Role of Prolene Mesh in the repair of Recurrent Congenital Inguinal Hernia: a Pilot Study

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1 Annals of Pediatric Surgery, Vol 5, No 1, January, 2009, PP Original Article Role of Prolene Mesh in the repair of Recurrent Congenital Inguinal Hernia: a Pilot Study Ehab El-Shafei Pediatric Surgery Department, Ain-Shams University, Cairo, Egypt Background/purpose: Most recurrent congenital hernias are indirect and probably result from tearing of a friable sac, a slipped ligature at the neck of the sac, or failure to ligate the sac high enough at the internal ring. Dissection in recurrent cases is usually difficult and technically demanding. Herniotomy might be enough, but repair is usually needed especially in direct cases. This article describes a new technique to simplify the repair. The aim of this study was to evaluate the feasibility and outcome of using Prolene mesh in the repair of some difficult cases of recurrent inguinal hernia in infants; when the recurrent hernia is incarcerated, early recurrence (within 1 month of surgery), and /or evident posterior wall weakness. Patients and methods: This prospective study was carried out at the pediatric surgery department, Ain Shams University Hospital starting from January 2007 to December A tiny piece of Prolene mesh (2-3cm X 1-2 cm) was used to perform the repair of difficult cases of recurrent inguinal hernia. We analyzed data of infants, who underwent repair using this technique, including: patients data, operative details, as well as early and late postoperative complications. Results: Twenty one infants underwent repair of recurrent inguinal hernia during the period of the study using Prolene mesh. Patients ages ranged from 1 month to 4 years (mean: 11.2 months). Male to female ratio was 19:2. Six cases were incarcerated at time of presentation (28.5%). Weak posterior wall (direct hernia) was evident in 11 cases (52.3%). Eight cases (30%) had their recurrence earlier than 1 month. Follow up period ranged from 2 to 24 months (mean: 16.4 months). No major complications or recurrence were recorded during the period of follow up. Conclusion: Repair of difficult and incarcerated recurrent inguinal hernia using Prolene mesh is simple, easy and safe. Index Word: Congenital inguinal hernia, Recurrence, Prolene mesh. T INTRODUCTION he reported recurrence rate for uncomplicated hernia repair is ranging from 0% to 0.8%. This rate rises to 15% for premature infants and up to 20% after operation for incarcerated hernias. 1 Most recurrent congenital hernias are indirect and probably result from tearing of a friable sac, a slipped ligature at the neck of the sac, or failure to ligate the sac high at the internal ring. 2 There are several risk factors for recurrence, the most important is incarceration 3. A direct hernia occurring after an indirect hernia is either a concomitant hernia that was not recognized at the original operation, or a new pathology caused by damage of the posterior wall of the inguinal canal during the initial dissection 1,3. Herniotomy might be enough, but repair especially in direct cases is usually needed. 4-6 Dissection in recurrent cases is a real challenge, and carries a high risk of damaging adherent important structures.7,8 This article describes a new technique to simplify the repair. The aim of this study is to evaluate the feasibility and outcome of using Prolene mesh in the repair of recurrent inguinal hernia in infants in some difficult situations including incarceration; early recurrence Correspondence to: correspondence to: Ehab Abdelaziz El-Shafei. MD. FRCSI, 3 elmattbbaa buildings, Abbassia, 11331, Cairo Egypt, Phone: , Fax: , ia_shaf@hotmail.com

2 (within 1 month of surgery); and /or evident posterior wall weakness. PATIENTS AND METHODS This prospective study was carried out at the pediatric surgery department, Ain Shams University Hospital during the period from January 2007 to December A tiny piece of Prolene mesh (2-3X1-2 cm) was used to perform the repair of difficult cases with recurrent inguinal hernia. (Fig 1,2) Inclusion criteria: 1- Incarcerated cases. 2- Early recurrence (less than 1 month of surgery). 3- Evident posterior wall weakness. The study was approved by the ethical committee of the Department, and an informed written consent was obtained from the parents in each case. Surgical technique: The approach is planned through the scar of previous surgery except if it was malpositioned, when a new classic incision is made. (Fig 3) External oblique aponeurosis overlying the inguinal canal and external ring should be identified. The cord is exposed after opening the external oblique aponeurosis and the contents are reduced when viable. It is very important to identify and securely dissect the vas and vessels, and retract them laterally, away from the field. The sac is transfixed if possible, but if not, we just close its remnants at the internal ring level (Fig 4). A rectangular tailored Prolene mesh is sutured with either stitches at the junction between its upper 1/3 and lower 2/3, in order to plug in the internal ring. The rest of the mesh is allowed to lie down on the posterior wall, and to be fixed to the inguinal ligament and the under surface of the conjoint tendon. (Fig 5-8) The testis is gently pulled down in the scrotum, and the external oblique is closed over the rearranged cord structures. We analyzed data of infants, who underwent repair using this technique, including: patients data, operative details, as well as early and late postoperative complications Fig 1. A four- year old boy with huge recurrent inguinal hernia, and evident weakness of the posterior inguinal wall Fig 2. A three- month old boy with early recurrent hernia at the same night of surgery. Fig 3: Recurrent hernia with a malpositioned scar (arrows). Fig 4. Marked friable tissues arenoted in early recurrence. Annals of Pediatric Surgery 12

3 Fig 5: The rectangular tailored Prolene mesh is sutured with the transfixed sac, in order to plug it in the internal ring. Fig 6: The mesh is sutured to the remnants of the sac. Fig 7: Fixation of the mesh to the under surface of the conjoint tendon. Fig 8: Fixation of the mesh to inguinal ligament. Fig 9: Recurrent hernia in a 4 month old girl with irreducible ovary. 13 Vol 5, No 1, January 2009

4 RESULTS Twenty one infants underwent repair of recurrent inguinal hernia in our department, during the period of the study, using Prolene mesh. All cases, except one were referred from other hospitals. Seven cases (33.3%) were primarily performed by qualified pediatric surgeons. Patients age ranged from 1 month to 4 years (mean: 11.2 months). Male to female ratio was 19:2 (90.4%). Six cases were incarcerated at time of presentation (28.5%). (Fig 9) Weak posterior wall (direct hernia) was evident in 11 cases (52.3%). Eight cases (30%) had their recurrence earlier than 1 month, ranging from day 1 to 28 (mean: 10.1 days). One case required resection of nonviable bowel loop; this was performed through a separate abdominal incision. Follow up period ranged from 2 to 24 months (mean: 16.4 months). No major complications or recurrence were recorded during the period of follow up. Uncomplicated seroma developed in 2 cases (9.5%), and were completely resolved by simple drainage. Edema of the cord developed in 33.3% of cases, while residual hydrocele developed in 23.8 % of cases DISCUSSION As a tertiary referral center, we have a relatively high flow of recurrent congenital inguinal hernia in comparison to other studies 3. Malpractice and lack of specialization in rural areas leads to increased incidence of iatrogenic damage to the posterior wall and recurrence. This explains the high incidence of recurrence in the form of direct hernia (52.3%) in our series, and in others. 3,9 There is no specific technique for repair of recurrent hernia described in the literature, but all of which require identifying the edges of the sac as well as different anatomical landmarks. 1 This is risky and technically demanding, especially in cases with our chosen inclusion criteria, in which tissue edema and friability is more evident and conventional repair is unfeasible. Although laparoscopic repair in primary cases carries high risk of recurrence 10 and is abandoned by some authors, especially in males 1 yet, Chang and others. 8,11 advise laparoscopic repair in recurrent cases, in order to avoid the previous operative site. In our study, we accomplished the repair through inguinal approach, using a tiny piece of mesh for the repair. We were aiming at avoiding excessive dissection of the cord structures and converting it into a relatively simple procedure. Although mesh repair is now the standard technique in repair of inguinal hernia in adults. 12,13 yet, to our knowledge, it has not been reported in pediatric age group. Before attempting to use the mesh, we reviewed the literature reporting experience in adults, and we took them as reference to our technique. 14,15 Mesh migration is a rare, but reported complication in adults. 16,17 We think that migration risk will be increased in the growing infant. So, we preferred to fix the mesh, at least to two points until fibrosis would be fully established. Our tiny piece of mesh played both roles of a plug, and a support to the posterior wall. Decreasing tension was not our main goal, we just use it to initiate tissues reaction and induce fibrosis. If resection of nonviable bowel loop and anastomosis is needed, as the case in one patient in this seies, we prefer using a separate incision, as advised by Glick and Boulanger 1, avoiding any risk of partial contamination of the wound. The incidence of cord edema and residual hydrocele was not increased in our study (33.3%, 23.8% respectively), indicating that dissection and lymphatic impairment were minimal. This was reported by Glassberg and colleagues 18, determining the role of lymphatic preservation in decreasing the incidence of hydrocele after varicocelectomy in adolescents. Based on our early experience, we found that mesh insertion was simple and much less technically demanding than conventional techniques. The same finding was reported in adults 12, and that represented a major advantage. CONCLUSION Repair of difficult and incarcerated recurrent inguinal hernia in children using Prolene mesh is simple, easy and safe. No postoperative recurrence or major complications was noted during the follow up period. REFERENCES 1. Glick PL, Boulanger SC. Inguinal hernias and hydroceles. In Grosfeld JL, O Neill JA, Fonkalsrud EW and Coran AG (ed) Pediatric surgery, sixth edition, Mosby, 2006, pp Annals of Pediatric Surgery 14

5 2. Fette AM, Höllwarth ME. Special aspects of neonatal inguinal hernia and herniotomy. Hernia 5:92-96, SteianuG, Tretner Kh, Feeken G, et al. Recurrent inguinal hernia in infants and children. World J Surg 19:303-6, Banieghal B. A simplified technique for giant inguinal hernia repair in infants. Pediatr Surg Int 24:737-9, Yokomori K, Ohkura M, Kitano Y, et al. Modified Marcy repair of large direct inguinal hernis in infants and children. J Pediatr Surg 30:97-100, Osifo OD, Irowa OO. Indirect inguinal hernia in Nigerian older children and young adults: is herniorrhaphy necessary? Hernia 12:635-9, Esposito C, Montupet P. Laparoscopic treatment of recurrent inguinal hernia in children. Pediatr Surg Int 14:182-4, Chang KL. Laparoscopic repair of recurrent childhood inguinal hernias after open herniotomy. Hernia 11:37-40, Wright JE. recurrent inguinal hernia in infancy and childhood. Pediatr Surg Int 9:164-6, Schier F. Laparoscopic surgery of inguinal hernias in childreninitial experience. J periatr Surg 35: , Perlstein J, Du bois J. The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 35: , Reuben B, Neumaver L. Surgical management of inguinal hernia. Adv Surg 40: , Elsebae MM, Nasr M, Said M. Tension free repair versus Bassini technique for strangulated inguinal hernia: A randomized controlled study. Int J Surg 6:302-5, Lichtestein IL. The tension free hernioplasty. A J Surgery 157: , Gilbert AI. Sutureless repair of inguinal hernia. A J Surgery 163: , Stout CL, Foret A Christie DB, et al. Small bowel volvulus caused by migrating mesh plug. Am Surg 73:796-7, Jeans S, Williams GL, Stephenson BM. Migration after open mesh plug inguinal hernioplasty: a review of literature. Am Surg 73:207-9, Glassberg KI, Poon SA, Gjertson CK, el al. Laparoscopic lymphatic spairing vericocelectomy in adolescents. J Urol 180:326-30, Vol 5, No 1, January 2009