Minimally Invasive Open Preperitoneal Inguinal Hernia Repair

Inguinal hernia is the most common form of hernia in adults, and is the result of either a congenital or acquired weakness in the lower abdominal wall, resulting in a defect through which the lining of the abdomen, or peritoneum, protrudes. An indirect inguinal hernia results from dilation of the internal ring over time, or a congenital patent processus vaginalis. In either case, a peritoneal sac herniates through the internal ring and often the external ring as well. In a direct inguinal hernia, transversalis fascia stretches out allowing for preperitoneal fat or peritoneal contents to herniate through Hasselbach’s triangle. This can result in swelling of the lower abdomen and, at times, pain. In severe cases, abdominal contents such as bowel can protrude through the weakness as well, creating a life-threatening condition. The aim of inguinal hernia surgery is to repair the structural integrity of the lower abdomen, and, in adults, placement of a mesh reduces the risk of reformation, or recurrence, of the hernia. The difficult recovery associated with traditional inguinal hernia repair, where the inguinal canal is opened, has driven interest in less invasive alternatives, such as laparoscopic and open preperitoneal approaches. In experienced hands, these latter approaches result in equivalent rates of recurrence with much improved postoperative recovery.

History of inguinal hernia is usually consistent with a lower abdominal mass, which may or may not change in size. Most patients feel some discomfort or pain with lifting, sitting or exercise. Symptoms are often worse at the end of the day. Some patients may remain symptom free for years. If there are complaints of pain without any history of a mass, causes other than inguinal hernia should be sought. Patients who present with a history of a severe pain, associated with an inflamed lower abdominal mass should be evaluated emergently for incarceration of abdominal contents within a hernia.

Most inguinal hernias present as a visible bulge in the groin. This is often associated with mild discomfort, or pain. Patients presenting with severe pain may have incarceration and/or strangulation of abdominal contents, which is a surgical emergency. Many times the hernia can be visually identified, and then reduced by the examiner, clinching the diagnosis. At times, the findings can be more subtle. If a hernia is suspected but not immediately obvious, palpation of the inguinal canal while the patient performs a Valsalva maneuver or coughs can elicit the bulge of an inguinal hernia.

Although the vast majority of inguinal hernias are diagnosed through the physical examination, in rare cases various imaging modalities can help decide equivocal cases. Specifically, CT scans can be used in patients whose body habitus prevents an accurate physical exam.

The natural history of all inguinal hernias is one of progressive enlargement of the hernia and weakening of the lower abdominal wall, with a small but persistent risk of incarceration and strangulation of abdominal contents. There is a wide variability of patient complaints that range from a painless visible bulge to severe pain without an obvious mass. Evaluation by a surgeon is important for diagnosis and risk stratification. There is even evidence of a long period of symptom quiescence¹. Due to this, watchful waiting for this latter group is a legitimate management strategy in some patients.

Options for nonoperative treatment include watchful waiting for minimally symptomatic hernias, and trusses for larger and symptomatic hernias. Symptomatic hernias are treated with surgical correction of the defect in the abdominal wall. The general surgical approaches can be broken down into anterior and posterior approaches. All surgical repairs include both the repair of the primary defect often with placement of a mesh to prevent future recurrences.

The anterior approach is the category of repairs that include both traditional tissue-only repairs and mesh repairs placed by opening the inguinal canal from the front. Examples of tissue-only repairs include the Bassini and Shouldice repair, and examples of mesh repair are the Lichtenstein and plug and patch repairs. There are many varieties of products and approaches for these repairs.

Surgical repair was recommended in this patient due to his young age and symptoms. The author has significant experience with laparoscopic inguinal hernia repair, but now routinely performs the Kugel or open preperitoneal repair because of the faster recovery and decreased postoperative pain. This particular procedure corrects the defect while avoiding the long recovery time associated with anterior approaches, a particular advantage in young, active patients.

Patients who have had a radical prostatectomy are generally not candidates for laparoscopic hernia surgery, but may be eligible to undergo an open preperitoneal repair. Patients who have had a previous laparoscopic (posterior) approach on the same side and have a recurrent hernia are not candidates for an open posterior approach.

The traditional anterior inguinal hernia repair, where the inguinal canal is opened and the repair performed below the internal inguinal ring, has been utilized for decades with low hernia recurrence rates. With the advent of the Lichenstein, or tension-free, repair, which utilizes a biologically inert mesh to bolster the body’s soft tissues rather than through rearrangement of the soft tissue itself, recurrence rates dropped even further. However, even with the advance associated with a tension-free repair, the recovery associated with the anterior approach has typically been long and uncomfortable, traditionally incapacitating the patient for several weeks. More recently, a posterior approach, first described by Renee Stoppa, has been advocated. The analogy often used to describe the difference between anterior and posterior approach for hernia repair is the repair of a hole in a bicycle tire. The anterior approach is equivalent to repairing the hole with a plug in the tire and the posterior approach is equivalent to placing a larger patch in between the inner tube and the tire. In the posterior approach, the repair takes place in the preperitoneal space, above the internal inguinal ring, with the mesh material placed entirely within the preperitoneal space. A laparoscopic approach to hernia repair has been developed, modeled on the posterior approach; however, due to high reported rates of recurrence associated with this approach, as compared to traditional anterior approaches,^{2, 3}, it is usually reserved for treatment of recurrent hernias after an anterior repair². Nevertheless, there is evidence to show that in experienced hands, posterior repairs of primary inguinal hernias have success rates approaching that of the anterior approach, with vastly improved postoperative recovery².

Traditional hernia surgery carries a high risk of chronic pain. As many as 17% of patients can have significant pain for years after traditional hernia surgery. This high incidence is likely secondary to the location of the mesh used for this kind of surgery. With the open preperitoneal repair, the nerves responsible for the chronic pain are avoided, leading to a lower incidence of this problematic complication⁴.

More recently the Kugel preperitoneal and the ONSTEP approaches have been described as less invasive and less costly alternatives to laparoscopy⁵. With the open preperitoneal procedure, also known as the Kugel repair, we have found that typically patients are back to work in a matter of days, with return to full activity in two weeks. This is due to the extensive dissection in the preperitoneal space, including below Cooper’s ligament, which allows us to place the mesh without any need for suturing, allowing passive pressure of the peritoneal contents to keep the mesh in place. The entire procedure is done under local with sedation in patients with a BMI of 28 or less, and most patients need only acetaminophen for pain control postoperatively. The key advantage of this repair over that of the laparoscopic repair is that local anesthetic is infiltrated into every layer of the abdominal wall before any dissection is performed. This dramatically reduces the need for anesthesia and postoperative pain medication.

With this surgery, three hernia defects are repaired every time: direct, indirect and femoral. Our series of Kugel repairs now extends to over a thousand hernia patients. In our experience, the recurrence rates are similar to that of published series of anterior approaches, with vastly improved postoperative recovery times, including time to return to work, use of pain medication, and chronic pain complaints. This is in line with findings regarding outcomes after laparoscopic hernia repair for primary hernias^{6, 7} of which our approach is a variation. There is also a cost savings advantage to our approach. Although the cost of the open preperitoneal approach is greater than the standard anterior approach – almost entirely due to the cost of the mesh used – it is significantly less than the laparoscopic approach⁸. Due to all of the above mentioned factors, we believe the open, minimally invasive approach to preperitoneal hernia repair offers a very attractive option to those patients suffering from hernias.

In addition to a minor surgical tray used in traditional hernia surgery, the surgeon must use a bright headlight as the incision is only 3-4 cm in size. The best mesh for this repair is the Ventrio ST patch (Davol - Cranston, RI). Most of the dissection deep in the space is performed with 2 medium Debakey forceps. No penrose drain is needed and a generous amount of local is used.

No Disclosures.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published on-line.

12/2019: In 2018, this technique was modified to suture the mesh to Cooper’s instead of to the transversalis fascia.