Chapter 206: Generations of the Plug-and-Patch Repair: Its Development and Lessons from History
Two other papers deal with complex or recur- indicate that the Lichtenstein repair has a ten-
rent inguinal hernias. Beltrán and Cruces (World
J Surg 2006;30:2281–7) used the qualitative and
quantitative measurement instrument (QQMI)
to evaluate 75 patients who underwent recur-
rent inguinal hernia repair and 287 patients who
underwent primary repair in Chile. The results
206 Generations of the Plug-and-Patch Repair: Its
Development and Lessons from History
Jerrold Young and Arthur I. Gilbert
INTRODUCTION
The principle of hernia repair using an open
approach for placing mesh in the properito-
neal retromuscular space of Bogros is based
on protecting the myopectineal orifice
(MPO) from behind. This has been the the-
ory behind the development of many tech-
niques of hernia repair including those of
Nyhus, Stoppa, Kugel, and more recently,
laparoscopic techniques. Furthermore, the
concept of protecting an opening from in-side
the defect has resulted in modification of the
technique of repair of other hernias,
including ventral, umbilical, and particu-
larly, incisional hernias.
In 1985, Gilbert borrowed Lichtenstein’s
idea of creating a rolled plug and used it to
repair indirect inguinal hernias. The intact
indirect sac was dissected and invaginated. A
hand-rolled mesh plug was placed into the
internal ring and two permanent su-tures
were used to fix it to the crura of the ring
(Fig. 1). To complement this, a flat mesh
patch was used to reinforce the floor of the
inguinal canal over Hesselbach’s tri-angle.
This worked well, but the plug was
annoyingly palpable in some thin patients, a
problem that was solved by altering the
Fig. 1. Original rolled plug sutured in
internal ring and onlay patch.
cated pattern of the huge hernias and their ap-
dency to get better results in the primary repairs
but, if surgeons do not have any experience with
laparoscopic repairs, the Lichtenstein repair is
appropriate.
Beitler et al. (Hernia 2009;13:61–6), writing
from Rio De Janiero, have addressed a compli-
shape of the plug. Gilbert then changed to a
hand-rolled plug which he placed through the
internal ring into the properitoneal space,
allowing it to unravel there—it be-came
seated against the anterior abdomi-nal wall. It
literally blocked the peritoneal sac and its
contents from protruding through the internal
ring. Although no su-tures were used, that
technique proved sat-isfactory, providing a
lasting repair for small- and medium-sized
indirect hernias.
Gilbert soon recognized certain prob-lems
uniquely related to the rolled plug. These
included its inability to consistently unravel
enough to be anything but a wad of mesh,
thus limiting its area of protection, and some
patients still reported feeling it. Rarely, when
a plug became infected, surgi-cal drainage
and antibiotics were insuffi-cient to sterilize
its multiple layers, compel-ling its removal.
To avoid these problems, and to protect a
wider area, the mesh shape was changed
from a rolled plug to an opened patch. The
flat mesh was cut, folded to the shape of a
closed umbrella, and passed through the
internal ring into the properitoneal space.
There it was allowed to open and regain its
flat contour, avoiding a palpable plug, and
providing wider pro-tection (Fig. 2). Gilbert
originated the pro-cedure of using mesh
within the internal ring to repair indirect
inguinal hernias, and subsequently used the
internal ring as the passageway to place mesh
behind the ante-rior abdominal wall for the
repair of all types of indirect hernias.
LESSONS FROM HISTORY—
SUTURE REPAIRS
Gilbert’s approach developed from the work
of earlier surgeons interested in herniology.
Bassini of Padua is credited with beginning
the modern era of hernia surgery. Through
2117
proaches to what in the VA system we were prone
to call “wheelbarrow hernias.” Nonetheless, since
they were willing to deal well with the complica-
tions of huge hydroceles; they were able to show
good results.
J.E.F.
an anterior open approach in the groin, he
divided the posterior wall of the inguinal
canal, ligated the peritoneal sac, and con-
structed a sutured, three-layered tissue re-pair
in 262 patients, with a failure rate of ,3%. A
simplification of his technique avoided
opening the posterior wall, but ap-proximated
the transversus arch, or so-called conjoined
tendon, to the shelving edge of the inguinal
ligament with inter-rupted sutures. This
became known as the modified (North
American) Bassini repair. Lotheissen of
Austria and later Anson and McVay of South
Dakota, popularized an anatomic repair that
approximated the transversus arch to the
pectineal ligament (Cooper’s ligament),
which also required opening the floor. The
“McVay” repair be-came the preferred
procedure for treatment of femoral hernias
and many direct inguinal hernias. In 1946,
Shouldice of Toronto
Nongastrointestinal Transabdominal Surgery
Fig. 2. Creation and insertion of umbrella plug.