Surgical Science, 2013, 4, 554-557
Published Online December 2013 (
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Laparoscopic Inguinal Hernia Repair with Closure of
Hernial Defect and Central Mesh Fixation
Using Glubran 2
Ahmed E. Lasheen*, Adel M. Tolba, Hany Mohamed, Hatem Mohammed, Nadia A. Smaeil
General Surgery Department, Faculty of Medicine, Zagazig University,
Egypt and National Hospital, Riyadh, Saudi Arabia
Email: *
Received November 2, 2013; revised December 2, 2013; accepted December 10, 2013
Copyright © 2013 Ahmed E. Lasheen et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Laparoscopic tension-free repair of inguinal hernia was presented in 1990s, promising less pain and short
recovery period, but carrying the risk mesh bulging and migration. Objective: We have presented our technique in
which central zone of mesh is fixed only after closure of hernial defect. Patients and Methods: This study included 27
males patients (14 indirect inguinal hernias, 9 direct inguinal hernias, 4 both direct and indirect inguinal hernias on the
same side). These cases are undergoing tension-free mesh repair after closure of hernial defect, and the mesh is fixed
only at its central zone using Gulbran 2, between April 2011 and March 2013. The follow-up period ranged from 6 to
30 months. The intra and postoperative complications were recorded. Results: Mean hospital stay was 1 day. The age
of this group of patients ranged from 23 to 63 years (mean, 47 years). The operative time ranged from 30 to 100 min-
utes (mean, 45 minutes). The intraoperative complications were in form of mild bleeding in 7 patients (25.9%) during
hernial sac dissection. Postoperativ e complications were mild inguinal pain in 4 patients (14.8%) for three weeks. Mild
hydrocele in 3 patients (11%) was recorded. No recurrence or bulging at hernia site was noticed during the period of
follow-up. Conclusion: Laparoscopic inguin al hernia repair with central mesh fixation after closure of hernial defect is
effective, easy and free of complications.
Keywords: Laparoscopic Hernia Repair; Defect Closure; Mesh Fixation Glubrane 2
1. Introduction
Herniorraphy is the second prevalent operation after ap-
pendectomy in general surgery [1]. The standard method
for inguinal hernia repair had been changed little over a
hundred years until the introduction of synthetic mesh.
This mesh can be placed as either an open or a minimally
invasive endoscopic technique. The most common endo-
scopic techniques are transabdominal preperitoneal (TAPP)
[2] and totally extraperitoneal (TEP) [3] approaches.
Classical mesh fixation using tacher may be etiology of
postoperative pain, bladder injury and major blood ves-
sels injury [4]. Some surgeons advocated placing the
mesh without fixation (tension-free mesh repair) in the
preperitoneal space to avoid these complications, but
carrying the risk of mesh bulging or migration [5,6]. In
this study, the central zone (about central one third) of
mesh corresponding iliop ubic tract is fixed only by using
Glubran 2, afte r closure of hernia l defect .
2. Patients and Methods
This study was included 27 males patients (14 indirect
inguinal hernias, 9 direct inguinal hernias, 4 both direct
and indirect inguinal hernias on same side). All informa-
tion about the technique was discussed with all patients,
and all patients gave writing consent for inclusion of
their data in this study. The age of the patients ranged
from 23 to 63 years (mean, 47 years).
Surgical technique: Under general anesthesia, the
laparoscopic transabdominal preperitoneal (TAPP) tech-
nique is used in this patients group. The patient asked to
urinate, while in the surgical preparation room, in order
to empty the bladder. The Veress needle is inserted su-
pra-umbilically to install the pneumoperitoneum of 14
mmHg has been achieved. A 0-degree, 10 mm laparo-
*Corresponding a uthor.
scope is used for the whole procedure. Two additional
trocars of 5 mm in diameters, one on the right side of the
patient, at the level of umbilicus, lateral to the rectus
sheath, and another one, on left side of the patient,
slightly below the umbilicus, lateral to the rectus sheath.
The patient is in supine, Trendelenburg position, with the
right arm along the body and venous access on the left
arm. The surgeon takes up a position on the right side of
the patient and assistant and scrub nurse on the left. As
usually, the peritoneum is incised superiorly, three to
four cm above the hernia defect. This incision extends
from the medial umbilical ligament to the anterior supe-
rior iliac spine laterally. After dissection of hernia sac
and complete exposure of the preperitoneal space, the
hernia defect was closed helping spinal needle (No. 22G)
percutaneously and using prolene No. 2/0, and the suture
is tied ext racorporeal or intracorporeal (Figures 1(a)-(e)).
Suitable mesh is fixed at central zone (about one third)
only corresponding from anterior superior iliac spine to
the symphy sis pubis using Glubran 2 (Gem srl, Viare g gio ,
Italy) Figures 2(a)-(c). The peritoneum is closed with
using Vicryl No. 2/0, and the mesh remains in a com-
pletely extraperitoneal position. The pneumoperitoneum
is emptied under direct viewing with the laparoscope and
external pressure is applied to the inguinal region. The
trocar sites are closed and an elastic support for scrotal
compression is placed. The follow up period ranged from
6 to 30 months (mean, 22 months). The intra and postop-
(a) (b)
(c) (d)
Figure 1. (a) a—Anterior abdominal wall. b—Trocar port 5 mm. c—Hernia defect. d—Spinal needle No. 20G. e—Prolene No.
2/0 inside spinal needle. f—Peritoneal cavity. g—Posterior abdominal wall. The spinal needle and prolene No. 2/0 inside it
passed under the lower edge of hernia defect to peritoneal cavity. The prolene end was holed from peritoneal cavity by
grasper. (b) The spinal needle was partial withdraw and redirected to pass to peritoneal cavity above the upper edge of her-
nia defect with prolene thread. (c ) The spinal needle and prolene inside it passed to peritoneal cavity above the upper hernia
edge. Then, the other prolene end was holed by grasper. (d) The spinal needle was removed through prolene holding by
grasper. One suture is formed to pass under the lower edge of hernia defect, floor of defect, and above the upper edge of her-
nia defect. (e) The suture was tied extracorporeal or intracorporeal to close the hernia defect.
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(a) (b)
Figure 2. (a) One patient suffered from both (direct and indirect) types of inguinal hernia on right side and the dissection of
sacs started. (b) The hernia defects were closed by two sutures using prolene No. 2/0. (c) The central zone (about central one
third) of mesh corresponding to iliopubic tract was fixed to underlining tissue using Glubran 2.
erative complications were recorded.
3. Results
The mean surgical time was 45 minutes (ranged from 30
to 100 minutes). Twenty two patients (81.5%) of the
cases returned to their usual activities in one week and
five patients (18.5%) required up two weeks. Hydroceles
developed in three cases (11%), after correction of indi-
rect inguinal hernias, which were solved with a single
aspiration. Four patients (14.8%) experienced mild in-
guinal pain for three weeks. Mild bleeding occurred dur-
ing dissection of hernia sac from cord in 7 patients
(25.9%) which, controlled with cauterization. No recur-
rence or bulging of the mesh were recorded during the
period of follow up .
4. Discussion
The increased acceptance of inguinal hernia repair by a
laparoscopic approach has led to many reports confused
reports on technique, results, and complications related to
this procedure. Many of these complications are directly
related to lack of thorough knowledge of surgical anat-
omy or improper technique [7,8]. The complication rates
after laparoscopic hernioplasty vary from 5% to 13%, but
the definition of complications differs widely among
studies [9,10]. Severe bleeding usually due to vascular
injury of iliac vessels and generally occurs because the
using of staples during mesh fixation [11]. Patients who
undergo laparoscopic herniorraphy have 1.6% incidence
of neuralgias due to nerve entrapment during mesh fixa-
tion with staples [12]. Some surgeons advocated placing
the mesh without fixation in preperitoneal space to avoid
nerve injury [13]. In our technique, the central zone of
the mesh only fixed by using Glubrane 2 substance cor-
responding to iliopubic tract, preventing any injury to
nerves and vessels. Mesh bulging was considered a fail-
ure of the correct surgical techn ique to tightly stretch the
mesh over the hernia opening. Two factors are predis-
posed for mesh protrusion a loosely stretched mesh and
present of hernia defect [5]. The mesh in our technique is
fixed at central zone after closure of hernia defect to al-
low the mesh expanded peripherally when the pneumop-
eritoneum is released. The recorded recurrence rate is
0.1% following TAPP. The main cause of recurrence is
mesh not adequately fixed and presence of hernia defect
allowing the mesh to migrate through it [11]. The recur-
rence rate in our study is zero, this due to closure of her-
nia defect behind the mesh, which fixed adequately over
the closed hernial defect.
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5. Conclusion
Our technique for laparoscopic inguinal hernia repair is
easy, associated with good results and free of complica-
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