The preferred method (Mesh)
The use of the non-absorbable polyprolene mesh is now standard for many surgeons. In some centres over 90% of patients are now treated with a mesh. The mesh is used to reduce the rate of recurrence of hernias. It was not that long ago when studies showed absorbable materials or even non-absorbable materials without a mesh had a very high recurrence rate. Some other centres have reported excellent results without using mesh – that is the technique of the Shouldice Clinic of Canada.
THE MESH PROVIDES
1. An anatomical repair.
2. Early strength.
3. Long-term reinforcement.
Minimal non-absorbable suturing is used to restore the anatomy without having to pull the muscles together, this is done without tension – “THE TENSION FREE REPAIR”. If the muscle is pulled together with tension the suturing causes pain and as well when the patient coughs or exerts any pressure the stiches may cut out. This is what leads to a high rate of recurrence.
The mesh is fashioned to reconstitute a shutter mechanism at the internal ring (deep ring) – like a jacket with one lapel anterior (in front) to the cord (which transmits the vessels and vas to and from the testes in the scrotum) – and the other lapel posterior (behind). Thus, when the patient coughs or strains, the internal ring, through which indirect inguinal hernias often occur or recur is narrowed.
Mesh is being increasingly used for most other types of hernias including epigastric hernias, umbilical hernias, femoral hernias, incisional hernias and recurrent hernias. In addition many different types have now been designed – basically the same materials, but different shapes and sizes. In particular the plug technique, which was also originated or popularised by Lichtenstein, is used to fill in a defect, which is difficult to close without tension, or in some cases now, as a routine method.
Recent and continuing audit of the Melbourne Hernia Clinic demonstrates that many problems of the past have been reduced.
1. There is a low morbidity and recurrence rate.
2. Hospital stays have become shorter.
3. For the vast majority post-operative pain is not a great problem.
4. Early return to work is possible.
Over 70% of cases were treated as a day case. Over 20% stayed in one post-operative night only. The remainder stayed in hospital longer because of age, family circumstances or ill health. The technique of Local Anaesthetic infiltration is very safe for the elderly.