Editor,
We read with great interest the article by Patchayappan et al., concerning the three-stitch
hernioplasty, where the prolene mesh is fashioned as in Lichtenstein's repair, placed,
and fixed only by three prolene stitches. We agree with the authors as we are using
a similar technique with some technical differences.
Our technique suggests an alternative anatomical site for mesh fixation. We evaluated
iliopubic tract as a possible alternative site for it. Several studies have confirmed
that the iliopubic tract can be identified readily as thickening of the transversalis
fascia, running parallel and deep to the inguinal ligament.[1] Lichtenstein's avoids it in his technique because although iliopubic tract is always
present, it is considered to be of variable strength.[2] However, other open hernia repair techniques support the use of the iliopubic tract.[3],[4] Our aim is to highlight the anatomical importance of the iliopubic tract for tension-free
hernia repair.
Our modified technique is performed under local anesthesia and all patients received
antibiotic prophylaxis (second-generation cephalosporin Cefuroxim, 750mg IV, 1 h before
incision). We prefer a field block with multiple injections along the incision. The
incision we make is parallel to the inguinal ligament, the same way as in Lichtenstein's
procedure.[3],[5] Following the same steps with the authors, we reach the external oblique aponeurosis
after ligating the three named superficial subcutaneous veins. External oblique aponeurosis
is opened in a direction parallel to its fibers down through the external ring. A
plane of cleavage is created between the external oblique aponeurosis and the conjoint
tendon superiorly. The inguinal ligament is well defined by dissecting the floor of
inguinal canal. The cord structure is encircled with a Penrose drain. Ilioinguinal
nerve is preserved to avoid entrapment and chronic pain in the postoperative period.
After the completion of the investigation for the presence of a direct and an indirect
hernia, we reduce the sac of the hernia without opening, regardless of the hernia
type. We always use polypropylene mesh, usually 7 cm × 15 cm, which is placed over
the transversalis fascia. The difference of our technique compared with the one that
the authors presented lays on this step. We fix the lower edge of the mesh to the
iliopubic tract with a 4-0 continuous prolene suture instead of using the inguinal
ligament.[3]
Tension-free hernia repair has reduced the incidence of recurrences.[4] Using the iliopubic tract as the place of mesh fixation, we are trying to achieve
even less tension compared to the original Lichtenstein's technique. The disadvantages
of our technique are that the operating time is slightly longer because of the different
placements of the mesh and the higher risk of injury of iliac or femoral vessels,
especially the femoral vein, during the mesh fixation. This technique is performed
the last 5 years in our clinic with no recurrences or hematoma. Further research and
more studies are necessary to reach safer conclusions.
