Original Article

Mesh plug repair for paraumbilical hernia

S.N. Sinha and T. Keith
Department of Surgery, University of Tasmania & Royal Hobart Hospital, Tasmania, Australia

Correspondence to: S.N. Sinha, Department of Surgery, University of Tasmania, Private Bag 28, Hobart, Tasmania 7001, Australia

Introduction Methods Surgical technique

Results Discussion References

Background: The standard method of repair of paraumbilical hernia (PUH) is by the Mayo technique, using a double-breasted flap of the rectus sheath. The reproducibility of this technique in the hands of others is highly variable. The present study describes and evaluates the application of a Prolene mesh plug in the repair of PUH. The use of a mesh plug in hernia repair is not a new concept with previous investigators yielding consistently excellent results in the repair of femoral and inguinal hernias. Methods: The study is a retrospective analysis of hospital records and telephone interviews of 34 patients having undergone PUH repair using the mesh plug technique in the period March 1998-May 2002. There were 20 males and 14 females with a median age of 53 years (range 34-86 years). Seventy-six percent (26) of the patient sample was obese (median BMI 33). Whenever possible local anaesthetic was used. Principal outcome measures studied were post-operative complications, recurrences, length of stay in hospital, post-operative analgesia, duration of drain, return to normal activities and patient satisfaction. Results: Post-operative complications encountered included one case of seroma and a single wound infection with recurrence. Ninety-seven percent (32) of patients were satisfied with the procedure. Conclusion: Mesh plug repair can be performed with minimal postoperative complications, low recurrence rate, minimal post-operative pain and achieving excellent patient satisfaction. Prosthetic mesh plug repair under local anaesthetic could become the standard treatment for PUH in adults

INTRODUCTION
Umbilical hernia in adults is more accurately described as a paraumbilical hernia (PUH) because the defect is not through the original umbilical scar, but either immediately above or below it with no possibility of spontaneous closure.¹ The reported incidence of umbilical herniae varies between 10 and 14% of all herniae.^2,3

Elective operation in adults is advisable due to the recognised risk of incarceration and strangulation.^4,5

The modern operation for umbilical hernia dates from 1881 with the longitudinal overlapping of layers of fascia by Lucas-Championniere. Mayo in 1894 proposed a transverse rather than longitudinal overlapping of fascia.² Alternatively, repair with simple direct apposition of the fascial defect in a transverse orientation has also been described.⁴

Herniorrhaphy using simple suture or Mayo’s technique have remained the most frequently used methods of repair in specialised hernia centres in recent times.

However, retrospective studies have shown high recurrence rates (10-30%).^5,6 In Mayo’s original series recurrence was reported in only 2 out of 75 cases. This result, however, has not been equalled since. In the experience of Kelly, Pringle, Dubose and Turner, the results of this operation were not satisfactory. The recurrence rates in their series ranged from 22 and 40%. The lowest figure (7.5%) according to Askar (1978) seems to be the one reported by Gibson and Gasper.⁷

The use of a cylindrical rolled plug of synthetic mesh has been described earlier in the repair of femoral and recurrent inguinal hernias.^6,8,9

A retrospective review of the mesh plug (Prolene) technique by a single surgeon was undertaken to evaluate the efficacy and benefit of this simple technique in improving patient comfort and early return to normal activities with a low recurrence rate.

METHODS
Hospital records were reviewed for the period January 1998 - May 2002 for all cases of PUH repair using the mesh plug technique. The same surgeon performed all operations, either as the principal operator or assisting the trainee. All patients with umbilical hernia below 18 years were excluded.

A total of 34 patients were studied (20 male, 14 female) with a median age of 53 years (range 34 - 86). Nineteen patients (56%) had surgery under a local anaesthetic while general anaesthetic was administered in 15 (44%) patients. Of these 15, three patients needed general anaesthetic due to concomitant procedures, the pre-operative diagnosis in five patients was strangulation (of which two were confirmed at operation), and seven patients refused to have the operation under a local anaesthesia.

Principal outcome measures
Principal outcome measures included operating time, complications, length of stay, anaesthetic used, analgesia required, number of drains and duration in-situ, and recurrences.

Data collection
A five-item questionnaire was prepared to assess complication rate, return to activity and patient satisfaction. We have used return to usual activities of social life as the best generally applicable example of return to normal activities, because 75% (24) of the study participants were not in paid employment. 

Patients were categorised as satisfied according to the definition used by Reitter et al (2000).¹⁰ Patients were deemed satisfied if they had no complaints regarding their operation or operative results and if they would be willing to undergo the same procedure again if hernia repair was necessary. Patients were categorised as unsatisfied if they were dissatisfied with their operation or operative results or would not undergo the same procedure again. Direct telephone inquiry was used for all follow-up contacts.

SURGICAL TECHNIQUE
Patients were asked to cleanse their umbilicus daily with chlorhexidine solution for a week prior to the operation. 

Pre-operatively, Flucloxacillin (1gm) was given intravenously in every case, unless contraindicated because of hypersensitivity. Local anaesthesia was used with 1% Xylocaine mixed with 8.4% sodium bicarbonate (9:1). If there was no contraindication, 1% Xylocaine in adrenaline with 8.4% sodium bicarbonate (7.5:2.5) was preferred. The solution was injected subcutaneously after raising an intradermal weal and then around the hernia.

The incision (3-4cm) was made either supra-umbilically or infra-umbilically, depending on the location of PUH. The hernial sac was dissected from the surrounding tissue until the hernial ring was identified circumferentially. Once this was done the contents of the sac could be reduced, followed by the sac itself. In case of an incarcerated hernia a gentle sustained pressure on the sac with moist gauze was adequate to reduce the content. In rare cases it may be necessary to open the sac and excise the contents after suture ligation.

Figure 1: (a) incision; (b) dissection of the sac and outline of the defect; (c) contents reduced along with the empty sac; (d) mesh plug created; (e) mesh plug in-situ

A Prolene mesh plug was then prepared like a cigarette stub from a 2.5cmx10cm mesh sheet. If the hernial defect was more than 2cm in diameter a double layer was used. The stub was then inserted into the defect with its external margin flush with the hernial ring and fixed with 3/0 Prolene sutures in four quadrants. (Figure 1 a-e) A Mini-vac drain was used in all cases.

The incision was closed with a subcuticular suture. The patient was then discharged with advice to return after 48 hours for removal of the drain.

RESULTS

General
Thirty-four cases of PUH (20 male, 14 female) were operated on in the period between March 1998 and May 2002. Median operating time was 50 minutes (range 40-108 minutes). Seventy six per cent (26) of patients in the current series were obese (BMI >30), with a mean BMI of 32. Three patients underwent concomitant procedures; laparoscopic cholecystectomy, excision of omentum, and repair of right inguinal hernia.

Herniae
In the current series there were eighteen cases (53%) of incarceration and two cases (6%) of strangulated hernia. Duration of the hernia ranged from 1 week to 20 years. Forty-six per cent (16) of the patients had herniae for 4 years or more, with 15% (5) having herniae for over 10 years.

The size of the hernial defects ranged between 1 to 4 cm diameter, with eleven of the cases (32%) being = 2cm in diameter. All but two patients in the current series underwent primary umbilical hernia repair. These two patients had previously undergone umbilical hernia repair elsewhere using a simple suturing technique.

Significant concomitant medical problems were observed in the study participants. Twenty-six (76%) were obese (BM>30), 15 (44%) had cardiovascular problems, 16 (47%) had gastrointestinal disturbances, 12 (35%) neuro-psychiatric and 10 (29%) had pulmonary problems.

Post-operative recovery
Ninety-four per cent (32) of the patients were discharged within 48 hours of the procedure. Of the 19 patients repaired under local anaesthesia 17 (89%) were discharged within 24 hours. In comparison, 7 (47%) of the 15 patients who had undergone repair under a general anaesthetic were discharged within 24 hours. Twelve out of the last 15 repairs have been performed under a local anaesthetic.

Of the patients repaired under a general anaesthetic, an 86-year-old female experienced post-operative episodes of confusion and dizziness requiring prolonged hospital stay of 12 days.

Three patients who were repaired under local anaesthesia and not discharged on the day of the procedure for social reasons had uncomplicated recoveries. There were no perioperative or post-operative deaths and there were no adverse reactions to the local anaesthetic. Ninety-four per cent (31) of participants were able to “cope with duties around the home” within 1-7 days of the repair. In addition, 66% (21) of the study participants were able to “return to doing usual activities of social life” within 8-14 days and a further 13%(4) of patients by 15-21 days post-operatively.

Complications
There was one case of seroma was recorded. Only one patient had a recurrence at four months post-operatively and this was associated with a delayed wound infection. Ninety-one percent (31) of patients required non-narcotic analgesia post operatively. The drains were left insitu for a median of two days (median two days), (range one to nine days). 

Follow-up
All but one patient could be contacted for telephone interview. The median post-operative follow-up period was 14 months. Ninety-seven per cent (32) of patients who could be contacted were satisfied with the procedure and operative results.

DISCUSSION
Paraumbileacal hernia is more common in females, Caucasians and the obese.² It is relatively common, especially in the fifth and sixth decades of life, with an acquired defect in over 90% of cases.³

In the current series, there were more males with PUH and a greater number of males presented with incarceration than recorded in previous reports.^10,11 Several accounts in the literature have documented the tendency of PUH to strangulate.² Furthermore, incarcerated PUH are associated with an increased mortality.¹²

The median age of the study participants was 53 years. The operating time was 50 minutes. However, excluding the three concomitant procedures performed at the time of PUH repair, (laparoscopic cholecystectomy, excision of omentum, and repair of right inguinal hernia), the mean operating time was reduced to 44 minutes, comparable with the operating time reported by Arroyo et al. (2001).6 The repair of the two cases of incisional PUH, took on average 67 minutes. This type of repair is technically more difficult than the repair of primary PUH due to surrounding adhesions.

Local anaesthesia was used as the technique of choice for PUH repair in the current series, unless contraindicated by patient co-morbidities or patient refusal. Local anaesthesia was selected as it has the lowest rate of systemic complications without any increase in recurrence or local complication rates.¹³ In the present series 56% (19) of patients underwent repair under a local anaesthetic, including six cases with incarceration.

The median duration of stay recorded for the current series was one day. This appeared to be an improvement on Runyon and Juler (1985) who observed a mean hospital stay of 6.6 +/- 5.0 days.¹⁴ Celdran et al. (1995), using a H-configuration mesh repair for umbilical hernias, reported that patients were discharged from hospital between 24-48 hours.¹⁵ Interestingly, Arroyo et al. (2001) recorded a mean post-operative stay following umbilical hernia repair in the day surgery unit of 172 minutes.⁶ Thereafter, patients were discharged home. At home the “home care unit” followed the patient’s recovery.

Medina et al (1997) found patients undergoing herniorrhaphy with a BMI above 37 (97.5 percentile), were at a six-fold increased risk of surgical wound infection.¹⁶ Eleven obese patients (six male, five female; median age 69 years, median BMI 34) in the current series were admitted with large hernias and six of these were incarcerated. Five of the eleven cases were repaired under local anaesthesia. The median length of stay was two days and mean operating time was 63 minutes. Post-operative complications in this group were seen in only two patients. From the follow-up telephone interview all eleven patients were satisfied and 64% (7) were able to return to usual activities within one to seven days.

According to Askar (1984) closure of the hernial defect should not take place at the expense of increasing the stretch on the already exhausted stretched aponeurosis.¹⁷ The hernial orifice should be filled or closed without any additional tension.¹⁷ These fundamental principles appear to be satisfied by the mesh plug technique outlined in the current series.

The authors are aware that the follow-up period of this series is short, and the size of the sample is small. However, it is hoped that publication of these data may encourage others to conduct further trials to validate the results.

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Copyright: 17 February 2004