1. Anterior pre-peritoneal inguinal hernioplasty 經腹壁行腹膜前鼠蹊疝氣修補術 溫義輝 奇美醫學中心 Yih-Huei Uen, MD Division of General Surgery, Department of Surgery, Chi Mei Foundation Medical Center, Tainan, Taiwan, ROC.

2. Design(I) Modified device /technique of PHS: Modified device /technique of PHS: An improved method for deploying the polypropylene underlay patch of the PROLEN Hernia System: An improved method for deploying the polypropylene underlay patch of the PROLEN Hernia System: American Surgeon 2007 May, Yih-Huei Uen American Surgeon 2007 May, Yih-Huei Uen 通過專利審核 通過專利審核

3. Fig. 1: The procedures of development of a modified device of PHS.

4. Fig. 2: The procedures of intra-pocket manipulation

5. Table 1. Results 0 0 0 0 1 1 35.7 ±5.4 41.3 ±3.2 Modified group N=184 >0.051 Post OP recurrence (follow up>2years) *Student’s t test **Chi-square test 0 Mesh extrusion 0 Hydrocele 0 Intestinal obstruction 0 Wound infection >0.051Morbidity** <0.0531.6 ±4.8 Direct hernioplasty <0.0537.2 ±5.1 Indirect hernioplasty OP time (mean ± SD)* P value Original group N=32

7. Comparative Laparoscopic Evaluation of the “ Original ” versus “ Modified ” Design of PROLENE Hernia System in A Porcine- groin Hernia-Repair Model Study(II)

8. Material and Method 30 uncastracted male pig (average BW: 24Kg) 30 uncastracted male pig (average BW: 24Kg) Unilateral anterior inguinal hernioplasty Unilateral anterior inguinal hernioplasty Group Group 1. Original PHS(n=10) 2. Modified PHS with onlay fixation (n=10) 3. Modified PHS without onlay fixation (n=10)

9. Hand – assisted laparoscopic stress-loading test using dynamometer

11. Result (I) :The laparoscopy of the preperitoneally positioned mesh prosthesis § 10 0 0 0 group 3 (n=10) 107 Entire MOP + 03 single or double area <0.05 Covering boundary 00 insufficient 10 sufficient >0.05 Obliteration of fascial defect 03 moderate or marked wrinkle 107 flat to slight wrinkle <0.05 Configuration of prosthesis P value* group 2 (n=10) group 1 (n=10)

12. Result (II): Comparsion of the results of stress-loading test Bursting strength lb P<0.01 Group2 vs Group1 and 3 P>0.05 Group1 vs Group 3 10.57± 0.46 23.99± 0.89 10.20± 1.11

13. Discussion ( I ): Special design and unique technique of “ Modified ” PHS ● Harboring a deploying underlay “ pocket ” graft with a pressure reception perimeter ● Fixating underlay graft to the fascial edge ● Using a narrow angled metal pusher to perform intra-pocket manipulation

14. Full deployment of underlay graft against the inner surface of the inguinal floor to cover entire MPO (Pascal ’ s principle) Full deployment of underlay graft against the inner surface of the inguinal floor to cover entire MPO (Pascal ’ s principle) Secure obliteration of fascial defect Secure obliteration of fascial defect Increased stability of devices Increased stability of devices Self assessment of the adequacy of deployment Self assessment of the adequacy of deployment Discussion ( II ):Potential advantage of “ Modified ” PHS prosthesis

16. Discussion ( III ): The fixation stitches of onlay patch traditionally used in “ Original ” PHS can be substituted by those of fascial edge in “ Modified ” device if it is strong enough. The fixation stitches of onlay patch traditionally used in “ Original ” PHS can be substituted by those of fascial edge in “ Modified ” device if it is strong enough. Can post-operative pain be decreased? Can post-operative pain be decreased?

17. Discussion ( IV ): Hand-assisted laparoscopic stress-loading test with dynamometer: Hand-assisted laparoscopic stress-loading test with dynamometer: Firstly used in assessment of the stability of hernia repair prothesis Firstly used in assessment of the stability of hernia repair prothesis An useful tool :good exposure, mimic nature hernia protrusion, easy manipulation and high accuracy An useful tool :good exposure, mimic nature hernia protrusion, easy manipulation and high accuracy

18. Conclusion: Groin hernia repair with “ Modified ” PHS device/ technique is a simple and effective way to achieve full deployment of underlay graft along pelvic anatomy with increased stability. Groin hernia repair with “ Modified ” PHS device/ technique is a simple and effective way to achieve full deployment of underlay graft along pelvic anatomy with increased stability.

19. Design(II) Underlay pocket graft ( enough! ) Underlay pocket graft ( enough! ) Type I: PROLENE mesh Type I: PROLENE mesh Type II: ULTRAPRO (partially absorbable) mesh Type II: ULTRAPRO (partially absorbable) mesh

20. Underlay pocket graft with ULTRAPRO (partially absorbable) mesh Underlay pocket graft with ULTRAPRO (partially absorbable) mesh

21. Study(III) Randomized comparison of the clinical result of pre-peritoneal hernioplasty with PROLENE vs ULTRAPRO mesh underlay pocket graft Randomized comparison of the clinical result of pre-peritoneal hernioplasty with PROLENE vs ULTRAPRO mesh underlay pocket graft

22. Table 1. Results 0 0 0 0 0 0 38.7 ±5.3 44.3 ±3.9 ULTRAPRO group N=30 0 Post OP recurrence (short-term follow up) *Student’s t test **Chi-square test 0 Wound infection 1 Wound hematoma 0 Intestinal obstruction 0 Mesh extrusion >0.051Morbidity** >0.0537.6 ±4.7 Direct hernioplasty >0.0543.2 ±5.7 Indirect hernioplasty OP time (mean ± SD)* P value PROLENE group N=28

23. Discussion Although long-term follow-up is needed, the early result of pre-peritoneal hernioplasty using ULTRAPRO mesh is as efficient as PROLENE analogue. Although long-term follow-up is needed, the early result of pre-peritoneal hernioplasty using ULTRAPRO mesh is as efficient as PROLENE analogue.

24. Summary Underlay pocket graft, either along use or combined in PHS device, can facilitate the result of pre-peritoneal hernioplasty. It ’ s role in inguinal hernioplasty will be high- lightened by the usage of ULTRAPRO mesh. Underlay pocket graft, either along use or combined in PHS device, can facilitate the result of pre-peritoneal hernioplasty. It ’ s role in inguinal hernioplasty will be high- lightened by the usage of ULTRAPRO mesh.

25. Reference 1. Gilbert AI, Graham MF, Voigt WJ. A bilayer patch device for inguinal hernia repair. Hernia 1999;3:161-166. 1. Gilbert AI, Graham MF, Voigt WJ. A bilayer patch device for inguinal hernia repair. Hernia 1999;3:161-166. 2. Uen YH. Comparison laparoscopic evaluation of the PROLENE hernia system and the Perfix plug-and-patch device in a porcine groin hernia repair model. Journal of Laparoscopic & Advanced Surgical Technique 2004;14(6):363-373. 2. Uen YH. Comparison laparoscopic evaluation of the PROLENE hernia system and the Perfix plug-and-patch device in a porcine groin hernia repair model. Journal of Laparoscopic & Advanced Surgical Technique 2004;14(6):363-373. 3. Murphy JW. Use of the prolene hernia system for inguinal hernia repair: retrospective, comparative time analysis versus other inguinal hernia repair systems. American Surgeon 2001;67(10):919-923. 3. Murphy JW. Use of the prolene hernia system for inguinal hernia repair: retrospective, comparative time analysis versus other inguinal hernia repair systems. American Surgeon 2001;67(10):919-923. 4. Uen YH. An improved method for deploying the polypropylene underlay patch of the PROLEN Hernia System American surgeon 2007 May 4. Uen YH. An improved method for deploying the polypropylene underlay patch of the PROLEN Hernia System American surgeon 2007 May

26. Thanks for your attention ! Thanks for your attention !