“Reduction of inguinal hernia recurrence by Lichtenstein method� INTRODUCTION An external abdominal hernia is an abnormal protrusion of intra abdominal tissue through a facial defect in the abdominal wall. About 75% of hernias occur in the groin (Indirect inguinal, direct inguinal, femoral). The abdominal wall defect may be congenital or acquired and accordingly inguinal hernias are divided into two- 1. Congenital or indirect inguinal hernias, 2. Acquired or direct inguinal hernia. An indirect inguinal hernia occurs due to failure of processes virginals obliteration result a hernia sac passing through the internal inguinal ring occurring in the infant, children and young adult. Although these hernias most often present during the 1st year of life, the first clinical manifestation may not appear until middle or old age 1. In a direct inguinal hernia a weakness or defect in the transversals fascia which form the floor of the Hesselbach’s triangle results in a direct inguinal hernia. There is some evidence that direct inguinal hernia may be related to hereditary or acquired defect in the collagen synthesis or turn over 1. Smoking is a factor causing acquired collagen deficiency and making an individual susceptible to development of hernia 2. Fat is another factor which causes separation of muscle bundles and layers and weakens aponeuroses and thereby favours the appearance of par umbilical, direct inguinal and hiatus hernias. Any condition that chronically increases the intra abdominal pressure may contribute to appearance and progression of a hernia. Marked obesity, abdominal strains from heavy exercise or wt. lifting, cough, constipation & straining on micturition, cirrhosis with ascitis, pregnancy, and chronic ambulatory dialysis and chronically enlarged pelvic organs or pelvic tumors.
According to the revolutionary history of hernia repair for the past century following the lead of bassini and Marry Surgeons around the world, have repaired groin hernias by lowering a musculoaponeurotic and fascial curtain over the defective posterior aspect of the inguinal canal and anchoring it to the aponeurotic structures close to the superior pubic ramus. In fact, good result could be expected using Bassini’s, Mc Vay’s, Shouldice’s and Ferguson. Not with standing the excellent results reported by some individual series, worldwide rate of recurrence for hernia in adult repaired by above techniques ranges from 5-10% and in recurrent hernia failure rate was much higher (20-30%) 3. Attempting to reduce the rate of recurrence surgeons around the world try to replace the musculoaponeurotic curtain used to shield the defective transversalis fascia with autogenous skin, fascialata and more recently with synthetic materials. The introduction to synthetic mesh in 1950’s started a new era in hernia repair both incase of primary and recurrent hernias. The various repair procedures of inguinal hernia repair fall into two categories: Fascial repair (Bassini, Bassini with Tanner’s slide, McVay, Furguson and Shouldice) and tension free prosthetic (Polypropylene or polyester) repairs and these may be performed by anterior open approach or laparoscopically/endoscopically. 4 Various techniques using synthetic mesh repair are described in the literature. With a theme of reducing the recurrence of inguinal hernia and being convinced by the outstanding result, the method which has drawn our alarming attention is Lichtenstein mesh repair of inguinal hernia by open method.
SURGICAL ANATONY INGUINAL CANAL The inguinal canal contains the spermatic cord or the round ligament of the uterus, and in both sexes the ilio-inguinal nerve. It is oblique and about 4 cm. long, slanting downwards and medially, parallel with, and a little above, the inguinal ligament; it extends from the deep to the superficial inguinal ring 5. Boundaries of the canal: 2
The canal presents anterior and posterior walls, roof and floor, inlet and outlet 6. Anterior wall: It is entirely formed by the skin, superficial fascia and the external oblique aponeurosis, assisted laterally by the internal oblique muscle. Posterior wall: It is formed by the strong conjoint tendon medially and the weak transversalis fascia throughout which separates the canal from the extra-peritoneal tissue and peritoneum. Roof: The roof is formed by the lower edges of the internal oblique and transversus muscles, which arch over from in front of the cord laterally to behind the cord medially, where their conjoined aponeuroses, constituting the conjoint tendon, are inserted into the pubic crest and the pectineal line of the pubic bone 7. Floor: It is formed by the inrolled lower edge of the inguinal ligament, reinforced medially by the lacunar ligament7. Inlet: Inlet is formed by the deep inguinal ring which is an oval gap in the fascia transversalis about 1.25 cm above the midpoint of the inguinal ligament. From the margins of this opening the transversalis fascia is projected along the canal, like a sleeve, the internal spermatic fascia, around the structures that pass through the ring6,7.
\
Relations of deep ring: Above - Arched fibres of the transversus abdominis muscle. In front and laterally - internal oblique muscle. Medially- a) Interior epigastric artery, behind fascia transversalis. It acts as a guide to identify the deep ring. b) Sometimes the inter-foveolar ligament, which entends from the conjoint tendon to the superior ramus of pubis 6. Outlet: The outlet is formed by the superficial inguinal ring, which is an oblique triangular gap in the aponeurosis of external oblique, above and lateral to the pubic crest. From the margin of the ring the external spermatic fascia balloons over the spermatic cord. Measurements of the ring Apex to base - 2.5 cm At the base - 1.25 cm Structures passing through the superficial ring Ilio-inguinal nerve Spermatic cord or round ligament6. Boundaries of the superficial ring : Base: Formed by the pubic crest. 4
Apex: Directed above and laterally, formed by the convergence of the two crura and kept in position by the inter-crural fibres of the external oblique. Medially: By the superior crus which is attached to the symphysis pubis. Laterally: By the inferior crus which is fixed to the pubic tubercle 6.
6
Contents of the inguinal canal: 1. Spermatic cord in males, or round ligament and lymphatics from the uterus in females. 2. The ilio-inguinal nerve does not enter the canal through the deep ring, but by piercing the internal oblique muscle, i.e. it slips into the canal from the side, not from the back. The nerve lies in front of the cord 7. Spermatic cord: The spermatic cord has three coverings and six (groups of) constituents. Coverings of the spermatic cord: 1. Internal spermatic fascia is derived from the transversalis fascia at the deep inguinal ring. 2 Cremaster muscle and cremasteric fascia arises laterally from the inguinal ligament, the internal oblique and transversus abdominis muscles. The fibers spiral down the cord and loop back to become attached to the pubic tubercle. 3. External spermatic fascia, is acquired from the external oblique aponeurosis as the cord passes between the crura of the superficial ring 7, The constituents of the spermatic cord: 1. The ductus deferens, which usually lies in the lower and posterior part of the cord. 2. Arteries, the largest of which is the testicular artery, with the artery to the ductus and the cremasteric artery. 3. Veins - the pampiniform plexus.
4. Lymphatics - essentially those from the testis draining to para-aortic nodes, but including some from the coverings which drain to external iliac nodes. 5. Nerves - Genital branch of the genitofemoral nerve which supplies the cremaster muscle. Sympathetic twigs which accompany the arteries. 6. The processus vaginalis, the obliterated remains of the peritoneal connection with the tunica vaginalis of the testis7. Peculiarities of inguinal canal: 1. In female the canal is narrow; hence chance of inguinal hernia is less. 2. In the newborn the canal is directed almost straight forwards because muscles of the anterior abdominal wall are not properly differentiated 6. Development of the inguinal canal : The inguinal canal is developed from the differentiation of the muscles of the anterior abdominal wall around an inguinal fold of peritoneum, which contains the gubernaculum of testes or ovary during the descent of the respective sex gland. The canal is formed before the descent of the testes 6.
PATHOPHYSIOLOGY
DEFENSIVE MECHANISM OF INGUINAL CANAL (Shutter Mechanism)
1. The inguinal canal is oblique in direction so that the deep and superficial rings are situated at different places. In increased intra-abdominal pressure the posterior wall of the canal is pushed forwards and comes in contact with the anterior wall obliterating the canal like a flap-valve. 2. The construction of the canal is such that opposite the deep ring the anterior wall of the canal is strengthened by the fleshy fibres of the internal oblique muscle, and opposite the superficial ring the posterior wall is strengthened by the conjoint tendon and reflected part of inguinal ligament.
8
3. The arched fibres of the internal oblique and the transversus act as demisphincters in increased intra-abdominal pressure and obliterate the canal by bringing the roof in contact with the floor of the canal. 4. Cremasteric plug-In increased intra-abdominal pressure the cremaster muscle in male contracts and pulls the testes towards the superficial ring. Thus the outlet of the canal is closed like a plug (Ball-valve action). 5. When the abdominal muscle contract, the deep inguinal ring moves upwards and laterally. Thereby the canal is elongated and the lumen becomes more narrow 6. INGUIAL HERNIA Definition: When an abdominal content covered by a sac of peritoneum enters the inguinal canal abnormally, it is known as inguinal hernia. The contents of hernial sac vary from a piece of omentum to small or large gut. The hernia presents two types - Indirect or Oblique and direct 6. Indirect (syn. Oblique) inguinal hernia: This is the most common of all forms of hernia. It is most common in the young, whereas a direct hernia is most common in the old. In the first decade of life inguinal hernia is more common on the right side in the male2. The hernial sac is preformed due to persistence of processus vaginalis and enters the canal through the deep ring. The neck of the hernial sac lies lateral to the inferior epigastric artery 6. This is no doubt associated with the later descent of the right testis and a higher incidence of failure of closure of the processus vaginalis. In adult males, 65 per cent of inguinal hernias are indirect and 55 per cent are right-sided. The hernia is bilateral in 12 per cent of cases2.
Types of oblique hernia: Bubonocele - When the hernia is limited to the inguinal canal. Funicular - The processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia. Complete (syn. Scrotal) - The testis appears to lie within the lower pert of the hernia2.
Direct inguinal hernia: In adult males, 35 percent of inguinal hernias are direct. At presentation, 12 percent of patients will have a contralateral hernia in addition and there is a four-fold increased risk of future development of contralateral hernia if one is not present at the original presentation. A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal. In some cases the defect is small and is represented by a discrete defect in the transversalis fascia, while in others there is a generalised bulge. Direct hernia does not often attain a large size or descend into the scrotum. In contrast to an indirect inguinal hernia, a direct inguinal hernia lies behind the spermatic cord. The sac is often smaller than the hernial mass would indicate, the protruding mass mainly consisting of extraperitoneal fat. As the neck of the sac is wide, direct inguinal hernias do not often strangulate 2.
Composition of a hernia: As a rule, a hernia consists of three parts - the sac, the coverings of the sac and the contents of the sac. The Sac: The sac is a diverticulum of the peritoneum consiting of mouth, neck, body and fundus. The neck is usually well defined, but in some direct inguinal hernias and in many incisional hernias there is no actual neck. The diameter of the neck is important because strangulation of bowel is a likely complication where the neck is narrow, as in femoral and paraumbilical hernias. The body of the Sac: The body of the sac varies greatly in size and is not necessarily occupied. In cases occurring in infancy and childhood the sac is gossamer thin. In long-standing cases the wall of the sac may be comparatively thick. The covering: Coverings are derived from the layers of the abdominal wall through which the sac passes. In long-standing cases they.become atrophied from stretching and so amalgamated that they are indistinguishable from each other 2.
10
Contents: These can be – • omentum = Omentocele (syn. Epiplocele); • Intestine = Enterocele. More commonly small bowel, but may be large intestine or appendix; • A portion of the circumference of the intestine = Richter's hernia; • A portion of the bladder (or a diverticulum) may constitute past of or be the sole contents of a direct inguinal, a sliding inguinal or a femoral hernia; • Ovary with or without the corresponding fallopian tube; • A Meckel's diverticulum = A littres hernia; • Fluid — as part of ascites or as a residuum thereof2.
Classification of hernia: Irrespective of site, a hernia can be classified into five types. 1. Reducible 2. Irreducible 3. Obstructed 4. Strangulated (Complication of irreducible hernias) 5. Inflamed. Reducible hernia: The hernia either reduces itself when the patient lies down, or can be reduced by the patient or the surgeon. Irreducible: Here the contents cannot be returned to the abdomen, but there is no evidence of other complications. It is usually due to adhesions between the sac and its contents or from overcrowding within the sac. Obstructed hernia: This is an irreducible hernia containing intestine which is obstructed from without or within, but there is no interference to the blood supply to the bowel.
Strangulated hernia: A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents ischemic. Gangrene may occur as early as 5-6 hours after the onset of the first symptoms. Inflamed hernia: Can occur from inflammation of the contents of the sac, (e.g. acute appendicitis or salpingitis) or from external causes (e.g. the trophic ulcers which develop in the dependent areas).
AETIOLOGY OF INGUINAL HERNIA Nearly all inguinal hernias in infants, children and young adults are indirect inguinal hernias. Although these 'congenital' hernias most often present during the 1st year of life, the first clinical evidence of hernia may not appear until middle or old age, when increased intra-abdominal pressure and dilation of the internal inguinal ring allow abdominal contents to enter the previously empty peritoneal, diverticulum. An untreated indirect hernia will inevitably dilate the internal ring and displace or attenuate the inguinal floor. The peritoneum may protrude on either side of the inferior epigastric vessels to give a combined direct and indirect hernia, called a pantaloon hernia. In contrast, direct inguinal hernias are acquired as the result of a developed weakness of the transversalis fascia in Hesselbach's area. There is some evidence that direct inguinal hernias may be related to hereditary or acquired defects in collagen synthesis or turn over. Any condition that chronically increases intra-abdominal pressure may contribute to the appearance and progression of a hernia.
Marked obesity Abdominal strain from heavy exercise or lifting Cough Constipation with straining at stool 12
Prostatism with straining on micturition Cirrhosis with ascites Pregnancy Chronic ambulatory peritoneal dialysis Chronically enlarged pelvic organs Pelvic tumour Los of tissue turgor in Hesselbach's area, associated with a weakening of The transversalis fascia, occurs with advancing age and in chronic Debilitating disease1. SUTURES AND IMPLAMENTS IN SURGERY Definition: A suture is a strand of material used to tie (Ligate) blood vessels and / or to sew (approximate) tissues together8.
Ideal properties of sutures : • Suture material should have and maintain adequate tensile strength until its purpose is served. It should not shrink in the tissues. • It should stimulate minimal tissue reaction and should not create a situation favourable to bacterial growth. • It should be non-electrolytic, non-capillary, non-allergenic, non-carcinogenic (and non-thrombogenic in vascular surgery). • The material should handle comfortably and naturally by the surgeon and a knot should hold securely without fraying or cutting. • It should be inexpensive and easily sterilized. The histological reactions of all sutures are essentially the same for the first 7 days as these changes are secondary to trauma and passage of the needle and suture 8.
TYPES OF SUTURE MATERIALS9 A. Absorbable Catgut,
collagen
Non absorbable Homopolymer
of Polyester, polyamide Polypropylene,
glycolide Copolymers of glycolide and polyethylene Steel, silk Cotton, linen lactide
Homopolymer
of
polydioxanone Artificial B. Biological
Polyester, polyamide Polypropylene,
Catgut, collagen Silk,
polyglycolide
linen, cotton
polydioxanone, Steel
Polylactide,
Multifilament C. Monofilament
Polyester, polyamide Polyglycolide
Polyamide,
polypropylene
Polylactide,
Polyethylene,
polydioxanone
steel
silk,
cotton
Catgut, steel Twisted D. Braided
Cotton, linen
Polyester,
polyamide
Polyglycolide, polylactide, silk Uncoated E. Coated Polyester,
Polyamide Polypropylene. polyglycolide Polylactide,
Cotton, linen Polyethylene, catgut, collagen, steel
CHARACTERISTICS OF SUTURE MATERIALS
14
Linen,
Material
Characteristics
Chromic catgut
Rapidly absorbed Low tensile strength
Polyglactin910 (Vicryl)
Slowly reabsorbed
Polyglycolide (Dexon) Braided silk
Slowly reabsorbed Non-absorbable
Braided nylon (Nurolon)
Knots well Non-absorbable
Monofilament nylon
Non-absorbable High tensile strength
Monofilament
polypropylene
(Prolene)
Recoil memory Non-absorbable High tensile strength Recoil memory
Monofilament
polydioxanone
sulfate (PDS)
High
tensile
strength
Very slowly reabsorbed
REINFORCING MATERIALS FOR HERNIA REPAIR Biological (autograft): 1. Fascia lata Free Pedicle 2. External oblique aponeurosis (EOA). Synthetic (plastic): 1. Marlex- mesh (high-density polypropylene) 2. Mersilene (Dacron polyester) 3. Nylon (polyamide) 4. Others – a. Teflon (polytetrafluroethylene) b. Ivalon sponge (formalized polyvinyl).
Of the materials available today, knitted polypropylene mesh is the most popular, followed
by polyamide
and
the
new,
expanded polytetrafluroethylene. They
are nontoxic, pliable, strong, durable and resistant to fatigue and aging. They can be easily cut to any shape and size. They are practically indestructible in human tissues and will last and serve their purpose for the rest of the patient's life. Fibro vascular tissue grows through the pores and invades the mesh, which is eventually incorporated into the body in a strong and pliable collagen sheet.
THE VERSATILITY OF POLYPROPYLENE 1. More Toughness and Better Elongation Properties: Major advantage of polypropylene mesh is its impact strength. It is non-brittle and abrasion resistant due to its inherent elongation properties, which reduces cracking and damage. In addition, polypropylene has better bonding in the base coat due to higher surface area. 2. 100 per cent Alkali Resistant: Testing has proven that polypropylene mesh maintain 100 per cent of its original reinforcing strength. 3. Non-Hazardous and Worker Friendly: Polypropylene is non-hazardous which allows the installer to work all day without experiencing any irritations. 4. Flexibility: Due to the fact that polypropylene mesh is flexible. It enjoys numerous uses in the shapes industry as well as flatwork.
ADVANTAGES: Polypropylene mesh was chosen because it is easy to handle and is made of an inert, single-stranded, flexible material that can be sterilized by autoclaving. It can be cut with scissors, and due to its flexibility, it can be easily adapted to the receptor area. It does not suffer an/ fragmentation, is highly resistant to traction. These characteristics made it a first-choice material for substituting lost tissues. When used in critical conditions, good results have been reported. In patients who suffered great traumas with loss of substance and where wound closure was not possible, even
16
with flap rotation, the polypropylene mesh was used to close the wound successfully, and 20 days later there was granulation tissue covering it.
The material tested is widely accepted in surgical specialties, mainly in general surgery, where it has been used for the closure of abdominal wounds with loss of substance. Since the polypropylene mesh presents low toxicity to the tissues, it does not maintain an acute inflammatory process.
Fig: Polypropylene mesh
DISADVANTAGES: High-density polypropylene (Marlex) mesh used for hernia repairs may add to perivasal inflammation and increase the likelihood of vasal obstruction, which causes male infertility in more than 1 per cent cases 12. It is often time consuming and require prolonged anaesthesia. BIOCOMPATIBILITY OF POLYPROPYLENE MESH:
Formation of granulation tissue covering the mesh was reported when part of the abdomen of a soldier was reconstructed with a polypropylene mesh. There was decrease in inflammation from the 7th to 30th postoperative day. In the evaluation of the histological paraffin section on 7th postoperative day, few neutrophils and eosinophils were observed surrounding the implanted material. The absence of leukocyte polymorphonuclear infiltrate during this period is due to the low toxicity the material. Acute inflammation is a stereotype response to all forms of aggression, whatever the injurious agent may be. Plasma cells are hardly seen in normal connective tissue, but they appear in large numbers in areas of chronic inflammation.
REVIEW OF LITERATURE R.G. Holzheimer studied open mesh repair of primary inguinal hernia on 300 patients. Of them mean age was 51 years (19-86 years), 218 men (mean age 50) and 82 women (mean age 52). There were 170 direct, 28 indirect and 157 direct and indirect hernias (n = 355). All patients had a defect of The posterior floor (Nyhus Illa and b). In 55 patients they treated a bilateral hernia. There was no intra-operative complication. One patient (0.3%) complained from minor postoperative nausea and vomiting (PONV). One male patient (smoker) (0.3%) developed an inflammatory reaction in the groin incision; in five patients subcutaneous inflammatory tissue granuloma or seroma were treated surgically. There was neither a case of deep venous thrombosis (DVT), nor pulmonary embolus (PE), nor significant surgical site infection. The mean follow up of the patients was 13 months (range 1-30 months); 98% of the patients were included in the follow-up. There were four recurrences (1.1%) in 355 hernia repairs. There was no case of chronic pain related to the hernia repair nor a mesh-related complication. Leigh Neumayer al studied the Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia at 14 Veterans Affairs (VA) medical centers. The primary outcome was recurrence of hernias at two years. Secondary outcomes included complications and patient-centered outcomes. Of the 2164 patients who were randomly assigned to one of the two procedures, 1983 underwent an operation; two-year follow-up was 18
completed in 1696 (85.5 percent). Recurrences were more common in the laparoscopic group (87 of 862 patients [10.1 percent]) than in the open group (41 of 834 patients [4.9 percent]; odds ratio, 2.2; 95 percent confidence interval, 1.5 to 3.2). The rate of complications was higher in the laparoscopic surgery group than in the open surgery group (39.0 percent vs. 33.4 percent; adjusted odds ratio, 1.3; 95 percent confidence interval, 1.1 to 1.6). The laparoscopic surgery group had less pain initially than the open surgery group on the day of surgery (difference in mean score on a visual analogue scale, 10.2 mm; 95 percent confidence interval, 4.8 to 15.6) and at two weeks (6.1 mm; 95 percent confidence interval, 1.7 to 10.5) and returned to normal activities one day earlier (adjusted hazard ratio for a shorter time to return to normal activities, 1.2; 95 percent confidence interval, 1.1 to 1.3). In prespecified analyses, there was a significant interaction between the surgical approach (open or laparoscopic) and the type of hernia (primary or recurrent) (P=0.012). Recurrence was significantly more common after laparoscopic repair than after open repair of primary hernias (10.1 percent vs. 4.0 percent), but rates of recurrence after repair of recurrent hernias were similar in the two groups (10.0 percent and 14.1 percent, respectively). Samir et al15 studied Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein only mesh repair for inguinal hernia repair. They reviewed six hundred twenty-two charts during the 2 time periods (PHS mesh = 321, LMR = 302). The median follow-up for the study was 17 months. There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Overall, there was a trend toward decreased complications in the PHS mesh group compared with the LMR group (PHS mesh = 17%, LMR = 23%, P = 0.07), with a significant difference in the hematoma/seroma rates (PHS mesh = 6.9%, LMR = 12.6%, P = 0.015). Finally, there was a significant decrease in the recurrence rate for the PHS mesh group when compared with the LMR group (PHS mesh = 0.6%, LMR = 2.7%, P = .04). Danielsson al16 studied the repair of primary inguinal hernia on 200men in training in a district hospital in Sweden. 178 patients were available for evaluation (n=89 in each group). There were no significant differences in duration of operation, pain score or incidence of postoperative complications. Patients in the mesh group took significantly less sick leave (mean 18.2 days) than those in the shouldice group (23.8
days, P<0.05). The number of recurrences differed significantly between the groups with 9 in the shouldice group and none in the mesh group (P0.01). Koukouro al17 studied prospective randomized trial of polypropylene mesh compared with nylon darn in inguinal hernia repair. In this study One hundred men underwent 105 repairs by consultant surgeons and registrars; there were 54 mesh and 51 nylon repairs. Demographics in both groups were similar at the start of the trial, as were the types of hernia. The pain scores at 24, 48 and 72 hours were similar, as was the duration of analgesia requirement. There was no difference in early or late complications. Return to normal activity in each group was also similar, with a mean time of 5 weeks. The recurrence rate in both groups was comparable; 4 percent after mesh repair and 4 percent after darn repair at 1-year review.
PERSONAL SERIES AIMS AND OBJECTIVES 1. To asses the efficacy of the method in preventing hernia recurrence. 2. To establish the tradition of a tension free repair. 3. To establish the method for early return of the patient to work, office and manual. 4. To asses the method under local or regional block for day cares surgery. 5. To proceed the hernia reparative process with the demand of time. MATERIALS AND METHOD: The study has been carried out in the Department of Surgery unit-iv and unit-ii, Sylhet M.A.G. Osmani Medical College & Hospital. The study period was from August 2005 to February 2007. Criteria of patient selection were all direct inguinal hernia, indirect inguinal hernia and recurrent inguinal hernia, admitted in the department of surgery unit IV and II during this period. Number of cases were 60 and all were repaired by Polypropylene mesh. All of them were male, age was between 25-75 years, all of them were with average body built and in good health.
20
Criteria of exclusion were female sex, young age (under 16 yrs) and complicated hernias (obstructed, strangulated, gangrenous). Thorough clinical assessment and investigations were done. All operation were done under regional anesthesia or local anesthesia and average operation time was taken into account. Intravenous cephradin was given at the induction of anesthesia up to first 24 hours and oral form of cephradin was given for next 48 hours. During dissection the ilio-inguinal, iliohypogastric and
genital
branch
of
genitofemoral
nerves
were
preserved.
Polypropylene mesh of 15cmĂ&#x2014;7.5cm size was used in all cases. Mesh was placed over the floor of the inguinal canal and spermatic cord was passed through a slit on the lateral end of the mesh at deep inguinal ring. Mesh was fixed with 3/0 prolene. The medial end of the mesh was sutured to the aponeurotic tissue over the pubic bone, overlapping the bone by 1.5 to 2 cm. This was a crucial step in the repair, since failure to overlap the bone could result in recurrence.
Fig: Shape of a prolenemesh before implanted
Fig: View of operation site after implantation of prolene mesh Adequate postoperative analgesia was given and encouraged early mobilization of all patients. Most of them were predicted to discharge on 2nd and 3rd postoperative day and some of them were discharge as day care surgery with the advice to come after 1 week and 1 month for short-term evaluation. At the 2nd visit we advised to come every 3 months to evaluate the long term result. All study cases are analyzed statistically after entering the cases in the flow sheet and are also compared with other studies taken from different literatures. The conclusion is likely to be drawn regarding the mesh repair of inguinal hernia. RESULTS Information recorded from 60 cases with inguinal hernia were analyzed manually and presented here in tabulated form. Table-1: Age distribution of patients
22
Age 21-30 31-40 41-50 51-60 61-70 71-80
Number of patients 05 14 07 11 19 04
percentage 8.33 23.33 11.67 18.33 31.67 6.67
Between August, 2005 and February, 2007 a total number of 60 hernia repair were performed. The age of the patients ranges from 25 to 75 years and maximum number was between 61 to 70 years followed by 31 to 40 years.
Age distribution bar
Percentage
35 30 25 20 15 10 5 0 21-30 31-40 41-50 51-60 61-70 71-80 Age range
Table-2: Types of inguinal hernia (direct/indirect) inguinal Number of patients 26 34
Percentage 43 57
Bardiagram: Types of Hernia
60 Percentage
Types of hernia Indirect Direct
50 57%
40 30
43%
20 10 0
Indirect
Direct
Types of hernia
Pie chart: Types of hernia
Indirect 43%
Direct 57%
Table-3: Types of inguinal hernia (Primary/ Recurrent) Types of hernia Primary Recurrent
inguinal Number of patients
Percentage
48 12
80 20
Bar diagram: Types of hernia(Primary/Recurrent)
Percentage
80 60
80%
40 20
20%
Pie chart :Types of Primary Recurrent hernia(Primary/recurrent) 0
Types of hernia
Recurrent 20%
24
Primary 80%
Table-4: Types of inguinal hernia (Right sided/ Left sided/ Bilateral) inguinal Number of patients 38 12 10
Percentage 63 20 17
Bar diagram:Types of hernia (Left sided/Right sided/Bilateral)
Percentage
Types of hernia Right sided Left sided Bilateral
70 60 50 40 30 20 10 0
63%
20% Right sided
Left sided
17% Bilateral
Pie chart:Types of hernia (Left sided/ Types of hernia Right sided/ Bilateral) Bilateral 17% Left sided 20%
Right sided 63%
Table-5: Duration of operation Duration(Minute) 40-50 50-60
Number of patient 26 34
Percentage 43 57
Percentage
Bardiagram: Duration of operation
60 50 40 30 20 10 0
57% 43%
40-50
50-60
Duration of operation(min.)
26
Table-6: Complication of mesh repair of inguinal hernia
Complication
Number of patient
Percentage
Wound infection
02
3.33
Scrotal haematoma
01
1.67
Groin echymosis
03
5.00
Bleeding from wound
00
0.00
Early groin pain
03
5.00
Late groin pain
01
1.67
Hernia recurrence
00
0.00
60 patients were available for evaluation. Postoperative complications were observed regarding wound infection, scrotal haematoma, groin echymosis, bleeding from wound, early groin pain, late groin pain and hernia recurrence. Table-7: Duration of hospital stay
Duration (day)
Number of patient
Percentage
As day care
10
16.7
One day
08
13.3
Two day
27
45.0
Three day
13
21.7
Four day
00
0.0
Five day
00
0.0
Six day
00
0.0
Seven day
00
0.0
Eight day
01
1.7
Nine day
00
0.0
Ten day
01
1.7
Duration of hospital stay
As day care
One days
Two days
Three days
Four days
Five days
Six days
Seven days
Eight days
Nine days
Ten days DISCUSSION
28
Numerous studies have detailed the historical basis for the use of mesh. Billroth prophetically dreamed of artificial materials to replace fascia. Numerous materials were tried, but all of them fell in victim to the triple headed monster of infection, rejection and recurrence. However, after Franscis Usher of Germany introduced polypropylene mesh in 1962, a new era began during which this prosthesis, in uncontaminated groin hernias, began to overcome the current objections of mesh 20. Over the past decades true tension free mesh repair of primary inguinal hernias without suture closure of hernia margins has been examined and clarified and technique has been perfected, mainly by Lichtenstein, who began to use this tension free mesh repairing technique in 1984 and first published his results in 1986 21. Inguinal hernia is a frequent presentation in different level of health care centers in Bangladesh and abroad. Patients are admitted into inpatient department after attending outpatient department with relevant complaints, also they get entrance in inpatient department through emergency department while attending with emergency crisis and complications. Treatment strategy is the correction of cause with repair of hernia in routine cases and emergency operation is done in patients with complications like obstruction and strangulation. This study was done in a small percentage of patients who had undergone operation in the inpatient department of surgery unit II and IV at Sylhet M A G Osmani Medical College and Hospital, Sylhet. Inguinal hernia is most common in elderly patients. The present study includes age range from 25 to 75 years. The highest number of patients are seen in the seventh (32.67%) and fourth (23.33%) decades. Similar age incidence was shown by gianetta E, Cuneo S, Vitale B, Cemerini G, Marini P, Stella M 22 with a mean age of 65 years (range 30-89) and Millikan KW, cummings B, Doolas A showed mean age of 47 years (range 15-94). In our series most of the patients have direct inguinal hernia (57%). In most of the studies in western world, maximum patients were operated on under local anesthesia as day case surgery. In our series 10 cases were done under local anesthesia and day case basis. Duration of operation in this study was 40-50 minutes for 26 patients (43%) and 5060 minutes for 34 patients (57%) which is insignificant and comparable with the other studies.
In this study complications of surgery by Lichtenstein method include wound infection (3.33%), scrotal haematoma (1.67%), groin echymosis (5%), bleeding from wound (0%), early groin pain (5%), late groin pain (1.67%) and hernia recurrence (0%), the incidence of complications in our series is comparable to those of other westen series13,15.
CONCLUSION In the present study, an attempt is made to asses the reduction of inguinal hernia recurrence by Lichtenstein method. The study is observational regarding different variables related to mesh repair. The outcome of the study is judged by keeping a close eye over contemporary World Series of open tension free repair of inguinal hernia. The study may suggest Lichtenstein method as a time demanding method of choice for inguinal hernia repair. In our study of 60 patients who had been operated in surgery unit-II and IV, Sylhet M A G Osmani Medical College Hospital from August, 2005 to February, 2007, no recurrence was observed during follow up ranges from 12 to 30 months which can be comparable to any acceptable hernia repair series by Lichtenstein method. The limitation of mean cost can be minimized by government supply of mesh in a tertiary hospital. A multicentric study with large population is recommended to establish Lichtenstein method as gold standard to reduce the recurrence.
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