laparoscopic indirect hernia repair: an evaluation of the ring closure technique
TRANSCRIPT
INTRODUCTION
FEW CONDITIONS have received as much attention andbeen the target of such a variety of surgical options
both before and after the laparoscopic era as inguinal her-nias. This diversity indicates the absence of total satis-faction with any one of the available options. Each op-tion obviously carries its merits and demerits.
Since the introduction of laparoscopic cholecystec-tomy in the mid 1980s and its widespread use and suc-cess in the late 1980s and early 1990s, surgeons havetried to apply this minimally invasive technology to otheroperations. Inguinal hernias, being a common condition
met by the surgeon, were not ignored and had more thantheir share of applications of laparoscopy. In addition tothe minimal invasiveness, minimal pain, short hospital-ization, and quick recovery and return to work, surgeonswere willing to try laparoscopy in hernial repairs becauseperhaps they were not completely satisfied with the avail-able conventional methods of repair. This led to the de-velopment of a wide variety of operations ranging fromsimple closure of the defect (the internal ring) to dis-secting the peritoneum and applying a synthetic mesh orplug to the defect. Many of these methods are still beingtested.
The author, believing that simple is better, has chosen
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 11, Number 5, 2001Mary Ann Liebert, Inc.
Technical Report
Laparoscopic Indirect Hernia Repair: An Evaluation of the Ring Closure Technique
KHALID R. MURSHID, FRCS(C)
ABSTRACT
Background: The treatment of indirect inguinal hernias offers a wide variety of surgical methodsto choose from. The author has chosen the procedure combining most of the advantages and thefewest disadvantages while at the same time being simple. It entails a simple closure using laparo-scopic intraperitoneal intracorporeal suturing of the defect (the internal ring) with nonabsorbablematerial.
Patients and Methods: Forty-eight hernias were treated by laparoscopic intracorporeal closure ofthe internal ring using nonabsorbable suture. No mesh was used. The mean age of the patients was41.9 years with a mean duration of symptoms of 44.9 months. The mean operating time was 67 min-utes per hernia, and the postoperative hospitalization was 1.9 days. The mean follow-up was 32.67months.
Results: Only one hernia recurred (2%). None of the patients developed serious complications,and only 10 patients complained of port site discomfort.
Conclusions: Our results indicate that the laparoscopic internal ring closure method is simple,safe, and effective in treating indirect inguinal hernias. In addition, it appears to be cost effective.
Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia.
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the simplest method of repair of indirect inguinal hernias.That method is simple closure of the internal ring.
The dramatic success of laparoscopy in cholecystec-tomy led to enthusiasm to modify other abdominal pro-cedures to fit into the game. Inguinal herniorrhaphy isbut one such procedure. However, in order to revolu-tionize a well-established procedure, there should beadvantages associated with this change. The areas usu-ally targeted in an attempt to improve a surgical proce-dure are pain, cost, hospitalization, leave from work andeveryday activity, morbidity (including recurrence), andmortality. Do laparoscopic hernial repairs in general andlaparoscopic ring closure in particular fulfill these cri-teria?
Controversy is not new in the history of inguinal her-nia repairs, a procedure performed as far back as theearly Greeks. As early as the Middle Ages, this contro-versy in treating hernias was documented. The questionthen was whether to amputate the testicle along with thehernial sac or to offer the “royal repair”; i.e., excisionof the sac without orchiectomy.1 Since then, controversyhas continued to haunt hernial repairs. This pattern hasnot changed with the introduction of laparoscopy. As amatter of fact, the new techniques developed over thelast 15 years since the first report on laparoscopicherniorrhaphy by Ger in 19822 or since 1990, when itrapidly increased in popularity, are almost as numerousas those developed over the history of herniorrhaphy, ifnot more.
THE RING CLOSURE METHOD
A patent processus vaginalis at birth is a commonevent, occurring in approximately 25% of male children.Most, however, close. Despite this closure, it is still thecommonest cause of an adult indirect inguinal hernia,weakness of the ring being caused by the stretching ef-fect of abdominal viscera entering the patent processusvaginalis. Patients with an obliterated processus vaginalismay have a hernial defect lateral to the inferior epigas-tric vessels.3 This group’s internal ring incompetence isprobably caused by a defective shutter mechanism as aresult of either abnormal collagen metabolism4 or dener-vation of the internal oblique muscle attributable to anadjacent incision.
This defect forms the basis of the ring closure methodperformed by Ger through laparotomy as early as 1977and through laparoscopy as early as 1979 but only re-ported in 1982.2 In that year, Ger described the manage-ment of a variety of abdominal wall hernias through atransabdominal approach in patients who underwent lap-arotomy for other intra-abdominal conditions.2 He feltthat a hernia could be treated effectively by simply clos-
ing the peritoneal opening without dissection, ligation, orreduction of the sac. This was done using stainless steelMichel clips (3 3 15 mm) applied by using a Kocherclamp. The last patient in his series of 13 was donethrough a laparoscopic cannula in 1979. This patient wasfollowed for 8 years without evidence of recurrence. Geris therefore credited with performing the first laparo-scopic herniorrhaphy in a human patient. He and cowork-ers later published a study in beagle dogs with congeni-tal indirect inguinal hernias.5 They felt there werenumerous advantages of laparoscopic repairs that in-cluded smaller wounds, a lower chance of injuring thespermatic cord and testis, avoidance of ilioinguinal post-operative neuralgia, very high closure of the sac, mini-mal postoperative discomfort, and the ability to deal withboth sides. MacFadyen and associates6 studied differenttypes of laparoscopic hernia repairs, including high liga-tion of the sac with closure of the ring and transperitonealsuture repair of the transversalis fascia to the iliopubictract or Cooper’s ligament, and found the overall com-plication rates to be low.
This procedure (the ring closure technique), being thesimplest and involving neither introduction of mesh norextensive dissection, has been chosen as the basis for thisstudy.
PATIENTS AND METHODS
All patients above 16 years of age with indirect in-guinal hernias seen between January 1993 and No-vember 1999 were included in the study provided therewas no contraindication to general anesthesia and theywere willing to undergo a new procedure. There were48 hernias in 42 patients (41 men and 1 woman) witha mean age of 41.9 years. Twenty eight hernias wereon the right side and 20 on the left. The mean durationof symptoms was 44.9 months (range 0-300 months),with a median of 22 months. The procedure, performedby a single surgeon (the author), was explained clearlyto the patient, as was the conventional repair, and thepatient was allowed to choose after a full knowledgeof the advantages and disadvantages of each. Patientsgave consent for laparoscopic repair with possible con-version to conventional repair and possible need for la-parotomy.
General anesthesia was used, and the patient was putin the Trendelenburg position. No urinary catheter wasused. The hernia was reduced prior to preparing the pa-tient, and CO2 was used for insufflation with a maximumpressure of 12 mm Hg. The monitor was positioned atthe foot of the bed slightly toward the side of the hernia(Fig. 1). Three ports were used (Fig. 2): a 10-mm port atthe umbilicus for the laparoscope, a second 10-mm port
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at the lateral margin of the right rectus abdominis mus-cle for the needle holder (or USSC Endostitch™), and a5-mm port at the lateral margin of the left rectus abdo-minis muscle for the grasper.
After introduction of the camera, both internal ringswere inspected (Fig. 3A, B). Omentum or bowel waspulled out of the inguinal canal (if any remained in-side), and the internal ring was closed lateral to the vasdeferens and testicular vessels using three interruptedfigure-of-8 sutures of 0 nonabsorbable suture material.
Two methods were used to close the ring. One em-ployed a 5-mm laparoscopic needle holder and a con-ventional 0 silk suture on a round-bodied needle thesize of which is limited by the 10-mm port, and the sec-ond involved the USSC Endostitch with 0 Bralon™
(multifilament braided nylon). The choice was to usethe USSC Endostitch when available, as it was easierand faster. When it was not available, the needle holderwas used. The defect was closed in order not to be tootight; this was gauged by introducing a closed 5-mmport grasper medial to the most medial stitch comfort-ably but snuggly, and care was employed to avoid in-juring the vas and vessels by not introducing anystitches at the medial end of the defect. The sutures ap-proximated the transversus abdominis muscle to the il-iopubic tract (Fig. 3C), thereby closing the internalring. Avoidance of nerve damage was ensured by di-rect vision while taking the stitch bite, in addition tolimiting the stitches to the margins of the defect. Theumbilical port was closed under vision using 0Maxon™. A pressure dressing was applied to the portsites after closure of the skin with 3-0 nylon. Patientswere covered for pain with a single dose of pethidine
(meperidine) 1 mg/kg as needed. No antibiotics weregiven.
Patients were instructed to avoid straining and heavyactivity for at least 1 month after surgery with a gradualincrease in activity over the 2 months following that.
After discharge, usually on the first or second postop-erative day, the patient was seen in the clinic for any de-veloping symptoms or evidence of recurrence. Patientswere seen at 3 weeks, 3 months, 6 months, and 1 yearand then yearly. Each visit included questioning aboutrecurrence of symptoms, as well as a physical examina-tion.
RESULTS
The operating time averaged 67 minutes per hernia(range 20–130 minutes). The mean postoperative hospi-talization was 1.9 days (range 1–5 days), and the meanfollow up was 32.7 months (range 1–69 months). Themedian was 30 months (Table 1).
Eleven of the hernias were considered large, 13 weremedium sized, and 24 were small (Table 2). The term“large” was used to describe a hernia reaching the scro-tum, “medium” for a hernia causing an easily visibleswelling not reaching the scrotum, and “small” for a her-nia causing only a cough impulse or requiring the patientto stand up in order to be detected. Ten patients com-plained of discomfort at the port sites (mainly umbilical),but this was temporary. None of our patients developedwound infections or hydroceles. None of our patients de-veloped any serious complication related to laparoscopy
FIG. 1. Operating room set-up for laparoscopic hernioplasty(left-sided hernia).
FIG. 2. Sites of ports for laparoscopic repairs.
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FIG. 3. Anatomy of groin and hernia before and after repair. (A) Normal anatomy of right groin (intra-abdominal view). (B)Right wide internal (deep) inguinal ring (site of hernial defect). (C) Right internal (deep) inguinal ring after repair.
A
B
such as bowel, bladder, or vessel injury or even bowelobstruction or ileus. One hernia recurred (2%).
DISCUSSION
There are so many different types of repair of indirectinguinal hernias, a comparison between this method and
all of the others would be a difficult task and is not theobjective of this study. Instead, the author’s objective wasto assess a certain type of repair (the ring closure method),which the author believes to be simple and to the pointand avoids the complications of using a foreign body(other than the suture itself) as well as extensive dissec-tion, thereby reducing the disadvantages of the commonlyemployed laparoscopic approaches.
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Only one of our patients (2%) was a female. The sizeof the hernia was proportional to the age of the patient,younger patients presenting with smaller hernias. Thisfinding may be related to better education among theyounger population: this group of patients may under-stand the need for and be willing to seek medical adviceearly on.
As expected, the duration of symptoms was related tosize, as hernias are known to enlarge progressively withtime. Larger hernias took a longer time to repair than bothsmall and medium-size ones, the times for which weresimilar. However, the postoperative hospitalization wasnot related to size.
The operating time was, on average, 17 minuteslonger in hernias repaired by a needle holder than thoserepaired by the Endostitch, a difference that was not
statistically significant. The average duration of symp-toms was about 50% longer in the needle holder re-pairs.
We had only one recurrence out of 48; i.e., 2%, andthat occurred in a 45-year-old man with a medium-sizehernia repaired by needle holder. It recurred 8 monthspostoperatively. This compares well with the recent re-view by Condon and Nyhus,1 where the recurrence ratefor the anterior approach worldwide was 0 to 7%. Con-don and Nyhus show that this type of repair, although inuse for more than a century, requires suturing under ten-sion (in most cases) in addition to distortion of normalanatomy. Postoperative pain (an inevitable associatedfactor), if not from neuralgia, tissue injury, and edema,was caused by the tension associated with these repairs.This was not a factor in our patients. Although compli-
TABLE 1. CHARACTERISTICS OF PATIENTS AND OUTCOME ACCORDING TO TYPE OF REPAIR
Duration of Operating Postoperativesymptoms time hospitalization Follow-up
Type of repair Age (months) (min) (days) (months)
Hand Mean (SD) 39.8 (17.2) 49.4 (69.8) 72.6 (29.7) 1.9 (1) 37.6 (22.2)(N 5 33) Median 32.0 24.0 60.0 2.0 42.0
Range 19–80 0–300 20–130 1–5 1–69USCC Mean (SD) 46.3 (16.4) 34.9 (42.6) 55.7 (13.1) 1.8 (0.8) 21.8 (16.5)
(N 5 15) Median 46.0 12.0 60.0 2.0 13.0Range 23–65 0–120 35–85 1–3 7–53
Total Mean (SD) 41.9 (17.1) 44.9 (62.5) 67.3 (25.2) 1.89 (0.9) 32.7 (21.7)(N 5 48) Median 37.0 22.0 60.0 2.0 30.0
Range 19–80 0–300 20–130 1–5 1–69
C
FIG. 3. (continued).
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cations including recurrences may be associated with anyrepair, the economic factors are great, and although notseen as cost of surgical instruments are mainly in the formof loss of work days and delayed return to normal activ-ities.
It appears from our results that the recurrence rate forsuch a simple procedure is fantastically low. This canonly be attributed to a strong will on the author’s part forsuch a simple procedure to be successful, in addition tospecial care, while applying the stitches, to ensure strongenough bites.
A concern is a hydrocele developing in the distal sac.There were no cases where a hydrocele developed inour patients. This can be explained by the fact that theclosure is not air tight or, for that matter, fluid tight.The minimal natural peritoneal fluid can move freelybetween the sac and the abdomen; however, the ab-sence of bowel passing through the ring (and keepingit distended) will result in the distal sac shrinking andatrophying and later not collecting any fluid. This ofcourse is just a hypothesis, but it appears to be some-what confirmed by the fact that we have not encoun-tered any hydroceles.
Occasionally, we are confronted with a direct hernia,either instead of, or in addition to, the indirect hernia di-agnosed preoperatively. In these cases, simple closure ofthe ring was replaced by a transperitoneal on-lay Prolenemesh repair covered by peritoneum.
There are obvious advantages and disadvantages to laparoscopic herniorraphy. Although we enjoyed theseadvantages, we did not see any major disadvantage us-ing this simple approach. In addition, we had the advan-tage of avoiding the complications related to mesh (itsapplication and its presence). Even the operative cost wasreduced by avoiding the use of a mesh and may be al-
most completely eliminated by employing reusable in-struments (needle holder and trocars).
In the laparoscopic approach in general and this ap-proach in particular, these advantages are magnifiedwhen dealing with bilateral and recurrent hernias. This isso because one avoids two incisions (with their associ-ated scar and pain) in the former and bypasses an areawith difficult and altered anatomy in the latter.
CONCLUSION
It appears from the study that the ring closure tech-nique is a feasible method of repair of indirect inguinalhernias that is both safe and showed no significant complications. It is simple, avoids the use of foreignbody (apart from nonabsorbable suture), is almost to-tally painless, and is associated with short hospitaliza-tion and early return to nonstrenuous activity. On topof all of that, it appears to be economical and associ-ated with a low recurrence rate, low morbidity, and zeromortality, thereby fulfilling all of the criteria necessaryfor replacing a conventional well-established proce-dure.
On the basis of the study, we intend to recommend thistype of repair to all patients with indirect inguinal her-nias, especially to those with bilateral or recurrent her-nias.
ACKNOWLEDGMENT
The author would like to thank Mary Arlene Dascoand Timmie Luces Tinamisan for their secretarial sup-port in typing this manuscript.
TABLE 2. PATIENT CHARACTERISTICS, OPERATIVE FEATURES, AND OUTCOME IN RELATION TO HERNIA SIZE
Duration of Operating Postoperativesymptoms time hospitalization Follow-up
Size Patient age (months) (min) (days) (months)
Large Mean (SD) 50.9 (19.4) 127.8 (77.2) 74.6 (29.9) 2.0 (0.8) 31.4 (23.7)(N 5 11) Median 56.0 120.0 60.0 2.0 23.0
Range 19–80 36–300 40–120 1–3 3–64Medium Mean (SD) 40.0 (16.6) 39.2 (29.0) 64.6 (19.4) 1.5 (1.2) 23.8 (21.7)
(N 5 13) Median 38.0 36.0 60.0 1.0 13.0Range 20–70 8–120 40–120 1–5 1–69
Small Mean (SD) 38.7 (15.3) 9.96 (19.3) 65.4 (26.1) 2.0 (0.8) 38.1 (19.9)(N 5 24) Median 31.0 6.0 60.0 2.0 43.50
Range 22–80 0–96 20–130 1–4 7–64Total Mean (SD) 41.9 (17.1) 44.9 (62.5) 67.3 (25.2) 1.9 (0.9) 32.7 (21.7)
(N 5 48) Median 37.0 22.0 60.0 2.0 30.00Range 19–80 0–300 20–130 1–5 1–69
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REFERENCES
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2. Ger R. The management of certain abdominal hernias by in-tra-abdominal closure of the sac. Ann R Coll Engl 1982;64:342–344.
3. Gilbert AI, Nyhus LM, Stoppa R, et al. Hernia update. Con-temp Surg 1991;39:41.
4. Peacock EE, Madden JW. Studies on the biology and treat-ment of recurrent inguinal hernia II: Morphological changes.Ann Surg 1974;179:567–571.
5. Ger R, Monroe K, Duvivier R, Mishrick A. Management ofindirect inguinal hernias by laparoscopic closure of the neckof the sac. Am J Surg 1990;159:370–373.
6. MacFadyen BV Jr, Arregui ME, Corbitt JD Jr, et al. Com-plications of laparoscopic herniorrhaphy. Surg Endosc 1993;7:155–158.
7. Condon RE, Nyhus LM. Complications of groin hernias. In:Nyhus LM, Condon RE (eds): Hernias, 3rd Philadelphia: JBLippincott, 1989, p 253.
Address reprint requests to:Khalid R. Murshid, FRCS(C)
Department of SurgeryKing Khalid University Hospital
Riyadh, Saudi Arabia
E-mail: [email protected]
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