|Year : 2012 | Volume
| Issue : 1 | Page : 18-23
Single-layered tissue inguinal hernia repair
Abdulkadir Yakubu1, Hazakilu Usain2
1 Department of Surgery, Kazaure General Hospital, Jigawa State, Nigeria
2 Department of Surgery, General Hospital Jahun, Jigawa State, Nigeria
|Date of Web Publication||22-Sep-2012|
Department of Surgery, Kazaure General Hospital, Jigawa State
Source of Support: Funded in part by Sha, aibu Maigida Aujara, Conflict of Interest: None
Background: There is still no consensus about the best and most cost-effective surgical approach to inguinal hernia repair. This study analyzes our experience in an open, non-mesh, one-layered inguinal hernia repair.
Materials and Methods: From January 2001 to December 2008, 1238 patients who underwent inguinal hernia repair at two general hospitals were retrospectively reviewed. Their age ranged from 18 to 87 years, with a mean of 45.3 ± 11.0 years. Following clinical evaluation, herniorrhaphy was done under appropriate anesthesia. Patients were discharged home the same day on oral drugs. Wound dressing was changed and sutures were removed on the 3 rd and 7 th days of the follow-up visits, respectively. Demographic information, types of hernias, associated diseases, and complications were analyzed.
Results: Mean duration of symptoms before presentation was 3.4 ± 0.2 years. There were 742 patients (60.0%) with indirect hernia, 496 patients (40.1%) with direct hernia, 570 cases (46.1%) of inguinoscrotal hernia, 342 patients (27.6%) with bilateral hernia, and 33 patients (2.7%) with recurrent hernia. Local anesthesia was successful in 1046 patients (84.5%). Spinal anesthesia was used in 186 patients (15.0%). Six patients (0.5%) were operated under general anesthesia. The mean inpatient stay was 4.5 h. The average cost per patient was $99:00. The mean duration of surgery was 30 ± 2.0 min, ranging from 25 to 63 min. Postoperative pain syndrome was observed in 8.0% of cases. There was a recurrence of 2.7%.
Conclusion: Single-layered tissue inguinal hernia repair under local anesthesia can be confidently performed by skilled surgeons with low complication and recurrence rate and is recommended for low-income communities.
Keywords: Hernia, non-meshs repair, one layer
|How to cite this article:|
Yakubu A, Usain H. Single-layered tissue inguinal hernia repair. Arch Int Surg 2012;2:18-23
| Introduction|| |
Groin hernia repair is one of the commonest general surgery operations performed worldwide. The annual rate of herniorrhaphy is 10-25 per 1000 population in the UK and USA.  Inguinal hernia repair alone has a rate of 10 per 10,000 in the UK each year. 
There are constant clinical trials carried out for better results using unlimited methods of hernia repair.  The use of fascia or sutures under tension in hernia repair is highly associated with recurrence and led to introduction of tension-free inguinal canal reinforcement with nylon darns or polypropylene mesh. Irving Lichtenstein is a pioneer of tension-free hernioplasty and radically brought about a change in the technique, where patients are exposed to early ambulation, short hospital stay, and local anesthesia (LA).  Since then, Lichtenstein repair of inguinal hernias has become increasingly popular, and several randomized clinical trials have reported fewer recurrences with this technique than with conventional suture repair. ,
Long-term follow-up of traditional hernia repairs has shown a high recurrence rate of 15-30%. , On the other hand, there is evidence that long-term recurrence rates after both Lichtenstein mesh and Shouldice hernia repairs is less than 1%.  Therefore, differences in short-term outcome may be more important determinants in hernia repair techniques selection. ,, In modern days, several studies have focused on postoperative chronic pain and quality of life. , Many patients report a feeling of stiffness associated with the polypropylene mesh.  In addition, postoperative infection and neuralgia remain the common complications after mesh implantation. Incidence of these complications reflects environmental conditions and surgical expertise.  In laparoscopic hernia repair, complications are not uncommon; visceral, vascular, and neurological injuries are encountered in non-skilled hands.  Recurrences after laparoscopic repair are often attributed to the long learning curve. All the new techniques available are costly, and they demand modern, standard surgical conditions and skilled personnel.  Apart from this, there is still no consensus about the best and most cost-effective surgical approach to inguinal hernia repair. , There is no doubt that the cost of these methods is unacceptable in poor communities with very limited health care budget. This study analyzes our experience in an open single-layered tissue inguinal hernia repair with acceptable outcomes.
| Materials and Methods|| |
The present study was carried out retrospectively on patients managed for inguinal hernia from January 2001 to December 2008 at the surgical units of Jahun and Kazaure General Hospitals, Jigawa State, Nigeria. The catchment population of the hospitals is about 1 million from within and without the state. Moreover, there are seven other general and four other cottage hospitals evenly located in the state. The state is a region with a population of about 5 million.
During this period of 7 years, a total of 2573 patients comprising 2512 males and 61 females (40.3:1) underwent hernia repair at two general hospitals, of which 1634 (63.5%) had inguinal hernia repair. 1238 male adult patients (75.8%) among the latter subjects, aged from 18 to 87 years, with a mean of 45.3 ± 11.0 years, were evaluated retrospectively and included in this study.
On presentation routine general examination was carried out, and pulse and blood pressure were measured and recorded. Minimal laboratory investigations included full blood count, urinalysis, and fasting blood sugar. HBSAg and HIV tests were done in appropriate cases. Other more specific investigations were also done where indicated. All patients were booked for a day case hernia repair after their record and investigations were completed. Patients reported on their appointment days and underwent hernia repair.
Patients were observed in recovery room for 1 h and moved to wards for another 2-3 h. In the absence of any complications, they were discharged home the same day. Following a single intravenous cephalosporin, oral tablets were continued for 24 h postoperatively. Ibuprofen oral tablets for three postoperative days provided adequate analgesia for all patients.
Patients visited the hospital on 3rd and 7th postoperative days for follow-up. Wound dressing was changed and sutures were removed at first and second follow-up visits, respectively. There was no restriction of movement and feeds from the 1st postoperative day. Consequently, patients reported at an interval of 2 months in the first 6 months and then biannually for the remaining period of 2 years. Complaints, wound status, and complications were recorded at the time of follow-up visits. The follow-up period ranged from 2 to 24 months. An operative team of one surgeon, theater nurse, and medical officer participated in the inguinal hernia repair. One surgeon operated on all the cases.
Demographic information, cases' incidence, types of hernias, associated diseases, complications, and mortality were analyzed.
Following routine cleaning with povidone-iodine and draping, 1 g single intravenous dose of cephalosporin is given. Standard monitoring unit (electrocardiograph, noninvasive arterial blood pressure, and pulse oximetry) is connected. After local infiltration with 2% Lignocaine with Adrenaline 1:200,000 or spinal anesthesia (SA) 0.5% - 4 ml Bupivacaine, an incision of 6-7 cm is made over the inguinal canal [Figure 1]a, b. The inguinal ligament is fully exposed by proximal and distal dissection of the muscles [Figure 1]c. Inguinal canal is opened along the muscle fibers and its contents are examined. In all cases, ilioinguinal nerve is identified and spared [Figure 1]d, e. Other nerves related to the region are identified and spared too, but when there is high possibility of trapping them in the process of repair, they are transected. The sac is dissected from the spermatic cord in case of direct hernia; leaving the cord intact in its membranes. In indirect type of hernias, the cord coverings are opened, and the cremaster muscle, the vas deferens, and its vessels are separated from the sac [Figure 1]f. The sac is dissected from other structures as proximal as possible; the dissection is continued down to the base. Where a giant sac is encountered, a hemostat is applied distally and the sac transected proximal to the hemostat, leaving the distal part in situ. The neck is carefully dissected further up to the internal inguinal ring [Figure 1]g. The sac is opened, its cavity and contents inspected. The content is returned into the abdominal cavity. The neck is closed from inside with vicryl 2-0 purse string. The same suture is used to transfix the stump beneath the internal oblique and transverse muscles. The cord membranes are restored, and transverse fascia is used for reconstruction of the internal inguinal ring around the cord. After clearing the posterior wall, the inguinal ligament is approximated and adapted by 3 to 4 interrupted sutures to the transverse and internal oblique muscles all layers interrupted polypropylene 1-0 sutures [Figure 1]h. The first suture is placed close to the pubic bone through Gimbenat's ligament, not through the bone cartilage. The sutures are inserted at a minimum of 1 cm medial to the muscle margins and slightly tightened and knotted [Figure 1]i. The spermatic cord is placed back and the external oblique aponeurosis is closed with continuous 1-0 vicryl sutures [Figure 1]j. Operative site is infiltrated with 0.2% of Pubivacaine, hemostasis ensured with electrocautery, and wound is closed by subcutaneous and skin sutures.
|Figure 1: Step by Step inguinal hernia repair local filtration of Lignocain (a), an incision of 6-7 cm over the inguinal canal (b), external transverse muscle aponeurosis exposed (c), Inguinal canal opened along muscles fibres (d), illioinguinal nerve identified and spared (e), vas deferens and its vessels separated from the sac (f), the sac neck dissected up to the internal inguinal ring (g), inguinal ligament adapted to the transverse and internal oblique muscles by 3-4 all layers interrupted polypropylene 1-0 sutures (h), sutures slightly tightened and knotted (i), external oblique aponeurosis closed with a continuous 1-0 vicryl sutures (j)|
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| Results|| |
Duration of the hernias before presentation ranged from 1 day to 32 years, with a mean of 3.4 ± 0.2 years. There were 742 patients (60.0%) with indirect hernia, 496 patients (40.0%) with direct hernia, 570 cases (46.1%) of inguinoscrotal hernia, 342 patients (27.6%) with bilateral hernia, and 33 patients (2.7%) with recurrent hernia. Ipsilateral hydrocele was revealed in 106 patients (8.7%). Twenty-nine patients (2.3%) had sliding hernia [Table 1]. The number of hernias was more than the total number of patients as some patients had more than one hernia at presentation. Emergency herniorrhaphy was performed in 201 patients (16.2%). LA was successful in 1046 patients (84.5%). SA was used in 186 patients (15.0%). Six patients (0.5%) were operated under general anesthesia (GA), all with giant irreducible inguinoscrotal hernias [Table 2]. The mean of patients' stay was 4.5 h for LA and SA, with a duration range of 2 h to 7 days. There was unplanned admission in 2.6%. The mean time to return to normal activity was 10 ± 0.7 days. The average cost per patient was approximately 13,000.00 Naira ($99.00). The mean duration of surgery was 30 ± 2.0 min (25-63 min). There were no significant immediate postoperative complications observed.
Patients' follow-up ranged from 1 to 24 months. Sixty-seven percent and 53% of patients were seen at 1 and 2 years, respectively. There were 24 patients (1.9%) seen at unscheduled follow-up, of whom 18 cases (95%) were seen in the first month because of pain or surgical site infection.
Postoperative pain was observed in 8.0% of all cases. Distribution of complications is shown in [Table 3], and includes postoperative pain, surgical wound infection, seroma, hematoma, acute urinary retention, pururitis, recurrence, and erectile dysfunction. Thirty-three patients (2.7%) had recurrent hernia [Table 3]. There was no mortality associated with our surgeries.
| Discussion|| |
There is large variation of anesthesia in hernia surgery, which is based on center preferences rather than its feasibility for a given patient, complications, and costs. However, specialized hernia centers focus on local infiltration anesthesia.  The advantages of LA over GA has been demonstrated in the developing nations like Sri Lanka, the Solomon Islands, Nigeria, Ghana, and Togo, where it is the method of choice for doctors working single-handedly.  Safety of administering relatively large doses of lidocaine or bupivacaine into the groin area has been shown, especially when economic resources and medical personnel are scarce. , LA is feasible for routine use in more than 95% of patients. Exclusion criteria are large irreducible hernias, patients with psychiatric disease, and those who refuse to cooperate. In our study, LA, SA, and GA were used in 84.5%, 15%, and 0.5% of patients, respectively.
The principles in the modern era of hernia surgery are to lower the recurrence and complication rate. In trying to achieve this gold standard, the surgical technique has changed dramatically over the past 20 years. The Shouldice technique was considered to be the "gold standard" at the start of the 1990s and recurrence rates as low as 1-4% after 4-12 years of follow-up have been achieved.  Tension-free surgery with mesh has become the standard technique in inguinal hernia surgery with low recurrence, but is associated with complications such as groin pain, infection, discomfort, and infertility. 
Still there are few large randomized studies comparing long-term outcome of the various popular methods.  Any postoperative wound which is not dry and clean on day 3 of follow-up is considered to be infected until proved otherwise. This led to high infection rate of 4.7% in our patients. There was recurrence rate of 2.7% in the present study.
There is evidence that 3-6% of patients will have severe chronic pain and more than 30% will have mild pain 1 year after the Shouldice and Lichtenstein hernia repair. , These complications may have a significant effect on patients' daily activities. ,, It was concluded that pain after open hernia repair is not affected by elective division of the ilioinguinal nerve.  In most of our cases, we try to identify and spare the ilioinguinal nerve as there is no risk of trapping of the nerve compared to the mesh techniques. Of our patients, 11.0% complained of pain after the herniorrhapy.
Erect posture, weak posterior rectus sheath and transversalis due to anatomical defect in the evolution predispose humankind to high rate of groin hernias. Aponeurotic fibers of the transversus abdominis form a structure known as aponeurotic arch. Contraction of the transversus abdominis causes the aponeurotic arch to move downward toward the inguinal ligament, thereby constituting a form of shutter mechanism that reinforces the weakest area of the groin when intra-abdominal pressure is raised.  Our surgical technique is a modified and simplified Bassini repair, but the method is directed toward correction of the defect and restoration of the shutter mechanism by using the one-layer non-mesh methods. Therefore, it is imperative to understand that this technique is based on anatomical and physiological function of the inguinal region structures. The technique minimized the complications as there is much less tampering of tissues and other structures of the groin, whereas the expensive, difficult-to-learn, skilled expert methods which involve extensive dissection lead to impairment of innervations and blood supply, and clot formation. All these result in complications such as groin pain, infection, discomfort, fistulae, infertility, and recurrence. ,,
The tension-free repair is an important principle in all hernia surgeries where different types of mesh are used for this purpose. There is no doubt that the mesh placement is the cornerstone in repairing ventral and large inguinal hernias. The polypropylene and polyester mesh have a tensile strength that is far greater than the physiological tissue strength. The shrinking of mesh from 30 to 50% from the margins and migration from their primary site are also blamed for many complications. , It had been shown that there is no difference in the scarring in a long period between the mesh and the suturing repair; the mesh is replaced by scarred tissues that do not differ histologically from the tissues after the suture repair method. , We consider the use of mesh or other complicated methods as not necessary for small to moderate inguinal hernias as the tension-free repair is achieved by exposing the aponeurosis of external oblique muscle, reconstructing the internal ring, and adapting the layers with 3-4 interrupted sutures as described in the present study. This relatively loose adaptation of layers makes them to adjust and occupy their respective physiological positions.
All patients were allowed to feed, move, and walk on the first postoperative day. This leads to adjustment of repaired structures to the functional position and strength accordingly. During this process, the 1-cm gap between the interrupted sutures and the muscle margins prevents the muscle edges from pulling apart and causes a higher failure rate with recurrence, often in larger and more complex hernias. Moreover, the technique inhibits tension, encouraging full and effective healing of the repaired site. The cost of $99.00 includes all expenses consisting of surgical materials, anesthesia, drugs, hospital bed, and personnel's salary. It is clear that this amount is much lesser than that of other sophisticated methods. Therefore, in countries with minimal financial resources this technique may provide greatly enhanced services at low cost and should be considered as an alternative. However, a significant sector of surgical care can be provided at low cost by well-organized in-country programs.
The etiology of hernias is important in their surgical management; most of our patients were involved in farming at their working age. This gave our technique the chance to yield significant success in this group of patients. Therefore, our method should not be considered as universal for all inguinal hernia repairs; especially when the defect is large, trauma, myopathies, and other congenital abnormalities are identified as the main cause. For these special hernias, other methods are recommended.
| Conclusion|| |
The single-layered tissue inguinal hernia repair under LA can be used effectively by skilled surgeons with low complication and recurrence, which are comparable to other popular methods, especially in communities with poor income.
| Acknowledgment|| |
This work was funded in part by Sha, Aibu Maigida Aujara.
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[Table 1], [Table 2], [Table 3]