Controversies in Inguinal Hernia Repair

Inguinal hernia repair is one of the oldest operations ever documented-in fact, the first record of it dates prior to the Middle Ages. Today, herniorrhaphy is one of the most common surgical procedures-in 1996, surgeons performed more than 750,000 repairs, and more than 80 percent were ambulatory cases. Even though hernia repair is a relatively simple procedure, repair techniques differ widely, and it's likely that your surgeons will feel strongly about a particular kind.

Pre-made mesh plugs, topped with a mesh overlay, are becoming a popular repair choice for many surgeons. Shown here is Davol's PerFix Plug.

The key to making inguinal hernia cases profitable for your facility is trying to garner as many of those 750,000 cases as you can and making sure your surgeons, whatever method they choose, can perform the repairs efficiently and successfully. Consider that Medicare's proposed payment rate for inguinal hernia repair is $739. Out of that payment, you'll have to cover three main costs: OR time, recovery room time, and the cost of the prosthetic or device used to do the most commonly performed "tension-free" repairs (more on this later). The type of mesh or device your surgeons choose will almost always depend on the technique they employ; the cost of the prosthetic could run as high as $200 for a Kugel hernia repair patch. But if your surgeons are most comfortable with Kugel repair, if they perform it efficiently, and if patients can go home quickly with minimal post-op pain, it may be well worth the cost to accommodate them. Investing in a new laparoscopy suite for surgeons who only perform this type of repair is more expensive, but it still may make sense, especially if your surgeons can perform the repairs efficiently, build case volume, and get great results. Laparoscopic repair is also thought to be superior for some types of hernias.

Some surgeons will undoubtedly insist that one method is markedly superior to all the rest, but there's very little evidence to support this. Instead, the data overwhelmingly suggest that all of these techniques, performed by skilled surgeons, work well. By and large, all patients enjoy a quick recovery period and recurrence rates are low. But understanding what the different techniques are may help you evaluate them more effectively, determine what surgeons need, and decide which procedures you want to host in your facility. Read on for a brief crash course.

Traditional Repairs
Until the late 1980's, most surgeons repaired hernias by simply pushing back the protruding tissue and suturing together the edges of the defect in the abdominal wall. Today, some surgeons still use these "tension" methods (variations include the Bassini/Halsted, Cooper/McVay, and Canadian/Shouldice repairs). Surgeons at the Shouldice Hospital in Toronto, Canada, a dedicated hernia hospital, have completed more than 250,000 repairs using a tension or "pure tissue" technique that uses steel wire sutures to close the wound; they claim a recurrence rate of only one percent. Critics of the tension-free method say that suturing puts too much tension on the sides of the defect, causing pain and an increased recurrence rate. "As far as cost goes, tension hernia repair may be less expensive (in terms of materials used), but it may also be more difficult," says Dennis Witmer, MD, a Delaware-based general surgeon who used to perform conventional repairs but has since switched to newer techniques.

The Prolene Hernia System is a "three-in-one" system that combines the benefits of three techniques, proponents say.

Mesh-Based Repairs
The repairs that Dr. Witmer and most other surgeons now use are variations of a "tension-free," or mesh-based technique. All involve either plugging or patching the hole in the abdominal wall with a piece of polypropylene mesh.

In the mid-eighties, hernia surgeon Irving Lichtenstein, MD, caused a stir among his colleagues when he proposed that using a piece of polypropylene mesh was the best way to repair all inguinal hernias. Prior to this, surgeons had been using mesh only for large or recurrent hernias and only when they felt it was absolutely necessary-they felt that using a "foreign body" for repair increased the risk of infection. However, Dr. Lichtenstein persisted, and in 1989 published a study of 1,000 patients who received the Lichtenstein repair, experienced minimal complications, and had a zero recurrence rate after a follow up period of between one and five years. By the mid-nineties, many surgeons agreed that tension-free was easier to do and generally led to fewer recurrences and decreased recovery time. These days, most surgeons prefer tension-free techniques, since mesh does not place tension on the sides of the wound, gradually incorporates into the abdominal wall, and, in the vast majority of cases, does not pose any threat of infection.

There are three main types of tension-free hernia repairs. A breakdown:

Lichtenstein Hernia Repair: This type of tension-free repair uses an open anterior approach, meaning that the surgeon sutures a mesh patch over the hernia in front of the abdominal muscle wall. Parviz Amid, MD, a surgeon at the Lichtenstein Hernia Institute in Los Angeles, has no doubt that the Lichtenstein repair is an improvement over traditional tension techniques. "In an old-fashioned tension operation, the surgeon simply stitches together the edges of the patient's weakened tissue," he says. "When the patient coughs or strains, the edges of the defect can tear apart. Also, when the edges of the tissue are brought together forcefully, it causes greater post-op pain and a longer recovery period-sometimes as long as two months." The Lichtenstein repair, says Dr. Amid, "bypasses the problem of working with degenerated tissue by placing the edges of the patch on surrounding healthy tissue, providing a stronger reinforcement for the abdominal wall."

Dr. Amid also says that the Lichtenstein method is the easiest for surgeons to learn, has a near zero recurrence rate, minimal post-op pain, and a recovery period of two days to two weeks. He also claims that 80 percent of all surgeons who perform hernia repair perform tension-free procedures; of these, he says that 80 percent perform the Lichtenstein repair.

Mesh Plug or "Plug and Patch" Repair: In this technique, the surgeon uses a mesh plug to fill the defect in the abdominal wall (think of a cork stoppering a bottle). Surgeons used to hand-roll their own plugs from pieces of mesh, but many now favor pre-made tapered plugs (like the PerFix Plugs), which are shaped like a shuttlecock. The surgeon can customize the plug by removing the "petals" of the device; he then places the plug in the defect, tapered side down, and reinforces the repair with an onlay patch (which, unlike the Lichtenstein repair, does not need to be sutured into place).

Proponents of the mesh plug technique claim it is easier to perform than the Lichtenstein repair, requiring a smaller incision, fewer sutures, and less tissue dissection. They also believe the technique causes less post-op pain. One particularly vocal champion of the mesh plug method is Ira Rutkow, MD, who owns a surgical hospital dedicated exclusively to hernia repair in Freehold, N.J. While Dr. Rutkow concedes that most hernia repairs, done properly, will yield good results, he claims the mesh plug method is the easiest for surgeons to learn. Dr. Witmer, who switched from a conventional method to the mesh plug technique, agrees. "There seems to be very little pain, plus it's very easy to do," he says.

Surgeons who subscribe to the Lichtenstein method, however, question the mesh plug technique's effectiveness. According to Dr. Amid, mesh plugs were originally used to repair femoral hernias, another type of groin hernia that occur in a tunnel in the crease of the thigh. With femoral hernias, the plug technique works as it's supposed to-the "cork in the bottle" analogy is more applicable, he says. When mesh plugs are used for inguinal hernia repair, however, they tend to shrink, become loose, and in rare cases, poke into the bladder or intestines. Surgeons who use the mesh plug technique counter this claim, saying that these risks, while theoretically possible, are extremely low.

Laparoscopic Hernia Repair: In laparoscopic hernia repair, the surgeon uses a laparoscope to visualize the hernia and affix a mesh patch behind the abdominal muscle wall; in this technique, the patch rests against the thin inner lining of the abdomen called the peritoneum (this is commonly referred to as a posterior approach). "This is like repairing the hernia from the inside out," says Uyen Chu, MD, a laparoscopic hernia surgeon at the University of Kentucky Medical Center. Supporters of the laparoscopic technique claim that affixing the patch posteriorly provides a stronger repair; the natural intra-abdominal pressure pushes the patch up against the interior of the abdominal wall and holds it in place. They compare the abdominal wall and the peritoneum to the outer wall of a tire and the inner tube; the laparoscopic technique, they say, allows them to get "behind" the defect and armor plate the body's inner tube. Some surgeons also claim that the smaller incisions used to insert the laparoscopic instruments are less invasive than using the "open" approaches of the Lichtenstein and mesh plug techniques, allowing for the best recovery times.

Many surgeons hotly debate this last claim, saying that when you add up the multiple incisions used for laparoscopic repair, they closely approximate the length of a single open incision. Furthermore, critics say, laparoscopic repair is difficult to learn and always requires general anesthesia, while open methods usually require only local or epidural anesthesia. Finally, say critics like Dr. Amid and Dr. Rutkow, there's no clear evidence that laparoscopic repair leads to fewer recurrences or decreased recovery time. Even the critics agree, however, that laparoscopic repair does have its place: It may be a less invasive method to repair bilateral hernias, and it also may be useful to repair recurrent hernias without disturbing the site of a previous incision.

Other Repairs: The wide acceptance of mesh-based repair in the 1990's caused an explosion of interest in creating better mesh devices-preformed mesh plugs were among the first such devices. Two recent advancements of note are the Kugel Hernia Patch (cost: about $200) and the Prolene Hernia System (about $130), which are both used in open repairs.

The Kugel Hernia Patch combines a mesh patch with a patented "memory-recoil ring" around the device's perimeter. The surgeon places the patch behind the abdominal wall using a posterior approach, in a technique similar to laparoscopic repair. The ring is supposed to spring open inside the abdominal wall, helping to hold it in place with the help of one anchoring stitch.

The Prolene Hernia System is a "three-in-one" device consisting of an onlay patch that goes on top of the abdominal wall, a connector piece that plugs the defect, and an underlay patch that deploys in the preperitoneal space and provides support behind the abdominal wall. This device purportedly combines all the benefits of the Lichtenstein, mesh plug, and Kugel techniques. Arthur Gilbert, MD, a Florida-based surgeon who pioneered the development of the Prolene Hernia System, says this is the only device that covers the entire myopectineal orifice, while the other techniques leave areas of the abdominal wall vulnerable. He also claims that the anterior approach used to place the Prolene patch is simple to learn and perform; the Kugel patch, he says, has a steeper learning curve. Proponents of the Kugel Patch, of course, disagree. Timothy Fox, MD, who performs Kugel repairs at the Paoli Surgery Center in Paoli, Pa., routinely completes his repairs in under a half-hour; he says post-op pain and recurrences are minimal.

Besides coming up with new devices, many companies are developing variations on the standard polypropylene mesh; most experts agree that all types provide adequate strength, stimulate tissue ingrowth, and, in the vast majority of cases, don't increase the risk of infection.

Which to Choose?
- Despite the many different types of hernia repair and the cutthroat nature of the hernia device marketplace, most surgeons agree that when performed correctly, most tension-free hernia repairs work just fine, with an average recurrence rate of 2 to 4 percent and very little post-op pain. Most patients resume normal activities within days. Costs of the procedure depend almost completely on OR time; a surgeon skilled in a particular open technique can usually complete a case in under a half-hour. Laparascopic repairs may take longer; from 30-45 minutes, according to Dr. Chu, but the increased OR time could be warranted if your surgeon is comfortable with this technique and achieves good results.

You probably won't be able to convince a surgeon to choose one repair method over another; the key to hosting successful hernia procedures is making sure your surgeons are comfortable with their chosen method and have the devices, equipment, and staff to perform them well. Surgeons can squabble over technique at medical meetings; the debate matters little as long as the technique they use keeps your patients healthy and happy and allows you to stay profitable.