Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current and General Surgery is created and edited by Jeffrey Ponsky, Todd Ponsky, and Harveen Lamba in partnership with GlobalCastMD and is recorded and produced at Cleveland Clinic in Cleveland, Ohio. Good morning. I'm Dr. Jeffrey Ponsky. I'm a professor of surgery at the Cleveland Clinic Lerner College of Medicine and in the Department of Surgery at the Cleveland Clinic main campus in Cleveland, Ohio. And I'm here with Dr. Michael Rosen, who's also a professor of surgery at the Cleveland Clinic Lerner College of Medicine here in Cleveland, Ohio. And we're here today to discuss the simple topic of inguinal hernias. And I say the word simple because it's anything but simple. This is a topic which has challenged surgeons for a century. And every generation really believes that they have the correct answer to hernia repair. They're absolutely convinced and certain that the discussion is over and then the next generation comes up with a new solution to an old problem. I'm not convinced that we've accomplished the final solution yet, but we're here today to discuss Dr. Rosen's opinions on this. And Dr. Rosen always has a lot of opinions. Good morning, Mike. How are you? Good morning, good morning. So let's start out with the simple thing. If a patient comes to your office and they have a complaint, and we're going to talk about inguinal hernias, and they have a complaint of a bulge in their groin or some discomfort in their groin, you do a physical examination. And indeed, let's say you find a right inguinal hernia bulge. Let's assume that this patient is a 89-year-old gentleman who has been sent to you by his internist because the internist noticed this bulge in the groin. But this man says, this doesn't bother me whatsoever. What are your concerns and what are your thoughts at this point? So I think like anybody who sent you with an inguinal hernia, first you want to do an exam and you want to confirm whether they have an inguinal hernia. I have to say that can be one of the hardest things to do because there are small hernias that on physical exam are extremely difficult to feel. And there are many patients who are sent to me where the primary care physician thinks that they felt a hernia. And in fact, on my exam, I don't think they have one. So I think first you need to confirm it and just remember that anytime somebody stands up and coughs or does a valsalva, there's always the cord structures that are going to be giving you an impulse. So you really want to make sure that you actually see a bulge and it's a true hernia. Assuming that it is and then you take a detailed history and the patient's not symptomatic, not having any GI complaints, not having any urinary complaints, and it doesn't limit any of their activities, and you put this hernia in the asymptomatic to minimally symptomatic in an elderly patient, there is evidence that you can just watch these. So you're referring perhaps to Bob Fitzgibbon's study, the VA study, which suggested that perhaps we can watch these asymptomatic hernias. So Bob Fitzgibbon's study actually just had another study. He followed those patients longer term. And so I think it's really key. So his original study was in thousands of VA patients who had minimally symptomatic to asymptomatic hernias. They were in their 70s to 80s. And they basically randomized people to two groups, immediate surgery with an open operation and mesh to observation. And so there are two key findings out of this study. Number one is the risk of presenting with an emergency problem needing an operation due to your hernia due to incarceration or strangulation or something in the middle of the night was less than 1%. It was actually a third of 1%. So it's safe to watch people. But the problem with this study is this study was over two years. Almost a third of the patients went on to develop symptoms and need an operation. Now, they didn't do any worse with their operation. So it was safe to watch them. But they ultimately went on to surgery. He went on to follow those patients up even more long term. And by about five years, almost three quarters of the patients developed symptoms. So if you see somebody in your office who has an asymptomatic hernia, the patient you gave me was 89 years old. I think it's okay to wait and watch because the odds are in a couple of years, they might not have any symptoms and you'll be okay. But in a younger patient, the odds are against them that they're going to live the rest of their life without this becoming symptomatic. So for that patient, I would say when the time is right in your life, there's no emergency here. It is probably something that you ought to get fixed. So before we get into the surgery for hernia, which is what we are going to talk about, let's spend just a little bit of time talking about how not to operate on hernias. And both of us occasionally see patients who have very difficult comorbidities to manage. They may have had severe cardiac disease, ascites. They may have blood clotting disorders and all sorts of difficult problems, very low cardiac output. And we see these patients, they have perhaps even a large hernia, which is reducible, clearly reducible. But under any ordinary circumstances, we would operate on these patients, but they're horrible operative risks. What would you do with this patient? So I think those patients really need to be carefully counseled and take a detailed history and figure out whether this is symptomatic or not. If it is not symptomatic in that patient, I certainly would wait and see. I would teach them how to reduce it. I would explain to them what it means. I would have them lay down and teach them how to push it back in. You can wear a truss, although a lot of people find that uncomfortable and it can push on the nerves, but it can be done. But I think that if those patients are symptomatic, it is something that probably should be done. And we'll talk about technique, but these can be done in a local anesthesia. And so in a lot of those patients you mentioned with ascites, with terrible hearts, it's much worse for them to present with an emergency problem in the middle of the night, which could be life-threatening. So they still, if symptomatic, difficult reductions, they probably ought to be offered repair. So now that we're talking about patient's selection, let's talk about, assuming a patient has a primary inguinal hernia, the selection of the correct operative approach for that patient. You know, it used to be very simple. When I was just a young intern, it was just one thing to do. We just did an operative repair, and it was often at that time a McVeigh repair or a Bassini repair. Those were repairs, God forbid, without mesh and which were very standard at the time. We did a lot of Bassinis and often felt guilty because we didn't do the anatomical McVeigh repair. But those were what we did. We learned to do them under local anesthesia sometimes, and we got pretty fast file at it. Today we have a big menu of what we can do. We can do the open repairs. We can do them without mesh. We can do them with mesh, such as Lichtenstein. But we can then go to the laparoscopic repairs, and we can do the preperitoneal or extraperitoneal repairs. How do you select the correct repair for a patient who has never had a hernia repair before, who has a reducible, uncomplicated, but symptomatic inguinal hernia, who's at reasonable operative risk? Let's say the patient has no comorbidities of significance. So as far as literature support either decision, you can find ample literature on both sides that support all of the approaches that you mentioned, which would be a tissue repair, an open mesh repair, or a laparoscopic mesh repair. So I think for a unilateral primary hernia, any one of those approaches are okay. I think that the right answer to that question would be defined based on the patient that you have in front of you. And I think equally, if not more important, based on your skill set and where you're at with the learning curve of all of these operations. And there's clearly a learning curve to laparoscopy, but there's clearly a learning curve to open inguinal hernia as well. And I think that ultimately, it's been shown in the literature that the best approach is what you do best. Now, having said that, I'll take it from a personal perspective of what I do. And I do occasionally tissue-based repairs. I still do plenty of open repairs. And I do a lot of laparoscopic repairs. So I think if I had a young, healthy, active patient with a unilateral hernia, who was not an anesthetic risk whatsoever, and you are past your learning curve of laparoscopy, which is real. In some studies, 200 to 250 cases. In my practice, that would be a laparoscopic inguinal hernia repair. With the primary reason that there is one difference in skilled surgeons' hands that seems to be consistent, is that laparoscopy, you're putting the mesh away from the nerves, and the risk of chronic pain in laparoscopic inguinal hernia repair, when done right, is lower than the risk in open inguinal hernias. And I think that how do you measure chronic pain in open inguinal hernias depends. If you do a very detailed survey, you'll have a very high incidence of chronic pain. If you just wait until patients come back and present with chronic pain, it will be lower. But those patients are absolutely miserable, and it can happen due to a technical problem. It can just happen due to the mesh laying on the nerves. So in young, healthy patients, I prefer a laparoscopy, recognizing that it's not for every surgeon, and an opening or hernia is still a perfectly appropriate operation. All right, so let me just dive into that a little bit. When you talk about the laparoscopic repair, and I know that you particularly prefer the tap repair, the transabdominal preparitoneal, there are many surgeons who do that, but there is an equal number, if not greater, like the total extraparitoneal repair, using the balloon for dissection. Is there a significant difference in the literature on the results of those two procedures? No. I don't think it's ever been studied well enough to give you level one evidence for that. And again, I think that they both have their advocates. They both have their limitations. I think the TEP pair, it's a little bit more expensive because you need to use the balloon. It's a little bit smaller of a space, but perhaps the angles are a little bit easier to operate with. I think a TAP, you get a little bit of a better view. You get a little bit more of a working space. It's a little bit easier when you're early on your learning curve to be able to look intraperitoneally and see if you actually reduce the hernia, which is a common issue when you're learning how to do laparoscopic hernias. So I think that they're both appropriate. The way that I look at it is it's the same room. One comes through the front door. One comes through the ceiling. Ultimately, you work in the same space, and it should be the same operation regardless. So when you talk to a patient about the difference between the open repair and the laparoscopic repair, how do you present the advantages or disadvantages of each? Well, one of the things that I say to the patients, and I say this to everybody when we talk about different approaches, is that if it was my family member who called me and had an inguinal hernia and was seeing a surgeon, I would say make sure you pick somebody that you like who's done this operation a lot. Because I think that that surgical skill is critical. And you don't want to be getting an inguinal hernia in the surgeon's first couple laparoscopic inguinal hernia operators because there is a real learning curve. So what I tell them is in my hands, I think that they're both equivalent. But the laparoscopic repair offers you about a week to 10 days earlier recovery. It's not a month. It's not three or four months, but it is about a week to 10 days in my practice. And it offers you a place to place a mesh away from the nerves. I think the disadvantage of it is that you have to operate near the intestines, whereas open, you're in a separate plane. So there is a risk of intestinal injury. There's a risk of injury to the major blood vessels because you're in that area. But again, if you are safe and know those planes, that risk should be incredibly low. And the consequence of chronic pain, which is starting to become one of the most common things that I see in my clinic with open mesh repairs, is not worth that risk in a young, healthy, active patient who can tolerate general anesthesia and would likely benefit from getting back to activity a week or two faster than an open. In an elderly patient, any anesthetic risk, and I should mention anybody who's on any anticoagulation needs to start back up quickly. I don't want to dissect out that retroperineal space. They get an open operation. At full disclosure, it's rarely under local anesthesia. Most of the time it's still under at least LMA-type anesthesia, but a lighter anesthetic without having to its flight their abdomen. So let me go back over this again with you. So certainly another thing that I often present is that if there's any question of a hernia on the opposite side, the laparoscopic approach lets you go in with minimal morbidity, see the other side, and fix it if necessary. So that's an advantage, isn't it? Let me interrupt you there. So interestingly, it's a pro and it's a con, because what do you do in a 78-year-old patient who has a symptomatic hernia on one side and you're laparoscopically going in and you see an asymptomatic hernia on the other side that you would have never seen open? I fix it. So I don't fix it. And let me just tell you, you know, the problem is you see something there that you would have not seen open, and now you're doubling the anesthetic time, albeit maybe another 45 minutes, but still longer. You increase the risk of hematoma. So in an elderly patient, I don't. In a younger active patient, I think the chance of that going on to be symptomatic is much, much higher. So you at times can see things that are irrelevant to these patients. Okay. So another factor is the consideration of the cardiac status of a patient prior to selecting your procedure. A patient with reduced cardiac capacity may suffer from decreased cardiac return with increased pneumoperitoneum, right? Do you consider that an issue? So I think the pneumoperitoneum is rarely a problem. Now, I think that's something that we worried about in the past. I think as long as you know their cardiac function, you insufflate very slowly. You drop your insufflation pressures and work at the lowest pressure possible. And most of the time, you're going to be in trinella, bros. You're going to help these patients out a little bit. That's a rare but not zero issue. But I think that you also have to remember that, and I said this before, but, you know, the benefits of laparoscopy are small for the vast majority of patients. Still worthwhile. But you have to check your minimally invasive ego at the door and make sure that you also can do opening oral hernias or in a patient who's a candidate, send it to somebody who can do opening oral hernias. Because if you're pushing it laparoscopically in a sick, comorbid patient, more often than not, it's because you don't feel comfortable doing it the opening of the way and you use your go-to move. So let's talk about cases where you would not do laparoscopy. Let me give you some suggestions and comments. Previous abdominal surgery, comment on that. Can be done laparoscopically but would not be done in my hands, especially if it's lower abdominal surgery. Increases the risk of enterotomy, increases the OR time. And as long as they haven't had an opening or a hernia, I would do that operation the easiest way possible. Patient with previous prostate surgery. I've done those in the past and they are unpredictable. At times they can be straightforward and easy and at times they can be brutal. Today in my practice that would be an opening or hernia. Okay. So we have the differentiation and indications for one procedure versus another. So let's talk a little bit about the operations themselves. When you do a, let's first talk about the laparoscopic approach. And we're doing a laparoscopic approach. And I happen to think that the anatomy is very clear, probably even more clear sometimes than it is with open surgery. You can see the femoral space, the direct space, the indirect space all at one time, even obturator occasionally. Do you vary your repair based on what you see as the type of hernia? For example, if you see the patient has a femoral hernia versus a straight direct or versus an indirect, do you vary your tap repair in any way? Or do you just put the piece of mesh in the same place and be done? So I mean, I think there's basic tenets to any laparoscopic hemoral hernia repair that have to be met. And then there might be a bit of tailoring. So some of the basic tenets are you need a wide dissection plane. I think early in people's laparoscopic experience, there was a lot of time spent talking about the lateral dissection plane. And in fairness, I think that's because that's the easiest space to create, but it's the least relevant for recurrence. I think the most important part of any laparoscopic repair, and it's a basic principle that Rene Stoppa promoted during open preperitoneal repairs, which is parietalization of the cord, which essentially just means stripping the peritoneum off the cord inferiorly and posteriorly. And that length is what's critical because when you lay your mesh for whatever type of hernia you have, femoral, direct, or indirect, the risk of recurrence to the peritoneum coming under the mesh and then going back out to the defect. Inferiorly. Inferiorly. And the inferior dissection is the Achilles heel of any laparoscopic repair because it's awkward to view it. It's a little bit scary that you're going to start to make holes in it, and you're taking it very close off the vessels. And I think that when I watch a lot of laparoscopic repairs, that's where the weaknesses start to show up. And the other issue with that, when you don't take that peritoneum far enough back, in my opinion, is when you start to use a smaller piece of mesh. And so the question was about tailoring the repair. What will oftentimes happen is people tailor the size of the mesh to the defect. And we know all mesh contracts to some degree. All mesh can move. And while we espouse that in laparoscopy we're doing a stopa-type repair, if you go back and read stopa's original descriptions, his description, if you were doing a unilateral inguinal hernia, was to never use less than a 15 by 15 centimeter piece of mesh or a 6 by 6 inch piece of mesh, which is much bigger than the vast majority of laparoscopic preform meshes or meshes that are being placed. So I think you need a very wide dissection plane. Whatever type of hernia I do, they get the same dissection plane because that's how I'm used to seeing it. I think maybe if they have a femoral hernia, I think a little bit more down in the space of Rhetzius. Certainly if they have an obturator hernia, I will go much lower than I usually do. I don't routinely dissect out the obturator space, but for direct and indirect, it's typically the same. The only other advice I will give for a large direct hernia is I think your mesh choice should change a bit, and you probably should be using a heavier weight material. There's now lighter weight meshes, which we define. Okay, you stepped into it now. Yeah. So I got you now. So talk to me. And here I am, just a simple guy doing a hernia repair. I've got this beautifully dissected. Now I turn to my nurse and say, what mesh should I use? Because she might know better than me. What kind of mesh should we really use considering what's effective, what's proven to be better, and what the costs are? Got it. Okay. So first of all, I think that there is a litany of meshes now. And it's created much, much more confusion, much, much more expense. And particularly for inguinal hernias, I'm not sure any clinical benefit over a standard piece of polypropylene mesh. But in general, the way that we define, and this will just be for polypropylene mesh, uncoated polypropylene mesh. There's basically three categories, heavyweight, midweight, and lightweight. And those categories were not defined based on science. They're defined based on marketing companies and with theoretical advantages of one over the other. So a heavyweight mesh would be something in the 90 grams per meter squared range, which is typically what we think of Marlex or proline mesh, depending on the company. A midweight mesh is somewhere between 40 to 50 grams per meter squared. And then a lightweight mesh is really only one category, which is ultra pro, which is less than 30 grams per meter squared. It actually starts out a little bit heavier than that, but then it goes away over time and gets down to about 28 grams per meter squared. So the advantage of the lighter weight material is there's less foreign body. You feel it less. Perhaps it contracts less because it ingrows more. The disadvantage of it is you have half the material. And depending on the stresses and particularly in a direct hernia where it's a bridge and the muscles will never come back together, that mesh is at risk for fracturing. And there's a couple reports that are starting to show up now where you have central mesh failures where they break. Now, the heavier weight mesh rarely breaks, but sometimes people feel it, particularly in their groin, if there's wrinkles or buckles in the mesh. And that can cause issues as well. So I think you should tailor the mesh to the patient. And then I should say now there's preformed meshes for the inguinal hernia anatomy that open up, are certainly technically easier to place. But one word of caution, and this is very common, and I've certainly seen much of this, surgeons tend to downsize that mesh to a much smaller piece of mesh. And I think if you're doing an inguinal hernia, I don't think you should ever use smaller than a large of those preformed meshes because you need to cover the whole myelope. So that's a great point because if the mesh is too big, you haven't done enough to section. And so if you're doing a laparoscopic inguinal hernia repair and you are struggling with the mesh, it is never that you're not a good enough laparoscopic surgeon. It's that you didn't dissect out the space to put the mesh. And it's not because you have too big of a mesh. It's because you need to take out the mesh and dissect bigger. Okay, so let's move along a little bit. I want to ask you a bunch of questions with quick answers so we can get through this. Number one, how do you fix the mesh in place? So I believe you should fix it. I use Protax. There are people who use glue, and there are people who use no fixation. If you're a no fixation guy, still select them. If you have a big direct, everybody will use fixation. So how about the absorbable versus non-absorbable tags? No evidence that absorbable fixation causes reduction in pain, better fixation, or improve long-term outcomes. So I use permanent fixation. And absorbable fixation, if you put it through the nerve, it's the neuroma that causes the problem, not the attack. Okay. Let's go to open repairs now. Okay. A little bit. So which open repair do you like? I do a Lichtenstein. All right. And so the Lichtenstein is, again, with the mesh, and it's a tension-free repair, which has become the standard over the last, say, 20 or 30 years. So we all like that. There's been a discussion of what to do when you have an infected field or a contaminated field. What do you think about that? So there's certainly mounting evidence that you can put a medium-weight polypropylene in a contaminated field. We have several series in ventral hernias. I think depending on the level of contamination, depending on the indication of the operation, it's perfectly appropriate to do that. But I also think it's perfectly appropriate to do a Bassini operation or a McVeigh. I certainly do that. That's still a great operation for the vast majority of cases. So let me talk a little bit about McVeigh. McVeigh is something that I used to do. It was under so much tension I hurt when I left the operating room. But now that we have the Lichtenstein concept with mesh, you can do a McVeigh repair without tension and create sort of a normal floor reaching down to transercellus fascia. And I think that's an acceptable repair for femoral hernias done from an open approach. Talk about your approach to femoral hernias. Do you do the infraligamentous repair ever, or do you always do a straight-ingual repair? So I think it's a great little pearl. If you have a patient with an incarcerated femoral hernia that you know that there's bile there, what I will do for those patients is I make a vertical incision, almost like a vascular exposure, dissect right down onto the hernia sac. You often can't reduce these. If there's a compromised piece of intestine, you can actually just bring it out and resect it, infra-inguinal, do your anastomosis, and then the hard part is getting it back in. Another little pearl. I'm not a fan of dividing the inguinal ligament. I don't think you typically need to do that to get it back in. I do that occasionally. I know you do. That's why I'm trying to correct this right. So what I would recommend you do is, as we know that the anatomy is the inguinal ligament comes down, medial to the femoral space, it gives off the lacunar ligament, which is the arc-shaped ligament that's going down to the pectoneal line. What you can do, and if you remember, lateral to the femoral space is the femoral vein. All you have to do is put your right angle in and let the bow or the hernia contents be lateral, and you can just take scissors or a bovee and cut medially. You can get an extra centimeter by releasing the lacunar ligament. You don't have to destroy the inguinal floor or the inguinal ligament, and almost always you can get that reduced back in. And then what I'll do is actually, I call it a reverse McVeigh. So you're looking in front inguinally, and in a McVeigh, you're taking the inguinal ligament down to Cooper's ligament. I can do that from below, taking the outside or inferior border of the inguinal ligament and sewing it down. I start immediately so I see the femoral vein to make sure that you don't impinge on it, and I can close the space from below. You don't use a piece of mesh in there? I don't like to plug that. I have actually done that in the past. You know, the femoral hernias tend to be thin women, and I've had a DVT due to the irritation on the femoral vein. So I don't like to. I just do a reverse McVeigh. And if they get a recurrence, then I can always go back laparoscopically from the other place. So let me just give you a few final questions to have you comment on. Recurrent hernias, which is your favorite approach? I think for a recurrent hernia, you should go where nobody's been before. If somebody's been in both places, you should go where you're best. Okay, very good. Number two, if you have a patient with bilateral hernias, what do you do? If there are no bilateral hernias and you're a skilled laparoscopic surgeon, I think laparoscopy is the way to go. I think if you're not, it's not the hernia operation to learn on because it makes it twice as hard. I think if you're going to learn and get through the learning curve, you should avoid bilateral and recurrent hernias laparoscopy. Although that might be the patient that gets the most benefit, it's the patient that has the highest risk. But you would agree that a skilled laparoscopic surgeon can do bilaterals? The best approach. The best approach. No doubt. Okay. Finally, and this is what gives me pause, is the incarcerated inguinal hernia done laparoscopically. Do you do them that way? So what I'll do is put a patient to sleep. If it's an inguinal scrotal, let's say if it's a really big inguinal scrotal, when I was younger, I did them laparoscopically. Now I do them all open. If I can't reduce it in the office and it's truly a scrotal hernia, they get an open operation. If it's just difficult to reduce, then I'll typically put them to sleep, reduce their energetic anesthesia. I do TAPPs. I think if you only do TEPs, truly incarcerated hernia is not a good idea because you want that stuff out of the contents. I'll put people to sleep, try and reduce it. There's several mechanisms to do that. You can actually laparoscopically go in and you can cut the internal ring while looking at the epigastric and going at the two o'clock position to get it to reduce back in. But if I can't reduce it, I'll just do it open. You can open, reduce it, and go back and put the max laparoscopically as well. But you want to be careful because if you make holes in the bowel, the morbidity this operation goes up unacceptably high. So let me just summarize a few things here. However, a skilled hernia surgeon should understand both the open option and the laparoscopic option, be good at both of them, and choose which one is optimal for his patient. Would you agree with that? A hundred percent. All right. I want to thank Dr. Michael Rosen, professor of surgery at the Cleveland Clinic Lerner College of Medicine, for being our expert today and for helping us understand this complicated yet common problem of inguinal hernias. Thank you very much, Michael. Thanks for having me. It's been a pleasure. We hope you enjoyed this episode of Stay Current in Surgery. You can listen, watch, or read all content anytime by downloading the Stay Current in Surgery podcast app in the Apple iTunes Store or Google Play. Send comments or questions to staycurrentpodcasts at gmail.com. We'll see you next time. And the in-sus-mout. I know. I know. I know. I know. I know.
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