Characteristics of the Endoprostheses Used in the Treatment of Inguinal Hernias by the Method of I.L. Lichtenstein

Vitaly Konstantinovich Donchenko; Донченко Виталий Константинович; Alexander Alexeyevich Andreev; Андреев Александр Алексеевич; Anton Petrovich Ostroushko; Остроушко Антон Петрович; Anastasia Yuryevna Laptieva; Лаптиёва Анастасия Юрьевна; Maria Alexandrovna Yashkova; Яшкова Мария Александровна

doi:10.18499/2070-478X-2023-16-1-98-103

Characteristics of the Endoprostheses Used in the Treatment of Inguinal Hernias by the Method of I.L. Lichtenstein

Authors: Donchenko V.K.¹, Andreev A.A.¹, Ostroushko A.P.², Laptieva A.Y.¹, Yashkova M.A.¹
Affiliations:
1. N.N. Burdenko Voronezh State Medical University
2. Voronezh State Medical University named after N.N. Burdenko
Issue: Vol 16, No 1 (2023)
Pages: 98-103
Section: Review of literature
URL: https://vestnik-surgery.com/journal/article/view/1684
DOI: https://doi.org/10.18499/2070-478X-2023-16-1-98-103
ID: 1684

Cite item

Full Text

Abstract
Full Text
About the authors
References
Supplementary files
Statistics

Abstract

Ventral hernias remain the most common surgical pathology, which occurs in 3-8% of the population or in 510-570 million people. The "gold standard" in the treatment of ventral hernias today remains the use of synthetic materials, and the main method of their treatment is non–tensioning prosthetic hernioplasty according to the method of I.L. Lichtenstein, which is implemented in 70-90% of patients with inguinal hernias. The properties of endoprostheses, which in their physical and mechanical properties should be as close as possible to the tissues of the patient's body, have a great influence on the results of surgical treatment of this contingent of patients. To date, more than 160 names of mesh endoprostheses are used, which differ, including in biological and mechanical characteristics. The paper presents information about the differences between implants used in hernioplasty using the Lichtenstein method in strength, elasticity, cell size, types of weaving and chemical composition of mesh prostheses. The study showed that the properties of endoprostheses, in particular, their structure, type of polymer, structure of filaments, biodegradability, plasticity, inertia of the material and others have a great influence on the results of surgical treatment when performing hernioplasty using the Lichtenstein method. The comparative effectiveness of the application of the developed materials during hernioplasty of inguinal hernias should include, among other things, data on the properties of the implant material and the features of its modeling, the technique of the operation, the results of general clinical, immunological, ultrasound, radiological and histological research methods.

Keywords

inguinal hernias, hernioplasty, endoprostheses, non-tensioning hernioplasty according to Liechtenstein, implants

Full Text

Relevance

Ventral hernias remain the most common surgical pathology, which occurs in 3-8% of the world's population, which is approximately 510-570 million people [2, 32]. The "gold standard" in the treatment of ventral hernias today remains the use of synthetic materials, and the main method of their treatment is non–tensioning prosthetic hernioplasty by the method of I.L. Lichtenstein [4, 6, 10, 15, 17, 25]. This method is implemented in 70-90% of patients with inguinal hernias [22, 34]. Herniation by I.L. Liechtenstein has become popular due to its minimal invasiveness, easy and convenient execution technique, low rates of relapse and cost [26, 35]. According to some data, the use of mesh prostheses increases the percentage of wound complications, significantly worsens the quality of life of patients, since they are foreign bodies and contribute to the maintenance of an inflammatory reaction in the implantation zone [10, 12]. Referring to their own experience and conservatism of surgical views, some authors adhere to the principle of autoplasty [24], the frequency of relapses of the disease in which can reach 8-10% [24, 25]. After hernioplasty by the method of I.L. Lichtenstein, relapses develop in 1-3% of cases and their occurrence is associated with the body's reaction to a "foreign body" and a violation of microcirculation in the area of the postoperative wound [11, 24]. It is unequivocal that the properties of endoprostheses, which by their physico-mechanical properties should be as close as possible to the tissues of the patient's body, have a great influence on the results of surgical treatment of this contingent of patients [2].

Goal

To study and compare and evaluate endoprostheses used in the treatment of inguinal hernias by the method of I.L.Lichtenstein.

Materials and methods

A review of the data presented in PubMed, eLibrary, CYBERLENINKA was performed, the search was carried out by the keywords "I.L.Lichtenstein method", "inguinal hernias", "hernioplasty", "polypropylene mesh" and is limited to the period 2006-2021. Exclusion criteria from the analysis: description of individual clinical cases; books and documents; comparison of treatment results of individual patients.

The main part of the article

To date, more than 160 names of mesh endoprostheses are used, which differ in the method of production, type of polymer, structure, thread structure, biodegradability and other characteristics, which ultimately determines their variety of mechanical and rheological properties [31, 32]. Their use in the plastic of hernial defects requires knowledge of their properties [32, 40-46].

The simplest classification of mesh implants, depending on the volume of holes and the amount of material, conditionally divides them into "light" (weight up to 70 g/m2), which are characterized by tissue germination, mobility with the possibility of destruction of the surgical suture on the aponeurosis, and "heavy" (weight more than 70 g/m2), which are encapsulated [14, 32]. It is worth noting that when choosing an implant in practical surgery, preference is not given to any particular type of material - the selection should be carried out in accordance with the elasticity of the patient's anterior abdominal wall [31]. Therefore, the concept of an "ideal" implant can exist only in the case of the greatest approximation of its elasticity to the patient's tissues [31, 47].

In particular, in the work of V.A. Samartsev. et al., 2017, the analysis of surgical mesh implants is carried out: microporous polypropylene SurgiproTM SPMM (Medtronic, Ireland) (specific gravity – 90 g/m3, pore size – 0.8 mm), macroporous polyester ParietexTM Lightweight Monofilament Mesh (Medtronic, Ireland) (specific gravity – 46 g/m3, pore size – 1.5 mm), macroporous polyfilament polyester Parietex ™ Hydrophilic 2-Dimensional Mesh (Medtronic, Ireland) (specific gravity – 116 g/m3, pore size – 1.63 mm), a polymer based on methacrylic acid derivatives and reinforced woven mesh made of polypropylene "Reperen" [31]. The cell sizes of Marlex and Prolene approach 100 microns [13]. The size of mesh prosthesis cells determines the time and quality of their implantation into the body: with pores of more than 75 microns, the implant grows to the full depth of collagen fibers and fibrocytes within a month; with smaller pores, histiocytic infiltration of endoprostheses prevails, which leads to its weaker fixation in tissues [13, 48]. It should be noted that inert materials that do not cause moderate inflammation necessary for the formation of a full-fledged scar can provoke a recurrence of hernia [19].

Braided suture materials provide more pronounced immunological reactivity, which increases the risk of inflammatory wound complications in the postoperative period [21]. Implantation of mesh endoprostheses made of titanium thread during Lichtenstein inguinal hernia repair did not lead to specific complications, the development of fertility disorders, did not worsen the blood supply to the testicle, general and local aseptic inflammation was weakly expressed, but this endoprosthesis was practically not visible on the X-ray [3, 5, 7].

Currently, endoprostheses made on the basis of both monofilament and polyunit polypropylene are widely used in hernioplasty [13, 27, 25, 29, 33, 37], polyester [20, 38], polytetrafluoroethylene [13], polyethylene teriftolate, polytetrafluoroethylene and polyvinylidene fluoride [31], polytetrafluoroethylene and others, including including combined materials [13, 14].

The use of the Prolene Hernia System (a two-layer polypropylene synthetic plate connected by a polypropylene cylinder) during observation for more than 91 months did not reveal significant differences in the frequency of relapses and postoperative pain when compared with standard Lichtenstein surgery [17]. According to other data, the use of the Prolene Hernia System (PHS) led to a decrease in complications from 23% to 17%, the recurrence rate from 2.7% to 0.6%, compared with traditional surgery [36].

The use of Parietene Progrip (a non-fixable composite semi-absorbable mesh consisting of 50% polypropylene and 50% absorbable polylactic acid) showed no advantages compared to Lichtenstein's technique, although it was significantly more expensive than conventional polypropylene mesh [17].

Polypropylene is a monofilament non-absorbable inert material, but despite its bioinertness, a significant inflammatory reaction with a predominance of the exudative component can develop during its implantation [13]. In 24.2% of patients after Lichtenstein's hernioalloplasty using polypropylene mesh, long-lasting persistent seromas with maceration of the skin around the wound were observed in the early postoperative period [25]. According to other data, Lichtenstein surgery using polypropylene mesh was accompanied by the development of early complications in 50% of patients (25% – wound complications, 12.5% – hyperthermia, 3.1% – acute urinary retention and 9.4% - foreign body sensation) and late complications in 21.9% (complications from the genitourinary system systems: dropsy of the membranes and testicular atrophy, spermatic cord cyst, orchitis, epididymitis, etc.; compression-ischemic: postoperative neuritis, neuralgia, pain, inguinal-genital neuropathy) [27]. According to ultrasound data, the use of a mesh polypropylene endoprosthesis in non-tensioning hernioplasty in 70.9% of patients in the early stages is accompanied by the formation of postoperative seromas without clinical manifestations [30]. Chronic pain syndrome for 6 months during hernioplasty using the I. Lichtenstein technique was detected in 16% of patients, a foreign body (polypropylene mesh) and the presence of a limited accumulation of fluids, soft tissue edema were detected in soft tissues; the thickness of the fibrous capsule was 0.3-0.5 cm [18]. It should be noted that in the experiment, a standard polypropylene mesh leads to a rough scarring process involving the vas deferens, respectively, its routine use in men of reproductive age for inguinal canal plastic is undesirable [6]. When examined 30-48 months after hernioplasty using the I. Lichtenstein technique, relapses were detected in 3.7% of patients [37].

Hernia gate plastic surgery using prostheses with polyhydrosialkanoate coating, compared with the use of traditional polypropylene mesh, reduced the percentage of early complications from 31.8% to 15%, as well as the duration of hospitalization and temporary disability, the percentage of persistent decrease in linear blood flow rate six months after surgery from 15.2% to 0% [8, 50].

The use of polyester mesh for inguinal hernia repair according to Lichtenstein is comparable to the use of polypropylene mesh in this situation with respect to postoperative pain and quality of life [38]. When comparing the use of polypropylene and polyester implants, it was concluded that the implant material does not affect the presence or absence of hernia recurrence, hormonal changes after inguinal canal plastic surgery according to Lichtenstein [20, 49]. The use of polyester mesh did not reduce the severity of chronic pain after 3 months compared to polypropylene mesh [38-51].

Широкое распространение в настоящее время получили сетчатые имплантаты из политетрафторэтилена, характеризующегося несмачиваемостью водой, инертностью в тканях, но инфицированный протез из данного материала должен всегда удаляться, в отличие от других материалов [13].

Relatively favorable results are associated with the use of endoprostheses made of polyvinylidene fluoride and reperene [6].

Open Lichtenstein plastic surgery with a synthetic Lintex implant leads to 7.69% of complications in the early postoperative period; scrotal hematomas and seromas were found in 37.7% of operated patients [16].

Of interest is the use of bioengineering achievements in the creation of autologous tissues, autologous dermis in the surgical treatment of hernias, which ideally integrates in the implantation zone without rejection and reabsorption [13].

Yakovlev A.V. et al., 2010, compared the clinical use of polypropylene mesh endoprostheses with a biocompatible coating of polyhydroxyalkanoates and without it in inguinal hernia repair using the Lichtenstein method [1]. In the group of patients with covered prostheses, there were fewer late complications, a reduction in the duration of hospitalization, temporary disability, and no persistent deterioration in the blood supply to the testicle [1].

To improve the quality of treatment, a simultaneous introduction of a polypropylene mesh and a collagen-chitosan plate into the patient's tissues was developed, i.e. the creation of a so-called combined endoprosthesis that reproduces a local inflammatory reaction [4]. Due to this, at earlier stages, it is possible to achieve the formation of mature connective tissue, mostly consisting of type III collagen and elastic fibers [4, 50].

Based on a practical study of 60 patients, half of whom had polypropylene mesh, and the other half had combined endoprostheses, we can talk about the following conclusions [4, 49-51]. It was found that the addition of a collagen-chitosan plate did not increase the time of operations, as well as the duration of hospitalization [4]. Regarding the thickness of the inflammatory infiltrate, according to ultrasound data on the 7th day, there were no significant differences between the groups of patients, however, when using a combined endoprosthesis, subclinical seromas did not appear so often [4].

The reason for the recurrence was the partial covering of the hernial sac with a prosthesis, i.e. a situation when the selected prosthesis was cut improperly – in this case, a small size (10-15 cm), or the mesh prosthesis wrinkled, rolled up and detached from the attachment site [23]. To prevent such outcomes, it is necessary: to select an acceptable mesh size, taking into account the anatomical features of the inguinal canal of the patient, to carefully cut and fix the mesh implant [24-28].

It is worth noting that many researchers are convinced that the occurrence of relapses in compliance with all the rules and accurate calculations, as well as high-quality surgery correlates with the presence of undifferentiated connective tissue dysplasia in the patient [4].

Attention is also drawn to the possibility of the development of the adhesive process in patients, the fourth degree of which was established in patients after non-protracted Lichtenstein hernioplasty, and the occurrence of the second degree was observed after the combined modified method [23].

Thus, when performing hernioplasty according to the method of I.L. Lichtenstein, the properties of endoprostheses, in particular, their structure, type of polymer, thread structure, biodegradability, plasticity, inertia of the material and others have a great influence on the results of surgical treatment. The evaluation of the comparative effectiveness of the use of the developed materials during hernioplasty of inguinal hernias should include a comprehensive analysis, including detailed data on the properties of the implant material and its modeling, the technique of the operation, the results of not only general clinical, but also immunological, ultrasound, radiological and histological research methods.

About the authors