The The KugelKugel repair for groin repair for groin herniashernias

FouadFouad Hachem,M.DHachem,M.D

l 900,000 hernia repairs/yrl 65% utilize mesh :80% lichtensteinl 20% PHSl 27% Tension repair(Bassini,McVay)

RR 10%6% Laparoscopic1% others

The anatomy of inguinal region is misunderstood by some surgeons of all levels of seniority

R.Condon (Hernia ,Second edition 1978)

Myopectineal orifice: “window of groin”Henry Fruchaud

Boundaries: laterally IliopsoasMedially lateral rectusSuperiorly (IOM/TOM)Inferiorly Cooper’s ligament

Triple triangle of groin :No muscle coverage

Traditional repairsTraditional repairs

q Eduardo Bassini(1844-1924)-radical cure of inguinal hernia-1887

q William Halsted (1852-1922)Halsted I -1889Halsted II(Ferguson-Andrews)-1893

q Earl Shouldice(1891-1965)overlapping(imbricated)transversalisfascia-1930

Traditional repairsTraditional repairs

qChester McVay(1911-1987)-pectineal ligament-1948

Mesh RepairsMesh RepairsqF.C. Usher

- “Marlex mesh:a new plastic mesh” –1959qJ.Rives

- “treatment of the inguinal hernia with Dacron” 1967

qR.E. Stoppa“ interposition without fixation of Dacron”–1973

qIrving Lichtenstein -the tension-free hernioplasty-1989

Open mesh vs.nonOpen mesh vs.non--mesh for mesh for repair of inguinal herniarepair of inguinal hernia

l Decreased RR between 50-75%l Cochrane Database Syst Rev

2002;(4):CD002197l 20 TRIALS

More progress has been made in hernia surgery in last 15 yrs than has been made in the previous 1500 yrs

There has been greater appreciation for the mechanical advantage of a posterior or preperitoneal hernia repair

By applying the prosthesis to the same side of the abdominal wall As the higher pressure,that intra-abdominal pressure actually contributes to the integrity of the repair instead of being the constant enemy,as it is with anterior repair

Principles of hernia surgeryPrinciples of hernia surgeryqTension freeqPreperitoneal placement of mesh

preperitonealsubmuscular

qSuturelessqProtect femoral canalqMinimally invasive

q1.Recurrenceq2.Pain

““TensionTension--freefree””--Why?Why?

qSimplified placementqPerfect conformity

hydrostatic tissue forcesintraabdominal pressure

qDecreased pain

SuturelessSutureless--why?why?

q Incidence greater than 1%?qOccult femoral herniasqDiagnosis?

Femoral HerniaFemoral Hernia

qMinimal damageqMinimal riskqShould not be defined by instrumentation

What is minimal invasionWhat is minimal invasion

q1992 Laparoscopic repair-first Kugel repairq1993 Evolving patchq1994 first placed Kugel Patchq1994 first public presentation at ACSq1996 First commercial patches available

Background of Background of KugelKugel PatchPatch

l Double layerl Outer apronl Recoil Ringl Tissue apposition holesl V-shaped cutsl Transverse slit

Incision siteIncision site

lMidpoint between ASIS &PTl 2/3 medial and 1/3 lateral to an imaginary

line between these 2 pointsl 3-4 cm incisionl Slightly superior to internal ring

IncisionIncision

Continued entry and Continued entry and TransversalisTransversalis fascia exposurefascia exposurel Open external oblique parallel to its fiberslMuscle splitting incision in IOM l Avoid ileoinguinal &ileohypogastric nerves

in this tissue plane

Continued entry and Continued entry and TransversalisTransversalis fascia exposurefascia exposure

Entry into Entry into preperitonealpreperitoneal spacespace

l The transversalis fascia is opened vertically and the preperitoneal space is entered(about 2-3cm superior to the internal ring)

l Digital and blunt dissection are utilized to free the peritoneun from the overlying transversalis fascia and preperitoneal fat

l Identify epigastric vessels (anterior and medial)

Entry into Entry into preperitonealpreperitoneal spacespace

l All three potential hernia defects can be easily palpated within the preperitoneal space

l Indirect sac should be reduced and carefully seperated from underlying cord structures

l Special care should be taken to complete the dissection posterior to the point where the vas deferens deviates from the spermatic vessels.this will allow the inferior edge of the patch to lie back over the iliac vessels

Create PocketCreate Pocket

l Dissection is continued ,creating a pocket only slightly larger than the kugel Patch

l Direct – pseudosac should be completely seperated from preperitoneal fat and peritoneum

l Femoral-reduce sac

l It is important to make sure that Cooper’s ligament is visible and the pocket is freed up well below this level

Key landmarksKey landmarks

l Medial-behind the symphysis pubis

l Lateral-approximatley3 cm beyond the transversalis incision

l Inferior-must extend well below the level of the inguinal ligament

Identify and reduce herniaIdentify and reduce hernia

l Approximately 3/5 of patch should sit above the level of the inguinal ligament and the remaining 2/5 below level of the ligament

l Patch should conform to the peritoneum

Anchor PatchAnchor Patch

l Transversalis fascia closed using an absorbable suture

l The anterior layer of the patch is picked up with one SINGLE Stitch

l Test repair

A Complete RepairA Complete Repair

l It covers the direct spacel It covers the internal ringl It covers Cooper’s ligament and the femoral

canal

PostPost--op Courseop Course

l No specific restrictionsl Patients are only limited only by their

discomfortlMaximum discomfort one to two daysl Return to “regular”activities in a few days

to a week

In SummaryIn Summary

The Kugel repair isI. Minimally invasiveII. NonlaparoscopicIII. PreperitonealIV. Sutureless