Table of Contents  
COMMENTARY
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 381-382  

Recent concepts in inguinal hernia repair


Department of Surgery, Command Hospital, Lucknow, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Subhash Chawla
Command Hospital, Lucknow - 02
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Chawla S. Recent concepts in inguinal hernia repair. Med J DY Patil Univ 2013;6:381-2

How to cite this URL:
Chawla S. Recent concepts in inguinal hernia repair. Med J DY Patil Univ [serial online] 2013 [cited 2024 Mar 28];6:381-2. Available from: https://journals.lww.com/mjdy/pages/default.aspx/text.asp?2013/6/4/381/118278

Hernias are among the oldest known afflictions of humankind and surgical repair of the inguinal hernia is the most common general surgery procedure performed today; however, the newer repair techniques continue to evolve. It is estimated that 5% of the population will develop an abdominal wall hernia, but the prevalence may be even higher. About 75% of all hernias occur in the inguinal region. Two thirds of these are indirect, and the rest direct. Males are 25 times more likely to have a groin hernia than females. As per the statistics, inguinal hernia repair is the commonest elective surgery performed in young males.

Bassini, an Italian surgeon, is credited as the father of modern herniorrhaphy. Traditional tissue repairs have stood the test of time since its inception as these are economical and acceptable in a rural setup.[1] But for the last two decades, there has been dramatic evolution in the management of inguinal hernia with the aim to reduce postoperative pain, recurrence, and period of work loss and disability. The turning point in hernia surgery was the discovery of synthetic polymers by Carothers in 1935. The commonest surgery performed for inguinal hernia is the open tension-free Lichtenstein's mesh hernioplasty, following which patients are observed in sheltered appointment for long duration, thereby losing on the long number of man-hours. [2] Prolene hernia system (PHS) was introduced in 1998 and was devised to combine the benefit of an anterior and posterior mesh repair because the mesh has both an overlay and underlay component.

After 1990, the attention was focused on the laparoscopic repair and this technique has made hernia surgery glamorous. Laparoscopic hernia repair is a relatively newer repair technique which has been widely used with an even lower recurrence rate (0-5%). The type of hernia, bilateralism, return to daily life in a short time, less pain, and shorter period of hospitalization are some factors that influenced surgeons to choose the laparoscopic procedure. However, these benefits are outweighed by several factors like its longer learning curve, higher cost, need for general anesthesia. Currently, there are two types of laparoscopic hernia repair; the transabdominal pre-peritoneal (TAPP) repair and the totally extraperitoneal (TEP) repair. Both approaches of laparoscopic hernia repair replicate the concept of Stoppa by placing large mesh within the pre-peritoneal space to cover 1/2 of the abdominal wall and all the vulnerable areas myopectineal orifice of Fruchaud including area of internal ring, Hasselbach's triangle, and the femoral ring. The laparoscopic TEP repair is an innovative concept in the hernia surgery and was announced by Arregui and Dion in the early 1990s. TEP repairs, as they are technically easier after the learning curve, provide a better view of the anatomy and do not require further equipment beyond that is normally available in most departments performing laparoscopic cholecystectomy. TEP is becoming the gold standard in the hands of expert surgeons for bilateral and recurrent hernias. However, laparoscopic surgery is associated with its own set of complications like scrotal hematoma or seroma, neuralgia, mesh infections. In TEP, the incidence of recurrence is 3%.[3]. Recurrence after laparoscopic repair is definitely a technical failure.

Success of any technique depends on surgeons' understanding of the anatomy and physiology of inguinal region, detailed knowledge of technique and technology including prosthetic materials. Failure of tissue-based repairs is due to excessive suture line tension leading to high recurrence rate and postoperative pain. But authors have successfully used rectus sheath incision to reduce the tension on suture line in this study. The true role of surgery is good surgical care to all people, in all places at minimal cost. Surgeons in rural areas of India are doing tension-free repairs using indigenous mesh (mosquito net) which is autoclavable and has similar weave, tensile strength, chemical composition, and biological response as commercially available mesh. [4] Final word on hernia repair is yet to be written. All methods of hernia repair are good in expert hands depending on the availability of infrastructure, resources, and the affordability. We should not take a fundamentalist stand on the superiority of one method over the other.

"Groin hernia repair does not have the glamour of a Whipple or of a heart transplant, but in terms of preserving years of useful life, in sheer volume, is one of the most important surgical procedures."

Jonathan E. Rhoades

 
  References Top

1.Udwadia TE. Inguinal hernia repair: The total picture. J Min Access Surg 2006;2:144-6.   Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Kouhia ST, Huttunen R, Silvasti SO. Lichtenstein hernioplasty versus laparoscopic hernia repair. Ann Surg 2009;249:384-7.  Back to cited text no. 2
    
3.Myers E, Browne KM, Kavanagh DO. Laparoscopic versus open hernia mesh repair. World J Surg 2010;34:3059-64.   Back to cited text no. 3
    
4.Tongaonkar RR, Reddy BV, Mehta VK, Singh NS, Shivade S. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg 2003;65:89-95.  Back to cited text no. 4
    




 

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