Dr. Vipul D Yagnik MS

Assistant Professor, Department of Surgery, Pramukhswami Medical College, Karamsad, Gujarat, India


I read an article titled “A Different Technique of Primary Indirect Inguinal Hernia Repair by Inserting a Synthetic Mesh into the Pre and Retroperitoneal Spaces to Wrap the Peritoneal Reflection”: Preliminary Report by Professor Aydın Altan (Surgery) Turkey with interest. I would like to congratulate author for his work on a different technique. The technique described seems good. However; I would like to seek few clarifications from author.

Site of indirect stump is potential site for recurrence because in that region complete approximation of tissue is prevented by spermatic cord and one can’t close the internal ring completely. Closed stump is going to heal in 24 hrs as it is peritoneum. I don’t think for that reason we need to do this much dissection.

In Methodology, which type of anesthesia is used should be mentioned. I don’t think these much dissection is possible with local anesthesia. The gold standard technique for inguinal hernia repair can be done under local anesthesia and was found to be superior as compared to regional and general anesthesia [1].

Author has mentioned polyester fiber mesh as a choice of mesh. I would like to mention that polyester, polypropylene, and e-PTFE meshes are all satisfactory. Lightweight polypropylene (PROLENE) mesh may be best suitable for preperitoneal repair.

For evaluation of recurrence rate most of the large study showed either 5 years or 10 years follow up. In this study, follow up is very short and not even two years for all cases. Out of 5, probably one or two (40%) cases did not follow for 1 year. Even author himself talked about 10 years follow up in discussion. This follow up is even not sufficient to document early recurrence which develops within the first two years of the initial operation. Recurrence rate with Lichtenstein tension-free repair is very low even after follow up of 5 years (0.2%-0.5%) [2,3]. Recurrence should not be only criteria to evaluate efficacy or success of hernia, success can also be evaluated by degree of post operative pain and return to normal works.


  1. Javid PJ, Brooks DC. Hernia, Maginot’s abdominal operations. 5th Edition, New York, NY: McGraw-Hill. 2007;108.
  2. Schulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for primary inguinal hernias: results of 3,019 operations from five diverse surgical sources. Am Surg. 1992 Apr;58(4):255-7.
  3. Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg. 1998 Apr;186(4):447-55; discussion 456.

Dr. Vipul D Yagnik
Email: vipul_yagnik@yahoo.com


It is stated that indirect recurrences occur in the region of indirect sac stump through the internal ring as an early or late complication after repairing of primary indirect inguinal hernia [1]. Therefore, this region is a potential site for recurrence even though closed stump will heal in 24 hours and certain techniques obliterating or covering the site of sac stump have been developed such as Gilbert’s plug mesh. Dissection is not much in our method especially in Gilbert Type I-II hernia. Preperitoneal dissection is already made in certain preperitoneal repairing techniques such as Kugel’s patch repair.

Our patients were operated under epidural anesthesia as mentioned in “Patients’ subsection of Methodology”. In our procedure, local anesthesia technique of inguinal region involves pre and retroperitoneal dissection area (approx. 5 cm in both spaces) and may be used just as preperitoneal Kugel patch repair performed under local anesthesia [2-5].

Three types of meshes (polyester, polypropylene and e-PTFE) may be used. Any lightweight or soft mesh is essentially preferred because it adheres to the peritoneum and stays in place without sutures, with the aid of positive intra-abdominal pressure. Out of our 5 cases, four were operated in 2005 (one in May, one in June and two in October). The fifth case was operated in April 2008. Needless to say that follow up is short and it is necessary to perform this procedure in a large number of cases for definitive evaluation, as I stated in conclusion of the article. Recurrence, postoperative pain, seroma and return to work have been evaluated as follow-up criteria in this study. This technique is a minor modification of preperitoneal repairing and the article is a report of five cases carried out by this procedure which represents its applicability.


  1. Campanelli G, Pettinari D, Nicolosi FM, et al. Inguinal hernia recurrence: classification and approach. Hernia. 2006 Apr;10(2):159-61.
  2. Behnia R, Hashemi F, Stryker SJ, et al. A comparison of general versus local anesthesia during inguinal herniorrhaphy. Surg Gynec Obstet. 1992 Apr;174(4):277-80.
  3. Amado WJ. Anesthesia for hernia surgery. Surg Clin North Am. 1993 Jan;73(3):427-38.
  4. Van Nieuwenhove Y, Vansteenkiste F, Vierendeels T, et al. Open, preperitoneal hernia repair with the Kugel patch:a prospective, multicentre study of 450 repairs. Hernia. 2007 Feb;11(1):9-13.
  5. Li J, Zhang Y, Hu H, et al. Early experience of performing a modified Kugel hernia repair with local anesthesia. Surg Today. 2008;38(7):603-8.

Professor Aydın Altan
Email: aydinal@ttmail.com