Overview
Definition:
The plug-and-patch repair is a surgical technique used to treat inguinal hernias, particularly in recurrent or complex cases
It involves the placement of a prosthetic plug (usually conical or mushroom-shaped) into the internal inguinal ring to close the defect, followed by a prosthetic patch (a flat piece of mesh) to reinforce the surrounding posterior wall of the inguinal canal
This method aims to provide durable repair by creating a tension-free closure
It can be performed open or laparoscopically.
Epidemiology:
Inguinal hernias are common, with a lifetime incidence of up to 27% in men and 3% in women
Recurrence after primary repair can range from 0-10%, increasing the need for techniques like plug-and-patch for revision surgeries
The incidence of primary inguinal hernias peaks in infancy and in individuals over 50 years old.
Clinical Significance:
Plug-and-patch repair offers a tension-free solution for a challenging surgical problem, aiming to reduce recurrence rates, especially in patients with large or multiple defects
Its application in both open and laparoscopic settings provides versatility
Understanding this technique is crucial for surgical residents preparing for DNB and NEET SS examinations, as hernia management is a core surgical competency
Proper execution minimizes complications and improves patient outcomes, directly impacting the quality of surgical care.
Indications
Indications:
Primary indication is for recurrent inguinal hernias after previous repairs, particularly those with a wide internal ring
It is also considered for complex primary inguinal hernias, especially in obese patients or those with a lax abdominal wall
It can be used for both direct and indirect hernias
In some cases, it may be an option for bilateral inguinal hernias
Laparoscopic plug-and-patch may be chosen for patients with a desire for minimal invasiveness and faster recovery, provided there are no contraindications to laparoscopy.
Contraindications:
Absolute contraindications include patient refusal, active infection at the surgical site, and uncontrolled coagulopathy
Relative contraindications may include severe medical comorbidities that increase surgical risk, inability to tolerate anesthesia, or significant intra-abdominal adhesions from previous surgeries that would complicate laparoscopic access
For laparoscopic approach, uncorrected bleeding disorders or severe cardiac/pulmonary disease may be relative contraindications.
Preoperative Assessment:
Thorough history including previous hernia repairs, prior complications, and medical comorbidities is essential
Physical examination should assess the size and reducibility of the hernia, presence of bulge, and tenderness
Baseline laboratory investigations including complete blood count, coagulation profile, and electrolytes are performed
Imaging, such as ultrasound or CT scan, may be used to confirm the diagnosis or assess complex anatomy, especially in recurrent cases
Preoperative antibiotics are typically administered for mesh-based repairs.
Procedure Steps
Open Technique:
An incision is made in the inguinal region
The hernia sac is dissected and reduced
The internal inguinal ring is identified
A prosthetic plug is inserted into the internal ring to occlude it
A prosthetic mesh patch is then sutured or stapled to reinforce the posterior wall of the inguinal canal, extending beyond the defect margins
Care is taken to avoid injury to the spermatic cord or femoral vessels
The overlying tissues are closed.
Laparoscopic Technique:
Typically performed under general anesthesia
Three small incisions are made for port placement
The peritoneum is entered and dissected to expose the myopectineal orifice
The hernia sac is reduced
The internal ring is identified
A plug-shaped prosthesis is placed within the internal ring
A larger, flat mesh patch is then placed over the anterior aspect of the myopectineal orifice, covering the plug and reinforcing the posterior wall
Fixation with tacks or sutures may be used depending on the mesh type and surgeon preference
The peritoneum is then closed.
Mesh Choice:
Various prosthetic materials are available, including polypropylene, PTFE, and composite meshes
The choice depends on surgeon preference, patient factors, and whether it is an open or laparoscopic approach
Composite meshes with a pore size designed to minimize tissue ingrowth into the viscera may be preferred in laparoscopic repairs
The plug is usually a conical or mushroom-shaped piece of the same or similar mesh material.
Postoperative Care
Immediate Postoperative:
Patients are monitored for pain, bleeding, and voiding
Adequate pain management is crucial, often involving multimodal analgesia with opioids and NSAIDs
Early ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
Diet is advanced as tolerated
Patients are instructed on wound care and activity restrictions.
Discharge Criteria:
Discharge is usually considered when the patient can tolerate a regular diet, ambulate independently, manage pain with oral medications, and has no signs of infection or significant bleeding
Clear instructions on follow-up appointments, wound care, and activity restrictions are provided
Patients should be advised to avoid heavy lifting and strenuous activities for 4-6 weeks.
Long Term Follow Up:
Follow-up appointments are typically scheduled at 2-4 weeks postoperatively to assess wound healing and symptom resolution
Further follow-up may be required based on patient symptoms or surgeon preference
Patients should be educated to report any signs of recurrence, such as a new bulge or persistent pain.
Complications
Early Complications:
Seroma formation is common
Hematoma can occur
Wound infection, although less common with mesh, remains a risk
Pain, particularly at the mesh or plug site, can be significant
Nerve injury leading to chronic groin pain or numbness is a concern
Urinary retention can occur postoperatively
Ischemic orchitis or testicular swelling is a rare but serious complication, especially with extensive dissection around the spermatic cord.
Late Complications:
Chronic pain syndrome due to mesh or nerve entrapment is a significant long-term issue
Mesh migration, extrusion, or shrinkage can occur, leading to recurrence or fistulization
Adhesions can form, potentially causing bowel obstruction
Erosion of the mesh into adjacent organs like the bladder or bowel is rare but serious
Hernia recurrence, despite the mesh, can still happen, particularly if the plug dislodges or the mesh is inadequately placed.
Prevention Strategies:
Meticulous surgical technique is paramount
Adequate hemostasis and gentle tissue handling minimize hematoma and seroma
Using appropriate mesh size and secure fixation (where indicated) prevents migration
Careful dissection around the spermatic cord and identification of nerves can reduce nerve injury risk
Preoperative antibiotics and sterile technique reduce infection risk
Choosing appropriate indications and patient selection also plays a role in preventing complications.
Key Points
Exam Focus:
Understand the indications for plug-and-patch repair, especially in recurrent hernias
Differentiate between open and laparoscopic approaches and their respective advantages/disadvantages
Recognize potential complications like chronic pain and recurrence and their management
Be aware of the rationale behind using a plug in conjunction with a patch for internal ring closure.
Clinical Pearls:
In recurrent cases, meticulously identify the previous repair site and anatomical landmarks
Use a plug of appropriate size to effectively occlude the internal ring without causing undue tension
Ensure adequate overlap of the mesh patch over the defect
For laparoscopic repairs, excellent visualization and peritoneal closure are key to preventing visceral complications
Pain management is critical for patient satisfaction and early recovery.
Common Mistakes:
Over-reliance on plug-and-patch for all hernia types
it is best suited for specific recurrent scenarios
Inadequate plug size leading to inadequate internal ring occlusion
Insufficient mesh overlap, increasing recurrence risk
Excessive dissection around the spermatic cord, risking testicular ischemia
Poor fixation of mesh in laparoscopic repairs leading to displacement
Failure to adequately address potential nerve entrapment during closure.