Alex G. Shulman, M.D.,Lichtenstein Hernia Institute Los Angeles, California
Just over one century ago, Eduardo Bassini, an Italian surgeon, first described the classic hernia repair that is still in vogue today. The recurrence rate of that operation has consistently remained approximately 10% for the past century.
Causes of Early and Late Recurrence of Hernias
There is a weak area in the groin, the floor of the inguinal canal, which is covered by the fascia transversalis, a flimsy structure of little strength. This is the only area of the abdominal wall not supported by muscle layers, and is extremely vulnerable to injury. Hernial protrusions commonly result.
Clearly, the canal floor requires reinforcement, to correct what nature has failed to do.
This weak area, in which the strong transversus abdominis tendon is widely separated from the inguinal ligament (iliopubic tract), is present in at least 15% of males. Forced surgical approximation of these semirigid structures to close this gap as is commonly done to correct a hernial defect inevitably creates tension on tissues or on suture lines and can result in early hernia recurrence. It is at this site that 50% of hernia failures are found. Another 40% of recurrences appear initially at the internal ring, along side the site of emergence of the spermatic cord. Here, secure surgical closure is prevented by the presence of the spermatic cord.
Late recurrence of hernia repairs can be explained by the steady deterioration of tissue with age. Defective collagen metabolism (either decreased formation or increased degradation) has been shown to result in weakening of tissue with time. This, in addition to a familial predisposition, explains the increasing incidence of hernia in persons over 50 years of age. Thus, despite the many books and countless articles on the subject in the past century, there has been little improvement in results. Why?
As early as 1890, Billroth, the most famous surgeon of his day, suggested that the ideal way to repair hernias was to use a prosthetic material to close the hernial gap. Many materials were tried, but they all fell victim to the triple headed monster of infection, rejection and recurrence and proved to be unacceptable. Compounding the dilemma, was the use of unsuitable multifilamented suture material, which caused their own special problems. Surgeons became disenchanted with the popular cotton and silk sutures because of the frequently tiresome rejection syndrome and the endless recurring infections that often resulted. The use of such sutures to secure mesh in place undoubtedly contributed to and aggravated the existing bias against mesh.
Polypropylene mesh (Marlex) to repair going hernia was introduced by Francis Usher in 1962, and its early use was not associated with the complications previously associated with other prosthetics. This record has been maintained for three decades.
Polypropylene mesh is unique in many respects. It is monofilamented and thus cannot harbor infection. (Indeed, it is more resistant to infection than is human tissue.) It is neither allergenic nor oncogenic (able to cause the growth of cancer). It cannot be felt by either patient or physician when placed beneath muscle and is not radiopaque (able to stop the passage of x-rays). It is readily available, permanent, and will not break, shred, or tear with time. Perhaps its most valuable feature is that it stimulates fibroblasts to grow into its interstices, thereby producing an impenetrable collagenous structure that resembles strong, normal tissue.
Today, many surgeons agree that use of a prosthetic mesh is the preferred way to repair most recurrent hernias. But why not prevent such recurrences by using the mesh for the treatment of all primary repairs? Surgeons who piously insist that no foreign material should ever be used for hernia repair often select nonabsorbable monofilamented polypropylene (Prolene) as their preferred suture for many kinds of operations. Because the Marlex mesh and the Prolene suture are both made of polypropylene, objections to using the mesh because it is a foreign body, become pointless.
It should be emphasized that the hernia repair depends on the strength and permanency of the mesh itself, not on the degree of scar tissue which subsequently develops in and around the mesh.
Use of the "Patch"
There is an inherent disadvantage of forcibly bringing together the two sides of a hernia defect. With distorted muscle fibers and later contraction of muscles, as they normally tense the abdominal wall, stress can result in the tearing of tissue and the beginning of a recurrence. However, a simple patch can be expeditiously placed over the defect thereby correcting the hernia in this way, with no tension whatsoever
Employing this principle, we began in 1984 to use a tension-free repair, suturing a polypropylene mesh patch over the defect without attempting to close the hernial hole. Only 4 failures have occurred in more than 2,975 primary hernia repairs. Upon analysis, these failures were readily explained by our use of too small a patch in the early days of our experience, an error which we quickly corrected. Since reporting our own success with the polypropylene patch, we have investigated the results obtained by surgeons in four other different geographical areas who are now using the same technique. Less than 1% of wound infections has been reported in approximately 5,000 operations, and there have been no instances of mesh rejection..
The advantages of using the polypropylene mesh prosthesis are self-evident. The operation is simple to perform and can be done rapidly. Since it does not create tension on tissues, there is no post-operative restriction of activity on the part of patients after operation. It produces permanent repairs with a success rate approaching 100%, and is virtually free of complications.
The problem with the standard methods of hernia surgery in patients with Ehlers-Danlos syndrome is the slow and often inadequate healing of tissues forcibly held together by sutures. It is this failing which has produced a long saga of repeated recurrences following hernia operations.
In June of 1992, a woman with EDS, with a troublesome hernia had been turned down for surgical operation by six surgeons in her home area in another state. She was referred to us because we are known for popularizing the tension-free repair of applying mesh and not sewing together the hernial defect.
Using this approach, she sustained a successful and uneventful repair, the operation having been carried out on an outpatient basis, under local anesthetic. She was able to fly back to her home on the second day after surgery, and has remained well.
While this represents only one patient, it seems logical that the method should be applicable to others with the same problem or even to those with recurrent hernias. Should this continue to be successful when used for other such patients, it may represent a breakthrough in the ability to offer some help to people with the Ehlers-Danlos syndrome.
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