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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1159-1164

Mesh repair in complicated inguinal hernia


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Dessouk, Kafr Elshiekh, Egypt
2 Department of Surgery, Ministry of Health, Dessouk, Kafr Elshiekh, Egypt

Date of Submission24-May-2017
Date of Acceptance07-Aug-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Amr N Frig
Dessouk, Kafr Elshiekh, 33511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_322_17

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  Abstract 


Objective
The aim of this study was to evaluate the role of mesh repair short-term outcome in adult incarcerated inguinal hernia from the point of view of availability, advantages and disadvantages.
Background
Hernia is the most frequent abdominal surgery. The standard treatment of inguinal hernia is hernioplasty with mesh repair; we aimed to evaluate the short-term complications after mesh repair in incarcerated inguinal hernia in emergency.
Patients and methods
This study was carried out on 20 consecutive adult men in Menoufia University Faculty of Medicine and Dessouq General Hospital; all of them presented with symptoms of irreducible inguinal hernia from April 2015 to September 2016. This study included 20 patients because of the limited number of patients presented to our hospital in this period of time and those who fulfill the inclusion criteria, to assess postoperative short-term complications.
Results
A total of 20 cases did mesh repair in incarcerated inguinal hernia in the same admission in hospital, operative time and the difficulty was average; all of them (100%) had no recurrence in the postoperative follow-up.
Conclusion
Mesh repair in adult incarcerated inguinal hernia is safe and should be done during the same hospital admission to prevent further attacks of recurrence.

Keywords: complicated inguinal hernia, incarceration, the Liechtenstein repair


How to cite this article:
Zeineldin AA, El Tatawy AG, Frig AN. Mesh repair in complicated inguinal hernia. Menoufia Med J 2018;31:1159-64

How to cite this URL:
Zeineldin AA, El Tatawy AG, Frig AN. Mesh repair in complicated inguinal hernia. Menoufia Med J [serial online] 2018 [cited 2024 Mar 28];31:1159-64. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1159/252044




  Introduction Top


Inguinal hernia regardless of the type is one of the most common diseases that a surgeon has to manage. Improved surgical techniques and a better understanding of the anatomy and physiology of the inguinal canal have significantly improved the outcomes for many patients. Inguinal hernia repair has been evolving for the past 130 years and the pace of evolution accelerated in the last decade with the introduction of the tension-free repair, the laparoscopic repair and the growth of the specialist hernia clinic. From a list of traditional suturing techniques such as Bassini's, Darning, Shouldice and Bassini repairs, in its modified versions it is widely still practiced in this part of the world. Traditional suture repair of inguinal hernia is fast giving way to routine tension-free mesh repair. This operation is called a 'hernioplasty'. In many countries, mesh repair is now more common than suture repair[1]. Lichtenstein presented his open mesh repair technique for inguinal hernia in 1986. The Lichtenstein technique has since become the most commonly used[2] (with various modifications) on account of its ease of operation and because it provides a tension-free repair with good long-term results[3]. Tension-free mesh repair is nevertheless associated with complications such as foreign body reaction, infection, pain, fistula formation, migration, shrinkage and recurrence[4]. Other complications include skin anaesthesia, bruising and haematoma formation, seroma formation, orchitis and testicular atrophy.

Incarcerated inguinal hernia is a commonly encountered urgent surgical condition, and tension-free repair is a well-established method for the treatment of noncomplicated cases. Recent studies have demonstrated that biomaterials represent suitable materials for performing urgent hernia repair. Certain studies recommend mesh repair only for cases where no bowel resection is required.

The aim of the work was to evaluate the role of the mesh repair short-term outcome in adult incarcerated inguinal hernia from the point of view of availability, advantages and disadvantages.


  Patients and Methods Top


All participants gave written informed consent before inclusion into the study. This was a follow-up study carried out on 20 consecutive patients in Menoufia University, Faculty of Medicine and Dessouq General Hospital; all of them presented with symptoms of incarcerated inguinal hernia from April 2015 to September 2016.

A written informed consent from each patient was obtained before study participation and after full explanation of the technique and its possible complications. The study was approved by our faculty ethics committee.

Inclusion criteria

Patients with incarcerated inguinal hernia were approved by history taking, physical examination and ultrasonographic findings.

Exclusion criteria

Incarcerated inguinal hernia with strangulation, incarcerated inguinal hernia in infants and children, bad general condition and patient medically unfit for general anaesthesia.

All patients were subjected to history taking and physical examination. The following groups underwent further investigations: patients complained of manifestations of incarcerated inguinal hernia as of irreducible groin swelling with burning, gurgling or aching sensation at the bluge and pain or discomfort in the groin especially when bending over, coughing or lifting.

These patients were subjected to the following investigations:

  1. Laboratory investigations: complete blood picture, coagulation profile, hepatic and renal profile
  2. Imaging: abdominal ultrasonography, chest and abdominal erect radiography and ECG or echo for patients over 45 years or high-risk cardiac patients.


Operative technique

A tension-free repair is performed under spinal or general anaesthesia and consists of reinforcement of the inguinal floor using polypropylene mesh. The prosthesis is ∼8 × 16 cm (Egymesh made in Egypt, First Industrial zone - Block 13023 - Building 8 Obour city - Cairo - Egypt) to provide sufficient tissue-mesh interface beyond the floor of the inguinal canal. As a result, the entire inguinal floor is completely and permanently protected from all future mechanical and degenerative adverse effects. Therefore, the procedure is both therapeutic and prophylactic.

Repair technique

A 5–6 cm transverse incision is made within a Langer's line, beginning from the pubic tubercle. The external oblique aponeurosis is opened. The spermatic cord with its cremasteric covering, external spermatic vessels and the ileoinguinal nerve are freed from the inguinal floor. The spermatic cord is also dissected free from the pubic bone area for ∼2 cm medial to the pubic tubercle in order to make room for extending the mesh beyond the pubic tubercle.

Next, the external oblique aponeurosis is dissected from the underlying internal oblique muscle and aponeurosis high enough to make room for a prosthesis. The iliohypogastric nerve comes into the view during this part of the dissection.

The sac is then dissected from the cord beyond its neck and inverted into the properitoneal space without ligation or excision. If the sac is very large, as in a scrotal hernia, the sac is divided at the midpoint of the inguinal canal. The proximal end is closed, dissected away from the cord structures and inverted into the preperitoneal space after reduction of healthy contents. The distal end is left behind in order to reduce the possibility of testicular complication.

No special preparation is needed for direct inguinal hernias if it is not too large. When the direct hernia bulge is large, it is inverted utilising a purse–string or a continuous suture on the transversalis fascia without incorporating the iliopubic tract or the inguinal ligament. This is only to make the floor of the inguinal canal flat in order to facilitate placement of the mesh.

The medial side of the mesh is shaped to the patient's anatomy. The first anchoring suture of the mesh fixes the mesh to the anterior rectus sheath where it inserts into the pubic bone. The lower edge of the mesh is sutured to the inguinal ligament using the same suture in a continuous fashion with not more than four passages. This suture ends at the lateral border of the internal ring.

At this point, a slit is made on the lateral end of the mesh creating two tails – 2/3 above and 1/3 below. The upper tail is then passed under the cord and pulled towards the head of the patient, placing the spermatic cord in between the two tails.

The upper tail is then crossed over the lower one and held with a pair of hemostats. The tails are later sutured together and tucked under the external oblique aponeurosis.

Haemostasis was achieved, a tube drain was placed if clinically indicated and the incision closed in layers.

Postoperative management

Postoperative analgesia was carried out with nalufin, morphia and pethidine during the first 24 h postoperatively and thereafter at the request of the patient.

Patients were observed for sepsis, bleeding, seroma and testicular swelling. These complications could occur usually within the first 24 h postoperatively.

Routine postoperative laboratory tests: complete blood count, coagulation, hepatic and renal profile.

All patients had warm oral liquids the evening after the operation, provided there was no nausea or vomiting.

The majority of patients were discharged from the hospital after 24 h. Patients were reviewed at weeks 1 and 4 postoperatively in the surgical outpatient clinic.

Patients were instructed to notify after discharge about any clinical symptoms or any laboratory or imaging data that they had obtained because of the possibility of a postoperative infection or recurrence.

Postoperative assessment

Surgical site infection (SSI), pain, total length of hospital stay, recurrence, seroma formation and testicular swelling occurrence.

Follow-up of the cases

Complications were defined as any intraoperative or postoperative (30 days after the operation) event that altered the clinical course such as complications of mesh repair (infection, pain, recurrence, etc.), additional procedures and readmissions.

Later on, patients were followed-up in the outpatient clinic after 1 and 4 weeks for clinical and ultrasonographies of the abdomen were performed to exclude infection, seroma or recurrence.

Follow-up by clinical observation of abdominal pain, SSI, recurrence, seroma and testicular oedema. Ultrasonography of the abdomen (after 1 month).

Statistical analysis of the data

Data were fed to the computer and analysed using IBM SPSS software package version 20.0. (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percentage. Quantitative data were described using range (minimum and maximum), mean, SD and median. Marginal homogeneity test was used to analyse the significance between the different stages. Significance of the obtained results was judged at the 5% level.


  Results Top


The studied population included 20 adult men. Their age was between 26 and 62 years with a mean of 49 years. The median age was 50 years [Table 1].
Table 1: Distribution of the studied sample according to comorbidities (n=20)

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Comorbidities

Eleven (55%) patients are healthy; nine (45%) patients had comorbidities; three patients had hypertension; one of them had diabetes mellitus; other medical problems included hepatic disease, ischaemic heart disease and obesity as shown in [Table 1].

Local examination

By local examination all of patients had palpable irreducible tender groin swelling.

Preoperative laboratory investigations

As a routine tests like complete blood count, hepatic and renal profile, etc.

Postoperative hospital stay

In between 1 and 3 days with a mean of 1.65 days and a median of 2 days [Table 1].

Surgical procedures

Seventeen (85%) patients had Leichtenstein repair, whereas three (15%) had mesh plug repair.

Postoperative complications

Mentioned in paragraphs through two visits (short outcome) through first postoperative visit after 1 week of discharge and second postoperative visit after 4 weeks of discharge for assessment of wound healing, wound complications (SSI, pain seroma formation and testicular odema) and early recurrence.

Surgical site infection

Eight (40%) patients had wound complications (swelling, hotness and tenderness) whereas 20 (60%) patients had no wound complications on first visit, which disappeared in the second visit.

General sepsis

The manifestations are fever, chills, altered mental status, increased respiratory rate and low blood pressure. Two (10%) patients had general sepsis criteria whereas 18 (90%) patients had no similar complications on first visit and symptoms and signs of general sepsis disappeared on second visit [Table 2].
Table 2: Comparison between the studied groups according to different parameters (n=20)

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Postoperative pain

Using visual analogue scale it was found that eight (40%) patients complained of mild pain, six (30%) patients of moderate pain and two (10%) patients of severe pain on first visit.

On second visit, two patients had minimal pain; six patients had mild pain; and two patients had moderate pain [Table 2].

Recurrence

No recurrence recorded in 1-month postoperative observation.

Seroma formation

Twelve (60%) patients of studied cases had no odema at the site of operation, whereas eight others had variable degrees of seroma formation on first visit. On second visit 20 (100%) patients had no problems and seroma disappeared [Table 2].

Testicular odema

On first visit 10 (50%) patients had no testicular swelling, whereas 10 (50%) patients had it and resolved in 16 (80%) patients on second visit [Table 2].


  Discussion Top


Elective surgery for groin hernias, even in elderly patients is known to be a very safe procedure with almost negligible mortality[5],[6].

Inguinal hernia repair is a clean surgical procedure with a small exposed area, minimal blood and fluid loss and no involvement of the digestive tract. If no strangulation, dietary intake can be resumed a few hours after the operation.

Although the incidence of postoperative complications is acceptable, the most common complications noted are chronic pain and testicular oedema.

A significant proportion of our patients present late with complete hernia, which are bigger and have wider defects than simple inguinal hernia. Hence, the need to reinforce the posterior wall with a repair is deemed mandatory. In the light of this discussion mesh repair truly is an obvious improvement in the repair of inguinal hernia. In an attempt to reduce the incidence of recurrence following the repair of inguinal hernia, various techniques have been used, such as autologous tissue techniques and a variety of biomaterials. The Lichtenstein technique and its modifications have become some of the most popular and frequently performed surgeries[7]. It is a simple, operator-friendly technique that is easy to learn and perform. The incidence of perioperative and postoperative complications is minimal. Most of the patients return to routine life within 48 h and 60% of physical labourers return to work within 4 weeks. Yet, there is a high incidence of chronic groin pain following hernia repair[8], and chronic groin sepsis after mesh repair requires complete removal of mesh to treat the sepsis. Possible damage to the spermatic cord and nerve entrapment following mesh repair because of extensive fibrosis are also concerns raised by this technique. Depending on the level of expertise and the degree of handling the incidence of postoperative pain is greatly altered.

Yet, the results from a study conducted by Danielson et al. among a list of open repairs Lictenstein's requires lesser expertise with a less steep learning curve. The mean age in Ayub J. study is 48.78 ± 14.41 years, which is comparable to our study age ranged between 26 and 62 years with the mean of 49.0 ± 10.21 year. The side of inguinal hernia was dominantly found peroperatively on the right side in 60 (53.6%) patients, whereas the type of hernia was predominantly of the indirect type; 62 (55.4%) patients comparable to the study conducted by Lau H[9]. The results of this study took into account the early complications of surgery following the Lichtenstein technique. In the postoperative six patients presented with scrotal swelling, four (3.6%) patients had developed seroma and two (1.8%) patients had haematomas. This was comparable to a study by Desarda et al.[10]. In our study, on the first visit 10 (50%) patients had no testicular swelling, whereas 10 (50%) had it and four (20%) patients were seen to have it on their second visit. Twelve (60%) patients of the studied cases had no odema at site of operation, whereas eight others had variable degrees of seroma formation on first visit and disappeared on their second visit[10]. These complications require drainage which is another procedure requiring follow-up and anticipation of other complications such as infection. During the first month following surgery, five (4.5%) patients presented with wound infection. Septic complications of the prosthesis have been reported by various studies to occur in 0.2–0.8% of patients. In these cases, apart from antibiotic therapy, puncture and drainage of these infected collections under ultrasound control that have been described, in most cases prosthesis removal is inevitable. In our study, eight (40%) patients had wound complications (swelling, hotness and tenderness), whereas 20 (60%) patients had no wound complications on first visit, which disappeared on their second visit. On recording fever, altered mental status, increased respiratory rate and low blood pressure, that three (15%) patients had general sepsis criteria whereas 17 (85%) patients had no similar complications on first visit; symptoms and signs of general sepsis disappeared on their second visit.

Considering the length of stay that was 3.83 days in the present study and the evolving trends to the application of these procedures as day cases, there are reasons to perform the procedure in routine under local anaesthesia. This duration includes the preoperative phase of preparation till discharge and is deemed inevitable considering this series of surgery is being conducted under general anaesthesia. Other limitations include its nonavailability in every part of the world, it increases the cost of the operation and because the groin is a mobile area there is a tendency for the mesh to fold, wrinkle or curl. In our study, the mean hospital stay was 1.65 ± 0.67 with a median of 2.0 days. Some studies reported chronic groin pain following open mesh repair in 28.7–43.3%. During the acute phase, 53 (47.3%) patients required only reassurance with oral analgesia; 42 (37.5%) patients required further increments in doses with parenteral analgesia and 17 other patients with more severe pain needed parenteral analgesia, but majority settled during hospital admission and according to our study eight (40%) patients complained of mild pain, six (30%) patients of moderate pain and two (10%) patients of severe pain on first visit; on second visit two patients had minimal pain, six patients had mild pain and two patients had moderate pain. No recurrence was recorded in 1-month postoperative observation. Wound pain was the most troublesome postoperative discomfort following inguinal hernia repair. A combination of oral opioid analgesic and nonsteroidal anti-inflammatory drug seemed to be satisfactory analgesic agents without any noticeable side effects[11]. The cost of meshes needs to be considered, and a larger sample size and further studies are needed for a more objective comparison of outcome between mesh repair and traditional suture.


  Conclusion Top


Mesh repair in adult incarcerated inguinal hernia is safe and should be done during the same hospital admission to prevent further attacks of recurrence. It is not contraindicated to use mesh with obstructed inguinal hernia except in strangulated hernia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schumpelick V, Klinge U. Prosthetic implants for hernia repair. Br J Surg 2003; 90:1457–1458.  Back to cited text no. 1
    
2.
Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg 2004; 91:44–48.  Back to cited text no. 2
    
3.
Scott N, McCormack K, Graham P, Go PMNYH, Ross SJ, Grant AM. Open mesh versus non-mesh repair of inguinal hernia (cochrane review). Cochrane Database Syst Rev 2002; 4:CD002197.  Back to cited text no. 3
    
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Elango S, Perumalsamy S, Ramachandran K, Vadodaria K. Mesh materials and hernia repair. Biomedicine (Taipei) 2017; 7: 16. Published online 2017 Aug 25. doi: 10.1051/bmdcn/2017070316.  Back to cited text no. 4
    
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Dieng M, El Kouzi B, Ka O, Konaté I, Cissé M, Sanou A, et al. Strangulated groin hernias in adults: a survey of 228 cases. Mali Med 2008; 23:12–16.  Back to cited text no. 5
    
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Jancelewicz T, Vu LT, Shawo AE, Yeh B, Gasper WJ, Harris HW. Predicting strangulated small bowel obstruction: an old problem revisited. J Gastrointest Surg 2009; 13:93–99.  Back to cited text no. 6
    
7.
Desarda MP. No-mesh inguinal hernia repair with continuous absorbable sutures: a dream or reality? (a study of 229 patients). Saudi J Gastroenterol 2008; 14:122–127.  Back to cited text no. 7
    
8.
Bay-Nielson M, Perkins FM, Kehlet H. Danish Hernia Database. Pain and functional impairment 1 year after inguinal herniorrhaphy nationwide study. Ann Surg 2001; 233:1–7.  Back to cited text no. 8
    
9.
Lau H, Lee F. An audit of the early outcomes of ambulatory inguinal hernia repair at a surgical day-care centre. Hong Kong Med J 2000; 6:218–220.  Back to cited text no. 9
    
10.
Desarda MP, Ghosh A. Comparative study of open mesh repair and Desarda's no-mesh repair in a District Hospital in India. East Central Afr J Surg 2006; 11:28–34.  Back to cited text no. 10
    
11.
Fasih T, Mahapatra TK, Waddington RT. Early results of inguinal hernia repair by the 'mesh plug' technique –First 200 cases. Ann R Coll Surg Engl 2000; 82:396–400.  Back to cited text no. 11
    



 
 
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