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February 1, 2004

Exploiting vs Avoiding the Preperitoneal Space in Inguinal Hernia Repair

Arch Surg. 2004;139(2):130. doi:10.1001/archsurg.139.2.130

Before laparoscopic inguinal hernia repair was pioneered in the early 1990s, exploiting the preperitoneal space was limited to the repair of recurrent inguinal hernias in the hands of a limited number of surgeons (eg, Lloyd Nyhus, MD, Robert Condon, MD, Rene Stoppa, MD, Raymond Read, MD, and George Wantz, MD). Since the laparoscopic inguinal hernia repair was introduced, more attention has been focused on using the preperitoneal space for mesh placement in the repair (open and laparoscopic) of both primary and recurrent inguinal hernias. As a result, many surgical procedures (such as the Stoppa procedure, Wantz procedure, the Kugel procedure, and the Ugahary approach) and devices (such as the Kugel hernia patch [Davol Inc, Cranston, RI], WINGS mesh [Angiologica, San Martino Siccomario, Italy], Bard 3D Max mesh [Davol Inc], Folding mesh [SOFRADIM International, Trévoux, France], Anatomic mesh [SOFRADIM International], Obtura mesh [Cousin Biotech SAS, Wervicq-Sud, France], and Endoroll and Prolene Hernia System [ETHICON Inc, Somerville, NJ]) have been marketed, and more procedures and devices will likely be introduced in the future. As more preperitoneal inguinal hernia repairs are performed, general surgeons, vascular surgeons, and urologists have expressed growing concern about exploiting the peritoneal space in inguinal hernia repair.1-4 Because of the severe adhesion-producing effect of reticular prosthetics, implantation of different meshes in the preperitoneal space can lead to obliteration of spaces of Retzius and Bogros, rendering subsequent urological and vascular surgeries (particularly radical prostatectomy and lymphnode dissection) extremely risky and difficult, if not impossible.1-4 In fact, according to one report4 of a series of 13 radical prostatectomies performed after preperitoneal hernia repair with bilateral mesh prosthetics, the procedure was completed without difficulty in only 1 of 13 patients. These difficulties are not surprising; they are merely an echo of the extreme difficulty of performing open and laparoscopic preperitoneal inguinal hernia repair subsequent to open prostatectomy, a concern that, as suggested by Katz et al,1 should be brought to the patient's attention. It would also be prudent for the mesh manufacturers to do the same in their product inserts.