kugel

Minimally Invasive Open-Preperitoneal Herniorrhaphy (Kugel)

Gene D. Branum, MD

The minimally invasive open-preperitoneal herniography (Kugel) uses a mesh patch (Surgical Sense, Inc, Arlington, TX) composed of two layers of polypropylene mesh and a proprietary monofilament self-expanding ring. The design allows placement of the mesh into the preperitoneal space using a minimally invasive incision. The mesh placement mimics that of totally extraperito- neal laparoscopic herniography (TEP), but is most often performed under local anesthesia with sedation and requires no specialized equipment.

Preperitoneal hernia repair has had many proponents. Drs Nyhus and Stoppa have advocated the approach for primary and, especially, recurrent groin hernias. 1,2 The laparoscopic approach to the preperitoneal space has been popularized within the past 10 years, but many

From the Department of Surgery, Emory University School of Medicine, Atlanta, GA.

Address reprint requests to Gene D. Branum, MD, Department of Surgery, Emory University School of Medicine, Surgery Research, 5105 WMB, 1639 Pierce Dr, Atlanta, GA 30322.

Copyright �9 1999 by WB. Saunders Company 1524-153X/99/0102-0010510.00/0

surgeons are uncomfortable with the expense of this technique and the requirement for general anesthesia. 3-5

Stoppa's giant prosthetic reinforcement of the visceral sac (GPRVS) calls on Pascal's principle of hydrostatic pressure and the incorporation of the mesh into healing connective tissue to achieve its excellent results. From an engineering perspective, the principle of distributing intra-abdominal pressure over a wide area instead of relying on sutures close to a hernia defect from an anterior approach is very attractive. The Kugel repair uses the same principle as the GPRVS with a minimally invasive approach.

The Kugel herniorrhaphy uses a 2.5- to 4-cm incision for access to the preperitoneal space. After digital dissection and direct visualization of the space and reduction of any direct, indirect, or femoral hernias, the two-layer, self-expanding, polypropylene mesh patch is placed and positioned to cover the direct space, internal ring, and femoral canal. Neither stapling nor suturing the mesh to Cooper's ligament or the iliopubic tract is required, and the mesh is secured to the transversalis fascia with a single stitch.

Operat ive Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 203-210 203

2 0 4 Gene D. Branum

SURGICAL TECHNIQUE

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1 The landmarks for the skin incisions are the location on the skin overlying the pubic tubercle and the location on the skin overlying the anterior superior iliac spine (ASIS). The midpoint of this line is then used as a guide for an incision that is one third lateral and two thirds medial to that point. This horizontal incision is carried down to the external oblique fascia. Local anesthetic is used in each layer and beneath the external oblique fascia. An ilioinguinal nerve block is recommended but not essential. The incision should be at least 4 cm above the superior border of the symphysis pubis, so the midpoint may need to be moved I to 3 cm superiorly. This drawing shows the location of the skin incision relative to the underlying structures. Note that the incision is lateral to the inferior epigastric vessels and lateral to the rectus sheath. The incision is superior and medial to the internal ring. The ilioinguinal nerve is rarely seen, because it is inferior and lateral to the dissection.

Open Preperitoneal Herniorrhaphy (Kugel) 205

2 The external oblique is retracted and blunt dissection with clamps exposes the transversalis fascia, which is then incised vertically exposing the underlying golden-yellow preperitoneal fat. It is critical that dissection begin beneath the transversalis fascia, with the epigastric vessels elevated medially using a retractor. Dissection above the transversalis will lead to confusion and the inability to properly deploy the patch. Cooper's ligament is palpable medially and inferiorly through the preperitoneal fat. Blunt dissection is used to expose Coo- per's ligament and the symphysis pubis medially. This blunt dissection reduces a hernia sac from the direct space. A sponge that is completely opened and placed medially into the space facilitates the dissection.

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] The cord structures and an indirect hernia sac are evident at the lateral aspect of the incision. The sac is reduced through the internal ring and is separated from the cord structures in a manner analogous to an anterior cord dissection. The dissection must be carried superiorly to the point where the vas deferens and cord vessels diverge. At this point, the sac may be transected and removed (recommended) or packed away superiorly and posteriorly.

206 Gene D. Branum

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4 The striped area shows the location of the patch at final placement. These areas must be cleared of peritoneum and preperitoneal fat. The dissection is analogous to that performed by the preperitoneal balloon in the TEP repair. Peritoneum must be swept superiorly off of the transversalis fascia medially and laterally, off the iliac vessels posteriorly, and from the iliacus vessel laterally. The size of the dissected space should correspond to the size of the patch to be inserted (ie, more room for a medium versus a small patch).


5 At the completion of the medial dissection Cooper's ligament (arrow) is visible in the base of the space with no overlying peritoneum or fat. The inability to confirm this indicates that the dissection is not complete. A direct defect is easily felt lateral to the tubercle and superior to Cooper's ligament, whereas with an indirect hernia the ring is palpable and the cord is visible exiting the ring.

208 Gene D. Branum

6 When the patch is deployed, it extends medially across the symphysis pubis and laterally well beyond the lateral aspect of the internal ring, The mesh lies anterior to the cord and iliac vessels and extends well below Cooper's ligament inferiorly. The preperitoneal fat and hernia sac (if not excised) lie within the curve of the mesh. An examining finger through the hernia defect confirms that the patch lies between the defect and the preperitoneal fat. An absorbable stitch is then used to secure the mesh to the transversalis fascia.


7 The mesh is shown in its final position from an anterior view. The transversalis fascia is reapproximated with a single absorbable stitch, incorporating a small bite of the mesh. The external oblique fascia and skin are closed in the usual fashion. Note that the direct, indirect, and femoral spaces are covered by the patch.

DISCUSSION

The minimally invasive open-preperitoneal herni0rrha- phy (Kugel) was developed to address the need for a minimally invasive approach to the preperitoneal space without the expense and time required by the laparoscopic approach, and with the ability to avoid general anesthesia in most cases.

Reddick et aP studied the Kugel and TEP approaches prospectively. Forty-seven percent of Kugel repairs were performed under local anesthesia with sedation, whereas all laparoscopic repairs required general anesthesia. Op- erative time was shorter in the Kugel group (average, 44 minutes) than the TEP group (average, 69 minutes). Complications were lower in the Kugel group (7% vs 16%) and average return to routine activities (8 days) was equal within the two groups. The cost of the Kugel repair was $776 less per case than the laparoscopic repair.

The collection of long-term results for this new repair are ongoing. The developer of the repair, Dr Robert Kugel, reports a recurrence rate of less than 1% (R. Kugel, personal communication, i999). The author has performed 450 repairs with five recurrences (1.17%). Three of the five were caused by inadequate lateral coverage of the internal ring in large indirect hernias. Using a medium instead of a small patch would have prevented this problem. Inadequate dissection below Cooper's ligament with medial recurrence of a direct hernia occurred in two cases. Thirty percent to 40% of the mesh must be positioned below Cooper's ligament to ensure proper

placement. The mesh placement mimics that of TEP, therefore long-term recurrence rates should be similar.

There have been no instances of ilioinguinal nerve syndrome in over 1,200 cases, a distinct advantage of the repair compared with anterior approaches. 6,7 In 450 cases, the author has encountered one deep mesh infection requiring removal of the mesh. This was surprisingly easy, because the infection had prevented incorporation of the mesh into the preperitoneal tissues. Four patients (0.9%) have developed seromas in the hernia pseudosac, none requiring aspiration. Eight patients (1.7%) developed cord hematomas that resolved spontaneously. Two patients developed superficial wound infections, which required local care but no packing. Seventy-five patients with bilateral hernias have had simultaneous repairs. The complication rate has been no different in this population than in unilateral repairs. Seventy percent of patients in the author's practice have chosen local anesthesia with sedation.

There is a learning curve for the Kugel repair, as for any other "new" procedure. It is the experience of those who train other surgeons in the technique, that surgeons who have previously used the TEP or the open preperitoneal approach have an easier time grasping the principles of the Kugel repair. It is the experience of the author, that some surgeons simply cannot visualize the concept of the preperitoneal space, whether by TEP or the open approach.

Surgeons who wish to apply the Kugel repair should undergo didactic teaching, training on pelvic models,

210 Gene D. Branum

and be precepted or proctored for their first uses on patients. Surgeons should limit their initial experience to nonobese patients without chronically incarcerated scro- tal hernias. As experience increases, the only contraindi- cations are prior preperitoneal surgery or the presence of infection. The patch should not be used in children.

Experience with the Kugel technique has led to several observations that are critical to the ease and success of the procedure. Beginning at the "beginning," proper placement of the incision is critical. Basing the incision on the midpoint of a line between the ASIS and pubic tubercle prevents opening the transversalis fascia medial to the epigastric vessels or lateral to the cord. Making the incision at least 4 cm cephalad to the symphysis pubis ensures its placement superior and medial to the inguinal floor. When placing the skin marks for the incision, allow the skin to be in its resting state, not the depressed position sometimes required to feel the landmarks (ie, in obese patients). Placing the skin marks in the depressed position will lead to a poorly placed incision.

The incision in the transversalis fascia should be in a vertical orientation to facilitate its closure at the end of the procedure. Specific attention and a directed effort must be made to assure that dissection is begun below the transversalis fascia and epigastric vessels. Placing the mesh above the epigastric vessels will invariably lead to a recurrence.

Reduction of a direct sac is typically easy and is accomplished by the dissection of the preperitoneal fat and sac cephalad from the direct space. At the completion of the reduction and adequate dissection of the space, Cooper's ligament will invariably be visible without any overlying peritoneum, fat, or adventitia. Even if a direct sac is found, the cord structures must be identified to confirm the presence or absence of an indirect sac. A useful technique to prevent seroma formation after repair of a direct hernia is to invert the pseudosac from the direct defect and excise a portion of it, thus allowing dissemination of any reactive fluid throughout the tissues.

Indirect sacs may be difficult to reduce if chronically incarcerated or long-standing. The technique of reduction is similar to that used in traditional anterior approaches, except that cephalad traction must be main- tained on the sac to reduce it through the internal ring. To ensure adequate dissection, the divergence of the vas deferens and spermatic vessels must be seen. Excision of the sac is by surgeon preference, and the author excises

the sac whenever feasible. As in the anterior approach, opening the sac, reducing the contents, and reclosing the sac is sometimes necessary in chronically incarcerated hernias. At the completion of the dissection, however, every landmark can be visualized no matter how large or incarcerated the hernia.

Medial dissection to the symphysis, lateral clearance of the peritoneum from the iliacus muscle, and adequate dissection of the peritoneum from the transversalis fascia is critical to allow complete deployment of the patch. Adherent attachments between the transversalis fascia and peritoneum must sometimes be divided with scissors or caute W. The self-expanding ring should not have bends or wrinkles at the completion of the case, and should resemble a taco shell that opens cephalad.

Kugel patches are supplied in small, medium, and large oval sizes. The author chooses the patch based on the patient size and the size of the hernia defect. In general, any defect that will admit two fingers should have a medium patch. Only small defects (1 to 2 cm) are repaired with small patches.

Although not exhaustive, the preceding caveats will serve surgeons well as they apply this innovative and simple minimally invasive technique.

REFERENCES

1. Nyhus LM: The Nyhus procedure (preperitoneal approach and iliopubic tract repair), in Skandalakis LJ, Gadacz TR, Mansberger ARJr, et al (eds): Modern Hernia Repair--The Embryological and Anatomical Basis of Surgery. New York, NY, Parthenon Publishing Group, 1996, pp 162-163

2. Stoppa R: Stoppa's inguinal herniography, m Skandalakis LJ, Gadacz TR, Mansberger AR Jr, et al (eds): Modern Hernia Repair The embryological and anatomical basis of surgery. New York, NY, Parthenon Publishing Group, 1996, p 179

3. Reddick EJ, Morton CE, Bradham WG, et al: Kugel Herniography: An Outpatient Option to Laparoscopic Hernia Repair. Sixth World Congress of Endoscopic Surgery, Rome, Italy, June 3-6, 1998

4. Heikkinen ]7, Haukipuro K, Leppala J, et al: Total cost of laparoscopic and Lichtenstein inguinal hernia repairs: A randomized prospective study. Surg Laparosc Endosc 7:1-5, 1997

5. Payne JH, Grininger LM, Izawa M, et al: Laparoscopic or open inguinal hernia? A randomized prospective trial. Arch Surg 129:973- 984, 1994

6. Lichtenstein IL, Shulman AG, Amid PK, et al: Cause and preven- tion of post-herniorrhaphy neuralgia: A proposed protocol for treatment. AmJ Surg 155:786-790, 1998

7. Gatt MT, ChevrelJP: The treatment of neuralgia following inguinal herniorrhaphy: A report of 47 cases. Postgrad Gen Surg 4:142-147, 1992

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