Current approaches to inguinal hernia repair

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Abstract

The repair of a simple inguinal hernia or a complicated incisional hernia no longer involves just the sewing together of a defect in the musculature. Present-day hernia operations require that the surgeon more fully understand the functional anatomy and pathophysiology of the abdominal wall and groin. Hernia surgeons must be familiar with a myriad of surgical techniques, ranging from the traditional tissue repairs with suture to the mesh-based “tension-free” open and laparoscopic techniques. Furthermore, the surgeon must comprehend outcome analysis in evaluating differing therapies. Several approaches have been used for repair of groin hernias and have included tissue repairs (later termed “tension” repairs), as well as mesh or tension-free repairs and laparoscopy. Although each of these repairs boasts its successes, there are advantages and disadvantages to each approach. This article highlights each of these repairs through review of the literature.

Section snippets

Brief historical overview

Since the mid 1800s, there have been several important milestones in the evolution of hernia surgery. In 1871, Marcy, a disciple of Joseph Lister, recognized the importance of the transversalis fascia and internal ring closure and used carbolized catgut to suture the ring with a 2-suture technique in 2 female patients [3], [4]. Bassini [5], considered today to be the “father of modern herniorrhaphy,” was the first to dissect and reconstruct the inguinal canal to preserve functional anatomy. He

Classification of inguinal hernias

Over the years, multiple classification systems have been developed, such as Halverson-McVay, Lichtenstein, Gilbert, Nyhus, Schumpelick-Arit, and Zollinger classifications, all of which evolved and sought to expand on the traditional classification of hernias as indirect, direct, or femoral [18], [25], [26], [27], [28], [29], [30]. When approaching groin hernia repair, a classification system that is easy to use can be extremely valuable in the decision-making process about which type of repair

Most commonly used groin hernia repairs

Improved understanding of groin anatomy initially led to the tension hernia techniques, such as the Marcy, Bassini, Halstead, McVay, and Shouldice techniques. With the exception of the Shouldice repair, the other tension repairs have been plagued with higher recurrence rates and greater patient discomfort. It was estimated that primary inguinal hernia repairs had a 10% to 30% recurrence rate and that the rate was >35% for recurrent hernia repairs [32], [33]. The Shouldice repair has been the

Prolene Hernia System

In 1998, the PHS—consisting of an onlay and an underlay patch (open posterior and anterior approach)—was introduced as an option for tension-free open repair of inguinal hernias and is touted for the repair of direct, indirect, and femoral hernias. The PHS “3-in-1” repair consists of an underlay patch and an overlay patch with an intervening connector (Fig. 4). The underlay is placed either through the internal ring or through the transversalis fascia, and in theory is seated in the

Conclusion

Outcome studies after inguinal hernia repairs have demonstrated a pattern of continued improvement over the past decade. Improved understanding of groin anatomy has led to a greater appreciation for the vulnerability of the entire MPO. Innovations in technique and product design have continued to spur advances in hernia repair, and it is hoped that they will continue to improve outcomes. These improvements have occurred most notably in centers specializing in hernia surgery, with some

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