hernia current.docx

8/11/2019 hernia current.docx

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TYPES OF THE OPERATIONS FOR INGUINAL HERNIA

The goal of all hernia repairs is to eliminate the peritoneal sac in the

case of an indirect hernia) and to close the fascial defect in the inguinalfloor. Traditional repairs approximatednative tissuesusing

permanentsutures. More recently, a permanent mesh has been used

with greater frequency to decrease tension on the repais. As surgeons

have gained more experiencewith the technique, laparoscopic

approaches have increased in frequency as well as in their success.

Simple high ligation of the sac through an inguinal incision is the key to

repair of indirect hernias in infants and children. Combined with

athightening of the internal ring, it is called Maercy repair.

Inguinal hernia in adults can ne repaired successfully through an inguinal, preperitoneal, or abdominal

approach, though inguinal repairs are most widely use today. While a given repair may be championed

by a particular surgeon or group, comparative studes do not conclusively demonstrate the superiority of

any one tye; inn fact, it seems likely that all the methods in common use give aquivalent results when

properly performed. Details of technique and the experience and skill of the surgeon are more likely to

account for the success of the procedure than is the type of the repair.

Thought most methods of repairing indirect inguinal hernias in

adults emphasize high ligation of the sac, as in children, elimination

of the sac by reducing it may suffice. The factor common to all

succsesfull methods of inguinal hernia repairs in adults is repair ofthe inguinal floor. Over the past 15-20 years, mesh repairs have

gradually gained in popularity and have become the most commonly

employed methods. Comparative studies show a clear superiority of

open mesh repairs over the most traditional repairs using native

tissue alone.

Over the past decade, increased wxperience has been gained with the laparoscopic and other minimally

invasive techniques. Althought laparoscopic approaches offer less pain and more rapid return to work or

normal activities, no long term studies are yet available to assure that hernia recurrence rates are as low

as tose seen with open mesh hernia repairs. Operative time and procedutre costs are generally highwrfor laparoscpic hernioraphies have lower hernia recurrence rates,

Among the traditional autologous tissue repairs, the Bassini repairwas the most widely use method. In

this repair : the conjoined tendon is approximated to Pauparts ligament and the spermatic cord remains

it is normal anatomic position under the external oblique aponeurosis.


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The Halsted repairplaced the external oblique beneath the cord but otherwise resembles the Bassini

repair. Cooper`s ligament (Lotheissen-McVay) repair brings the conjoined tendon farther posteriorly

and inferiorly to Coopers ligament.

Unlike the Bassini and Halsted methods, MacVays repair is effective for femoral hernia but always

requires a relaxing incision to relieve tension. Reccurense rates after these open nonmesh repairs vary

widely according to skill and experience of the surgeon, but range around 10%.


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Thought the Shouldice repairhas a low reported reccurance rate, it is not widely used, perhaps because

of the more extensive dissection required and belief that the skill of the surgeon may be as important as

the method itself. In the Shouldice repair, the transversalis fascia is first divided and then imbricated to

Pouparts ligament. Finally, the conjoined tendon and internal oblique muscle are also approximated in

layers to inguinal ligament.

The preperitoneal approach exposes the groin from between the transversalis fascia and peritoneum via

a lower abdominal incision to effect closure of the fascial defect. Because it requires more initial

dissection and is associated with higher morbidity and recurrence rates in less experience hands, it has

not been widely favored. For recurrent or large bilateral hernias, a preperitoneal approach using a large

piece of mesh to span all areas of potential herniation has been described by Stoppa. Laparoscopic

preperitoneal approaches have demonstrated excellent success, with low recurrence and complication

in experienced hands.

A desire to decrease the recurrence rate of hernias has prompted in ancreased use of prosthetic

materials in repair of both recurrents and first-time

hernias. Methods include plugs of mesh inserted

into the internal ring and sheets of mesh to create a

tension free repair. The most widely used

technique is that of Lichtenstein, an open mesh

repair that allows and early return to normal

activities and a low complication and recurrence

rate.


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Virtually all laparoscopic approaches utilize mesh in the repair. Several methods have been explore

from

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a transabdominal intraperitoneal onlay of mesh (IPOM)

-

transabdominal preperitoneal mesh technique (TAPP)

-

total extraperitoneal (preperitoneal) mesh placement (TEP).


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The high incidence of complications that occurred in early studies prompted revisions in operative

technique to avoid injury to lateral nerves. Several prospective

randomized trials have demonstrated decrease pain and faster

return to work with the minimally invasive techniques but atincreased cost of the procedures has not yet been established.

Spesific situations in which minimally invasive procedures may

be particularly advantageous include the repair of bilateral

hernias simultaneously, and repair in patients who must return

to work particularly quickly.

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hernia current.docx