Critical scrutiny of the open "tension-free" hernioplasty

Tension-free hernioplasty is rapidly gaining worldwide acceptance. Since June 1984, 3,125 consecutive adult male primary inguinal hernias have been repaired by employment of an open tension-free prosthetic repair without approximation of the margins of the defect. Since the original publication of our technique in the 1989 February issue of The American Journal of Surgery, we have encountered four recurrences. These recurrences were caused by technical errors early in our experience and have since been corrected. The purpose of this paper is to bring those errors to the attention of surgeons, as well as to suggest certain modifications to further simplify the operation. Three of the recurrences occurred at the pubic tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the pubic bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Poupart's ligament. The error here was utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.