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Gilbert double layer graft method for groin hernias in patients with ascites
General information:
Institution: Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University;
PI(s) and their leadership and/or academic titles: Dr. Wang Yong, MD, PhD, Chief Physician; Dr. Yu Yongyang, MMed, Associate Chief Physician; Dr. Zhou Zongguang, MD, PhD, FACS, Professor; Dr. Yang Shiwei, MD, Doctoral candidates; Dr. Li Junting, MMed, Doctoral candidates; Dr. SHAHID ALI, MMed, Doctoral candidates;
Contact information: E-mail: wydoctor1974@aliyun.com, Phone: +86 18228053217, Address: No 37, Guo Xue Xiang St, 610041 Chengdu, China
Introduction
Ascites is often associated with an increase in abdominal pressure and can increase tension on any operative repair of the abdominal wall. The presence of ascites may play an important role in promoting the occurrence or recurrence of a repaired inguinal hernia. Recent publications have reported that the incidence of umbilical hernias affects ~3% of the population but increases to ~20% of patients with cirrhosis and ascites. Thus, compared to the general population, patients with ascites have an increased incidence of groin hernias.
Patients with ascites have generally poor systemic medical status and are more sensitive to physiologic stress. Importantly, these inguinal hernias have a negative effect on the patient`s quality of life. In principle, most all healthy patients with symptomatic groin hernias should be treated by herniorrhaphy, but controversy remains regarding the safety of elective herniorrhaphy in patients with ascites. In our present study, we suggested that the Gilbert, double layer, tension-free herniorrhaphy is both feasible and safe for selected patients with a symptomatic inguinal hernia who also have ascites, which was supported by Prof. Michael G. Sarr, Editor-in-chief of Surgery and Emeritus Professor of Surgery, Mayo Clinic, and this study had been published by Surgery (DOI: 10.1016/j.surg.2020.02.025).
Operations were performed with injections of anesthetic solution layer by layer. All patients underwent a tension-free hernia repair with implantation of a light, composite mesh using the UltraPro Hernia System (UHS) (Ethicon, Norderstedt, Germany). After opening the external oblique aponeurosis, we dissected widely beneath the medial and lateral flaps of the external oblique aponeurosis. The peritoneum was then freed from its attachments to the posterior wall of the inguinal floor by carefully inserting a 10 × 10 cm gauze through the internal ring into the preperitoneal space to bluntly and gently enlarge the preperitoneal space. The underlay patch of the mesh device was spread to cover the entire posterior surface of the myopectineal orifice, while the onlay patch of the device was placed anterior to the transversalis fascia and fixed to the conjoint tendon and the inguinal ligament with single sutures . The operation was completed successfully in all patients. The mean operative time was 46 ± 20 minutes (range 20–255 minutes). A drain was left in the wound in 65 cases and was removed at a median of 3 days (interquartile range 2–4) after the operation. The hospital stay after the operation was 3 ± 2 days (range 1–12 days). Postoperative complications included a seroma in 9 patients, scrotal edema in 4 patients, and no wound infections. There was no recurrence of the hernia after 24 months of follow-up in any patient.
Our study suggests that a tension-free hernia repair using the UHS system led to excellent results with minimal morbidity, no mortality, and no recurrences with a mean follow-up of 24 months. Therefore, we recommend the Gilbert double layer method for the repair of inguinal hernias in selected patients with ascites.
