hernia repair bali basrul,dr

Tension FreeTension Free Hernia RepairHernia Repair

Basrul HanafiBasrul HanafiDigestive Surg, Dept. of Surgery Padjadjaran Digestive Surg, Dept. of Surgery Padjadjaran

University, Hasan Sadikin HospitalUniversity, Hasan Sadikin Hospital

BandungBandung

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Abrahamson et al. Maingot’s Abdominal Operations. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Abrahamson et al. Maingot’s Abdominal Operations. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

HERNIAS:HERNIAS:

Prevalence,Causes, Prevalence,Causes, and Repairsand Repairs

Estimated incidence in the general population is 3%Estimated incidence in the general population is 3%11

Male-to-female ratio: 25:1Male-to-female ratio: 25:122

More than 700,000 hernia repairs performed annually More than 700,000 hernia repairs performed annually in the United Statesin the United States33

Indirect 2:1 DirectIndirect 2:1 Direct Type 4 direct is single most commonType 4 direct is single most common

Estimated incidence in the general population is 3%Estimated incidence in the general population is 3%11

Male-to-female ratio: 25:1Male-to-female ratio: 25:122

More than 700,000 hernia repairs performed annually More than 700,000 hernia repairs performed annually in the United Statesin the United States33

Indirect 2:1 DirectIndirect 2:1 Direct Type 4 direct is single most commonType 4 direct is single most common

HERNIAS:HERNIAS:

Recurrence RatesRecurrence Rates

10% to 30% recurrence rate with primary 10% to 30% recurrence rate with primary inguinal hernia repairinguinal hernia repair11

Estimated 35% or higher recurrence rate Estimated 35% or higher recurrence rate with recurrent hernia repairswith recurrent hernia repairs22

10% to 30% recurrence rate with primary 10% to 30% recurrence rate with primary inguinal hernia repairinguinal hernia repair11

Estimated 35% or higher recurrence rate Estimated 35% or higher recurrence rate with recurrent hernia repairswith recurrent hernia repairs22

1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.2. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.

1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.2. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.

Abdominal wall layersAbdominal wall layers

1. Peritoneum2. Subperitoneal fat 3. Transversalis fascia4. Transversus abdominis muscle5. Internal oblique muscle6. External oblique muscle7. Subcutaneus fat8. Skin

Inguinal ligament

External oblique m. & apon.

Rectus m.

Spermatic cord

Linea alba

INGUINAL REGION

Cremaster

External oblique apon.

External oblique

Internal oblique m. & apon.

Inguinal ligament

Saphenous v.

Femoral vein

Conjoint Tendon

INGUINAL REGION

INGUINAL REGION

External inguinal ring

Cremaster (sperm. cord)

External oblique apon. External

oblique m.

Internal oblique m.

Transversus abdominus m.

Inferior epigastric vessels

Conjoint tendon

Cooper’s ligament

Transv. fascia

INGUINAL REGION

Preperitoneal View

Rectus m.


Lacunar ligament

Cooper’s lig

Spermatic cord

Iliac vessels

Internal inguinal ring

Inguinal ligament

Transversus m.

Pubis

Transversalis fascia

INGUINAL REGION

Testicular vessels

Vas Deferens

Iliac vessels


Spermatic cord

Inguinal lig.

Lacunar lig.

Pubis

Cooper’s lig.

Femoral vessels

Parietal peritoneum

Transversalis fascia

External oblique apon.

Abdom. muscles

Preperitoneal fat

INGUINAL REGION

Iliac vesselsAbdominal aorta

Cooper’s lig.

Pubis

Lacunar lig. Femoral vessels

Inguinal lig.

Iliac crest

INGUINAL REGION

Iliac vessels

Iliac crest

Abdom. m.

Ext. oblique apon.

Femoral vessels

Inguinal lig.

Sperm. cord

Ext. inguinal ring

Transv. fascia

Peritoneum

Rectus m.

Pyramidalis m.

HESSELBECH’S TRIANGLEHESSELBECH’S TRIANGLE

rectussheath

internal ring

inguinalligament

inferiorepigastricartery

pubis

Inguinal Hernias:Inguinal Hernias: ClassificationClassification

Type 1 Type 2 Type 3

Type 4 Type 5

From Gilbert. Perspectives in General Surgery. 1991;2(1):113-129. From Gilbert. Perspectives in General Surgery. 1991;2(1):113-129.

Milestones in Hernia RepairMilestones in Hernia Repair

Marcy (1870s) Marcy (1870s) Recognized importance of transversalis fascia Recognized importance of transversalis fascia

and internal ring closureand internal ring closure Used carbolized catgut to suture the ring Used carbolized catgut to suture the ring

Lucas-Championniere (1880s)Lucas-Championniere (1880s) Slit external oblique aponeurosis to expose the canalSlit external oblique aponeurosis to expose the canal Dissected and ligated sac at internal ring under Dissected and ligated sac at internal ring under

direct visiondirect vision

Marcy (1870s) Marcy (1870s) Recognized importance of transversalis fascia Recognized importance of transversalis fascia

and internal ring closureand internal ring closure Used carbolized catgut to suture the ring Used carbolized catgut to suture the ring

Lucas-Championniere (1880s)Lucas-Championniere (1880s) Slit external oblique aponeurosis to expose the canalSlit external oblique aponeurosis to expose the canal Dissected and ligated sac at internal ring under Dissected and ligated sac at internal ring under

direct visiondirect vision

From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.

Milestones in Hernia RepairMilestones in Hernia Repair (Cont’d)(Cont’d)

Bassini (1880s) “Father of Modern Herniorrhaphy”Bassini (1880s) “Father of Modern Herniorrhaphy” Dissected and reconstructed inguinal canal Dissected and reconstructed inguinal canal

to preserve functional anatomyto preserve functional anatomy Repaired transversalis fascia and reinforced Repaired transversalis fascia and reinforced

the canal’s posterior wall the canal’s posterior wall

Shouldice (1945)Shouldice (1945) Multi-layered repair, suturing only local tissues Multi-layered repair, suturing only local tissues

without prosthetic material; local anesthesiawithout prosthetic material; local anesthesia

Bassini (1880s) “Father of Modern Herniorrhaphy”Bassini (1880s) “Father of Modern Herniorrhaphy” Dissected and reconstructed inguinal canal Dissected and reconstructed inguinal canal

to preserve functional anatomyto preserve functional anatomy Repaired transversalis fascia and reinforced Repaired transversalis fascia and reinforced

the canal’s posterior wall the canal’s posterior wall

Shouldice (1945)Shouldice (1945) Multi-layered repair, suturing only local tissues Multi-layered repair, suturing only local tissues

without prosthetic material; local anesthesiawithout prosthetic material; local anesthesia

From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.

Milestones in Hernia RepairMilestones in Hernia Repair(Cont’d)(Cont’d)

Martin and Shureih (1983) Martin and Shureih (1983) Used MarlexUsed MarlexTM TM mesh deep to the transversalis fascia mesh deep to the transversalis fascia

in primary inguinal hernia repairin primary inguinal hernia repair

Stoppa (1984, 1987)Stoppa (1984, 1987) Extensive prosthetic reinforcement of the peritoneumExtensive prosthetic reinforcement of the peritoneum

using Mersileneusing MersileneTM TM (Dacron) mesh between the (Dacron) mesh between the peritoneum peritoneum and transversalis fasciaand transversalis fascia11

Martin and Shureih (1983) Martin and Shureih (1983) Used MarlexUsed MarlexTM TM mesh deep to the transversalis fascia mesh deep to the transversalis fascia

in primary inguinal hernia repairin primary inguinal hernia repair

Stoppa (1984, 1987)Stoppa (1984, 1987) Extensive prosthetic reinforcement of the peritoneumExtensive prosthetic reinforcement of the peritoneum

using Mersileneusing MersileneTM TM (Dacron) mesh between the (Dacron) mesh between the peritoneum peritoneum and transversalis fasciaand transversalis fascia11

1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.


Lichtenstein (1986) e.g. Prolene MeshLichtenstein (1986) e.g. Prolene Mesh Used nonabsorbable sutures and prosthetic mesh screen Used nonabsorbable sutures and prosthetic mesh screen

to reinforce new canal floorto reinforce new canal floor22

Lichtenstein (1986) e.g. Prolene MeshLichtenstein (1986) e.g. Prolene Mesh Used nonabsorbable sutures and prosthetic mesh screen Used nonabsorbable sutures and prosthetic mesh screen

to reinforce new canal floorto reinforce new canal floor22

2. Lichtenstein. Am J Surg. 1989;157:188-193.2. Lichtenstein. Am J Surg. 1989;157:188-193.


Gilbert (1987)Gilbert (1987)11 Used internal ring as direct access to the peritoneal spaceUsed internal ring as direct access to the peritoneal space Used polypropylene plug (later changed to the patch)Used polypropylene plug (later changed to the patch)

to repair indirect herniasto repair indirect hernias

Gilbert (1991)Gilbert (1991)22

Used sutureless “hand-fashioned umbrella” polypropylene Used sutureless “hand-fashioned umbrella” polypropylene plug to open as an underlay patchplug to open as an underlay patch

Gilbert (1987)Gilbert (1987)11 Used internal ring as direct access to the peritoneal spaceUsed internal ring as direct access to the peritoneal space Used polypropylene plug (later changed to the patch)Used polypropylene plug (later changed to the patch)

to repair indirect herniasto repair indirect hernias

Gilbert (1991)Gilbert (1991)22

Used sutureless “hand-fashioned umbrella” polypropylene Used sutureless “hand-fashioned umbrella” polypropylene plug to open as an underlay patchplug to open as an underlay patch

1. Gilbert. South Med J. 1987;80:191-195.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.1. Gilbert. South Med J. 1987;80:191-195.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.


Robbins and Rutkow (1993)Robbins and Rutkow (1993)33

Fabricated, cone-shaped plug, with sutures and onlay Fabricated, cone-shaped plug, with sutures and onlay graftgraftwithout sutures for indirect and direct herniaswithout sutures for indirect and direct hernias

Robbins and Rutkow (1993)Robbins and Rutkow (1993)33

Fabricated, cone-shaped plug, with sutures and onlay Fabricated, cone-shaped plug, with sutures and onlay graftgraftwithout sutures for indirect and direct herniaswithout sutures for indirect and direct hernias

3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

TENSION-FREE REPAIR:TENSION-FREE REPAIR:

PrinciplesPrinciples High dissection of inguinal sacHigh dissection of inguinal sac

Head, neck and shoulders of the sacHead, neck and shoulders of the sac Prevent recurrence at the internal ringPrevent recurrence at the internal ring Reinforce the canal floor without tensionReinforce the canal floor without tension

High dissection of inguinal sacHigh dissection of inguinal sacHead, neck and shoulders of the sacHead, neck and shoulders of the sac

Prevent recurrence at the internal ringPrevent recurrence at the internal ring Reinforce the canal floor without tensionReinforce the canal floor without tension

SHOULDERS

NECK

HEAD

SPERMATICCORD

Image courtesy of Arthur Gilbert, MD. Image courtesy of Arthur Gilbert, MD.

TENSION-FREE REPAIR:TENSION-FREE REPAIR:

AdvantagesAdvantages

SimpleSimpleRapidRapidLess painfulLess painfulEffectiveEffectivePrompt resumption of unrestrictedPrompt resumption of unrestricted

physical therapyphysical therapyLow recurrence rateLow recurrence rate

SimpleSimpleRapidRapidLess painfulLess painfulEffectiveEffectivePrompt resumption of unrestrictedPrompt resumption of unrestricted

physical therapyphysical therapyLow recurrence rateLow recurrence rate

Common Common Tension-Free RepairsTension-Free Repairs

Lichtenstein – “repair patch”Lichtenstein – “repair patch”11

Plug and patchPlug and patch33

Kugel RepairKugel Repair Lap Hernia RepairLap Hernia Repair The Prolene Hernia SystemThe Prolene Hernia System

Lichtenstein – “repair patch”Lichtenstein – “repair patch”11

Plug and patchPlug and patch33

Kugel RepairKugel Repair Lap Hernia RepairLap Hernia Repair The Prolene Hernia SystemThe Prolene Hernia System

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.3. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.3. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.

Common Common Tension-Free Repairs - Tension-Free Repairs - LichtensteinLichtenstein

Solid repair with good reported resultsSolid repair with good reported results Anterior supportAnterior support Suture intensiveSuture intensive No posterior supportNo posterior support Take about 40 minutesTake about 40 minutes EffectiveEffective Low recurrence rateLow recurrence rate No migrationNo migration

Solid repair with good reported resultsSolid repair with good reported results Anterior supportAnterior support Suture intensiveSuture intensive No posterior supportNo posterior support Take about 40 minutesTake about 40 minutes EffectiveEffective Low recurrence rateLow recurrence rate No migrationNo migration

Pre-shaped mesh in the inguinal boxPre-shaped mesh in the inguinal box

Closure of the aponeurosisClosure of the aponeurosis

Common Common Tension-Free Repairs - Plug & Tension-Free Repairs - Plug & PatchPatch

Good idea and has some good results Good idea and has some good results reportedreported

Suture intensive (the plug and the overlay Suture intensive (the plug and the overlay mesh)mesh)

No posterior supportNo posterior support Can take as much as 40 - 60 minutesCan take as much as 40 - 60 minutes No protection of the femoral canal No protection of the femoral canal Reported cases of mesh migrationReported cases of mesh migration Reported cases of patient discomfort longer Reported cases of patient discomfort longer

termterm

Good idea and has some good results Good idea and has some good results reportedreported

Suture intensive (the plug and the overlay Suture intensive (the plug and the overlay mesh)mesh)

No posterior supportNo posterior support Can take as much as 40 - 60 minutesCan take as much as 40 - 60 minutes No protection of the femoral canal No protection of the femoral canal Reported cases of mesh migrationReported cases of mesh migration Reported cases of patient discomfort longer Reported cases of patient discomfort longer

termterm

•Erosion of a shrunken soft Marlex™ plug into the bladder wall.Image courtesy of Parviz K. Amid, MD.

•3 plugs in one patient with a recurrence.Image courtesy of Karl LeBlanc, MD.

Plug & PatchPlug & Patch(also known as “umbrella”)(also known as “umbrella”)

Common Common Tension-Free Repairs - Kugel Tension-Free Repairs - Kugel PatchPatch Good idea. The repair is in the preperitoneal spaceGood idea. The repair is in the preperitoneal space Difficult to visualize the anatomy (approach)Difficult to visualize the anatomy (approach) A few anecdotal reported cases of mesh migrationA few anecdotal reported cases of mesh migration Reported cases of recurrenceReported cases of recurrence High cost of the meshHigh cost of the mesh

Good idea. The repair is in the preperitoneal spaceGood idea. The repair is in the preperitoneal space Difficult to visualize the anatomy (approach)Difficult to visualize the anatomy (approach) A few anecdotal reported cases of mesh migrationA few anecdotal reported cases of mesh migration Reported cases of recurrenceReported cases of recurrence High cost of the meshHigh cost of the mesh

Common Common Tension-Free Repairs - Lap Tension-Free Repairs - Lap Hernia Hernia

Solid repair!Solid repair! More challenging than open approachMore challenging than open approach General anesthesiaGeneral anesthesia Cost!!!Cost!!!

Solid repair!Solid repair! More challenging than open approachMore challenging than open approach General anesthesiaGeneral anesthesia Cost!!!Cost!!!

Common Common Tension-Free Repairs - The Tension-Free Repairs - The PHSPHS

Combines the three most common repairs (overlay, Combines the three most common repairs (overlay, plug, underlay)plug, underlay)

Non-Suture intensiveNon-Suture intensive Posterior support. Protects Femoral Canal from Posterior support. Protects Femoral Canal from

anterior approachanterior approach Can be done in 20 minutesCan be done in 20 minutes Conforms to anatomy in posterior space. Conforms to anatomy in posterior space.

Patient comfort longer term!Patient comfort longer term! To date, no reported cases of recurrence To date, no reported cases of recurrence

Combines the three most common repairs (overlay, Combines the three most common repairs (overlay, plug, underlay)plug, underlay)

Non-Suture intensiveNon-Suture intensive Posterior support. Protects Femoral Canal from Posterior support. Protects Femoral Canal from

anterior approachanterior approach Can be done in 20 minutesCan be done in 20 minutes Conforms to anatomy in posterior space. Conforms to anatomy in posterior space.

Patient comfort longer term!Patient comfort longer term! To date, no reported cases of recurrence To date, no reported cases of recurrence

Appeal of The PROLENE* Appeal of The PROLENE* Hernia Hernia SystemSystem

Surgeons who want a posterior repair from a simple Surgeons who want a posterior repair from a simple anterior approach.anterior approach.

Surgeons who want a procedure under local or Surgeons who want a procedure under local or regional anesthesia.regional anesthesia.

Surgeons who want to test the repair in OR.Surgeons who want to test the repair in OR.

Surgeons using alternative methods and have grown Surgeons using alternative methods and have grown concern with issues of mesh shrinkage, plug concern with issues of mesh shrinkage, plug migration, patient comfort, cost, and recurrence rates.migration, patient comfort, cost, and recurrence rates.

OverlayMesh

CylinderConnector

UnderlayMesh

The Onlay/Underlay The Onlay/Underlay Patch DevicePatch Device

From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.

The PHS Innovative Three-In-One The PHS Innovative Three-In-One Design:Design:combines the three most popular combines the three most popular tension free techniques utilized today tension free techniques utilized today in the repair of inguinal herniasin the repair of inguinal hernias

The Onlay Patch, like the Lichtenstein flat mesh repair, covers the entire floor of the canal; the system overlaps the pubic tubercle for added support, and provides the security of conventional patch techniques.

The Connector, provides the simplicity of a plug repair. Additionally, it secures the underlay patch to minimize incidence of migration. Its profile is a significant improvement over the bulk of conventional plugs

The Underlay patch, like a laparoscopic repiar, provides posterior support from a simple anterior approach. This underlay patch lays in the preperitoneal space and opens to cover the entire Myopectineal orifice.

Covers both the Femoral and Inguinal regions to minimize the possibility of recurrence.

Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)

From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.

Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.


Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.


Onlay/Underlay Patch Device Onlay/Underlay Patch Device Incorrectly Positioned During Hernia Incorrectly Positioned During Hernia RepairRepair


Summary and Summary and Overview of Available Overview of Available ResourcesResources

Mesh ‘plug’ repair vs Lichtenstein ‘patch’ Mesh ‘plug’ repair vs Lichtenstein ‘patch’ repairrepair 26 male pts, unilateral, primary, inguinal hernia repair26 male pts, unilateral, primary, inguinal hernia repair Randomised to 2 groups : plug and patch repairRandomised to 2 groups : plug and patch repair

Operating Operating time (mins)time (mins)

Ease of Ease of operation*operation*

Return to Return to work (days)work (days)

Return to Return to normality normality (days)(days)

Pain score**Pain score** Analgesia Analgesia (no. of (no. of tablets)tablets)

Lichtenstein Lichtenstein mean (+/- SD)mean (+/- SD)

38 (7)38 (7) 4.6 (2.1)4.6 (2.1) 29 (18)29 (18) 35 (12)35 (12) 3.9 (1.8)3.9 (1.8) 19 (10)19 (10)

Mesh plug Mesh plug mean (+/- SD)mean (+/- SD)

29 (6)29 (6) 2.7 (0.9)2.7 (0.9) 22 (13)22 (13) 25 (11)25 (11) 2.1 (1.5)2.1 (1.5) 13 (9)13 (9)

P valueP value 0.010.01 0.020.02 0.40.4 0.040.04 0.010.01 0.150.15

* Score out of ten(zero being the easiest and ten the most difficult – by visual analogue scale).

** Score out of ten (zero being no pain and ten the worst experience ever).

Open and Laparoscopic Approaches:Open and Laparoscopic Approaches: A ComparisonA Comparison

Selection by patient age No Limits Not for very young or old

Anesthesia Usually local/regional General

Expenses Operating room time Less Greater

Procedure time Less GreaterEquipment Less Greater

ComplicationsMinor Equal EqualMajor Less Greater

Recurrence Rate Lower Higher

Selection by patient age No Limits Not for very young or old

Anesthesia Usually local/regional General

Expenses Operating room time Less Greater

Procedure time Less GreaterEquipment Less Greater

ComplicationsMinor Equal EqualMajor Less Greater

Recurrence Rate Lower Higher

Factor Open Laparoscopic


From Gilbert. Int Surg. 1995;80:4-8 and Gilbert, personal communication. From Gilbert. Int Surg. 1995;80:4-8 and Gilbert, personal communication.

Open and Laparoscopic Approaches:Open and Laparoscopic Approaches: A Comparison (Cont’d)A Comparison (Cont’d)

Surgeon ExperienceTraining Less MoreAcceptance Greater Less

Difficulty of Procedure Less Greater

Patient Discomfort Initial 2 hr Less Greater

2–48 hr Equal or greater Less or equalAfter 48 hr Equal Equal

Activity ResumptionNormal Equal EqualStrenuous Equal Equal

Surgeon ExperienceTraining Less MoreAcceptance Greater Less

Difficulty of Procedure Less Greater

Patient Discomfort Initial 2 hr Less Greater

2–48 hr Equal or greater Less or equalAfter 48 hr Equal Equal

Activity ResumptionNormal Equal EqualStrenuous Equal Equal



From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-512 and Gilbert, personal communication. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-512 and Gilbert, personal communication.

PROLENEPROLENE Polypropylene Polypropylene Hernia System:Hernia System:Characteristics and BenefitsCharacteristics and Benefits

Designed to repair all abdominal wall herniasDesigned to repair all abdominal wall hernias Produces minimal tissue reactionProduces minimal tissue reaction Strong tensile and bursting strengthsStrong tensile and bursting strengths Maximum exposed flat mesh surfaceMaximum exposed flat mesh surface

for tissue ingrowthfor tissue ingrowth Large pore sizeLarge pore size

Designed to repair all abdominal wall herniasDesigned to repair all abdominal wall hernias Produces minimal tissue reactionProduces minimal tissue reaction Strong tensile and bursting strengthsStrong tensile and bursting strengths Maximum exposed flat mesh surfaceMaximum exposed flat mesh surface

for tissue ingrowthfor tissue ingrowth Large pore sizeLarge pore size

From King et al. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Boca Raton, Fla:CRC Press Inc;1994:chap 15.From King et al. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Boca Raton, Fla:CRC Press Inc;1994:chap 15.

PROLENEPROLENE Polypropylene Polypropylene Hernia System:Hernia System: SummarySummary

Tension-free techniques reduce the likelihoodTension-free techniques reduce the likelihoodof hernia recurrencesof hernia recurrences

Prosthetic mesh is ideal for bridging defectsProsthetic mesh is ideal for bridging defectsin the abdominal wallin the abdominal wall

Posterior-wall defect can be repaired with combined underlay Posterior-wall defect can be repaired with combined underlay and onlay patchesand onlay patches

Tension-free repair made possible with mesh prosthetics Tension-free repair made possible with mesh prosthetics allows repair without distortion of normal anatomy and suture-allows repair without distortion of normal anatomy and suture-line tensionline tension

Tension-free techniques reduce the likelihoodTension-free techniques reduce the likelihoodof hernia recurrencesof hernia recurrences

Prosthetic mesh is ideal for bridging defectsProsthetic mesh is ideal for bridging defectsin the abdominal wallin the abdominal wall

Posterior-wall defect can be repaired with combined underlay Posterior-wall defect can be repaired with combined underlay and onlay patchesand onlay patches

Tension-free repair made possible with mesh prosthetics Tension-free repair made possible with mesh prosthetics allows repair without distortion of normal anatomy and suture-allows repair without distortion of normal anatomy and suture-line tensionline tension

Sekian Sekian

hernia repair bali basrul,dr

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