Herniorrhaphy:
A Comparison of Two Minimally Invasive Preperitoneal Repairs

Eddie Joe Reddick, MD, FACS, Charles E. Morton, MD, FACS,
William G. Bradham, MD, Michael J. O'Reilly, MD, FACS

From the Surgical Services of Southern Hills Medical Center, Nashville, TN and the Advanced Laparoscopic Training Center, Marietta, GA.

Address reprint request to:
Eddie Joe Reddick, MD
397 Wallace Road, Ste 414
Nashville, TN 37211

Abstract

Laparoscopic herniorrhaphy has proven to be an effective minimally invasive operation with low recurrence rate when performed correctly. It involves the use of specialized equipment, which increases the cost of the procedure significantly. The Kugel repair mimics the laparoscopic repair as a tension free, preperitoneal herniorrhaphy, but does not require specialized equipment, thereby, decreasing cost. This study compares the Kugel hernia repair with the laparoscopic repair. Forty-five patients underwent the Kugel repair and 28 had the laparoscopic repair. The groups were evenly matched with bilateral hernias, incarcerated hernias, and direct and indirect hernias. Patients were older in the laparoscopic group (46 years vs. 59 years).

Average operating time was less with the Kugel repair (44 vs. 69 minutes). Return to work activities was eight days in each group. The Kugel group had 7% morbidity. There was 16% morbidity in the laparoscopic group. One recurrence occurred in the Kugel group and none with the laparoscopic group.

The laparoscopic repair cost $776.00 per case more than the Kugel repair. Local anesthesia was utilized in 47% of the Kugel repairs and none of the laparoscopic repairs. There were no anesthetic complications.

The laparoscopic repair is safe and effective, but has a higher cost. The Kugel repair costs less than the laparoscopic repair, but still provides a minimally invasive, tension free operation with similar results.

Laparoscopic and Kugel Herniorrhaphy:
A Comparison of Two Minimally Invasive Preperitoneal Repairs

Eddie Joe Reddick, MD, FACS, Charles E. Morton, MD, FACS,
W. Glenn Bradham, MD, Michael J. O'Reilly, MD, FACS

Laparoscopic herniorrhaphy has been the primary hernia repair offered to our patients since its description in 1990 (1). It was initially performed utilizing the transabdominal technique (1), but was later modified to a preperitoneal approach (2). With the decrease in reimbursement for hernia repairs, attention has been directed toward a less expensive operation.

The Kugel herniorrhaphy (3) is being evaluated since it is a minimally invasive, tension free, preperitoneal herniorrhaphy utilizing a specially prepared onlay polypropylene mesh (Kugel Patch, Surgical Sense, Inc., Arlington, TX). This repair mimics the laparoscopic repair without the expense of video equipment, trocars, and laparoscopic instruments.

This paper reviews the early experience of one of the authors (EJR) with this repair and compares it to laparoscopic herniorrhaphy performed by two of the other authors (CEM, WGB).

Materials and Methods

During the period from August 1997 to March 1998, all herniorrhaphies performed at Southern Hills Medical Center in Nashville, Tennessee, USA were reviewed. All patients presenting to two other surgeons (CEM, WGB) were treated via the laparoscopic preperitoneal approach.

All patients were followed at one to two weeks postoperatively, then by telephone for this review. Cost of each operation was determined by hospital financial records for each type surgery.

Technique

The Kugel hernia repair utilizes a specially designed patch of polypropylene mesh which has a stiff memory ring incorporated around its edge to keep it expanded. The mesh is placed preperitoneally through a 3-cm incision after blunt dissection of the preperitoneal space. Much like the laparoscopic repair, it covers the direct, indirect and femoral spaces, but does not require sutures or staples to stabilize it.

The incision is placed on the midpoint of a line between the anterior superior iliac spine and the pubic tubercle. The three-centimeter incision is placed with two centimeters medial to the line and one centimeter lateral. The incision is carried sharply to the external oblique, which is opened in line with its fibers for three centimeters. The external ring is not opened. The internal oblique muscle and transversalis fascia are opened bluntly until the preperitoneal fat is identified. An index finger is placed into the preperitoneal space, deep to the inferior epigastric vessels, and the preperitoneal space is developed medially to the symphysis pubis, laterally one centimeter lateral to the internal ring, posterior to the iliac vessels where the spermatic vessels and the vas deferens diverge and anteriorly two centimeters cephalad. This creates an oval preperitoneal pocket measuring about 8x10 cm. The vas deferens is identified and an indirect sac is searched for and removed if present.

The Kugel patch is placed medially to cover the symphysis pubis, Cooper's ligament, the direct space, and the femoral space. The lateral portion of the patch is than inserted to cover the indirect space. The posterior edge of the mesh material should be flipped posterior and cephalad until it lies smoothly on the iliac vessels. The patch is anchored with a single stitch of absorbable suture to the transversalis fascia as the transversalis is being reapproximated. The wound is closed in layers.

Results

During the nine-month study period, 117 patients had hernia operations performed at our institution by the authors. Forty-five patients underwent the Kugel herniorrhaphy, 48 had a preperitoneal laparoscopic repair, and four had traditional open operations (one Cooper's Ligament, one Lichtenstein, and two Shouldice). Twenty patients undergoing laparoscopic repair also had another operation performed at the same time. These 20 and the four open operations have been dropped from the study group leaving 28 patients in the laparoscopic group and 45 patients in the Kugel group. None of the twenty-four deleted patients had any untoward complications; however, the concomitant procedure would make them unsuitable for evaluation for operative time and recovery time.

The Kugel group was composed of 13 right inguinal hernias, 22 left inguinal hernias, and 10 bilateral hernias. Direct and indirect were evenly divided (22 in each group), nine had both direct and indirect components, and there were two femoral hernias.

The laparoscopic group had 11 right sided hernias, 9 left sided and eight with bilateral hernias. Fifteen were direct 13 indirect, six had both direct and indirect hernias, and there were two femoral hernias.

Six of the repairs were for recurrent hernias and two for incarcerated hernias in the Kugel group. The laparoscopic group included six recurrent hernias and one incarcerated hernia.

The average age of the patients undergoing the Kugel repair was younger (46 years, range 22-66) than the laparoscopic group (59 years, range 20-90).

Operating time averaged 44 minutes (20-75 min.) in the Kugel group and 69 minutes (25-180 min.) in the laparoscopic group. Although some of the older patients did not return to work due to retirement status, the average return to routine activities in both groups was eight days.

There were three complications in the Kugel group (7%), one hematoma, which resolved spontaneously, one patient with persistent testicular discomfort, and one osteitis pubis which has responded to steroid injections, but is not resolved. Complications in the laparoscopic group (16%) included four seromas, two hematomas, one superficial wound infection and two patients with prolonged groin pain for longer then two months. One hematoma and one seroma wee aspirated, the others resolved spontaneously. Both patients with prolonged pain resolved. The wound infection was treated with antibiotics and the graft was not removed.

The follow up of this series is short, so recurrence rates are of little value. One of the earliest patients in the Kugel group had a hernia recur in the recovery room. He was taken back to the operating suite and repaired with a Lichtenstein technique (4). He had a large direct hernia and the mesh pushed through the defect when he strained.

Equipment used in the laparoscopic operations cost $776.00 per case more than the Kugel procedure.

Local anesthesia was utilized in 21 patients (47%) undergoing the Kugel repair. General anesthesia was used in all the laparoscopic repairs.

Discussion

Laparoscopic hernia repair has been our procedure of choice for the past seven years, however, the cost of the operation, contrasted to the decreasing reimbursement mandated by third party payers, prompted us to look for a less expensive alternative which has similar results. Almost every series in the literature comparing laparoscopic versus open procedures demonstrates the advantages of a minimally invasive approach with decreased pain and early return to activities (5,6). Mesh placement, allowing a tension free operation, has become the gold standard for hernia repairs (7). The Kugel operation allows placement of a tension free mesh patch in the preperitoneal space through a minimally invasive incision. This essentially gives the patient all the benefits of the laparoscopic repair (I.E. minimal pain, excellent cosmesis, rapid return to work, a tension free onlay patch), without the elevated costs inherent in the laparoscopic approach.

There was a decrease cost per case of $776.00, simply by not using video equipment, trocars, balloon dilators and disposable staplers. This corresponds well with others studies, which have demonstrated up to a 20% higher cost for laparoscopic hernia repairs over open surgery (8,9).

Since the Kugel repair is essentially the same as the laparoscopic repair, it is expected that the recurrent rates will be similar and the early return to activities will be similar. In a report, which compared the preperitoneal laparoscopic repair to the open Stoppa operation, the recurrence rate was slightly higher with the laparoscopic repair (6% vs. 2%), but the series was small and these were not statistically significant (10). Return to work, hospital stays were shorter in the laparoscopic group, but operating time was longer.

Our return to activities was the same for both series; however, the operating time was decreased in the Kugel group. The one recurrence we had with the Kugel repair was a technical error that occurred during the learning phase of the operation, resulting in a recurrence rate of 2% for this early series. There were no recurrences in the laparoscopic group.

Complication rate in the laparoscopic repair was 16%, which correlates well with other reported series (11). While these were minor complications, they were considerably higher than the 7% complication rate seen in the Kugel series.

Even though the Kugel operations in this series included the early learning experience of the operator and extra time was taken for photographing and taping the procedures for teaching purposes, the operating time was still considerable less than that of laparoscopic repair, thereby decreasing anesthesia time and surgeon time.

Although there were no anesthetic complications in this series, despite the elderly age of some of the patients, the ability to use local anesthesia may be desired in some cases. Local anesthesia was utilized in over 40% of the Kugel cases. General anesthesia is utilized routinely for laparoscopic procedures.

Since sutures are not utilized near the nerves, injury to the lateral femoral cutaneous and genitofemoral nerves should be minimized. The incision is approximately 2 centimeters cephalad to the standard open incision and the external ring is not opened, so the ilioinguinal nerve should be well caudad to the incision and out of the field of dissection.

Conclusion

The Kugel herniorrhaphy is essentially the same operation as the laparoscopic preperitoneal repair, utilizing a different approach to the preperitoneal space, and should have similar results to the laparoscopic operation. We have confirmed that with this study and have demonstrated the Kugel procedure can be performed in a shorted surgical time at a decreased cost per case and can be performed under local anesthesia. The Kugel hernia repair provides the patient with a cost efficient, minimally invasive, tension free operation.

References

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