Inguinal Hernia Surgery PDF
9.42 MB PDF
Preface
Our clinical experience, mainly focused on the study and surgical repair of abdominal wall defects (from the simplest to the most complex, from the most common to the rarest), started in the first half of the 80s, even before the introduction of modern prosthetic materials.
In the following years, with the advent of implants (meshes and plugs), many new surgical techniques were proposed and tested worldwide for the treatment of abdominal hernias, some of them performed with traditional laparotomy, others with laparoscopy or even with robotic surgery, reflecting the technological advances which we have witnessed in the last 30 years.
During all these years we made ourselves global promoters of this amazing surgical discipline, one that today fully deserves to be defined as highly specialized, a nascent art that requires great professional and intellectual dedication to be understood in its vastness and depth.
This exciting scientific endeavor led us soon to consider, among other aspects, that we cannot limit ourselves to adopting one standardized operating procedure for all patients with the same type of hernia, but, on the contrary, we must distinguish the different indications and most appropriate treatment options for each individual case and for each single patient.
For these reasons we like to define this surgery as a “tailored surgery”. Of course, in the “international” light of the guidelines that we have contributed to realize in these years we can state, without doubt, that for the routine repair of daily primary uncomplicated inguinal hernias, a perfect knowledge of at least the Liechtenstein technique and TAPP repair is enough for the majority of general non-specialized surgeons.
Indeed, every intervention we propose must be as far as possible adapted to the individual patient; in particular, we have to consider the patient’s constitution, the presence of possible comorbidities, the patient’s age, gender, overall physical performance, and personal daily needs and, of course, the quality of the tissues involved, the anatomy and the type of hernia defect, which must be properly identified and characterized, and, finally, the possible improvement in quality of life achievable in each single case.
All these parameters are reflected on the most appropriate choice not only of prosthetic material but also of surgical approach. The prosthetic material is selected from among a large variety of materials that may or may not be used (synthetic or biological, soft or rigid, with different elastic-physical, morphological and structural characteristics), and must be suitably shaped and calibrated in relation to the existing anatomical differences between individuals, considering the pathophysiological dynamics involved in the genesis of the disease, and the total and actual size of the hernia defect identified in each case. Similarly, the best surgical approach is chosen based on the above parameters and the additional purposes to be achieved with a given type of repair.
No doubt the first among these additional purposes is the respect of the physiology of the abdominal wall, which must always be preserved to the greatest possible extent, by respecting and protecting the noble structures and sparing the nerves of the region involved in the repair, so as to minimize postoperative pain and ensure patient comfort with a more rapid and efficient recovery of the patient’s usual daily activities.
Even the mastery of surgical techniques to be performed under local anesthesia, which allow patients to return home within hours of the surgery, plays an important role in this concept of “tailored surgery”.
To give a few examples, in surgery of primary unilateral groin hernia, we generally choose to perform sutureless and tension-free techniques with a miniincision (2.5 to 6 cm), which guarantee a very low recurrence rate in the long term (0.02%), comparable to the rates observed for the widespread Lichtenstein’s technique (which today still represents the golden standard treatment for this type of pathology, together with the laparoscopic TAPP approach). These techniques significantly reduce suture-related postoperative pain and can be easily performed under local anesthesia on a day-case basis.
We have personally led and developed many scientific studies also concerning fixation of the different types of meshes with fibrin glue, which shows excellent results in terms of efficacy and tolerability, as an alternative to traditional sutures. These devices are particularly suitable for the treatment of the hernias in the young and in athletes.
Nevertheless, in each case we have achieved great accuracy in detecting whether such techniques are suitable and fruitful for the individual patient: in other words, we have the option of using other kinds of repair such as the preperitoneal approach, anterior or posterior, plug, with absorbable (biologic) meshes, dynamic repair and, of course, laparoscopy. The laparoscopic approach can, for instance, be useful for the repair of bilateral groin hernia, whether primary or recurrent. Laparoscopy can be the first choice for incisional hernia repair in obese patients, in athletes with a small ventral defect, or in those patients who have already undergone a previous laparotomic repair.
Even in the open surgery of “simple” incisional hernias it is possible to adopt sutureless and tension-free techniques, exploiting the law of Pascal and employing fibrin glue for fixing the mesh in most of the cases.
In the presence, for example, of a real loss of substance, it is appropriate to fill the gap with an at least partially biologic prosthesis, which remains in contact with the viscera without causing adhesions and other well-known complications. In the same cases, the knowledge of and the ability to perform each kind of component separation (open, laparoscopic, anterior, posterior transversus abdominis release) is mandatory in order to really be able to realize an appropriate tailored approach.
The extent of the repair must be carefully evaluated in the preoperative phase, whatever the surgical technique that will be proposed to the patient, with careful choice of the most appropriate prosthetic materials: also the most suitable size of mesh must be well thought out and commensurate to the type of hernia defect identified in each case.
This eclectic approach requires, on the one hand, deep knowledge, culture and skill in all the possible techniques and, on the other, a continuous exchange of information among peers to enable a real and honest evaluation of results and ensure the best possible outcome for patients.
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