A prospective analysis comparing stoppa’s repair with conventional repair in complex bilateral and recurrent inguinal hernias

INTRODUCTION: The reconstruction of the posterior barrier of the groin represents one of the major objectives in groin hernia repair. There are 2 primary methods used to achieve this objective: “tissue repair technique” and “tension-free repair”. Recently, tension-free repair has become the gold standard procedure for repairing inguinal hernias. Many techniques have been described by different authors. Tension-free repair involves the use of synthetic prosthetic materials for rebuilding the posterior inguinal wall. The prosthetic materials, now disposable, have a well tolerated bioreactivity, allow efficient fibroplasia, diminish postoperative pain, and significantly reduce the recurrence rate and convalescence period. The Stoppa procedure, or giant prosthetic reinforcement of the visceral sac (GPRVS), is performed by wrapping the lower part of the parietal peritoneum with prosthetic mesh. The mesh contributes to a physiological healing process that creates a special bilateral anatomical reinforcement in the inguinal region, which effectively prevents inguinal hernia recurrence. The procedure’s rationale is based on an elegant surgical and anatomical prosthetic placement that occludes the myopectineal ostium of Fruchaud. The GPRVS procedure requires wide dissection of the subfascial preperitoneal space. As a corollary, the GPRVS operation calls for the use of suction drainage. Sometimes this drainage procedure is responsible for longer hospitalization that may be as long as 9.7 days. Since the description of GPRVS procedure, many surgeons have reported good outcomes. AIM OF THE STUDY: 1. To evaluate Stoppa’s (giant prosthetic reinforcement of the visceral sac) repair as a treatment for complex and B/L inguinal hernias. 2. To compare the operation time, immediate post op events and mean duration of hospital stay between the Stoppa’s and the conventional bilateral hernia repair group. 3. To compare the risk of recurrence, if any, between the two groups. 4. To study the cost effectiveness of the Stoppa’s repair over the conventional bilateral hernia group. PATIENTS AND METHODS: Fifty patients, of ASA I or II, attending the Govt.GH Chennai in our surgical unit large bilateral inguinal hernias or recurrent hernias or complex groin hernias are prospectively studied over a period 2 years from September 2005 – September 2007. Twenty five patients, mostly with recurrence and large bilateral hernias underwent Stoppa’s procedure and the other twenty five with mostly bilateral hernias and that associated with hydrocele underwent bilateral conventional hernia repairs. The following parameters are studied: • Pre operative diagnosis and the procedure done. • Mean duration of the operation (calculated from the time of incision to wound dressing after closure). • Mean rate of wound infection (reported when frank pus discharge or showing positivity in culture and sensitivity). • Mean rate of seroma collection (noted clinically as pink non purulent discharge or collection). • Duration of stay in the hospital. • Local recurrence if any. The patients are followed up in the 6th month and 1 year post operatively for any event of recurrence. The patients who are discharged early are advised to report immediately in case of wound infection or seroma collection. MATERIALS: A (6” x 6”) monofilament poly propelene mesh (undyed) is used on each side for a conventional hernia repair and due to non availability of big size mesh the same are fashioned in to a single mesh according to the pelvic measurements of the patient and thus are individualized. CONCLUSIONS: 1. Stoppa’s repair is a better procedure for complex bilateral and recurrent hernias than the conventional repair due to its pre peritoneal approach, clear delineation of anatomy and vast size of mesh. 2. The mean operation time increased by 20 minutes (p<.05 significant) in Stoppa’s repair, but the operating team lessened by half. 3. There is no difference in the wound infection rates (4%) between the two groups. 4. The mean seroma collection rates in stoppa’s repair (12%) is thrice that of the conventional group (4%) (p<.05% significant), but can be overcome with strict hemostasis, suction drains and experience. 5. There is no difference in the recurrence rates (4%) between the two groups at 1 year follow up. A bigger sample size and more years of follow up are necessary. 6. Our study correlates well with – “GPRVS for complex bilateral and recurrent inguinal hernias” by Thapar V et al JPGM April – June 46;2, 80 – 2