What is the step-by-step operative technique for mesh hernioplasty in a patient undergoing hernia repair?

Step-by-Step Operative Technique for Mesh Hernioplasty

Preoperative Preparation

For clean surgical fields without contamination, synthetic mesh repair is the definitive approach, providing superior outcomes with significantly reduced recurrence rates compared to non-mesh techniques. 1, 2

Patient Positioning and Anesthesia

• Position the patient supine with arms tucked at sides 3
• Local anesthesia with infiltration at the hernia site is safe and effective, reducing cardiopulmonary complications and enabling shorter hospital stays (mean 27.27 hours) 3
• General or spinal anesthesia may be used based on patient factors and surgical complexity 4

Antibiotic Prophylaxis

• Administer short-term antimicrobial prophylaxis for clean surgical fields (CDC Class I) 2
• Extend to 48-hour prophylaxis if intestinal strangulation or bowel resection without gross spillage occurs (CDC Class II) 2

Surgical Approach Selection

Open Anterior Approach (Standard Technique)

• Make a 6-8 cm oblique incision 2 cm above and parallel to the inguinal ligament 5
• Incise the external oblique aponeurosis in the direction of its fibers 5
• Identify and protect the ilioinguinal, iliohypogastric, and genital branch of genitofemoral nerves throughout the procedure 5
• Isolate the spermatic cord and retract it medially 5

Laparoscopic Approach (TAPP or TEP)

• TAPP (Transabdominal Preperitoneal) involves entering the peritoneal cavity and placing mesh in the preperitoneal space 2
• TEP (Total Extraperitoneal) places mesh in the preperitoneal space without entering the peritoneal cavity 2
• Laparoscopic approach demonstrates lower wound infection rates, shorter hospital stays, and allows evaluation of hernia content viability 2
• Median operation time: 45 minutes for unilateral primary hernias, 50 minutes for recurrent hernias, 76 minutes for bilateral hernias 4

Hernia Sac Management

• Dissect the hernia sac from surrounding structures 5
• For indirect hernias, separate the sac from the spermatic cord structures 5
• For direct hernias, reduce the sac by inverting the weakened transversalis fascia 5
• Ligate large indirect sacs at the internal ring; small sacs may be inverted 5

Mesh Selection and Preparation

Mesh Type Based on Surgical Field

• Clean fields (CDC Class I): Use synthetic polypropylene mesh, which remains the most commonly used material due to durability and tissue compatibility 2
• Clean-contaminated fields (CDC Class II): Synthetic mesh can be safely used even with intestinal strangulation and/or bowel resection without gross enteric spillage 1, 2
• Contaminated fields (CDC Class III): Consider biological mesh for defects >3 cm, or polyglactin mesh as alternative 1, 2
• Large-pore synthetic meshes demonstrate superior resistance to infection compared to small-pore designs 2

Mesh Size Requirements

• Ensure mesh extends beyond defect boundaries by at least 3 cm in all directions 2
• For umbilical hernias specifically, the 3 cm minimum overlap is preferred 2
• Use appropriately sized mesh to cover all potential areas of weakness (direct, indirect, and femoral spaces) 5

Mesh Placement Technique

Preperitoneal Placement (Preferred)

• Dissect the preperitoneal space to create adequate room for mesh placement 4
• Position the mesh to cover the myopectineal orifice, including direct, indirect, and femoral hernia sites 2
• The mesh serves as a scaffold for host tissue ingrowth, with fibroblasts depositing new collagen and inducing angiogenesis around the implant 2

Mesh-Plug Technique (Alternative)

• Insert a cone-shaped mesh plug into the hernia defect 6
• Place an onlay mesh over the posterior inguinal floor 6
• This tension-free technique eliminates recurrences through decreased dissection and no tissue tension 6

"All-in-One" Technique (Modern Variation)

• Place a smaller prosthesis on the floor of the inguinal canal to strengthen all areas of weakness 5
• Envelop the mesh with a fibro-cremasteric sheath to avoid contact with neural structures, preventing chronic neuralgia 5

Mesh Fixation

• Secure mesh using tackers or transfascial sutures 2
• Critical pitfall: Avoid placing tackers near vital neurovascular structures to prevent chronic pain 2
• Ensure tension-free placement without excessive traction 6
• For laparoscopic repairs, fix mesh to Cooper's ligament medially and the anterior abdominal wall laterally 4

Wound Closure

• Re-approximate the external oblique aponeurosis over the spermatic cord 5
• Close Scarpa's fascia with absorbable sutures 5
• Close skin with subcuticular sutures or skin adhesive 5

Expected Complications and Their Management

Common Complications

• Seroma formation: Occurs more frequently with mesh repair (RR 1.63) but typically resolves spontaneously 7
• Wound infection: Slightly more common in mesh group (RR 1.29), occurring in approximately 1 in 200 cases 7
• Hematoma: Actually reduced with mesh repair (RR 0.88) compared to non-mesh 7
• Mesh infection: Occurs in 1.9-5% of cases, with 72.7% requiring complete mesh explantation 2

Risk Factors for Mesh Infection

• Emergency operations 2
• Smoking 2
• ASA score ≥3 2
• Longer operative duration 2

Postoperative Management

• Discharge within 24 hours is typical for uncomplicated cases 5, 3
• Most patients (96.8%) report no pain after the first postoperative week 5
• Approximately 47.6% of patients require no pain medication at home 5
• Return to normal activities occurs a mean of 2.87 days sooner with mesh repair compared to non-mesh 7

Outcomes and Recurrence Prevention

Mesh repair prevents one hernia recurrence for every 46 mesh repairs compared with non-mesh repairs (RR 0.46). 7

• Current recurrence rates with proper technique are as low as 0.5% 4
• Mesh repair demonstrates significantly lower recurrence rates than tissue repair (0-4.3% vs 19-42%) 2, 8
• Neurovascular and visceral injuries are actually more common in non-mesh repairs (RR 0.61), making mesh repair safer 7

Critical Pitfalls to Avoid

• Never use synthetic mesh in grossly contaminated fields (CDC Class III/IV) as infection rates can reach 21% 2, 8
• Never dismiss the importance of nerve identification and protection to prevent chronic neuralgia 5
• Never place mesh under tension as this increases recurrence risk and patient discomfort 6
• Never use absorbable prosthetic materials as they lead to inevitable hernia recurrence due to complete dissolution 1