**3. Surgical technique**

A skin incision is made, the aponeurosis of the external oblique muscle is opened, and the spermatic cord is identified. The subaponeurotic nerves (iliohypogastric and ilioinguinal nerves) need not be identified. Using a diathermy coagulator, a longitudinal medial incision is made along the cremasteric muscle and external spermatic cord fascia (fibrous cremasteric sheath); these are then separated from the spermatic cord to the inguinal ligament. The cremaster muscle, a continuation of the internal oblique abdominal muscle, arises at the pubic tubercle and the inguinal ligament. It forms the middle covering layer of the spermatic cord between the external and internal spermatic fascias, as it passes through the inguinal canal and distally to the common tunica vaginalis, an extroflexion of the transverse fascia.

The medial borders of the cremasteric sheath are grasped with Klemmer clamps (**Figure 4**), and the hernia sac is identified and separated from the spermatic cord. In direct or internal oblique inguinal hernia, the sac should be isolated from the surrounding anatomical structures and the transversalis fascia up to its neck when present. The area of weakness is then flattened by plicating the transversalis fascia. The deep internal inguinal ring is then prepared for applying section A of the mesh (**Figure 5**). In external oblique inguinal hernia, the hernia sac should be freed from the deep inguinal ring so that it can be completely reduced in the abdominal cavity. If present, a

**Figure 4.** (1) Cremasteric sheath, (2) transversalis fascia, (3) spermatic cord, (4) external oblique inguinal hernia.

voluminous prehernia lipoma can be resected or reduced in the abdominal cavity together with the hernia sac. If necessary, the deep inguinal ring is then narrowed with resorbable interrupted sutures. In all cases, the posterior wall is reinforced with the prosthetic mesh, as shown in **Figure 5**.

This innovative, semiresorbable pre-cut mesh (70% polyglycolic acid and 30% polypropylene) is designed to reinforce the entire floor of the inguinal canal. It is shaped to conform to anatomy without the risk of wrinkling or need to trim it. Polypropylene is noted for its ability to induce an inflammatory fibrous reaction that promotes rapid, firm adhesion of the mesh onto tissues [19]. The mesh is available as a large*-*pore woven mesh that promotes infiltration and integration of connective tissue [16, 20, 21]. Less susceptible to bacterial colonization, the mesh can be left in place in case of infection [20, 22, 23].

Section A of the mesh is applied to surround the spermatic cord contents and form a cone around them by overlapping the two tails (A1 and A2). The length of the tails can be shortened to adjust the opening of the cone apex to the diameter of the spermatic cord. If present, diffuse lipomatosis

**Figure 5.** "All-in-one mesh" device.

weakness of the transversalis fascia at the floor of the inguinal canal are contemporaneously reinforced by apposition of a single prosthetic mesh designed to conform to the anatomy and function of the inguinal canal. The resulting rapid integration of fibroblasts into the mesh and the transversalis fascia strengthens the new wall, rendering the entire area of weakness of the inguinal canal floor more resistant to weakening under elevated intra-abdominal pressure.

A skin incision is made, the aponeurosis of the external oblique muscle is opened, and the spermatic cord is identified. The subaponeurotic nerves (iliohypogastric and ilioinguinal nerves) need not be identified. Using a diathermy coagulator, a longitudinal medial incision is made along the cremasteric muscle and external spermatic cord fascia (fibrous cremasteric sheath); these are then separated from the spermatic cord to the inguinal ligament. The cremaster muscle, a continuation of the internal oblique abdominal muscle, arises at the pubic tubercle and the inguinal ligament. It forms the middle covering layer of the spermatic cord between the external and internal spermatic fascias, as it passes through the inguinal canal and distally to the common tunica vaginalis, an extroflexion of the trans-

The medial borders of the cremasteric sheath are grasped with Klemmer clamps (**Figure 4**), and the hernia sac is identified and separated from the spermatic cord. In direct or internal oblique inguinal hernia, the sac should be isolated from the surrounding anatomical structures and the transversalis fascia up to its neck when present. The area of weakness is then flattened by plicating the transversalis fascia. The deep internal inguinal ring is then prepared for applying section A of the mesh (**Figure 5**). In external oblique inguinal hernia, the hernia sac should be freed from the deep inguinal ring so that it can be completely reduced in the abdominal cavity. If present, a

**Figure 4.** (1) Cremasteric sheath, (2) transversalis fascia, (3) spermatic cord, (4) external oblique inguinal hernia.

**3. Surgical technique**

48 Hernia Surgery and Recent Developments

verse fascia.

**Figure 6.** (1) Transversalis fascia after flattening the direct inguinal hernia, (2) isolation of the cremasteric sheath, (3) prosthetic mesh reinforcing the inguinal hiatus, (4) spermatic cord.

of the spermatic cord can be resected. The cone is closed with a suture tying the overlapping tails. While the assistant elevates the spermatic cord with Bottini forceps, the surgeon inserts the prosthetic ring into the deep inguinal ring using two anatomic forceps (**Figure 6**).

> a resorbable suture. The spermatic cord is returned to its natural position, and the external oblique aponeurosis is closed over the cord with interrupted resorbable sutures, as are the

> **Figure 8.** (1) Cremaster, (2) prosthetic mesh, (3) musculoaponeurotic layer, (4) external oblique muscle fascia, (5) spermatic

**Figure 7.** (1) Transversalis fascia, (2) reduced direct inguinal hernia flattened by suturing the transversalis fascia, (3) transverse muscle, (4) internal oblique muscle, (5) aponeurosis of the external oblique muscle, (6) spermatic cord, (7) all-in-one mesh placed as described in the text. The special mesh configuration allows for deployment in left and

All-in-One Mesh Hernioplasty: A New Procedure for Inguinal Hernia Repair

http://dx.doi.org/10.5772/intechopen.75387

51

superficial layers.

cord.

right hernioplasty.

The cone serves to strengthen the area of weakness at the deep inguinal ring. When inserted into the ring, the cone depth is such that the implant does not interfere with or compromise the many underlying vessels, including the iliac vein medial to the artery and collateral vessels. Bendavid reported that the distance between the iliac vein and the transversalis fascia at the deep inguinal ring is between 0.8 and 1.2 cm [24]. A plug inserted any deeper would certainly comprise vessel function.

Sections B and C of the mesh are placed on the transversalis fascia. Section B connects section A in a medial angle to section C, which covers the entire floor of the inguinal canal and reinforces the middle and the medial fossa. So applied, the mesh sits laterally with its lesser convexity abutting the concavity of the inguinal ligament and extends medially to the conjoint tendon or above it, depending on the length of the canal, so as to avoid mesh wrinkling. A smooth mesh surface prevents the formation of dead spaces that delay fibroblast infiltration to the site and increase the risk of mesh-related infection and hernia recurrence. The distal end of section C (about 1 cm) is fixed to the pubic tubercle (not the periosteum) using resorbable suture (**Figure 7**). The shape of the mesh is configured so that it can be used for left- and rightsided inguinal hernia repair.

The medial edge of the previously identified cremasteric muscle is retrieved and sutured to the musculoaponeurotic structures using a running resorbable suture to cover the mesh (**Figure 8**). The cremaster serves only as a cover to prevent contact between the spermatic cord and the underlying mesh. If the muscle is injured during dissection, it can be repaired with

**Figure 7.** (1) Transversalis fascia, (2) reduced direct inguinal hernia flattened by suturing the transversalis fascia, (3) transverse muscle, (4) internal oblique muscle, (5) aponeurosis of the external oblique muscle, (6) spermatic cord, (7) all-in-one mesh placed as described in the text. The special mesh configuration allows for deployment in left and right hernioplasty.

of the spermatic cord can be resected. The cone is closed with a suture tying the overlapping tails. While the assistant elevates the spermatic cord with Bottini forceps, the surgeon inserts the

**Figure 6.** (1) Transversalis fascia after flattening the direct inguinal hernia, (2) isolation of the cremasteric sheath, (3)

The cone serves to strengthen the area of weakness at the deep inguinal ring. When inserted into the ring, the cone depth is such that the implant does not interfere with or compromise the many underlying vessels, including the iliac vein medial to the artery and collateral vessels. Bendavid reported that the distance between the iliac vein and the transversalis fascia at the deep inguinal ring is between 0.8 and 1.2 cm [24]. A plug inserted any deeper would

Sections B and C of the mesh are placed on the transversalis fascia. Section B connects section A in a medial angle to section C, which covers the entire floor of the inguinal canal and reinforces the middle and the medial fossa. So applied, the mesh sits laterally with its lesser convexity abutting the concavity of the inguinal ligament and extends medially to the conjoint tendon or above it, depending on the length of the canal, so as to avoid mesh wrinkling. A smooth mesh surface prevents the formation of dead spaces that delay fibroblast infiltration to the site and increase the risk of mesh-related infection and hernia recurrence. The distal end of section C (about 1 cm) is fixed to the pubic tubercle (not the periosteum) using resorbable suture (**Figure 7**). The shape of the mesh is configured so that it can be used for left- and right-

The medial edge of the previously identified cremasteric muscle is retrieved and sutured to the musculoaponeurotic structures using a running resorbable suture to cover the mesh (**Figure 8**). The cremaster serves only as a cover to prevent contact between the spermatic cord and the underlying mesh. If the muscle is injured during dissection, it can be repaired with

prosthetic ring into the deep inguinal ring using two anatomic forceps (**Figure 6**).

certainly comprise vessel function.

50 Hernia Surgery and Recent Developments

prosthetic mesh reinforcing the inguinal hiatus, (4) spermatic cord.

sided inguinal hernia repair.

a resorbable suture. The spermatic cord is returned to its natural position, and the external oblique aponeurosis is closed over the cord with interrupted resorbable sutures, as are the superficial layers.

**Figure 8.** (1) Cremaster, (2) prosthetic mesh, (3) musculoaponeurotic layer, (4) external oblique muscle fascia, (5) spermatic cord.

Fixed between the deep inguinal ring and the pubic tubercle, the mesh reinforces the posterior inguinal wall as it extends between the cremaster muscle and the transversalis fascia. The spermatic cord, subaponeurotic structures, and pressure exerted by the tissues compress it. Rapid fibroblast infiltration of the prosthesis incorporates it into the tissues to form a triple retaining layer, without the formation of dead space which could lead to the development of hematoma and/or seroma or nerve entrapment, all of which are causes of chronic pain that is notoriously difficult to treat. Surgery is performed with local anesthesia [25].

**3.** Reduced surgical trauma, with no or minimal postoperative pain and rapid return to activities

All-in-One Mesh Hernioplasty: A New Procedure for Inguinal Hernia Repair

http://dx.doi.org/10.5772/intechopen.75387

53

**6.** Reduced risk of chronic neuropathic or somatic pain caused by contact of mesh prosthesis

**8.** Potential reduction of hernia recurrence since the mesh covers the entire area of weakness of the floor of the inguinal canal and does not come into contact with the overlying layer, as oc-

We considered a cohort of patients suffering from primary unilateral inguinal hernia that underwent the "all-in-one" mesh hernioplasty technique consecutively, at our institution. Hernias were divided according to the European Hernia Society criteria (**Table 1**). The work described has been carried out in accordance with the code of ethics of the World Medical Association. Written informed consent was obtained from each patient included in the study. All data of the cohort were registered in a specific database. Spinal anesthesia was adopted, and 2.0 g cefazolin was administrated intravenously over 30 minutes before the incision for all patients, and the procedure was performed on a 1-day surgery basis. From September 2012 to August 2015, we treated 250 adult patients for primary inguinal hernia, 241 males and 9

Postoperative pain was gauged on the ward by a surgeon of the team. At discharge, all patients received a data sheet designed for the evaluation of postoperative pain using visual analogue scale (VAS) score, quantity of pain medication, and any postoperative discomfort. The patient's discomfort was assessed in terms of limitation of daily activities during the postoperative period, and return to work, and sports. Patients were asked for an overall opinion on the operation, on the postoperative period, and on the final result. These data were recorded by patients themselves on data sheet after 1, 2, and 3 weeks from discharge. The first clinical evaluation was made 7 days after surgery by a member of the surgical team. The second and third week interviews were made on the phone. The postoperative data registered by patients were collected. Follow-up, made to evaluate local signs, any kind of chronic pain, any sensation of foreign body, and recurrence, took place at 3, 6, 12, 18, and 24 months after surgery in the outpatient clinic by a surgeon of the team. All patient data were collected in a database of our institution.

**4.** Minimal use of mesh material and elimination of problems related to mesh wrinkling.

with nerves and surrounding musculoaponeurotic structures.

curs with the Lichtenstein and Trabucco procedures (**Figure 9**).

females with an average age of 61.7 years (range, 22–90).

of daily living.

**4. Personal case**

**4.1. Population**

**4.2. Follow-up**

**5.** Early hospital discharge.

**7.** No plugs used; no risk of plug migration.

#### **3.1. Advantages**

Compared with other techniques currently in use, this novel procedure has the following advantages:


**Figure 9.** (1) Transversalis fascia, (2) reduced direct inguinal hernia flattened by suturing the transversalis fascia, (3) transverse muscle, (4) internal oblique muscle, (5) aponeurosis of the external oblique muscle, (6) spermatic cord, (7) all-in-one mesh placed as described in the text, (8) mesh prosthesis placed according to Lichtenstein procedure or modifications thereof.


Fixed between the deep inguinal ring and the pubic tubercle, the mesh reinforces the posterior inguinal wall as it extends between the cremaster muscle and the transversalis fascia. The spermatic cord, subaponeurotic structures, and pressure exerted by the tissues compress it. Rapid fibroblast infiltration of the prosthesis incorporates it into the tissues to form a triple retaining layer, without the formation of dead space which could lead to the development of hematoma and/or seroma or nerve entrapment, all of which are causes of chronic pain that is

Compared with other techniques currently in use, this novel procedure has the following

**2.** Shorter operating time and greater ease of execution, without the need to isolate nerves, prepare the site for subaponeurotic placement, trim the mesh, fix it to the surrounding muscu-

**Figure 9.** (1) Transversalis fascia, (2) reduced direct inguinal hernia flattened by suturing the transversalis fascia, (3) transverse muscle, (4) internal oblique muscle, (5) aponeurosis of the external oblique muscle, (6) spermatic cord, (7) all-in-one mesh placed as described in the text, (8) mesh prosthesis placed according to Lichtenstein procedure or

notoriously difficult to treat. Surgery is performed with local anesthesia [25].

**1.** A relatively simple procedure with a short learning curve.

loaponeurotic structures, or apply one or more plugs.

**3.1. Advantages**

52 Hernia Surgery and Recent Developments

modifications thereof.

advantages:

