Review
Open preperitoneal groin hernia repair with mesh: A qualitative systematic review

https://doi.org/10.1016/j.amjsurg.2017.01.014Get rights and content

Highlights

  • There seem to be a benefit of placing the mesh for groin hernia repair in the preperitoneal plane.

  • Nine different methods were identified through systematic search and screening of the literature.

  • This review provides an overview of open preperitoneal techniques, along with available evidence and technical descriptions.

  • Placement of a mesh through an open approach is promising compared with the standard anterior techniques.

Abstract

Background

For the repair of inguinal hernias, several surgical methods have been presented where the purpose is to place a mesh in the preperitoneal plane through an open access. The aim of this systematic review was to describe preperitoneal repairs with emphasis on the technique.

Data sources

A systematic review was conducted and reported according to the PRISMA statement. PubMed, Cochrane library and Embase were searched systematically. Studies were included if they provided clinical data with more than 30 days follow up following repair of an inguinal hernia with an open preperitoneal mesh technique.

Conclusions

A total of 67 articles were included, describing nine different methods: Kugel, TREPP, TIPP, Onstep, Horton/Florence, Nyhus, Ugahary, Read, and Stoppa. In general, results regarding pain, recurrences and complications seem promising. It was not possible to conduct a meta-analysis. Open preperitoneal techniques with placement of a mesh through an open approach seem promising compared with the standard anterior techniques. This systematic review provides an overview of these techniques together with a description of surgical methods and clinical outcomes.

Introduction

Optimal repair of inguinal hernia is still a discussion among surgeons. Important issues are recurrences and especially chronic pain, and in order to find the best way to repair inguinal hernias, new randomized clinical studies are still being conducted.1, 2, 3 Placement of the mesh in relation to nerves is a possible contributing factor to chronic postoperative pain.4 Laparoscopic repair of inguinal hernia reduces the risk of early and chronic pain compared to open anterior techniques.5 The major difference between the open anterior repairs and the laparoscopic repairs is the plane of dissection and placement of the mesh. In the open anterior repair, the surgeon dissects through the inguinal canal and places the mesh close to the nerves and structures in this area. On the contrary, when placing the mesh behind the muscles of the abdominal wall in the preperitoneal plane posteriorly to the transversalis fascia, the dissection of the inguinal canal as well as the placing of mesh in close proximity to the nerves can be avoided. Thus, preperitoneal mesh placement might be beneficial regarding chronic pain compared to an anterior approach. When operating on the posterior side of the fascia transversalis the ilioinguinal and the hypogastric nerves are only present in the most lateral part of the field. Furthermore, there is often fatty tissue protecting the nerves in this area, unless the patient is very skinny.

Preperitoneal mesh placement can be performed by a laparoscopic approach or by an open preperitoneal technique. When choosing the optimal open procedure, open preperitoneal techniques needs therefor to be considered. Several open surgical methods have been described where the purpose is to place the mesh in the preperitoneal plane through an open access.6, 7, 8, 9 The authors of a Cochrane review chose to only include three methods,10 but since that review, additional methods have been presented. The aim of this study was to describe open preperitoneal repairs with emphasis on the techniques and the published clinical evidence.

Section snippets

Material and methods

This systematic review was conducted in accordance with the PRISMA statement,11 and the PRISMA-P was used to guide the protocol.12 The study was registered on PROSPERO (ID no. CRD42016017325). The following criteria were used to select studies: Patients had to have an inguinal hernia and receive surgical treatment with an open procedure where the mesh was placed in the preperitoneal space. The follow-up of the patients had to be at least one month and the language had to be either English or

Results

The systematic search identified 2296 records, 647 records were removed for being duplicates (Fig. 1). Reports were screened on title and abstract. Hereby, 162 reports were found potentially relevant, and full texts were retrieved. A total of 67 reports were included for this review, describing nine different methods of preperitoneal repair of inguinal hernias, see Table 1.

The number of patients operated preperitoneally varied from 1914 to 956.15 Several different meshes and fixation methods

Discussion

This systematic review identified nine methods of placing a mesh in the preperitoneal space through an open approach. In general, the results regarding pain, complications and recurrence rates are promising. However, some of the reports were from specialized centers, especially regarding the newest techniques. The available evidence is generally from cohorts and only few randomized clinical trials. Furthermore, there is a lack of head-to-head comparisons of different open preperitoneal

Conclusion

In general, the benefit of these preperitoneal techniques is the avoidance of the anterior plane where the nerves are vulnerable to surgical trauma during the operation and afterwards are vulnerable to compression and fibrosis from the mesh in the healing process. There are concerns when operating in the preperitoneal space because delicate structures are located here such as large vessels and the bladder. Bladder injuries were reported by several authors and with several techniques. Therefore,

References (80)

  • M.W. Prins et al.

    Study protocol for a randomized controlled trial for anterior inguinal hernia repair: transrectus sheath preperitoneal mesh repair compared to transinguinal preperitoneal procedure

    Trials

    (2013)
  • P.K. Amid et al.

    New understanding of the causes and surgical treatment of postherniorrhaphy inguinodynia and orchalgia

    J Am Coll Surg

    (2017)
  • K. McCormack et al.

    Laparoscopic techniques versus open techniques for inguinal hernia repair

    Cochrane Database Syst Rev

    (2003)
  • A. Lourenco et al.

    The onstep inguinal hernia repair technique: initial clinical experience of 693 patients, in two institutions

    Hernia

    (2013)
  • J.F. Lange et al.

    Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia: the first 1,000 patients

    World J Surg

    (2014)
  • E.P. Pelissier et al.

    Inguinal hernia: a patch covering only the myopectineal orifice is effective

    Hernia

    (2001)
  • W. Willaert et al.

    Open preperitoneal techniques versus lichtenstein repair for elective inguinal hernias

    Cochrane Database Syst Rev

    (2012)
  • D. Moher et al.

    Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement

    Syst Rev

    (2015)
  • T. Greenhalgh et al.

    Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources

    BMJ

    (2005)
  • K.B. Williams et al.

    Postoperative quality of life after open transinguinal preperitoneal inguinal hernia repair using memory ring or three-dimensional devices

    Am Surg

    (2013)
  • K.T. Mok et al.

    Laparoscopic versus open preperitoneal prosthetic herniorrhaphy for recurrent inguinal hernia

    Int Surg

    (1998)
  • F. Ugahary et al.

    Groin hernia repair via a grid-iron incision: an alternative technique for preperitoneal mesh insertion

    Hernia

    (1998)
  • G.G. Koning et al.

    The transrectus sheath preperitoneal mesh repair for inguinal hernia: technique, rationale, and results of the first 50 cases

    Hernia

    (2012)
  • O. Dogru et al.

    Comparison of Kugel and lichtenstein operations for inguinal hernia repair: results of a prospective randomized study

    World J Surg

    (2006)
  • S. Nienhuijs et al.

    Pain after open preperitoneal repair versus lichtenstein repair: a randomized trial

    World J Surg

    (2007)
  • O. Bender et al.

    Systemic inflammatory response after Kugel versus laparoscopic groin hernia repair: a prospective randomized trial

    Surg Endosc

    (2009)
  • M. Azeem et al.

    Prospective randomized study for pain outcome after modified Kugel mesh repair versus lichtenstein repair

    PJMHS

    (2015)
  • K. Arslan et al.

    Minimally invasive preperitoneal single-layer mesh repair versus standard lichtenstein hernia repair for inguinal hernia: a prospective randomized trial

    Hernia

    (2015)
  • J. Li et al.

    Preperitoneal groin hernia repair with Kugel patch through an anterior approach

    ANZ J Surg

    (2008)
  • J. Li et al.

    Early experience of performing a modified Kugel hernia repair with local anesthesia

    Surg Today

    (2008)
  • T. Misawa et al.

    Kugel herniorrhaphy: clinical results of 124 consecutive operations

    Surg Today

    (2005)
  • R. Hompes et al.

    Chronic pain after Kugel inguinal hernia repair

    Hernia

    (2008)
  • V. Ceriani et al.

    Kugel hernia repair: open “mini-invasive” technique. Personal experience on 620 patients

    Hernia

    (2005)
  • Y. Van Nieuwenhove et al.

    Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs

    Hernia

    (2007)
  • K.M. Reddy et al.

    Inguinal hernia repair with the Kugel patch

    ANZ J Surg

    (2005)
  • D.M. Schroder et al.

    Inguinal hernia recurrence following preperitoneal Kugel patch repair

    Am Surg

    (2004)
  • W. Hoste et al.

    Early Belgian experience with the Kugel patch inguinal hernia repair

    Acta Chir Belg

    (2006)
  • B. Dasari et al.

    Immediate and long-term outcomes of lichtenstein and Kugel patch operations for inguinal hernia repair

    Ulst Med J

    (2009)
  • H.C. Chiang et al.

    Inguinal hernia repair outcomes that utilized the modified Kugel patch without the optional onlay patch: a case series of 163 consecutive patients

    Hernia

    (2015)
  • K. Suwa et al.

    Modified Kugel herniorrhaphy using standardized dissection technique of the preperitoneal space: long-term operative outcome in consecutive 340 patients with inguinal hernia

    Hernia

    (2013)
  • Cited by (0)

    View full text