A promising open inguinal hernia operation called Onstep was developed in 2005. The technique is without sutures to the surrounding tissue, causing minimal tension. A specific mesh is used with a memory recoil ring in the border, which may cause pain superficial to the lateral part of the mesh for slender patients. The aim of this study was to illustrate an easy procedure that alleviates/removes the pain. A male patient had persistent pain six months after the Onstep operation and therefore had a ring removal operation. The procedure is presented as a video and a protocol. At the eleven-month follow-up, the patient was free of pain, without a recurrence. It is advised to wait some months after the initial hernia repair before removing the ring, since the mesh needs time to become well integrated into the surrounding tissue. The operation is safe and easy to perform, which is demonstrated in a video

Andresen, Kristoffer

Rosenberg, Jacob

Öberg, Stina

Case Reports in Surgery

English

PubMed

Copenhagen University Research Information System

u n i ve r s i t y  o f  co pe n h ag e n  Københavns UniversitetHow to Surgically Remove the Permanent Mesh Ring after the Onstep Procedure forAlleviation of Chronic Pain following Inguinal Hernia RepairÖberg, Stina; Andresen, Kristoffer; Rosenberg, JacobPublished in:Case Reports in SurgeryDOI:10.1155/2016/5209095Publication date:2016Document versionPublisher's PDF, also known as Version of recordDocument license:CC BYCitation for published version (APA):Öberg, S., Andresen, K., & Rosenberg, J. (2016). How to Surgically Remove the Permanent Mesh Ring after theOnstep Procedure for Alleviation of Chronic Pain following Inguinal Hernia Repair. Case Reports in Surgery,2016, [5209095]. https://doi.org/10.1155/2016/5209095Download date: 03. Feb. 2020Case ReportHow to Surgically Remove the Permanent MeshRing after the Onstep Procedure for Alleviation of Chronic Painfollowing Inguinal Hernia RepairStina Öberg, Kristoffer Andresen, and Jacob RosenbergCenter for Perioperative Optimization, Department of Surgery, Herlev Hospital, University of Copenhagen,Herlev Ringvej 75, 2730 Herlev, DenmarkCorrespondence should be addressed to Stina O¨berg; stina.oeberg@gmail.comReceived 10 March 2016; Accepted 3 May 2016Academic Editor: Gabriel SandblomCopyright © 2016 Stina O¨berg et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.A promising open inguinal hernia operation called Onstep was developed in 2005. The technique is without sutures to thesurrounding tissue, causing minimal tension. A specific mesh is used with a memory recoil ring in the border, which may causepain superficial to the lateral part of the mesh for slender patients. The aim of this study was to illustrate an easy procedure thatalleviates/removes the pain. A male patient had persistent pain six months after the Onstep operation and therefore had a ringremoval operation. The procedure is presented as a video and a protocol. At the eleven-month follow-up, the patient was free ofpain, without a recurrence. It is advised to wait somemonths after the initial hernia repair before removing the ring, since the meshneeds time to become well integrated into the surrounding tissue.The operation is safe and easy to perform, which is demonstratedin a video.1. IntroductionInguinal hernia surgery is a common procedure [1] and itis estimated that surgeons worldwide perform more than 20million inguinal hernia repairs annually [2]. The most com-monly used surgical techniques are the laparoscopic tech-niques and the open Lichtenstein procedure, but they haveproblems such as recurrences and chronic pain [3]. In2005, two surgeons developed a new open inguinal herniaoperation calledOnstep [4].Themesh used for this techniqueis made of polypropylene, with a memory recoil ring inthe border of the mesh (PolySoft Mesh-Bard, Davol Inc.,Warwick, RI). Studies have shown promising results for theOnstep operation, with both a low chronic pain rate andfew recurrences [4, 5]. The mesh is laterally secured aroundthe spermatic cord, and medially it lies in the preperitonealarea, but no sutures are used to secure the mesh to thesurrounding tissue. The ring prevents the mesh from foldingand helps keeping it in place. Lateral to the spermatic cord,the only structures separating the mesh from the skin aresubcutaneous fat and the fascia of the external oblique. Inour department, a few slender patients have had pain ordiscomfort due to pressure of the ring in the mesh againstthe skin [5]. The inventors of the Onstep technique alsoobserved this complication among a few patients (personalcommunication), but the pain disappeared after a simpleprocedure where the memory ring was removed [4].Because of the promising results of the Onstep operation,it is expected that more surgeons will start to use this newtechnique for inguinal hernia repairs. Therefore the numbersof patients with complaints from the ring may rise and it isimportant that surgeons know how to remove the ring in themesh.The aimof this studywas to provide a surgical video of theprocedure, which shows surgeons how to quickly and easilyalleviate or remove the pain for affected patients. The videodemonstrates how to remove the ring from themesh, withoutincreasing the risk of an inguinal hernia recurrence [4].2. Case PresentationThe patient had his primary Onstep operation six monthsprior to the ring removal operation, and his Body MassHindawi Publishing CorporationCase Reports in SurgeryVolume 2016, Article ID 5209095, 3 pageshttp://dx.doi.org/10.1155/2016/52090952 Case Reports in SurgeryIndex (BMI) was 19.6 kg/m2. The initial Onstep operationwas performed to treat a primary inguinal hernia. After theoperation, the ring in the mesh gave rise to a prominence lat-erally in the groin area, which caused daily pain that requiredan elective ring removal operation under general anesthesia.The ring removal procedure can be performed under localanesthesia as well [4], but since there may be pressure on thespermatic cord when removing the ring in the mesh, withresulting pain, general anesthesia is preferred. After the ringremoval procedure, we conducted two telephone interviewsat one and four months, respectively. The last follow-up wasby mail, eleven months after the operation.2.1. Surgical Procedure. The ring removal procedure is visu-alized and vocally explained in the video. The procedure isperformed through a small incision on top of the prominenceand dissection is done to the space where the mesh lies,between the internal and external obliquemuscles.The lateralpart of themesh is then visualized.The next step is to identifythe ring in the mesh. The ring is placed in a drawstring inthe border of the mesh and is divided laterally, so that thetwo ends make a separate fold inside the mesh. The surgeonshould cut in the mesh laterally, until one or both ends of thering are visualized and grasp one end of the ring with a clamp.The ring can thereafter be pulled out without removing therest of the mesh. It may be necessary to use some force toremove the ring since the mesh is well integrated in thesurrounding tissue. Finally, the only steps remaining are tosuture the fascia of the external oblique muscle and then theskin.The video is available as a supplemental file; see Video 1 inSupplementary Material available online at http://dx.doi.org/10.1155/2016/5209095.3. ResultsThe prominence disappeared after removal of the ring, andthe patient could return to work the same day. Preoperatively,the patient had daily pain, especially when wearing trousers.At one-month follow-up, the only pain left was when cough-ing heavily (the patient suffers from chronic lung disease) andthe patient had no sign of a hernia recurrence. At the four-and eleven-month follow-up, the painwhen coughing heavilywas gone.There was still no sign of a recurrence. Overall, thepatient was very satisfied with the operation.4. DiscussionThe patient in this study had a surgical removal of thering in a permanent hernia mesh, six months after theOnstep operation. The video demonstrates the technique ofhow to remove the ring, with an explaining voice-over. Thepreoperative pain from the protruding ring was gone at thelast follow-up, without development of an inguinal herniarecurrence.The Onstep operation has existed for more than 10 yearsand is now introduced to several European countries andvery soon to the rest of the world. Advantages of this openoperation are that it is easy to learn and the duration ofthe procedure is approximately 15 minutes. Studies have alsoshown that both chronic pain and recurrence rates are low,the latter ranging from 0.6% [4] to 3.8% [5]. Today thereare only two studies about the Onstep operation reported inEnglish language [4, 5], but since the results are promising,we expect an increased use of the technique in the yearsto come, and there are several ongoing clinical trials. It hascome to our knowledge that especially slender patients maydevelop pain from the ring in the mesh, where it laterallylies very superficially if the patient has a small amount ofsubcutaneous fat. When the lateral part of the ring, and/ortrousers, creates pressure on the skin, patients may developpain or discomfort. The patient in this study had chronicpain, since the pain persisted 6months after the initial Onstepoperation [6]. However, the attached video in this studyteaches the technique of how to decrease or remove the pain,and therefore chronic pain arising from a protruding ring canbe dealt with.Thus, it is important for surgeons to be aware ofthis complication following theOnstep operation and to learnthe procedure, since the cause of the pain can be surgicallyremoved [4].Before performing the procedure of ring removal, thesurrounding connecting tissue needs time to become wellintegrated into the mesh. This is important to ensure that themesh stays in place when the ring is pulled out. One studyshowed that, after 10 weeks, tissue integration was very goodfor polypropylene [7]. We normally recommend waiting sixmonths before removal of the ring is indicated, both to ensurethat the mesh stays in place and to make sure that the paindoes not diminish by itself, as was seen for some patients inthe Portuguese study [4]. However, timing of the removal ofthe ring needs to be based on an individualized assessment.The strength of this study was that the video illustratesthe ring removal procedure well, and the technique is alsoexplained by voice-over. The limitation of the study was thatthe video was obtained by the authors and not by a profes-sional film crew. This is a case-report with the purpose ofillustrating how to perform the ring removal procedure. Thepioneers of the Onstep technique have removed the ring onthree of the four patients with pain following Onstep, and thepain disappeared without any recurrence (one-year follow-up) [4]. The authors in this paper have a submitted case-series of the Onstep procedure, where six patients with a ringremoval had alleviation or disappearance of their complaints,without a recurrence (a couple of months postoperatively).In conclusion, the video demonstrates a safe and easyway to remove the ring in the mesh. Eleven months after theoperation, the patient was pain-free and without a recurrenceof the hernia.ConsentThe patient provided a written consent to obtain the video ofthe surgical procedure and to publish it in a medical journal.Competing InterestsStina O¨berg has nothing to disclose. Kristoffer Andresenreports personal fees from Bard, outside the submitted work.Case Reports in Surgery 3Jacob Rosenberg reports grants from Johnson & Johnson,grants and personal fees from Bard, and personal fees fromMerck, outside the submitted work.References[1] R. J. Fitzgibbons Jr. and R. A. Forse, “Clinical practice. Groinhernias in adults,” The New England Journal of Medicine, vol.372, no. 8, pp. 756–763, 2015.[2] A. Kingsnorth, “Treating inguinal hernias,” British MedicalJournal, vol. 328, no. 7431, pp. 59–60, 2004.[3] M. P. Simons, T. Aufenacker, M. Bay-Nielsen et al., “EuropeanHernia Society guidelines on the treatment of inguinal herniain adult patients,” Hernia, vol. 13, no. 4, pp. 343–403, 2009.[4] A. Lourenc¸o and R. S. da Costa, “The ONSTEP inguinal herniarepair technique: initial clinical experience of 693 patients, intwo institutions,” Hernia, vol. 17, no. 3, pp. 357–364, 2013.[5] K. Andresen, J. Burcharth, and J. Rosenberg, “The initial expe-rience of introducing the onstep technique for inguinal herniarepair in a general surgical department,” Scandinavian Journalof Surgery, vol. 104, no. 2, pp. 61–65, 2015.[6] M. U. Werner and U. E. Kongsgaard, “Defining persistent post-surgical pain: is an update required?” British Journal of Anaes-thesia, vol. 113, no. 1, pp. 1–4, 2014.[7] L. Boulanger, M. Boukerrou, E. Lambaudie, A. Defossez, andM. Cosson, “Tissue integration and tolerance to meshes used ingynecologic surgery: an experimental study,” European Journalof Obstetrics Gynecology and Reproductive Biology, vol. 125, no.1, pp. 103–108, 2006.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

How to Surgically Remove the Permanent Mesh Ring after the Onstep Procedure for Alleviation of Chronic Pain following Inguinal Hernia Repair

Stina Öberg

Kristoffer Andresen

Jacob Rosenberg

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How to Surgically Remove the Permanent Mesh Ring after the Onstep Procedure for Alleviation of Chronic Pain following Inguinal Hernia Repair

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