Kugel hernia repair: open “mini-invasive” technique. Personal experience on 620 patients

Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches

PURPOSE

International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs.

METHODS

We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use.

RESULTS

Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year.

CONCLUSIONS

This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.

Comparison of minimally invasive preperitoneal (MIP) single-layer mesh repair and total extraperitoneal (TEP) repair for inguinal hernia in terms of postoperative chronic pain: a prospective randomized trial

Objectives

The aim of this study was to compare minimally invasive preperitoneal (MIP) single layer mesh repair with total extraperitoneal (TEP) inguinal hernia repair in terms of complications, recurrence, and chronic pain.

Material and Methods

A total of 240 patients who underwent elective, primary, unilateral inguinal hernia operation between April 2011 and September 2012 were divided into two randomized groups. The first group underwent MIP repair and the second group underwent TEP repair. Visual Analogue Scale (VAS) and Sheffield Scale (SS) were used to evaluate chronic pain.

Results

In all, 225 (95%) of the patients completed follow-up and were included in analyses. A significant difference was not detected between groups in terms of demographics, operative time, or intraoperative, early, or late complications. Length of time before return to work was significantly shorter in the TEP group (p <0.001). Recurrence was seen in 1 (0.88%) patient in the MIP group and 1 (0.89%) patient in the TEP group (p= 0.993). Evaluation of chronic pain revealed no significant difference between groups in VAS and SS values at postoperative 6th, 12th, and 24th months.

Conclusion

In conclusion, it was observed that MIP repair for inguinal hernia has all of the advantages of preperitoneal repair and eliminates disadvantages of TEP repair. MIP technique is as safe as TEP repair and has similar qualities in terms of chronic pain, even though it is an open intervention.

Open preperitoneal groin hernia repair with mesh: A qualitative systematic review

BACKGROUND

For the repair of inguinal hernias, several surgical methods have been presented where the purpose is to place a mesh in the preperitoneal plane through an open access. The aim of this systematic review was to describe preperitoneal repairs with emphasis on the technique.

DATA SOURCES

A systematic review was conducted and reported according to the PRISMA statement. PubMed, Cochrane library and Embase were searched systematically. Studies were included if they provided clinical data with more than 30 days follow up following repair of an inguinal hernia with an open preperitoneal mesh technique.

CONCLUSIONS

A total of 67 articles were included, describing nine different methods: Kugel, TREPP, TIPP, Onstep, Horton/Florence, Nyhus, Ugahary, Read, and Stoppa. In general, results regarding pain, recurrences and complications seem promising. It was not possible to conduct a meta-analysis. Open preperitoneal techniques with placement of a mesh through an open approach seem promising compared with the standard anterior techniques. This systematic review provides an overview of these techniques together with a description of surgical methods and clinical outcomes.

Initial experience with application of single layer modified Kugel mesh for inguinal hernia repair: Case series of 72 consecutive patients

OBJECTIVE

This is an initial review of the safety and efficacy of anterior preperitoneal modified Kugel (MK) mesh herniorrhaphy application without using optional onlay mesh.

METHODS

We retrospectively reviewed patients who underwent herniorrhaphy by a single surgeon from July 1^st, 2009 to December 31^st, 2010. During these 18 months, a total of 72 patients underwent single-layer MK mesh herniorrhaphy. Anterior preperitoneal approach was used to place the mesh. If the patient's inguinal hernia defect did not exceed the memory ring of MK mesh, the onlay mesh was omitted. Postoperative results (wound infection, recurrence, and chronic pain/discomfort) were recorded and analyzed.

RESULTS

A total of 72 patients underwent anterior preperitoneal single layer MK mesh herniorrhaphy. One patient had recurrent hernia after 1 year and was treated with a laparoscopic transabdominal preperitoneal operation. The most common postoperative complaint was mild soreness which was self-resolving after 1 month. Mean total operative time (skin to skin) was 73 minutes. The average hospital stay was 2 days. Most of the postoperative complications including soreness (14%), pain for > 3 months (1.4%), and scrotal hematoma (1.4%) were self-resolving. One patient experienced wound infection, which was treated with oral antibiotics. One patient had recurrence 1 year after the operation.

CONCLUSION

The postoperative complication and recurrence rates of single-layer MK mesh herniorrhaphy was comparable with previously reported tension-free repair. Single-layer application is safe and feasible. A longer follow-up period and larger study group with a control group are needed to verify our method.

Kugel patch method prevents the development of a femoral hernia after inguinal herniorrhaphy

PURPOSE

A femoral hernia is a relatively rare condition, and no standard surgical methods have so far been established. In this study, we investigated the development of a femoral hernia after inguinal herniorrhaphy.

METHODS

A total of 1,969 patients who underwent surgery for an inguinal hernia from April 1992 to March 2012 were enrolled in this study. The patients were composed of 1,934 (98.2 %) inguinal hernia and 35 (1.8 %) femoral hernia patients. Of these, we retrospectively studied the femoral hernia cases with reference to the use of inguinal herniorrhaphy.

RESULTS

Of all 35 femoral hernia cases, six cases (17.1 %) were femoral type recurrences after inguinal herniorrhaphy performed by the conventional or mesh plug methods. The surgical methods used for the 35 cases were mesh plug repair in 15 cases (42.9 %), the Kugel patch method in seven (20.0 %) and conventional repair in 13 patients (37.2 %). Inguinal type recurrences developed in three cases (8.6 %) that were re-repaired by mesh plug repair or sac resection. There were no femoral or inguinal type recurrences after Kugel patch repair for a femoral hernia.

CONCLUSIONS

The results of this study suggested the importance of repairing all hernia orifices when repairing a groin hernia. The Kugel patch repair method is available for all inguinal region hernias by the same approach, and it seems to be useful for preventing the development of recurrence after surgery.

Colovesical fistula following an open preperitoneal "Kugel" mesh repair of an inguinal hernia

Erosion of the "Kugel" mesh into intraperitoneal organs has not been previously reported in the medical literature. We report such an occurrence in a 54-year-old male, 4 years following a "Kugel" preperitoneal repair of a left-sided inguinal hernia. The patient presented with septicaemia, pneumaturia and left iliac fossa pain. His computed tomography (CT) scan indicated the presence of gas in the bladder and a thickened loop of sigmoid colon attached to the region of the dome of the bladder. Colonoscopy showed some scattered diverticula in the sigmoid colon but no tumour. On surgical exploration, the "Kugel" mesh was found to erode the sigmoid colon and the bladder wall, leading to a colovesical fistula. An anterior resection of the rectum with removal of the mesh with closure of the bladder wall defect was performed.

Chronic pain after Kugel inguinal hernia repair

BACKGROUND

The incidence of chronic pain after Kugel herniorrhaphy is not well documented, since it was not used as a primary outcome measure in studies reporting on the Kugel technique. The aim of the present study was to report on the incidence and severity of chronic pain 1 year after Kugel herniorrhaphy and to identify the risk factors associated with the development of chronic pain.

METHODS

The study population comprised all patients in our teaching hospital who underwent a Kugel inguinal hernia repair between January 2002 and June 2005. Postoperative complications, analgesia consumption and postoperative functional impairment were recorded during an outpatient clinic after 4-6 weeks. Chronic pain and cutaneous sensory changes were followed-up by means of a telephone questionnaire 1 year after surgery.

RESULTS

After 1 year, 57 (15.1%) of 377 patients complained of mild to moderate pain. The incidence of mild and moderate chronic pain was 14.3 and 0.8%, respectively. None of the patients had severe chronic pain. Only one patient reported numbness in the groin area. Age and immediate postoperative pain were significant risk factors associated with chronic pain after Kugel inguinal herniorrhaphy. Although the difference was not significant, female patients seemed to be more prone to develop chronic pain.

CONCLUSIONS

The Kugel inguinal hernia repair is associated with a low rate of postoperative chronic pain. The minimally invasive preperitoneal approach of the Kugel technique probably causes less nerve damage and subsequent neuropathic pain. Chronic pain seems to be more common in young female patients with immediate postoperative pain.

Pain after open preperitoneal repair versus Lichtenstein repair: a randomized trial

BACKGROUND

The open preperitoneal approach in inguinal hernia repair might have the benefit of a mesh in the preferred space without the disadvantages of an endoscopic procedure.

METHODS

A total of 172 patients with primary inguinal hernia were randomized to undergo the open preperitoneal Kugel or the standard open anterior Lichtenstein procedure in a teaching hospital. The main outcome measures were operating variables, visual analog scale (VAS) pain scores, and consumed analgesics during the first 2 weeks postoperatively and at 3 months, neurological examination, and complications.

RESULTS

In the Lichtenstein group the operation took longer (54 min versus 41 min; p < .001). There were no clinically important differences in VAS pain score or number of analgesics during the first 2 weeks postoperatively. In the Kugel group the mean VAS pain score at 3 months was less (0.3 versus 0.9; p = .002), as was the proportion of patients reporting pain (21 versus 40%; p = .007). Pain was merely described as neuropathic, especially in the Lichtenstein group. With the anterior repair significantly more nerves were encountered, numbness reported, and cutaneous sensory changes found with neurological examination (all p < .001).

CONCLUSIONS

For those surgeons preferring an open approach, the Kugel procedure is a feasible alternative for the standard Lichtenstein procedure and is associated with less chronic pain at three months. Most likely the neuropathic pain and numbness with the Lichtenstein technique are results of more nerves at risk with the anterior approach.

Open, preperitoneal hernia repair with the Kugel patch: a prospective, multicentre study of 450 repairs

BACKGROUND

The Kugel patch inguinal hernia repair is a relatively new, open, minimally invasive procedure using a preperitoneal approach.

METHOD

Prospective multicentre case series of 450 consecutive Kugel patch repairs. Recurrence rates and persistent inguinal pain after at least 1 year as well as short-term outcomes were studied.

RESULTS

After a follow-up of 18 months, eight recurrences (1.9%) were found, and persisting inguinal pain was reported in 15 patients (3.5%). The mean operation time and hospital stay were 20 +/- 9 min and 19 +/- 1.3 h respectively. Less than 1% of patients planned for an ambulatory treatment needed prolonged hospitalisation. Analgesics were used for 3 +/- 2 days. Paracetamol was the only painkiller used in 69% of patients, and 13% did not take any painkiller at all. Half of all patients returned to their daily activities after 9 days and half of the employed patients returned to work after 14 days.

CONCLUSION

The Kugel patch repair is a quick technique with a low recurrence rate and good patient comfort. It offers the advantages of a preperitoneal inguinal hernia repair without the need for general anaesthesia or expensive laparoscopic equipment.

Femoral hernia repair

Plug insertion for primary femoral hernia repair may cause p.o. discomfort. The Kugel technique may avoid this problem. Patients' satisfaction to the Kugel and the plug techniques is compared in the present study. Demographics, surgical, outcome and analgesic consumption data of 26 patients treated for with the plug technique (P group) are compared with 24 operated with the Kugel patch (K group). Patients' p.o. discomfort to the two procedures was measured with quantitative (VAS score) and a qualitative (the short form of McGill pain questionnaire, SF-MPQ) methods, and compared. P group presented higher early p.o. pain (P<0.001), higher analgesic consumption and a significative delay in the return to physical activity (P<0.001). SF-MPQ scores at p.o. day 8, day 30 and month 6 were significantly lower for K group (P<0.001, P<0.001, P<0.005). The Kugel technique for femoral hernia treatment seems to cause less p.o. discomfort to patients than the plug technique.