GROIN HERNIA REPAIR

Warko Karnadihardja
Department of Surgery, Hasan Sadikin
Hospital
University of Padjadjaran
Bandung

EVOLUTION OF GROIN HERNIA

SURGERY

The McVay Coopers ligament repair

Moloneys nylon darn repair

The
Shouldice
repair

MESH REPAIR

MESH REPAIR

ETIOLOGY OF GROIN
HERNIA
1.
2.
3.
4.

5.

Patent processus vaginalis

Shutter mechanism
Raised intra adominal pressure
The integrity of the fascia transversals
Collagen
Cigarette smoking
General factors

RECURRENT GROIN HERNIA

The incidence after primary repair

varies
from 1% in specialized centers
to 30% in general survey
Most recurrences appear within 2-3
years of the primary repair

EARLY RECURRENCE
Etiologic factors
Experience of he surgeon
Tension
Infection
The suture material
Suturing technique
General factors
Local factors

LATE RECURRENCE

The incidence of recurrence of groin

hernias tappers off after the first 5 years
Sometimes some recurrences appear as
many as 30 years later
How about recurrent inguinal hernia in
middle age men who as children
underwent repair of an indirect hernia by
herniotomy on the same side ?

PROSTHETIC MESH

Originally used for the repair of incisional

hernia
Great success to the repair of recurrent
groin hernias
Possible to cure every hernia, regardless of
its size or shape

SYNTHETIC MESH FOR PRIMARY

REPAIR

Tension free repair: introduced by

Lichtenstein (1986)
Tensionless and sutureless : by Gilbert
(1995)
Open-mesh plug hernioplasty by Rutkow
(1995)

WHAT IS THE DIFFERENCE

BETWEEN CLASSIC VS PROSTHETIC
REPAIR ?

No need Skeletonizing
No need Extensive dissection
Less is now beatiful

To avoid recurrence of hernia !

TYPE OF MESH MATERIALS

Non absorbable
1. Knitted polypropylene
Prolene, marlex
2. Knitted polyester
Mersilene
3. Expanded polytetrafluoroethylene
CPTFE, Gore-tex
Absorbable
No place in hernia repair

APPROACH

Open method
Laparoscopic
Transabdominal / transperitoneal
Extraperitoneal

BASIC PRINCIPLES OF MESH

HERNIA REPAIR

The sheet must be sufficiently large to

overlap the hernia defect with an apron of
at least a few centimeters, allow a wide
area for fixation
The wider the area, the stronger the force
holding the mesh
The edges of the mesh must be fixed
firmly in place in good & strong tissues as
far from the weakened tissue

THESE BASIC PRINCIPLES IS

USED IN

Stoppa is giant prosthetic reinforcement of

the visceral sac (GPRVS)
Gilberts sutureless repair
Rutkows open-mesh plug hernioplasty
The deeper the level of the mesh, the less
likely a recurrence

MIGHT BE A FAILURE AND LEADING

TO RECURRENT HERNIA IF

Superficially place mesh, more prone to be

involved in any graft infection from
superficial wound infection
The inlay mesh position, is at a mechanical
disadvantage in that the full force of the intra
abdominal pressure is applied behind the
unsupported mesh sutured to the scarred
tissue along the edges of hernia opening
The onlay mesh placed on the outher
surface of the external oblique muscle, tends
to be lifted off the abdominal wall by intra
abdominal pressure

Laparoscopic Inguinal Hernia Repair

TAPP = Transabdominal Preperitonial Repair

Laparoscopic Inguinal Hernia Repair

TEP = Totally Extraperitonial Repair

MESH PLUG

ONLAY PATCH

THE LICHTENSTEIN REPAIR

THE LICHTENSTEIN REPAIR

THE STOPPA GROIN HERNIA

REPAIR
(GIANT PROSTHETIC
REINFORCEMENT OF THE
VISCERAL SAC = GPRVS)

Mainly used to manage complex hernias at

high risk for recurrence and recurrent groin
hernias
The essential features is the replacement
of the transversals fascia in the groin by a
large prothesis that extends far beyond
the myopectineal orifice (MPO)
GPRVS is sutureless and tension free

BILATERAL STOPPA

UNILATERAL STOPPA VIA ANTERIO

ABDOMINAL INCISION

UNILATERAL STOPPA VIA ANTERIO

ABDOMINAL INCISION

THE MYODECTINEAL ORIFICE

(MPO)

THE CHEVRON-SHAPED MESH IN

THE STOPPA OPERATION

CONCLUSION

The causes of primary groin hernia are

multi factorial and largely unaffected by
human behavior
The factors that bring about the recurrence
of groin hernias after failed attempts at
repair are almost controllable by relative
simple means
Patients undergoing herniorraphy have the
right to assume that the repair will last for
the rest of their life. It is the surgeons
responsibility to rise to these expectations