125 Medical Campus Dr.
Lansdale, PA 19446
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AMERICA'S LEADER IN ADVANCED HERNIA SURGERY
Review of Tension Free repair Methods
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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.
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.
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 (TIPP) 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 (TIPP TENSION FREE Technique) as the overall BEST for the overwhelming majority of patients.
- 1st- LAPAROSCOPIC HERNIA REPAIR-TEP, TAPP
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-Onlay Mesh 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.
- 3rd- "TENSION FREE" MESH TECHNIQUE-Trans-Inguinal Pre Peritoneal Repair (TIPP)
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. This technique is now commonly referred to as the Trans-Inguinal, Pre-Peritoneal (TIPP) method. This mesh, safely placed behind the muscle-fascia layer, extends well beyond the under edges of the defect to reduce pressure on the hernia defect opening, and reinforces the entire surrounding hernia-vulnerable area called the Myopectineal Orifice. 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.
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:
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.