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EDITORIAL ARTICLE FOR THE MONTH OF NOVEMBER The mess repair

“No disease of the human body, belonging to the province of the surgeon,

Requires in its treatment a better combination of accurate anatomical

Knowledge with surgical skill than

HERNIA in all its varieties.”

-       Sir Astley Paston COOPER,1804.

Thus inguinal hernia and its management is always the most favorite topic for the surgeons. More so to fancy is the mesh repair popularized by Lichenstein and colleagues. Lichenstein first published his experience of “onlay sutured mesh tension-free hernioplasty” in 1986(1). It included 300 consecutive cases of inguinal hernia which was updated in 1989 to 1000 cases with minimal complications and zero recurrence rate after a follow-up of between 1 and 5 years. However, Lichenstein was ridiculed by the Anglo – American surgical society and remarks like “…….results as presented are laughable” were allowed to appear in the issues of American Journal Of Surgery (2). Now, more than ten years after his first publication Lichenstein repair has become the sine quo non of hernia repair.

But the question is, “are we doing a mesh repair?”.

Lichenstein advises,

1.    Hernial sacs to be inverted into the abdomen without ligation, for ligation of the highly enervated peritoneal sac is a major cause of postoperative pain and nonligation does not increase the rates of recurrence (3).

2.    The medial end of the mesh is sutured to the anterior rectus sheath above the pubic bone and the perisoteum is avoided.

3.    A 8x16 cm size of the mesh is used for mesh reduction area in the first year is 20% (4).

4.     A thorough exploration of the groin is necessary to look for interstitial, low spigelian and femoral hernias.

5.    The lower edge of both the tails are sutured to the inguinal ligament to create a neo internal ring.

6.    atleast 5 cm of the mesh is left beyond the internal ring in the lateral side excess of which is trimmed.

7.    A mesh which is completely flat with no ripple in a patient under sedation and ina recumbent position will be subject to tension when the patient stands or strains or is in a standing position.

Are we doing any of what is advised?????

But still we pretend to call what we do as Lichenstein’s repair, which is really laughable.

To recall what exactly we do as mesh repair, always transfixation, ligation of the sac is done. The size of the mesh used is about 4x7 cm or even smaller. A neo internal ring is hardly ever created. Always a bite is taken in the periosteum of the pubic tubercle. Usually there is a full tension flat mesh repair.

Thus it is prudent to call it “mess repair” than “mesh repair”. I urge my fellow surgeons to keep in mind the literature and the proven studies to do to patients what is right rather than what they have been thought or thinking is right.

REFERENCES:

1.    Lichenstein IL. Hernia repair without disability, 2nd ed. St Louis: Ishiyaku EuroAmerica, 1986

2.    Sarr MG. The tension-free hernioplasty [Letter]. Am J Surg 1990; 160:139

3.    Smedgerg SGG et al. Ligation of hernia sac? Surg Clin Of N Am 1984;64:299-306

4.    Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997;1;12-19.

5.    Bailey and Love’s short practice of surgery

6.    Nyhus and Condon’s Hernia.

About the Author

Dr.A.Anirudhan

M.S Postgraduate

Department Of General Surgery

Madras Medical College, Chennai - 03.