1. HERNIA TECHNIQUE
COMPARISION-REVIEW OF
TENSION FREE METHODS
DR RAVICHANDRA MATCHA, M.S.,
ASSISTANT PROFESSOR OF SURGERY,
RANGARAYA MEDICAL COLLEGE,KAKINADA

2. INTRODUCTION
INGUINAL HERNIA REPAIR IS ONE OF THE
OLDEST OPERATIONS EVER DOCUMENTED—
IN FACT, THE FIRST RECORD OF IT DATES
PRIOR TO THE MIDDLE AGES. TODAY,
HERNIORRHAPHY IS ONE OF THE MOST
COMMON SURGICAL PROCEDURES—IN 1996,
SURGEONS PERFORMED MORE THAN 750,000
REPAIRS, AND MORE THAN 80 PERCENT WERE
AMBULATORY CASES.

3. INTRODUCTION CONTD……
 TRADITIONAL REPAIRS
UNTIL THE LATE 1980’S, MOST SURGEONS REPAIRED
HERNIAS BY SIMPLY PUSHING BACK THE
PROTRUDING TISSUE AND SUTURING TOGETHER THE
EDGES OF THE DEFECT IN THE ABDOMINAL WALL.
TODAY, SOME SURGEONS STILL USE THESE
“TENSION” METHODS (VARIATIONS INCLUDE THE
BASSINI/HALSTED, COOPER/MCVAY, AND
CANADIAN/SHOULDICE REPAIRS).

4. INTRODUCTION CONTD……
 SURGEONS AT THE SHOULDICE HOSPITAL IN
TORONTO, CANADA, A DEDICATED HERNIA
HOSPITAL, HAVE COMPLETED MORE THAN 250,000
REPAIRS USING A TENSION OR “PURE TISSUE”
TECHNIQUE THAT USES STEEL WIRE SUTURES TO
CLOSE THE WOUND; THEY CLAIM A RECURRENCE
RATE OF ONLY ONE PERCENT. CRITICS OF THE
TENSION-FREE METHOD SAY THAT SUTURING PUTS
TOO MUCH TENSION ON THE SIDES OF THE
DEFECT, CAUSING PAIN AND AN INCREASED
RECURRENCE RATE.

5. INTRODUCTION CONTD……
 MESH-BASED REPAIRS
 THE REPAIRS THAT DR. WITMER AND MOST OTHER SURGEONS
NOW USE ARE VARIATIONS OF A “TENSION-FREE OR MESH-BASED
TECHNIQUE. ALL INVOLVE EITHER PLUGGING OR PATCHING THE
HOLE IN THE ABDOMINAL WALL WITH A PIECE OF
POLYPROPYLENE MESH.
IN THE MID-EIGHTIES, HERNIA SURGEON IRVING LICHTENSTEIN,
MD, CAUSED A STIR AMONG HIS COLLEAGUES WHEN HE
PROPOSED THAT USING A PIECE OF POLYPROPYLENE MESH WAS
THE BEST WAY TO REPAIR ALL INGUINAL HERNIAS. PRIOR TO
THIS, SURGEONS HAD BEEN USING MESH ONLY FOR LARGE OR
RECURRENT HERNIAS AND ONLY WHEN THEY FELT IT WAS
ABSOLUTELY NECESSARY—THEY FELT THAT USING A “FOREIGN
BODY” FOR REPAIR INCREASED THE RISK OF INFECTION.

6. INTRODUCTION CONTD……
 HOWEVER, DR. LICHTENSTEIN PERSISTED, AND
IN 1989 PUBLISHED A STUDY OF 1,000 PATIENTS
WHO RECEIVED THE LICHTENSTEIN REPAIR.
THESE DAYS, MOST SURGEONS PREFER
TENSION-FREE TECHNIQUES, SINCE MESH DOES
NOT PLACE TENSION ON THE SIDES OF THE
WOUND, GRADUALLY INCORPORATE INTO THE
ABDOMINAL WALL, AND, IN THE VAST MAJORITY
OF CASES, DO NOT POSE ANY THREAT OF
INFECTION.

7. PATIENTS & METHODS
 AT OUR INSTITUTE WE CONDUCTED AN OBSERVATIONAL
STUDY ON PATIENTS COMING WITH UNCOMPLICARED
INGUINAL HERNIA OVER A PERIOD SPANNING 8 YEARS FROM
OCTOBER 2006 TO OCTOBER 2014.
 MAJORITY OF PATIENTS WHO WERE ENROLLED UNDERWENT
TENSION FREE MESH TECHNIQUE.
 WE FEEL THAT THIS TECHNIQUE IS NOT ONLY THE SAFE
PROCEDURE AVAILABLE BUT ALSO ASSOCIATED WITH THE
LEAST P.O. DISCOMFORT, MOST RAPID RECOVERY TO NORMAL
ACTIVITY, & IS ASSOCIATED WITH THE LOWEST RATE OF
RECURRENCE.

8. PATIENTS & METHODS CONTD……
 LICHTENSTEIN HERNIA REPAIR:
THIS TYPE OF TENSION-FREE REPAIR USES AN OPEN
ANTERIOR APPROACH, MEANING THAT THE SURGEON
SUTURES A MESH PATCH OVER THE HERNIA IN FRONT
OF THE ABDOMINAL MUSCLE WALL. PARVIZ AMID, MD,
A SURGEON AT THE LICHTENSTEIN HERNIA INSTITUTE
IN LOS ANGELES, HAS NO DOUBT THAT THE
LICHTENSTEIN REPAIR IS AN IMPROVEMENT OVER
TRADITIONAL TENSION TECHNIQUES. THE
LICHTENSTEIN REPAIR, SAYS DR. AMID, “BYPASSES THE
PROBLEM OF WORKING WITH DEGENERATED TISSUE BY
PLACING THE EDGES OF THE PATCH ON SURROUNDING
HEALTHY TISSUE, PROVIDING A STRONGER
REINFORCEMENT FOR THE ABDOMINAL WALL.”
 THIS TECHNIQUE WE FOLLOWED FOR OUR PATIENTS.

9. RESULTS
 WE IN OUR STUDY ADOPTED LICHENSTEINS MESH REPAIR ALSO
CALLED TRANSINGUINAL PRE-PERITONEAL REPAIR WHICH IS
A TYPE OF TENSION FREE REPAIR USING PROLENE MESH
SYSTEM.
 IN THIS TECHNIQUE ONCE HERNIA IS FREED FROM THE
SURROUNDING TISSUES BY GENTLE DISSECTION , IT IS
RETURNED THROUGH THE DEFECT INTO ITS PROPER
POSITION.
 RATHER THAN JUST COVERING THE DEFECT THE MESH IS
GENTLY PLACED THROUGH DEFECT.
 THE MESH SAFELY PLACED BEHIND MUSLE FASCIA LAYER ,
EXTENDS WELL BEYOND THE UNDEREDGES OF THE DEFECT
TO REDUCE PRESSURE ON THE HERNIA DEFECT, AND
REINFORCES THE ENTIRE SURROUNDING VULNARABLE AREA
CALLED MYOPECTINEAL ORIFICE.

10. RESULTS CONTD……
AFTER THIS , AN ADDITIONAL SHEET OF MESH IS INCLUDED
OVER THE DEFECT LIKE AN INSURANCE REINFORCEMENT.
THIS IS PLACED IN A COMPLETELY TENSION FREE FASHION,
BEING HELD IN PLACE BY VELCRO-LIKE EFFECT OF THE
MESH ITSELF.SINCE THERE IS NO TENSION & ONLY A
MINIMAL DISSECTION THERE IS LITTLE POST OPERATIVE PAIN
AND PATIENTS RETURN TO NORMAL ACTIVITI IN DAYS.
THIS TECHNIQUE HAS BEEN ESSENTIALLY UTILIZED FOR 8
YEARS , WITH RECURRENCE RARES OF 2% LOWER THAN ANY
OTHER TECHNIQUE INCLUDING CONVENTIONAL SUTURE
REPAIR (TENSION REPAIR), OR THE LAPAROSCOPIC KEY HOLE
APPROACH.

11. DISCUSSION
 TRADITIONAL HERNIA SURGERY (TENSION REPAIR) INVOLVES
CUTTING ADJUCENT MUSCLE , PULLING IT TOGETHER WITH
SUTURES OR WIRES.THIS CREATES EXTREME TENSION ON
MUSCLES AS IT MUST BE MOVED OUT OF ITS NORMAL
ANATOMIC LOCATION TO COVER HERNIA DEFECT WHICH
PRODUCES PAIN & SWELLING.
 THE TENSION INHIBITS FULL & EFFECTIVE HEALING OF THE
EDGES.THE RESULT OF INCOMPLETE HEALING IN THE
PRESENCE OF TENSION ,IS THE MUSCLE EDGES MAY PULL
APART CAUSING A HIGHER FAILURE RATE WITH RECURRENT
HERNIA.

12. DISCUSSION CONTD……
 THE TENSION FREE METHOD UTILIZING THE PROLENE HERNIA
SYSTEM USES A “THREE-IN-ONE” DEVICE CONSISTING OF AN ON
LAY PATCH THAT GOES ON TOP OF THE ABDOMINAL WALL, A
CONNECTOR PIECE THAT PLUGS THE DEFECT AND AN UNDERLAY
PATCH THAT DEPLOYS IN THE PREPERITONEAL SPACE AND
PROVIDES SUPPORT BEHIND THE ABDOMINAL WALL. THIS
DEVICE PURPORTEDLY COMBINES ALL THE BENEFITS OF THE
LICHTENSTEIN, MESH PLUG, AND KUGEL TECHNIQUES. DR.
GOODYEAR OF THE NORTH PENN HERNIA INSTITUTE IN
PENNSYLVANIA FEELS IT IS THE ONLY "TENSION FREE" DEVICE
THAT COVERS THE ENTIRE HERNIA PRONE AREA CALLED THE
MYOPECTINEAL ORIFICE.
THE PROLENE HERNIA SYSTEM IS A “THREE-IN-ONE” SYSTEM
THAT COMBINES THE BENEFITS OF THREE TECHNIQUES,
PROPONENTS SAY.

13. THE MODELOF PROLEN HERNIA
SYSETEM USED IN OUR STUDY
BILAYER PATCH REPAIR.BILAYER PROLENE MESH.3 IN 1 DEVICEWITH ROUND
DISK FOR PROPERITONEAL REPAIR,PLUG EFFECT OF CONNECTOR, AND
OBLONG SHAPEDONLAY COMPONENT.

14. ILLUSTRATION OF 3 IN 1 PROLENE MESH
SYSTEM FOR HERNIA

15. THE FINALPOSITION OF MESH