HERNIA SURGERY-TECHNIQUES

North Penn
Hernia Institute
2100 N. Broad St. Lansdale, PA 19446
215-368-1122
Fax:215-368-3569

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HERNIA TECHNIQUE COMPARISON

Review of Tension Free repair Methods

At the North Penn Hernia Institute, we utilize a mini-incision, TENSION FREE open mesh repair under local anesthesia. Our rate of recurrence with a follow-up of over 10 years with this method is less than 1/2%, the LOWEST recurrence rate of any procedure.
. At the North Penn Hernia Institute, the majority of our primary (first time) Inguinal Hernias are repaired using a "tension free" Mesh Technique. We fully feel that this technique is not only the safest procedure available, but also associated with the least post operative discomfort, most rapid return to normal activity and is associated with the lowest rate of recurrence when compared to the other techniques. We do, however, evaluate fully the anatomy of the hernia at the time of surgery. We feel that a single operation is not necessarily suited for all hernias, but that hernias vary from patient to patient. We therefore may on RARE occasion, modify our surgery to provide the patient with what we feel is the best TENSION FREE technique for them. But again, the tension free mesh repair satisfactorily repairs most primary hernias safely and effectively.

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OLDER SUTURE "TENSION" REPAIRS
Traditional (Tension Repair) hernia surgery involved cutting adjacent muscle, then pulling it together using sutures or wire. This creates extreme tension on the muscle as it must be moved out of its normal anatomic location to cover the hernia defect. This produces swelling and pain. More importantly, the tension inhibits full and effective healing of the edges. The result of incomplete healing in the presence of this continued tension is the muscle edges may pull apart causing a higher failure rate with recurrent (often larger and more complex) hernia. Also, when the muscle are pulled together adjacent tissue is weakened which too may eventually herniate. Recovery is prolonged with reduced patient flexibility, prolonged pain and restrictions imposed on activity.

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TENSION FREE REPAIRS
There are basically 3 techniques which can be considered tension free. Let me present them to you here, our personal opinion of these methods, and why we strongly feel the last one is the BEST (Safest, Most Effective, and Fastest Recovery). We have been doing hundreds of hernia repairs annually for over 20 years. This is our Specialty. We are trained, qualified and Certified in all of the techniques (certificate copies available if you like), but our experience and expertise has caused us to concentrate predominantly on the 3rd listed procedure (TENSION FREE Technique) as the overall BEST for the overwhelming majority of patients.

1st- LAPAROSCOPIC HERNIA REPAIR
This operation involves placing a mesh onto the hernia defect from inside the abdomen. It requires GENERAL ANESTHESIA (patient goes to sleep) which is associated with definite risk. Instruments and telescope are stabbed through the abdominal wall, risking injury to the intestine. These instruments are used to position the mesh over the weakness, held in place with staples. While the post operative discomfort is relatively small, the recurrence rate approaches 10-11% or more in recent published reports, which we believe is entirely too high. This landmark study published in the highly respected New England Journal of Medicine in April 2004 (vol. 350 no. 18), concluded that "The open technique is superior to the laparoscopic technique for mesh repair of primary hernias (L. Neumayer, A. Giobbie-Hurder, O. Jonasson, R. Fitzgibbons, D. Dunlop, et al. 2004)". Moreover, "the laparoscopic technique requires general anaesthesia (because the abdominal cavity has to be inflated with air) and it is more often associated with serious intra-operative complications than is open repair...( Lancet 1999;354: 185-90)." This, combined with the risks mentioned above has caused us to abandon this operation except in extremely unusual cases where hernias, repaired multiple times elsewhere, have recurred so many times, open approach is not feasible. Only then do we use the Laparoscopic Approach. This operation has not gained much favor around the world, and is being used less and less for the reasons mentioned. There is increasing reports of a chronic pain syndrome with this method, possible related to the use of staples or tacks to 'fix' the mesh internally.

2nd- LICHTENSTEIN REPAIR
This is a tension free repair performed "open" under local anesthesia. A mesh is applied OVER the weakness and sewn in place. This surgery has the advantage of safety with the use of local anesthesia, and direct visualization of the hernia, without using a "telescope". The incision is about 3-4 inches in length. However the recurrence rate here is still a bit high, in some series as high as 4-7%. There is a great deal of surgical dissection which causes post operative pain and slightly prolonged recovery. We feel that placing the mesh "over" the weakness only is like repairing a "bubble in a tire" by patching it on the outside. A recurrent hernia may eventually LIFT the mesh up. We strongly believe that if mesh is used, it should be placed inside of the weakness, under the muscle, not on top.

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3rd- "TENSION FREE" MESH TECHNIQUE
We are now convinced that this technique is truly the "STATE OF THE ART" in hernia surgery, providing the safest, most effective repair with the least post-operative pain. This technique is done under safe, local anesthesia via a small incision ( about 2 inches in most average patients). Once the hernia (bulge) is freed up by gentle dissection, it is returned through the hole or weakness into its proper position. Rather than just covering the weakness at this point, a specially designed mesh system is gently placed through the defect. It opens to cover and effectively repair the defect from the inside, the best place for mesh to be positioned. After this, an additional sheet of mesh is included over the defect as an insurance reinforcement. This is placed in a completely tension free fashion, being held in place by a "VELCRO-Like" effect of the mesh itself. Since there is no tension and only a minimal amount of surgical dissection, there is little post operative pain, and patients return to NORMAL ACTIVITY in DAYS. This technique has been essentially utilized for over 10 years, with recurrence rates of Less than 1/2 %, lower than any other technique including the conventional suture repairs, (TENSION REPAIR), or the Laparoscopic "Keyhole"Approach. WE FIRMLY BELIEVE THE TENSION FREE APPROACH IS THE MOST EFFECTIVE METHOD AVAILABLE.

TENSION FREE TECHNIQUE (More Details)

There are several products available for this "Tension Free" technique, all of which are available at the North Penn Hernia Institute. We feel that like patients, hernias differ, not one being like the next. We therefore believe strongly that a single operation or mesh product is not appropriate for all hernias. Therefore we are "SELECTIVE", choosing the appropriate mesh at the time of surgery to safely and effectively treat our patients. This selection is based on extensive experience in hernia repairs.

Some of these mesh products can be seen at: MESH PRODUCTS

Other hernia repair techniques, popular in both the USA and Canada, close the defect by suturing the muscle back together in an overlapping fashion. This creates a great deal of tension, which not only causes pain and prolonged recuperation, actually leads to a higher recurrence since the repair is under tension. This repair is quickly loosing favor among HERNIA SPECIALISTS such as us, and has largely been replaced by "TENSION FREE" techniques.

ARTICLE on TENSION FREE REPAIR-amended and edited for this site
OUTPATIENT SURGERY, August 2000
Inguinal hernia repair is one of the oldest operations ever documented—in fact, the first record of it dates prior to the Middle Ages. Today, herniorrhaphy is one of the most common surgical procedures—in 1996, surgeons performed more than 750,000 repairs, and more than 80 percent were ambulatory cases. Even though hernia repair is a relatively simple procedure, repair techniques differ widely, and it is likely that your surgeons will feel strongly about a particular kind. Traditional Repairs
Until the late 1980’s, most surgeons repaired hernias by simply pushing back the protruding tissue and suturing together the edges of the defect in the abdominal wall. Today, some surgeons still use these “tension” methods (variations include the Bassini/Halsted, Cooper/McVay, and Canadian/Shouldice repairs). Surgeons at the Shouldice Hospital in Toronto, Canada, a dedicated hernia hospital, have completed more than 250,000 repairs using a tension or “pure tissue” technique that uses steel wire sutures to close the wound; they claim a recurrence rate of only one percent. Critics of the tension-free method say that suturing puts too much tension on the sides of the defect, causing pain and an increased recurrence rate. “As far as cost goes, tension hernia repair may be less expensive (in terms of materials used), but it may also be more difficult,” says Dennis Witmer, MD, a Delaware-based general surgeon who used to perform conventional repairs but has since switched to newer techniques.

Mesh-Based Repairs The repairs that Dr. Witmer and most other surgeons now use are variations of a “tension-free,” or mesh-based technique. All involve either plugging or patching the hole in the abdominal wall with a piece of polypropylene mesh.
In the mid-eighties, hernia surgeon Irving Lichtenstein, MD, caused a stir among his colleagues when he proposed that using a piece of polypropylene mesh was the best way to repair all inguinal hernias. Prior to this, surgeons had been using mesh only for large or recurrent hernias and only when they felt it was absolutely necessary—they felt that using a “foreign body” for repair increased the risk of infection. However, Dr. Lichtenstein persisted, and in 1989 published a study of 1,000 patients who received the Lichtenstein repair, experienced minimal complications, and had a zero recurrence rate after a follow up period of between one and five years. By the mid-nineties, many surgeons agreed that tension-free was easier to do and generally led to fewer recurrences and decreased recovery time. These days, most surgeons prefer tension-free techniques, since mesh does not place tension on the sides of the wound, gradually incorporates into the abdominal wall, and, in the vast majority of cases, does not pose any threat of infection.

There are three main types of tension-free hernia repairs.
Lichtenstein Hernia Repair:
This type of tension-free repair uses an open anterior approach, meaning that the surgeon sutures a mesh patch over the hernia in front of the abdominal muscle wall. Parviz Amid, MD, a surgeon at the Lichtenstein Hernia Institute in Los Angeles, has no doubt that the Lichtenstein repair is an improvement over traditional tension techniques. “In an old-fashioned tension operation, the surgeon simply stitches together the edges of the patient’s weakened tissue,” he says. “When the patient coughs or strains, the edges of the defect can tear apart. Also, when the edges of the tissue are brought together forcefully, it causes greater post-op pain and a longer recovery period—sometimes as long as two months.” The Lichtenstein repair, says Dr. Amid, “bypasses the problem of working with degenerated tissue by placing the edges of the patch on surrounding healthy tissue, providing a stronger reinforcement for the abdominal wall.”

Laparoscopic Hernia Repair:
In laparoscopic hernia repair, the surgeon uses a laparoscope to visualize the hernia and affix a mesh patch behind the abdominal muscle wall; in this technique, the patch rests against the thin inner lining of the abdomen called the peritoneum (this is commonly referred to as a posterior approach). This is like repairing the hernia from the inside out. It however requires riskier General Anesthesia, and has risks of injury tom intestine, bladder and other intra-abdominal organs. Supporters of the laparoscopic technique claim that affixing the patch posteriorly provides a stronger repair; the natural intra-abdominal pressure pushes the patch up against the interior of the abdominal wall and holds it in place. They compare the abdominal wall and the peritoneum to the outer wall of a tire and the inner tube; the laparoscopic technique, they say, allows them to get “behind” the defect and armor plate the body’s inner tube. Some surgeons also claim that the smaller incisions used to insert the laparoscopic instruments are less invasive than using the “open” approaches of the Lichtenstein and mesh plug techniques, allowing for the best recovery times.
Many surgeons, including Dr. Goodyear of the North Penn Hernia Institute in Lansdale Pennsylvania, hotly debate this last claim, saying that when you add up the multiple incisions used for laparoscopic repair, they closely approximate the length of a single open incision. Furthermore, critics say, laparoscopic repair is difficult to learn and always requires general anesthesia, while open methods usually require only local or epidural anesthesia.
Finally, say critics like Dr. Amid, Dr. Goodyear and Dr. Rutkow, there’s no clear evidence that laparoscopic repair leads to fewer recurrences or decreased recovery time.

The TENSION FREE Method utilizing the Prolene Hernia System uses a “three-in-one” device consisting of an onlay patch that goes on top of the abdominal wall, a connector piece that plugs the defect and an underlay patch that deploys in the preperitoneal space and provides support behind the abdominal wall. This device purportedly combines all the benefits of the Lichtenstein, mesh plug, and Kugel techniques. Dr. Goodyear of the North Penn Hernia Institute in Pennsylvania feels it is the only "Tension Free" device that covers the entire hernia prone area called The Myopectineal Orifice, while the other techniques leave areas of this region of the abdominal wall vulnerable. Besides coming up with new devices, many companies are developing variations on the standard polypropylene mesh; most experts agree that all types provide adequate strength, stimulate tissue ingrowth, and, in the vast majority of cases, don’t increase the risk of infection.

The Prolene Hernia System is a “three-in-one” system that combines the benefits of three techniques, proponents say.

CLICK for Ethicon's PHS Information Web-Site

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Other Tension Free methods
Mesh Plug or “Plug and Patch” Repair: In this technique, the surgeon uses a mesh plug to fill the defect in the abdominal wall (think of a cork stoppering a bottle. Proponents of the mesh plug technique claim it is easier to perform than the Lichtenstein repair, requiring a smaller incision, fewer sutures, and less tissue dissection. One particularly vocal champion of the mesh plug method is Ira Rutkow, MD, who owns a surgical hospital dedicated exclusively to hernia repair. While Dr. Rutkow concedes that most hernia repairs, done properly, will yield good results, he claims the mesh plug method is the easiest for surgeons to learn. Dr. Goodyear adds that "easiest for the surgeon" is not necessarily "best for the patient"
Many Hernia Specialists, including Dr. Goodyear of the North Penn Hernia Institute in Lansdale Pennsylvania, question the mesh plug technique’s effectiveness. Dr. Goodyear states "These devises may not effectively cover the entire hernia-prone surrounding area of the hernia defect or weakness in the inguinal area, leaving exposed regions for the formation of recurrent hernias". "Properly designed and surgically placed mesh must cover the entire Myopectineal Orifice. It is what is best for the patient, not always what is easiest for the surgeon" he adds. "In my opinion, the plug and patch is not fully effective in many cases in this regard" states Dr. Goodyear. Dr. Amid notes that mesh plugs were originally used to repair femoral hernias, another type of groin hernia that occur in a tunnel in the crease of the thigh. With femoral hernias, the plug technique works as it’s supposed to—the “cork in the bottle” analogy is more applicable, he says. When mesh plugs are used for inguinal hernia repair, however, they tend to shrink, become loose, and in rare cases, poke into the bladder or intestines.

About Inguinal Hernias

A hernia is a defect or opening in the abdominal wall which allows soft tissue to poke through. They tend to occur at “natural” areas of weakness, where the muscle wall is not as strong and more vulnerable to intra-abdominal pressure. The inguinal canal, which is a tubular opening through the lower part of the abdominal wall, is one of those areas and the region where most hernias occur. In males, this canal contains the spermatic cord; in females, where the canal is not as developed, it contains the uterine round ligament. An inguinal hernia can be of the “indirect” or “direct” variety; the former is most common. Indirect hernias begin at the deep inguinal ring where several abdominal muscles overlap; in these hernias the tissue migrates through the inguinal canal and into the scrotum. In direct hernias the deep inguinal ring is intact, but the tissue protrudes through a weakness in the floor of the inguinal canal above the pubic crest. All types of hernia repair basically involve pushing the tissue back into the abdominal cavity and repairing the defect.

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