edges, leading to a failure and recurrence. The over-all recurrence rate in this series of problem hernias was 3.7 per cent, which is extremely good. However, the rate becomes outstanding if recurrences resulting from meshes unsuitable for GPRVS are excluded.