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Continued proliferation of Millikan tension-free plug and patch repair?
The plug and patch repair has gone out of favor because of chronic pain and associated erosions of the plug. I personally have dealt with it eroding into the colon on a left sided repair. Many others have described similar complications. In my practice I have found less pain and equivalent long term results with a combo suture repair of the floor of the canal and onlay with Pro-Grip self griping mesh for open repairs. However one of the biggest reasons that it has lost some steam is that many of us have switched to Lap repairs due to the decreased pain, decreased time to return to work, and the complete coverage of the Myopectineal Orifice with the lap repair. I initially used the plug and patch and felt like I was getting good results but the chronic groin pain and discomfort that my patients complained about was unacceptable in my opinion. That being said many surgeons get excellent results with many different techniques and sometimes the best technique is the one that your surgeon you choose is best at.
Any open repair can be done under local/IV anesthesia if you desire in most cases.
I would say in my experience that the recovery time and speed of operation are no different than with the classic Lichtenstein repair or a floor repair plus Lichtenstein. In fact, using the self-gripping mesh requires less fixation, minimizes pain, has very low recurrence, and is probably one of the fastest repairs that can be done.
If you are looking for low pain, least risk for chronic groin pain, low recurrence rate, and fastest return to work time then the Lap repair would be the most likely to accomplish all those things for you at the cost of cosmesis to some degree. With a Lap repair although small incisions, they will be visible to some degree when you have your shirt off. Most open repairs are hidden below the belt line.
That being said there are various permutations that make a Lap versus open repair make sense one way or the other. If there is any suggestion for weakness of the floor or possible hernia on the contralateral side then I would get an ultrasound with valsalva to confirm/rule out before suggesting one repair over the other. If clearly a contralateral hernia on exam then would lean toward Lap repair because you can fix both through the same incisions.
As far as watchful waiting that depends on the exam and on your size of hernia. If your hernia is reducible then the risk is as low as 2% per year for you having an adverse event/requiring repair. In other words watchful waiting is definitely something that can be done safely. On the other hand the natural progression is for these hernias to get worse over time and depending on your age and activity it is best to get them fixed electively when convenient. If on exam it is incarcerated/not reducible, causing significant pain, or contains intestines on imaging then I would proceed to fixing sooner than later.
Hope this helps a bit and feel free to be in touch and we can discuss on the phone if you like. Thanks for posting and doing such an excellent job at researching the different techniques and options to inform yourself so well. You will ultimately be glad and comfortable that you made the right choice of repair.
Dr. Szotek
317-660-5362
pszotek@gmail.com