Anterior pre-peritoneal Anterior pre-peritoneal inguinal hernioplasty inguinal hernioplasty

經腹壁行腹膜前鼠蹊疝氣修補術經腹壁行腹膜前鼠蹊疝氣修補術溫義輝 奇美醫學中心 溫義輝 奇美醫學中心 Yih-Huei Uen, MDYih-Huei Uen, MD

Division of General Surgery, Division of General Surgery, Department of Surgery, Chi Mei Department of Surgery, Chi Mei

Foundation Medical Center, Tainan, Foundation Medical Center, Tainan, Taiwan, ROC.Taiwan, ROC.

Design(I)Design(I)

Modified device /technique of Modified device /technique of PHS:PHS: An improved method for deploying An improved method for deploying

the polypropylene underlay patch of the polypropylene underlay patch of the the PROLENPROLEN Hernia System:Hernia System:

American Surgeon 2007 May, Yih-Huei UenAmerican Surgeon 2007 May, Yih-Huei Uen 通過專利審核通過專利審核

Fig. 1: The procedures of development of a modified device of Fig. 1: The procedures of development of a modified device of

PHS.PHS.

Fig. 2: The procedures of intra-pocket Fig. 2: The procedures of intra-pocket manipulationmanipulation

Table 1. ResultsTable 1. Results

0

0

0

0

1

1

35.7 ±5.4

41.3 ±3.2

Modified group

N=184

>0.051 Post OP recurrence (follow up>2years)

*Student’s t test

**Chi-square test

0Mesh extrusion

0Hydrocele

0Intestinal obstruction

0 Wound infection

>0.051Morbidity**

<0.0531.6 ±4.8Direct hernioplasty

<0.0537.2 ±5.1Indirect hernioplasty

OP time (mean ± SD)*

P valueOriginal group

N=32

Comparative Laparoscopic Comparative Laparoscopic Evaluation of the “ Original” versus “ Evaluation of the “ Original” versus “ Modified” Design of PROLENE Hernia Modified” Design of PROLENE Hernia

System in A Porcine-groin Hernia-System in A Porcine-groin Hernia-Repair Model Repair Model

Study(II)

Material and MethodMaterial and Method

30 uncastracted male pig (average BW: 30 uncastracted male pig (average BW: 24Kg)24Kg)

Unilateral anterior inguinal hernioplasty Unilateral anterior inguinal hernioplasty Group Group

1.1. Original PHS(n=10)Original PHS(n=10)

2.2. Modified PHS with onlay fixation (n=10)Modified PHS with onlay fixation (n=10)

3.3. Modified PHS without onlay fixation (n=10)Modified PHS without onlay fixation (n=10)

Hand–assisted laparoscopic stress-Hand–assisted laparoscopic stress-loading test using dynamometerloading test using dynamometer

Result (I) :The laparoscopy of the Result (I) :The laparoscopy of the preperitoneally positioned mesh preperitoneally positioned mesh

prosthesisprosthesis§§

10

0

0

10

0

10

group 3

(n=10)

107 Entire MOP+

03 single or double area

<0.05Covering boundary

00 insufficient

1010 sufficient

>0.05 Obliteration of fascial defect

03 moderate or marked wrinkle

107 flat to slight wrinkle

<0.05 Configuration of prosthesis

P value*

group 2

(n=10)

group 1

(n=10)

Result (II): Comparsion of the results of Result (II): Comparsion of the results of stress-loading test stress-loading test

0

5

10

15

20

25

30

1 2 3

組別

Bursting strength

lb

P<0.01 Group2 vs Group1 and 3

P>0.05 Group1 vs Group 3

10.57± 0.46

23.99± 0.89

10.20± 1.11

Discussion ( I ): Special design Discussion ( I ): Special design and unique technique of and unique technique of

“Modified” PHS“Modified” PHS ● Harboring a deploying underlay Harboring a deploying underlay

“pocket” graft with a pressure “pocket” graft with a pressure reception perimeterreception perimeter

● Fixating underlay graft to the fascial Fixating underlay graft to the fascial edgeedge

● Using a narrow angled metal pusher Using a narrow angled metal pusher to perform intra-pocket manipulationto perform intra-pocket manipulation

Full deployment of underlay graft Full deployment of underlay graft against the inner surface of the against the inner surface of the inguinal floor to cover entire MPO inguinal floor to cover entire MPO (Pascal’s principle)(Pascal’s principle)

Secure obliteration of fascial defectSecure obliteration of fascial defect Increased stability of devicesIncreased stability of devices Self assessment of the adequacy of Self assessment of the adequacy of

deploymentdeployment

Discussion ( II ):Potential advantage Discussion ( II ):Potential advantage of “Modified” PHS prosthesisof “Modified” PHS prosthesis

Discussion ( III ): Discussion ( III ):

The fixation stitches of onlay patch The fixation stitches of onlay patch traditionally used in “Original” PHS can be traditionally used in “Original” PHS can be substituted by those of fascial edge in substituted by those of fascial edge in “Modified”device if it is strong enough.“Modified”device if it is strong enough.

Can post-operative pain be decreased?Can post-operative pain be decreased?

Discussion ( IV ):Discussion ( IV ):

Hand-assisted laparoscopic stress-loading Hand-assisted laparoscopic stress-loading test with dynamometer: test with dynamometer: Firstly used in assessment of the stability of Firstly used in assessment of the stability of

hernia repair prothesishernia repair prothesis An useful tool :good exposure, mimic nature An useful tool :good exposure, mimic nature

hernia protrusion, easy manipulation and high hernia protrusion, easy manipulation and high accuracyaccuracy

Conclusion:Conclusion: Groin hernia repair with “Modified” Groin hernia repair with “Modified”

PHS device/ technique is a simple PHS device/ technique is a simple and effective way to achieve full and effective way to achieve full deployment of underlay graft along deployment of underlay graft along pelvic anatomy with increased pelvic anatomy with increased stability.stability.

Design(II)Design(II)

Underlay pocket graft ( enough! )Underlay pocket graft ( enough! )

Type I: PROLENE mesh Type I: PROLENE mesh

Type II: Type II: ULTRAPROULTRAPRO (partially absorbable)(partially absorbable)

meshmesh

Underlay pocket graft with Underlay pocket graft with ULTRAPROULTRAPRO (partially absorbable)(partially absorbable) meshmesh

Study(III)Study(III)

Randomized comparison of the Randomized comparison of the clinical result of pre-peritoneal clinical result of pre-peritoneal hernioplasty with PROLENE vs hernioplasty with PROLENE vs ULTRAPROULTRAPRO mesh underlay pocket mesh underlay pocket graft graft

Table 1. ResultsTable 1. Results

0

0

0

0

0

0

38.7 ±5.3

44.3 ±3.9

ULTRAPRO group

N=30

0 Post OP recurrence

(short-term follow up)

*Student’s t test

**Chi-square test

0Wound infection

1Wound hematoma

0Intestinal obstruction

0 Mesh extrusion

>0.051Morbidity**

>0.0537.6 ±4.7Direct hernioplasty

>0.0543.2 ±5.7Indirect hernioplasty

OP time (mean ± SD)*

P valuePROLENE group

N=28

DiscussionDiscussion

Although long-term follow-up is Although long-term follow-up is needed, the early result of pre-needed, the early result of pre-peritoneal hernioplasty using peritoneal hernioplasty using ULTRAPROULTRAPRO mesh is as efficient as mesh is as efficient as PROLENE analogue. PROLENE analogue.

SummarySummary

Underlay pocket graft, either along Underlay pocket graft, either along use or combined in PHS device, can use or combined in PHS device, can facilitate the result of pre-peritoneal facilitate the result of pre-peritoneal hernioplasty. It’s role in inguinal hernioplasty. It’s role in inguinal hernioplasty will be high- lightened hernioplasty will be high- lightened by the usage of by the usage of ULTRAPROULTRAPRO mesh. mesh.

Reference Reference 1.1.  Gilbert AI, Graham MF, Voigt WJ. A bilayer patch Gilbert AI, Graham MF, Voigt WJ. A bilayer patch

device for inguinal hernia repair. Hernia 1999;3:161-device for inguinal hernia repair. Hernia 1999;3:161-166.166.

2.2.  Uen YH. Comparison laparoscopic evaluation of Uen YH. Comparison laparoscopic evaluation of the PROLENE hernia system and the Perfix plug-and-the PROLENE hernia system and the Perfix plug-and-patch device in a porcine groin hernia repair model. patch device in a porcine groin hernia repair model. Journal of Laparoscopic & Advanced Surgical Journal of Laparoscopic & Advanced Surgical Technique 2004;14(6):363-373.Technique 2004;14(6):363-373.

3.3.  Murphy JW. Use of the prolene hernia system for Murphy JW. Use of the prolene hernia system for inguinal hernia repair: retrospective, comparative inguinal hernia repair: retrospective, comparative time analysis versus other inguinal hernia repair time analysis versus other inguinal hernia repair systems. American Surgeon 2001;67(10):919-923.systems. American Surgeon 2001;67(10):919-923.

4. Uen YH. An improved method for deploying the 4. Uen YH. An improved method for deploying the polypropylene underlay patch of the polypropylene underlay patch of the PROLENPROLEN Hernia Hernia System American surgeon 2007 MaySystem American surgeon 2007 May

Thanks for your Thanks for your attention !attention !