Hernia repair: plug

The description of the hernia repair using a plug covers all aspects of the surgical procedure used for the management of inguinal hernia. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: anesthesia, incision, repair. Consequently, this operating technique is well standardized for the management of this condition.

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Hernia   repair:   plug

Authors
E Pelissier
Abstract
The description of the hernia repair using a plug covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: anesthesia, incision, repair.
Consequently, this operating technique is well standardized for the management of this condition.
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Publication
2001-03
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E-publication
WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02en191.htm

Hernia   repair:   plug

1. Introduction
1974: Lichtenstein describes the first cylindrical plug for the treatment of femoral and recurrent inguinal hernias.
1992: Gilbert describes the treatment of inguinal hernias using a cone-shaped plug.
1993: Introduction of the Perfix plug, conceived and designed by Rutkow and Robbins. This preformed, pleated, cone-shaped plug, is reinforced by an inside arrangement of polypropylene petals.

Closing the hernial defect with a polypropylene plug offers numerous advantages, according to these authors:
- operation performed using local anesthesia;
- reduced postoperative pain;
- rapid resumption of physical activity;
- small recurrence rate (<1%);
- duplication of the procedure facilitated.
2. Anatomy
• Superficial tissues
1. Anterior superior iliac spine
2. External oblique muscle
3. Aponeurosis of the oblique muscle
4. Spermatic cord
5. Femoral vessels
• Deep tissues
1. Transverse muscle
2. Cremaster muscle
3. Spermatic cord
4. Femoral vessels
5. Inguinal ligament
• Inguinal canal
1. Transverse muscle
2. Cremaster muscle
3. Spermatic cord
4. Epigastric vessels
5. Transversalis fascia
3. Indications
Indications
- all types of inguinal and femoral hernias;
- external, oblique inguinal hernias beyond Type I defects, including recurrent hernias;
- direct hernias, notably recurrent hernias;
- large hernial defects, which often require the insertion of a very large plug;
The operation should be performed under local anesthesia: there are few contraindications linked to patients who are elderly or in poor general physical condition.

Contraindications
- young patient;
- disturbances of hematological parameters (borderline indication);
- cirrhosis (borderline indication);
- very large hernias;
- patient refusal;
- allergy to local anesthetics.
4. Operating room set-up
• Patient
This position should be comfortable for the patient as well as for the surgical team.
The patient is positioned on the back, the legs straight and both arms maintained at right angles in arm holders.
The installation of the operating field should be wide, covering the lower limbs, the entire thorax, the upper abdomen, the upper limbs, while leaving the head perfectly free to enable the surgeon to see the and talk with the patient.
1. Example for a right-sided hernia
• Team
The surgeon stands on the side of the hernia, which he/she is to operate.
The assistant stands opposite the surgeon.
The presence of a scrub nurse is not required.
1. Surgeon (right-sided hernia)
2. Assistant
• Equipment
1. Anesthetic equipment
2. Operating table
3. Instrument table
4. Electrocautery
The anesthetic equipment should enable cardio-vascular as well as oxymetric monitoring.
The surgical equipment should be kept to a minimum.
• Instrumentation
1. Syringe
2. Bladed surgical knife
3. Atraumatic grasper
4. Scissors
5. Perfix plug
6. Slit prosthesis
7. Gauze pads
8. Retractors
9. Auto-static retractor
10. Local anesthetic (lidocaine)
5. Anesthesia
• Products
100 mL of a lidocaine solution containing 0.5% adrenaline is used. In general, 60 mL to 80 mL are enough to ensure the infiltration of all tissue layers.
• Superficial tissue layer
This step begins by infiltration of the subcutaneous tissues along the path of the incision, going 1 to 2 cm beyond its edges.
• Deeper tissue layer
After the cutaneous incision, a pocket is created in the subcutaneous layer at the upper end of the incision to the aponeurosis of the external oblique muscle.
5 mL of lidocaine are then injected, just below the aponeurosis, without injecting into the cord itself.
Anesthesia is established while pursuing the incision of the subcutaneous layer.
• Inguinal canal
After incision of the external oblique muscle, the genital branch of the genitofemoral nerve is infiltrated, on the lower edge of the cord, near the internal ring.
During dissection, the hernia sac is infiltrated, notably at its neck.
6. Incision
• Superficial tissue layer
The 4 to 5 cm oblique cutaneous incision is performed alongside the inguinal canal and centered on the zone of tumefaction.
1. Anterior superior iliac spine
2. Pubic tubercle
• Deep tissue layer
An incision of the subcutaneous layer and of the external oblique muscle is performed, in order to sufficiently open the inguinal canal and visualize the spermatic cord. The incision of these deep layers is oblique, following the direction of the inguinal canal.
• Inguinal canal
• Opening/spermatic cord
The cord is placed on a self-retaining grasper.
A longitudinal incision of the sheath is made to free the hernia sac. The cremaster muscle is not resected.
• Dissection of hernia sac
The sac is dissected free to the internal ring using scissors and electrocautery.
• Reduction of hernia sac
The surgeon then pushes back the sac with a finger into the preperitoneal space. Still using the finger, high dissection is pursued in this space to completely free the sac and create a pocket into which the plug may be inserted.
7. Repair
• Generalities
The Perfix plug technique combines a conical plug, which is used to deeply push back the hernia sac, and a precut, slit onlay patch to cover the deep layer of the inguinal canal. The prostheses are made of non-absorbable polypropylene.
• Plug and onlay patch
• Plug
Cone-shaped with eight pre-set pleats, it is lined inside by two layers of polypropylene petals. Different sizes are available: 4.1 cm; 4.8 cm.
• Onlay patch
A precut, polypropylene patch with a slit terminated by an opening designed to leave a passage for the spermatic cord after positioning in front of the posterior wall of the inguinal canal. Available in one size, the patch may be adapted to the surface, which is to be covered.
• Plug and patch placement
• Plug insertion
After pushing back the hernia sac, the plug is inserted, tapered end first, through the internal ring until the wider base of the plug is positioned at the edge of the internal ring delimited by the deep muscular layer.
• Plug attachment
Once the plug is in place, it is attached by a small number of interrupted, non-absorbable sutures to the surrounding muscular layer.
• Onlay patch placement
The two parts of the split section of the onlay patch are positioned around the spermatic cord and sutured together with one stitch. The patch is then laid in position on the posterior wall of the inguinal canal posterior to the spermatic cord.
• Closure
The external oblique aponeurosis is reapproximated over the spermatic cord structures using a continuous, slowly absorbable suture. The subcutaneous tissues are then brought together with interrupted sutures and the skin edges are stitched with a running subcuticular suture.
• Variation
• Hernial topography
1. Direct hernia (sometimes recurrent);
2. External oblique inguinal hernia (sometimes recurrent);
3. Femoral hernia.
• Direct hernia
The cord is retracted either upwards or downwards to free the posterior wall of the inguinal canal.
The patient is made to cough in order to force out the hernia. The hernia sac is freed up against the transversalis fascia, which is incised around the hernia sac (including large sacs) allowing the surgeon to easily push back the peritoneal sac behind the fascia with the plug. The plug is then attached to the edges of the fascia opening.
• Recurrent hernia
In the case of a small recurrent hernia (often direct), dissection of the hernia sac is limited to the immediate area surrounding the sac, preserving the spermatic cord.
The transversalis fascia is incised around the sac. The sac is then pushed back inwards by the plug, which is attached to the edges of the fascia opening, in the same manner as for direct hernias.
• Crural hernia
When the diagnosis is certain, a direct femoral incision is performed. The hernia is dissected through the femoral opening, without having to open the inguinal canal. The hernia sac is reduced or resected, and a plug of a suitable size is inserted and fixed to the surrounding structures.
8. Postop period
Hospital discharge:
Same day as surgery if operation was early in the morning.

Postoperative care
Analgesics:
- surveillance of the wound;
- patient may shower if bandage is waterproof;
- stitches removed and postoperative check-up 10 days after surgery;
- 1 month, then 1 year check-up.

Activities:
- driving >24 hours;
- light loads <15 kg on D2;
- light activity as soon as pain goes away;
- moderate activity >D15;
- sports (biking, jogging, tennis) progressively >D21;
- strenuous activity >D30.
9. Conclusion
The minimally invasive technique is easily performed under local anesthesia.
The plug hernia repair technique may be performed in an outpatient setting.

In addition to the postoperative comfort and low recurrence rate associated with this technique, the decrease in hospitalization costs is an advantage for our health systems.