Femoral hernias are a relatively uncommon but significant type of groin hernia, occurring when abdominal contents push through a weakened area in the femoral canal, just below the inguinal ligament. Though more frequently diagnosed in women, femoral hernias can affect patients of any gender, often leading to pain, discomfort, and potential complications such as strangulated femoral hernia, which requires emergency surgery.
Hernia repair techniques have evolved significantly over the years, incorporating advancements in surgical mesh, laparoscopy, and minimally invasive surgery. Among the techniques once considered for femoral hernia repair, the plug-based approach—including the Umbrella-Plug technique—has fallen out of favor due to chronic pain issues, mesh-related complications, and long-term patient dissatisfaction. The use of plugs in femoral hernia repair has led to a high incidence of postoperative pain, foreign body reactions, and other complications, making alternative methods a far superior choice for patients.
Studies published in Google Scholar, PubMed, and journals such as Ann Surg, J Surg, and Coll Surg Engl have highlighted the risks associated with plug repairs, particularly in comparison to tension-free mesh-based alternatives or laparoscopic techniques. This article will explore the pitfalls of plug-based repairs, the complications they present, and why leading surgeons advocate against their use in femoral hernia repair.
Key Problems with the Umbrella-Plug Hernia Repair Technique
The Umbrella-Plug technique for femoral hernia repair was initially designed to enhance hernia repair outcomes while minimizing recurrence. However, clinical experience and long-term patient outcomes have demonstrated that this technique often leads to significant complications, outweighing any potential benefits. Below are the key reasons why the plug-based approach is no longer considered an optimal choice.
Mesh Plug Design: A Source of Chronic Pain and Foreign Body Reactions
Unlike traditional flat mesh patches, the Umbrella-Plug is shaped like a cone or umbrella, which often leads to excessive pressure on surrounding tissues. Because it is a 3D structure that occupies space, it can cause compression to surrounding stuctures. This can result in nerve entrapment, mesh migration, blood clot of the femoral vein and long-term discomfort. Numerous studies available on Google Scholar and PubMed have linked plug-based repairs to increased rates of chronic pain compared to suture-only repairs or alternative femoral hernioplasty techniques.
Insertion Process Leads to Long-Term Complications
While the Umbrella-Plug was designed as a minimally invasive technique, its insertion process poses significant risks. The forced expansion of the plug within the femoral canal can lead to pressure on nearby nerves, resulting in persistent pain that can become debilitating for patients. Clinical trials and studies indicate that patients undergoing plug-based repairs report a higher incidence of postoperative complications, including nerve pain and inflammation, than those who receive non-plug-based repairs.
Fixation Issues: Increased Risk of Migration and Pain
Secure fixation of the mesh plug is challenging in the femoral canal, and migration remains a concern. the medial border of the femoral canal is the femoral vein and the plug can be secured medially. Improper fixation combined with the rigid structure of the plug, can lead to irritation of key anatomical structures, including the femoral vein and surrounding nerves. Many surgeons have found that patients who received plug-based repairs experience higher recurrence rates and a greater likelihood of requiring revision surgery to address complications.
Why Surgeons Advocate Against Plug-Based Hernia Repairs
Chronic Pain: A Major Postoperative Concern
Unlike tension-free mesh-based alternatives, plug repairs introduce a significant risk of chronic pain due to nerve entrapment and foreign body reactions. Research confirms that patients who undergo plug-based repairs frequently report persistent discomfort that can interfere with daily activities and quality of life. Tension-free repair methods that do not involve plug insertion have been shown to provide superior long-term outcomes with lower complication rates.
Higher Risk of Mesh Migration and Foreign Body Reactions
One of the most significant drawbacks of the Umbrella-Plug technique is mesh migration. Due to the conical shape of the plug, movement over time can lead to irritation of adjacent structures, increasing the risk of recurrence and requiring further surgical intervention. Studies highlight the complications associated with migrating mesh plugs, emphasizing the need for better, more stable repair techniques.
Minimally Invasive Alternatives Provide Better Outcomes
While plug repairs were initially marketed as a quick, minimally invasive solution, better options now exist. Laparoscopic and robotic techniques, such as the transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) approaches, allow for precise hernia repair without introducing the risks associated with mesh plugs. These techniques provide the benefits of reduced pain, quicker recovery, and lower recurrence rates, making them the preferred choice among experienced hernia surgeons.
Moreover, it is recommended for all women with groin hernias to undergo minimally invasive repairs over open repairs. In this scenario, minimally invaive repairs allow for the diagnosis and repair of femoral hernias that may not be detected readily with open approaches.
Better Alternatives to Plug-Based Repairs
Tension-Free Mesh Repair
One of the best alternatives to the Umbrella-Plug technique is a tension-free mesh repair, which provides reinforcement without inserting a bulky, rigid plug. This approach allows the mesh to conform naturally to the patient’s anatomy, reducing the risk of chronic pain and foreign body reactions.
Laparoscopicor robotic Hernia Repair (TAPP and TEP Techniques)
Laparoscopic and robotic techniques offer a minimally invasive way to repair femoral hernias without the risks associated with mesh plugs. Studies from J Surg, Royal College of Surgeons, and clinical trials across the United States have demonstrated superior patient outcomes with laparoscopic methods, including lower pain levels and decreased recurrence rates.
Suture-Only Techniques in Select Cases
For certain patients, particularly those with small femoral hernias, a suture-only approach may be a viable alternative. This method avoids the risks associated with mesh placement while still providing effective reinforcement of the femoral canal.
Dr. Iskandar’s Thoughts on Plug Repairs
Dr. Iskandar firmly believes that plug-based hernia repairs, including the Umbrella-Plug technique, should no longer be used due to their high risk of complications and long-term patient dissatisfaction. The phrase “Say No to Plugs” has become a guiding principle for many leading hernia surgeons who prioritize patient outcomes over outdated surgical techniques. Instead, tension-free mesh repairs and laparoscopic approaches provide safer, more effective, and more comfortable solutions for femoral hernia patients.
Conclusion
The Umbrella-Plug technique for femoral hernia repair was once considered a viable option, but ongoing research and clinical experience have revealed its significant drawbacks. Chronic pain, mesh migration, and long-term complications make plug-based repairs a suboptimal choice. Surgeons worldwide are now advocating for tension-free mesh repairs, laparoscopic techniques, and suture-only approaches where appropriate. With patient safety and long-term outcomes in mind, the best approach is clear: Say No to Plugs.
https://journals.indexcopernicus.com/api/file/viewByFileId/699439
https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=3d2c78a7a4c29ad9c97ca930cdc460a7bbdffdee
https://pmc.ncbi.nlm.nih.gov/articles/PMC4201027/
https://jamanetwork.com/journals/jamasurgery/fullarticle/394820
