title: Anterior preperitoneal repair of extremely large inguinal hernias: An alternative technique.
abstract: BACKGROUND
  Standard open anterior inguinal hernia repair is nowadays performed using a soft mesh to prevent recurrence and to minimalize postoperative chronic pain. To further reduce postoperative chronic pain, the use of a preperitoneal placed mesh has been suggested. In extremely large hernias, the lateral side of the mesh can be insufficient to fully embrace the hernial sac. We describe the use of two preperitoneal placed meshes to repair extremely large hernias. This 'Butterfly Technique' has proven to be useful. Hernias were classified according to hernia classification of the European Hernia Society (EHS) during operation. Extremely large indirect hernias were repaired by using two inverted meshes to cover the deep inguinal ring both medial and lateral. Follow up was at least 6 months. VAS pain score was assessed in all patients during follow up. Outcomes of these Butterfly repairs were evaluated. Medical drawings were made to illustrate this technique. A Total of 689 patients underwent anterior hernia repair 2006-2008.
  
  
  METHODS
  Seven male patients (1%) presented with extremely large hernial sacs. All these patients were men. Mean age 69.9 years (range: 63-76), EHS classifications of hernias were all unilateral. Follow up was at least 6 months. Recurrence did not occur after repair. Chronic pain was not reported.
  
  
  CONCLUSIONS
  Open preperitoneal hernia repair of extremely large hernias has not been described. The seven patients were trated with this technique uneventfully. No chronic pain occurred.
  
  
  CONCLUSIONS
  The Butterfly Technique is an easy and safe alternative in anterior preperitoneal repair of extremely large inguinal hernias.
authors.affiliation: Department of Surgery, St. Elisabeth Hospital, Hilvarenbeekseweg 60, 5055 GC Tilburg, The Netherlands.
authors.forename: Giel G
authors.initials: GG
authors.lastname: Koning
authors.forename: Patrick W H E
authors.initials: PW
authors.lastname: Vriens