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Free Tension Herniorraphy

An Introduction to the pure prosthetic repair

Andy Maleachi
Why it is important to be discussed

A surgeon can do more for the community by

operating on hernia cases and seeing that his
recurrence rate is low than he can by operating on
cases of malignant disease.

Sir Cecil Wakely,1948

The repair of abdominal wall defects is one of the
most commonly performed general surgical
procedures, with over 1 million polypropylene
implants inserted each year.

Cobb WS, Kercher KW, Heniford BT. The argument for

lightweight polypropylene mesh in hernia repair.
Surg.Innovation 2005,12 :63-9
Denmark 1998-2003 :
Laparoscopic repairs 3606
Lichtenstein repairs 39537
Average : 7190 cases per year

Wara P et al. Prospective nation wide analysis of

laparoscopic versus Lichtenstein repair of
inguinal hernia. Br.J.Surg.2005;92:1277-81
Swedia 1992 2003

Groin hernia repairs women 6.895

Men 83.753
Total 90. 648

Average 7.554 cases per year.

Koch A. et al. Prospective evaluation of 6895 groin

hernia repairs in women. Br.J.Surg.2005,92:1553-8
Which herniorraphy ?

Since the epoch-making contribution of Bassini in

1888, no less than 81 inguinal dan 79 femoral
operative techniques have been described !

Bendavid R. New techniques in hernia repair. World J

Surg.1989; 13:522
The surgeon must understand that hernia repair is not
a simple procedure but one requiring precise skill and
judgment to give the patient a repair that is not only
durable but also enjoyable.

Cunningham J. The physiology anf anatomy of chronic pain

after inguinal herniorraphy. In Fitzgibbons R J, Greenburg A
G. Hernia 5th Ed. Lippincott Williams and Wilkins
Philadelphia, 2002
Four basic techniques :

Pure tissue repair

Combined tissue and prosthetic repair
Pure prosthetic repair
Nylon darn repair
Prosthetic repair

Advantage :
Decrease the incidence of hernia recurrence
compared with sutured repair

EU Hernia Trialist Collaboration. Mesh compared with non-mesh methods

of open groin hernia repair : Systematic review of randomized controlled
trials. Br J Surg 2000 ; 87 : 854-9
Butters M, Redecke J, Koninger J. Long-term results of a randomized
clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal
hernia repairs. Br J Surg. 2007; 94:562-5
Van Veen RN et al. Long-term follow up of a randomized clinical trial of non
mesh versus mesh repair of primary inguinal hernia. Br J Surg. 2007; 94 :
Prosthetic repair

Anterior approach
- Lichtenstein
- Sutureless, presheped mesh
- Plug repair

Posterior approach
- Kugel approach
- Stoppa (GPRVS)
- Ugahary

If we could artificially produce tissues of the density
and toughness of fascia and tendon, the secret of the
radical cure of hernia would be discovered

Billroth T. (1829 94)


Unbalanced distribution of collagen types I

(mature, high-tensile strength) and III (immature,
low-tensile strength).

Ajabmour MA, Mokhtar AM, Rafee AA, et al. Defective collagen

metabolism in Saudi patients in hernia. Ann Clin Biochem. 1992; 29 : 430-
Friedman DW, Boyd CD, Norton P, et al. Increases in type III collagen
gene expression and protein synthesis in patients with inguinal hernias.
AnnSurg.1993; 218 : 754-60
Difference in extracellular matrix



Control Stable Scar Incisional Reccurent

Hernia Incisional
Tenascin (Skin) + ++ +++ ++++
Tenascin ++++ ++ - -
Fibronectin +++ + ++ ++++
Fibronectin ++++ +++ - -
Difference in extracellular matrix

Control Stable Scar Incisional Reccurent

Hernia Incisional
MMP-1(Skin) +++ ++++ ++ ++
MMP-1 (fascia) +++ ++++ + -
MMP-13 (skin)
MMP-13 - - +++ ++++
(fascia) - - - -
Collagen 1/3
(skin) ++++ +++ ++ +
Collagen 1/3
++++ +++ ++ +

MMP, matrix metalloproteinases

Scale from absent (-) to predominant (++++)
The disorder of the collagen metabolism might explain
as well the success of surgical meshes inducing an
inflammatory foreign body reaction with a
consecutive, intense fibrosis resulting in a compound
of nonabsorbable mesh filaments as a mechanical-
sealing mechanism and an embedding collagen- rich
scar tissue. Both components form the mechanical
stable artificial abdominal wall. Consequently, hernia
patients showing a defect in forming stable scar tissue
will finally need a mesh repair.
Prosthetic repair


Groin pain/ meshodynia/ inguinodynia

Plug migration
Mesh shrinkage
Decrease compliance (infants, children, pregnant
Foreign body reactions

Pain, and in particular chronic pain, following

inguinal herniorraphy is one of the least appreciated
and yet most common complication of inguinal

Cunningham J. The Physiology and Anatomy of chronic pain

after inguinal herniorraphy. In Fitzgibbon RJ, In Fitzgibbons
R J, Greenburg A G. Hernia 5th Ed. Lippincott Williams and
Wilkins Philadelphia, 2002
Lichtenstein repair

N : 614
At D7 work not resumed = 344
Reasons : Pain 60,2 %
Wound complication 17,2 %
Other reason 12,2 %
Unrelated 2,0 %
Not specified 28,2 %
At D30 work not resumed = 44
Reasons : Pain 50 %
Wound complication 27,3 %
Other reason 16,2 %
Unrelated 13,6 %
Not specified 11,4 %

Bay. Nielsen M et al. Convalescence after inguinal

herniorraphy. Br J Surg.2004; 91 : 362-7
Surgical mesh

- Polyglycolic acid (Dexon)
- Polyglactic acid (Vicryl)

When prolonged tensile strength is required, as

in the case for hernia repair, absorbable mesh is
not indicated
Surgical mesh

Non absorbable
- Polypropylene
- Polyethylene terephthalete (polyester)
- Expanded polytetra-fenosethylene (ePTFE)
Surgical mesh

- Polypropylene + multifilamented polyglactin
- Polypropylene + monofilamented
polyglecaprone (ultrapro)
- Polypropylene + Polydioxanone + Oxidized
regenerated cellulose fabric (Proceed)

Marlex (CP Bard)

Visilex (CP Bard)
Prolene ( Ethicon)
Surgipro (Autosuture)
Atrium (Atrium Med.Co)
Surgimesh (Aspide Med)
Polyethylene terephthalete

Mersilene (Ethicon)
Parietex ( Sofradim)

Which mesh ?

Up to now, the superiority of either material has been

controversial. The various meshes differ largely in
their basic polymers, their weight, their pore size,
implying considerable differences of their textile and
mechanical properties.

Monofilament multifilament
Large pores small pores
Heavy-weight - lightweigth
Difference between burst strength
Difference between thickness
Monofilament - multifilament

- might reduce the attachment of bacteria
- usually increases the stiffness of the abdominal

- elevated pliability
- may cause problems in case of bacterial
Large pores small pores

A primary concern of surgeons is not to introduce a

substantial amount of foreign body that can harbour
or perpetuate infection. The ability to minimize
infection is due to the size of the pore or interstices.
The key number is 10 microns. Most bacteria are one
micron and most macrophages and neutrophilic
granulocytes are larger than 10 microns.

Goldstein HS. Selecting the right mesh. Hernia, 1999; 3 : 23 - 6

Large pores small pores
Small pores :
Encapsulation and contraction (shrinkage) of the

Dog model.
Heavyweight polypropylene mesh vs lightweight
polypropylene with absorbable polyglactin ( large
pores). Shrinkage : 46% vs 34%

Cobb WS, Kercher KW, Heniford BT. The argument for lightweight
polypropylene mesh in hernia repair. Surg.Innovation 2005,12 :63-9
Heavyweight lightweight

Table 1. Polypropylene meshes of differing densities

Surgiproa 110 g/m2
Proleneb 105 g/m2
Marlexc 95 g/m2
Prolited 90 g/m2
Prolene Soft Meshb 45 g/m2
Vypro IIb 35 g/m2
Ultraprob 28 g/m2

aUnited States Surgical,Norwalk,CT

bEthicon,Inc, Somerville,NJ

cCR Bard, Inc,Cranston,RI

d Atrium Medical Co, Hudson,NH

Lightweight polypropylene mesh may be preferable
for Lichtenstein repair of inguinal hernia

Port S, Wiss B, Willer M et al. Randomized clinical trial of

lightweight composite mesh for Lichtenstein inguinal hernia
repair. Br J Surg.2004; 91 : 44 - 8
Use of lightweight mesh was associated with less
chronic pain but an increase in hernia recurrence after
inguinal hernia repair. The latter may be related to
technical factors associated with fixation of such
meshes rather than any inherent defect in mesh.

ODwyer PJ, Kingsnorth AN, Molloy TG, et al. Randomized clinical

assesing impact of a lightweight or heavyweight mesh on chronic pain
after inguinal hernia repair. Br J Surg. 2005; 92: 166-70
Use of lightweight mesh for Lichtenstein hernia
repair did not affect recurrences rates, but improved
some aspects of pain and discomfort 3 years after

Bringman S, Wollest S, Osterberg J, et al. Br J Surg 2006; 93 : 1056-59

Difference between burst strength
How strong it needs to be?

Comparison of abdominal Pressure with Mesh Burst Strength

** Measured after absorption of the absorbable components

Difference between thickness
Comparison of thickness
Surgical mesh Thickness (cm)

Atrium 0,048
Marlex 0,066
Prolene 0,065

The rigidity and thickness impact conformability. The

conformability determines the distance between the mesh-tissue
interface and therefore the deposition of collagen
Anterior approach

The initial fixation strength of the various surgical

techniques and the tissue overlap of the prosthetic are
the principal factors in the early success of hernia
Anterior approach

Failure of hernia repairs nearly always occurs

laterally of the mesh tissue interface because of a
failure of fixation, incorporation, or lack of overlap
Anterior approach

The mesh should extend 2 cm across the pubic
tubercle, 3 4 cm above Hesselbachs triangle, and 5
6 cm lateral to the internal ring

New Developments in Hernia repair. Voeller GR. Surgical

Technology International XI, 2003