Recent advances in the repair of groin herniation

Introduction 

My interest in the field of herniology was sparked more than 50 years ago, while I was a student at Cambridge University. I became fascinated by the complexity and beauty of the groin. An extra year in anatomy deepened my passion. Later, as house surgeon to Harold Edwards, author of an authoritative review of herniology (1943)1 ,I learned the modified Bassini procedure, darning the inguinal canal with nylon at King's College Hospital London. After the operation, the patient stayed in a plaster of Paris hip spica for 7 to 10 days! During subsequent military service in the Royal Air Force, I encountered the unusual diverticular form of direct inguinal herniation, which had strangulated, in a pilot.

At Minneapolis, during my residency, I performed an operation in a man with Spigelian herniation and in a woman with incarcerated Spigelian herniation. As a result, I wrote an article and, later, a chapter for the first edition (and later editions) of Nyhus's bible on hernia.2 In 1961, I saw Nyhus'sexhibit on preperitoneal herniorrhaphy at the annual meeting of the American College of Surgeons in Chicago, which led me to decades of experience with this posterior approach. Serendipitously, I noticed attenuation of the anterior rectus sheath in patients with groin herniation. This observation evoked an abiding interest in biochemical degradation of connective tissues and the causes thereof in patients with groin herniation.

In 1967, I was invited to join with Chester McVay and Mark Ravitch on a review of inguinal herniation that was published in Current Problems in Surgery.3 Thus, began a long and fruitful association with the nobility in herniology, which happily has extended to the present time. A subsequent issue of Current Problems in Surgery in 1991, on the same topic, included contributions by Nyhus and colleagues.4 Although his operation and the operations of McVay, Shouldice, and Stoppa were portrayed, the most widely performed procedure was stated to be the “modified” Bassini. Lichtenstein's operation was considered inadvisable for type I or II defects. Plugs were not mentioned nor was laparoscopic repair. Few prospective trials had begun, and individual experience reigned.

Since that publication, enormous advances have been made in the field of herniology. “More progress in the evolution of hernia surgery has occurred in the past decade than in the preceding 100 years.”5 Tension-free prosthetic repair has come to be accepted worldwide, except for young patients and some women. The preperitoneal space is being used more and more for the dissection and repair of large, bilateral, and recurrent herniation. Prosthetic plugs are popular. Laparoscopic repair is now competitive with the time honored, open approach. Rates of recurrence and infection have fallen dramatically. Epidemiologic data are raising standards worldwide. Patients can now anticipate (unfortunately, with no guarantee) ambulatory surgical procedures, minimal postoperative pain, and almost no recurrence, with rapid return to normal activity.

Much of this vast improvement has resulted from the development of herniology into yet another subspecialty of general surgery with dedicated clinics and its own society and journal. Much credit for this evidence-based practice must go to to European surgeons who blazed the trail. Several large prospective randomized trials, now underway, provide hope that the mundane practice of groin herniorrhaphy (which was once relegated to the intern) finally will enter its proper academic place in the surgeon's pantheon.

Now that I have retired from surgical practice (1 or 2 years after my own inguinal hernioplasty), more time is available to review the recent literature. I deem it an honor and privilege to do so. Because I no longer have access to medical media or extensive secretarial support, I decided to do without illustrations. However, pertinent references are provided so that the originals can be examined.

Etiologic factors 

Historically, abdominal herniation has been attributed to a disparity between visceral pressure and the resistance of the musculature. Cooper in 18046 listed factors that increase intra-abdominal forces: cough, constipation, obesity, pregnancy, ascites, and unusual exertion (ie, heavy lifting). In regard to unusual exertion, despite enormous insurance and legal involvement, only 7% of patients with new onset groin herniation recalled such an incident.6 Today, besides the erect posture and aging, carcinomatosis, peritonitis, peritoneal dialysis, prostatism, cigarette smoking, and genetic influences would be added. In the 1960s, claims were made that, in later life, an inguinal protrusion presaged colon cancer. However, recent data have discounted any direct association.

Evolution of recent techniques 

Knowledge regarding the history of the field of herniology is important, as Santayana has stated,45 in another context, because “those who cannot remember the past are condemned to repeat it.” This was certainly true of those who created the many corruptions of Bassini's cure for groin herniation. Details of his technique, which were documented by many surgeons from around the world, were ignored. Myths were repeated unchallenged, even by leading herniologists. Fortunately, a consensus is now emerging that Bassini was indeed the father of modern herniology. This understanding has built on the excellent results that were obtained at the Shouldice Clinic with the “modern Bassini” operation. A further important contribution was that of Wantz,46 who reproduced Catterina's (Bassini's assistant) description of his chief's procedure.

Surprisingly, some herniologistscontinue to give credit to Lucas-Championierre for laying open the external oblique aponeurosis and high ligation of the indirect hernial sac, even though his articlewas published years after Bassini's many contributions.47 Similarly, Marcy still receives credit for dividing and reconstructing the transversalis fascial floor of the inguinal canal and suturing the internal ring. However, 20 years ago, after reviewing his many publications, I concluded that, before the publication of his second book on hernia in 1892, all of his inguinal herniorrhaphies were conducted through the external ring. Only in the large, neglected hernias, in which the 2 inguinal rings were superimposed, with obliteration of the obliquity of the inguinal canal, could he have closed the deep one around the spermatic cord. Halsted wrote “Bassini was firstMarcy never accepted Bassini's priority and labored with the help of friends to alter history, but to no avail.”48

Regardless, Annandale in 1876 did divide the roof and floor of the inguinal canal, ligate the inferior epigastric vasculature, and divide peritoneal sacs preperitoneally in a patient with both inguinal and femoral herniation.49 Bogros in 182350 used the same anterior approach to expose the external iliac artery, along with the inferior epigastric, for aneurysms of the latter and the femoral artery. Proximal ligation (Hunterian) was then performed.

The technique used at the Shouldice Clinic to repair groin herniation has been attributed solely to its founder, Dr Shouldice, in 1945. However, at that time, he was not dividing the transversalis fascial floor of the inguinal canal. This crucial step was only instituted sometime after Ryan joined the Clinic, with Obney, in the early 1950s. It was more than a decade before the details of the new operation were published.Some of the confusion was generated by the Clinic's practice of presenting data on their outcomes as a continuum from the end of World War II, when the hospital was founded. Nevertheless, the importance of the Shouldice contribution lies in the fact that this tissue repair was the gold standard for 30 years, until tension-free operations took hold.

The Shouldice Clinic also emphasized the use of local anesthesia, which was introduced at the end of the 19th century by Halsted and Cushing. This enabled early ambulation, which was pioneered by Nicoll in Scotland (1909). At the Shouldice Clinic, the patient walked off the table (with assistance). The importance of this step is that others were slow to follow. At the Massachusetts General Hospital, in 1969, patients who underwent hernia repair were hospitalized for 7 days until their skin sutures were removed. Finally, the Shouldice Clinic was the first facility that was dedicated only to the care of patients with herniation. Thus, it led the way to the development of the field of herniology into a subspecialty of general surgery. However, ambulatory surgery now means outpatient, not inpatient. This demands 24-hour availability for the surgeon, with a closer patient relationship.

Recognition of the innovator who creates something new is not only morally correct, but it also provides those who follow with insights into how obstacles are overcome. This enables further advances to be made. Thus, the most popular repair for groin herniation today is the tension-free procedure that was reported in 1986 by Lichtenstein.51 Even though most herniologistsassume that he invented the operation, he repeatedly denied this attribution. Newman52 had employed the procedure for 20 years while in private practice. He recommended it to Lichtenstein in the early 1980s.Newman followed Usher who, in 1958, conducted his repair in the preperitoneal plane.53 He first used polyethylene “Marlex” mesh, changing in 1962 to polypropylene (synthesized in Italy by Natta in 1954 and manufactured by Phillips Petroleum, Bartlesville, Okla), which he introduced because it could be autoclaved and cut without unraveling. The defect was not buttressed but both spanned and overlapped. A prosthesis, keyholed (which Usher later gave up for parietalization) to transmit the spermatic cord, which is remarkably similar to those in use today, was first used by the French surgeon Aquaviva in 1949.50 Unfortunately, it was made of nylon.

A similar superficiality in regard to the history of prosthetic plugs abounds. Many ascribe their introduction to Gilbert or Rutkow, even though both have been scrupulous in detailing their evolution. Gilbert pointed out Lichtenstein's application of a “2-suture” plug repair of femoral herniation in 1970, followed by its use in inguinal recurrences in 1974. Rutkow harked back to the 19th century and Gerdy's plugging of the external inguinal ring with inverted scrotal skin. Wurtzer secured it with a wooden plug instead of sutures. Wood in 1863 and MacEwen in 1886 used hernial sac, dissected blindly from the external inguinal ring, to plug the internal abdominal ring. It was fixed there to the posterolateral abdominal wall by transfixion sutures that were inserted with a Reverdin needle. Bassini showed, at autopsy, that these once popular operations failed because eventually the sac was absorbed. This experience prompted him to develop his own procedure. Kelly, Chief of Gynecology at Johns Hopkins Hospital, plugged the femoral ring with a marble when such herniation was found incidental to pelvic surgery. Cheatle in 1920 used saphenous vein; Annandale in 1876 used inguinal hernial sac.49

The plug principle is itself much older. It began with the Egyptians who bandaged protrusions. Guy de Chauliac (1300-1368) advocated a plaster over the “hernia gate,” secured by a band to ensure reduction. The patient was then required to stay in bed for 50 days! Ambroise Pare (1510-90) used a diverse group of trusses. Gilbert's placement of plugs in the preperitoneal plane was stimulated by Shockett's use of polypropylene rolls in 1984,54 as opposed to Usher's sheets. This procedure is continued today by Willmen's55 use of Vicryl pads, which induce collagenous connective tissue. Gilbert recounts his odyssey from a modified Bassini procedure to a Shouldice procedure to the Shouldice procedure that is reinforced by a preperitoneal polypropylene roll buttress to a plug in the internal inguinal ring. Later, the sutured Shouldice repair was replaced by an onlay prosthetic patch. Finally, the 2-layered prosthesis arrived.

Occasionally, a patient complained of feeling the plug. It was this complaint, accompanied by pain, that led to the removal of a significant number (in Kingsnorth's16 prospective, randomized, blinded, short-term study in 2000) of Rutkow plugs and the Lichtenstein procedure. Fortuitously, Gilbert found that the plug, when inserted deep into the space of Bogros, could not be coughed out of the internal inguinal ring. He now has a bilaminar prosthesis that is placed flat in the preperitoneal space and is covered by a keyholed sublay to the external oblique aponeurosis. Rutkow and Robbins56 also use a patch to reinforce the preperitoneal plug and to induce fibrosis. It is also keyholed around the spermatic cord. Gilbert's reason for the use of the plug and patch is to prevent recurrences that are lateral to the internal inguinal ring, which arose with plugs alone. Rutkow and Robbins56 use plugs alone in the repair of recurrent defects, in which minimal dissection is used.

Labeling of groin operations for the one who promotes them, rather than the originator, is commonplace in the field of herniology. “But in science, the credit goes to the man who convinces the world, not to the man to whom the idea first occurs.”57 Thus, Patino refers to the Nyhus procedure, even though this world class herniologist has given its provenance. This unilateral posterior preperitoneal approach to the groin was introduced in 1950 by McEvedy for the repair of femoral herniation.50 Its vertical incision was soon changed to transverse, and the operation was also used for inguinal hernias. Mikkelsen and Berne (1959) encouraged Harkins and Nyhus to use the midline Cheatle-Henry retroperitoneal approach to the groin.In 1960, Professor John Bruce, while visiting Seattle from Edinburgh, advised that Nyhus and his resident Condon change to the unilateral McEvedy operation.58 They put the technique on the map, by emphasizing the use of the iliopubic tract rather than the closely adjacent inguinal ligament for distal fixation.

McEvedy, from New Zealand, fought in Flanders during World War I. He then received medical training in England and practiced in Manchester. He died relatively young from cancer that arose in the stomach in a gastroenterostomy that was constructed during the 1930s for peptic ulcer disease. The work of Nyhus, Read, and Wantz, who used the unilateral preperitoneal posterior approach to the groin, in the United States coupled with Stoppa's introduction of the bilateral operation in France (especially the latter) provided the technique for laparoscopic repair. Many herniologistsbelieve that placement of the prostheses is conducted ideally preperitoneally, regardless of whether the anterior approach of Usher or Rives or the posterior approach of Cheatle, McEvedy, or Nyhus are used. Nevertheless, the widely successful Lichtenstein patch (1984) is placed in the middle muscular plane, just beneath the external oblique aponeurosis (v infra).Thus, excellent results can be achieved despite Fruchaud's dictum in 1956: “It is better to close the window rather than the curtain.”59 Concerns regarding the likelihood of recurrent interstitial hernias beneath the prosthesis, distal to the myopectineal orifice, have not been realized to any degree.

Anatomic features 

“No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a greater combination of accurate anatomical knowledge with surgical skill than hernia in all its varieties” (Cooper 1768-1841).6 Most surgeons today still believe that this admonition remains true, despite contradiction (“with the plug you do not need to know anatomy”). The groin is a complex transitional zone between the trunk, leg, and genitalia. Recently, the focus has been on the retroperitoneum, which is much larger in the living than is apparent in the cadaver. Its size allows for the distension of the bladder. Most surgical experience with this space has been from the posterior approach. Henry in 1936 made an important observation, which he illustrated. The junction of the processus vaginalis with the general peritoneal envelope is not at the internal inguinal ring, as has been taught, but 2 cm higher. This true neck explains the reason that Bassini had emphasized ligation “within the iliac fossa.” Lytle in 1945 described its fibrous sheath,part of the posterior lamina of transversalis fascia as a “supernumerary” internal inguinal ring in the preperitoneal space.50 Fowler in 1975 referred to it as the “secondary” ring.50 Spitzand Arregui60 described its fascial support as preperitoneal, composed of irregular strands of fibrous tissue that are interspersed with loculi of fat. I believe the main component to be the posterior lamina transversalis fascia.

The argument is not simply academic as Fisher, who is working with Wantz, has found out. Failure to divide this deeper layer of transversalis fascia, when using the anterior preperitoneal approach, means that the preperitoneal space is not reached. This avascular, easily cleaved, extensive plane is ideal for the insertion of a prosthesis. Otherwise, the surgeon ends up between the 2 layers of the transversalis fascia amid the inferior epigastric vasculature. Because both strata attach to the pecten pubis, it is impossible to overlap into the pelvis properly, thereby covering the obturator foramen, as is necessary. Wantz and Fisher61 stated that “The inferior epigastric vessels prevent deep implantation of the midportion of the mesh. Injury of the inferior epigastric vessel does not occur because the Mersilene is elastic and pliant and can bunch up around them.” Our pioneers were aware of the problem.50 Annandale and Rives from the same anterior approach, routinely or often, ligated the vasculature. Nyhus did the same on occasions from the posterior approach,but Wantz,61 Kugel,62 Ugahary,63 and Read,50 the latterfrom either exposure, have all insisted that these vessels do not have to be sacrificed if a retroperitoneal space is developed properly.Initially, some laparoscopic surgeons64 used the vessels for fixation of the prosthesis, which was hooked anterior to them. However, the risk of hemorrhage has discouraged this approach. The lesson is that, as Stoppa has emphasized, preperitoneal placement of a prosthesis, regardless of the approach, must be next to the peritoneum. It is this encasement, besides the coverage of Fruchaud's myopectineal orifice, which prevents recurrence.

These advances in our understanding of the surgical anatomy have meant that the derivation of the internal spermatic fascia that covers the vas deferens and spermatic vessels can no longer be taught as being the internal inguinal ring. It is at the supernumerary internal ring, formed by the posterior lamina of the transversalis fascia, that encloses the preperitoneal fascia. The preperitoneal fasciacontains “lipomata,” which are derived from the preperitoneal fat pad. These must be dissected back or excised when the true neck of the processus vaginalis is ligated, divided, or inverted. Thus, the vas deferens and spermatic vessels do not join together at the internal inguinal ring to form the spermatic cord. They are wrapped in internal spermatic fascia at a higher level to form a preperitoneal cord. This courses through the fatty, avascular space of Bogros.

Stoppa65 recommendsthat this internal spermatic fascia remain intact when one parietalizes the spermatic cord so that the external iliac vessels are protected from the prosthesis. As Bassini recommended,50 truly high ligation or inversion of an indirect inguinal hernial sac demands retroperitoneal dissection, proximal to the internal inguinal ring “within the iliac fossa.” Preperitoneal fat is a major component of the space of Bogros. It may be a source of sliding herniation. Such protuberances must be excised to determine whether they are merely extensions of the fat pad, giant lipomata, or even liposarcomata.66 To achieve all these goals, adequate exposure of the internal inguinal ring and beyond is essential. This was accomplished by Bassini and the Shouldice clinic by the resection of the cremasteric muscles, external spermatic vessels, and the genitofemoral nerve. Gilbert still does so, in his dissection, before the insertion of the bilaminar prosthesis. Bendavid, a staunch supporter of the unsullied Shouldice procedure, seems to think that this is not the case when this repair(modified) is supported by preperitoneal mesh (Moran).“ I do agree that there is no need to resect the cremaster muscle which results in a drop of the scrotum and testicle that becomes more marked with the passage of time.” He adds, however, that “Resection of the cremaster muscleresults in a generous exposure of the posterior wall of the inguinal canal, division of which allows confident verification of the absence of concomitant hernias.”67 Is testicular drop a real problem? Some surgeons eliminate it by tacking up the distal cremaster. Regardless, Moran has obtained good results. He parietalizes the cord without a keyhole. Unlike after the classic Shouldice operation, none of his recurrences were femoral, which was ascribed to a lack of tension on the inguinal ligament.

Amid and Lichtenstein68 in 1993 separated the genital branch of the genitofemoral nerve along with the external spermatic vessels that supply the cremasteric apparatus. This bundle, the lesser cord, was passed through a gap in the suture line along the inguinal ligament. Amid, Lichtenstein's professional heir, no longer thinks this is necessary. He leaves the cremaster alone. Rutkow,69 with his plug, agrees.

Because the external spermatic vessels arise from the inferior epigastrics and pierce the posterior wall of the inguinal canal, (medial to the internal inguinal ring), proper exposure of the inguinal ringdemands their division à la Bassini. Are we therefore in the 21st century, introducing another modified Bassini tissue repair, this time of the Shouldice operation or “modern Bassini”? Certainly, with Amid's modification of the Lichtenstein operation,68 the true neck of the processus vaginalis cannot be freed. The use of plugs does allow it to be fingered, at least! However, tension-free repair with a prosthesis keyholed on the exit of the spermatic cord at the muscular level may relieve the surgeon from acting on all of Bassini's dicta, in regard to proper dissection technique. Apparently, the external prosthetic sling protects against most residual sacs or lipomata. A recent case of interstitial herniation (recurrent) necessitates qualification. Allowing for prosthetic mesh contraction may risk compression.

Associated femoral herniation is excluded by Amid and Gilbert by fingering the femoral ring.An incision is made in the transversalis floor of the inguinal canal. Because of its rarity, Rutkow,69 with his plug repair, does not use this method. Tension-free prosthetic repairs that use the inguinal ligament for distal attachment are not associated with a significant incidence of postoperative femoral recurrences. This had been a problem with the Shouldice operation. It is for this reason that the Lichtenstein procedure has not been extended, by most surgeons, to cover all of Fruchaud's orifice, by occluding the femoral ring, although Fitzgibbons70 and some othershave described the use of this modification. Gilbert's bilayer prosthesis covers the opening, as does the anterior preperitoneal repair of Rives. Open posterior preperitoneal repairs of Stoppa and Wantz and all laparoscopic techniques do likewise.

Yet another inguinal ring has been described, the intermediate ring of Yeager,71 which is located in the middle muscular layer where the fibers of the internal oblique converge to form the cremasteric apparatus. This sphincter helps to close the inguinal canal, as stated by Cooper.6 Metabolic data by Sorensen and colleagues29 show a significant decrease in cell proliferation rates of cultures that were harvested by biopsy from the internal oblique and cremasteric muscles of patients with hernia. Thus, muscles in the groin have biochemical damage along with their fasciae. This effect can cause atrophy of the sphincter of Gallaudet, opening up the inguinal canal. Bassini treated this condition by incising the thinned out internal oblique musculature laterally and moving the spermatic cord out. He, of course, insisted on restoring as much obliquity to the inguinal canal as possible by medial suturing. Similar atrophy in the transversus abdominis muscle and aponeuroses may cause the variation in their attachments to the superior pubic ramus and rectus sheath, which have been ascribed by McVay and Anson13 to congenital factors that lead to herniation. The success of the keyholed patch in the Lichtenstein procedure may well rest on reinforcement of the muscular ring of Gallaudet, the relaxation of which allows protrusion into the distal portion of the inguinal canal.

As happened during its golden age, many of the recent advances in our knowledge of groin anatomy have originated with surgeons. Unfortunately, the emphasis in many medical schools has shifted from regional morphologic investigation to molecular research on the cell. Proper anatomic preparation of the newly trained surgeon is therefore devolving more and more to herniologists. Happily, laparoscopists have developed several excellent texts recently, which recognize the iliopubic tract as a landmark, below which course the nerves at risk during herniorrhaphy (eg, ilioinguinal, iliohypogastric, genitofemoral, femoral, and lateral cutaneous of thigh). From the anterior approach, it is easy to confuse the iliohypogastric nerve with the ilioinguinal, especially because the former frequently gives off branches to the latter. The ilioinguinal nerve passes out of the inguinal canal with the spermatic cord, whereas the iliohypogastric pierces the external oblique aponeurosis just above. They must be handled and retracted gently. Rough technique, potentially avoidable from the posterior preperitoneal approach, can doom the patient to severe postoperative pain, which necessitates reoperation.

Laparoscopic repair is a success story of the past decade. Evolving out of endoscopy, which was initiated by Hippocrates (500 BC), it has grown rapidly with advances in technology. First practiced at the turn of the 20th century, it was fostered by gynecologists after World War II. Applied to herniology by Ger in 1982, the endoscopic technique later adopted the posterior preperitoneal prosthetic approach of Stoppa. Anatomically, triangles of doom have been described, which relate to the external iliac artery, vas deferens, and spermatic vessels. Many investigators believe that the danger zone should be extended laterally and posteriorly to the iliopubic tract, where nerves are at risk from the staples that are used to anchor the prosthesis.

Experience with laparoscopic repair of inguinal defects has shown that bilateral inguinal defects, especially indirect, are more common than was realized. An increase to 20% to 40% of patients had been predicted by data from herniography,72 which is consistent with increasing evidence of systemic connective tissue damage. It is necessary to distinguish between patency of the processus vaginalis and a hernial defect with protrusion. A similar problem occurs at the femoral ring (v. infra).More multiple hernias have been diagnosed as the pneumoperitoneum distends their sacs. These include pantaloon, femoral, Spigelian, umbilical, and epigastric defects. Felix73 introduced the term “complex” to include such familial, recurrent, bilateral, or multiple hernias.Unusual types of femoral herniation, that include prevascular, lateral, retrovascular, retropsoas, and medial, all with exotic eponyms, are being revealed. They are more common than once thought but, fortunately, are easily treated laparoscopically.

Classification 

During the past decade, herniologists have actively pursued outcome studies that are statistically valid, rather than continuing to rely on anecdotal evidence. The anecdotal evidence that is obtained from experts with special skills and experience often cannot be reproduced by surgeons in the community. Randomized prospective trials of differing techniques depend, for their power, on the populations that are being similarly studied. The types of groin herniation must be comparable, too. The operative techniques that are used must be standardized as well. These strictures, to be satisfied, demand an agreed upon classification of groin defects. Unfortunately, even though severalhave been described over the past 40 years, none has satisfied most surgeons.

Recently, Zollinger74 has attempted to fill the need. He points out that most herniologists still use the traditional indirect, direct, inguinal, and femoral categorization, even though location, size, and number of defects have been added. After the procedures of McVay and Fruchaud,femoral hernias have been treated increasingly as a form of inguinal herniation. Reviewing the details of the McVay, Lichtenstein, Gilbert, Nyhus, Stoppa, Rutkow, Bendavid, and Shumpelick classifications, Zollinger based hison their best features. His procedure builds on the classic indirect, direct, inguinal, and femoral locations. The degree of competency at the internal inguinal ring and the integrity of the transversalis floor of the inguinal canal are then factored in, rather than the size of the protrusion. Hopefully this new “unified approach” will withstand the test of time and allow surgeons to communicate with each other better.

Evidence-based herniology 

Europe, led by Nilsson and Haapaniemi75 and Kingsnorth and colleagues16, has shown the way in the field of evidence-based herniology; however, the Veterans Administration in the United States has followed recently.76 Quality has been defined as “a measure of our capacity to relieve health problems without causing new ones.”75 This includes equalityand cost control. Goals must be outlined, and endpoints must be defined. Measurements must be made to gauge our progress. Thus, audits are demanded. Results must be measured against set standards. The gap between research and clinical practice must be narrowed.

Classically, recurrence rates have been used as the endpoint in the field of herniology even though an exact definition of this complication has not been agreed upon. Follow-up is tedious and expensive. It often is less than desirable for the practitioner. In the short term, follow-up frequently is incomplete, although early recurrence has long been considered the fault of the surgeon. Some investigators argue that examination by a surgeon is required to determine the failure of a repair, yet questionnaires or telephone calls often suffice. Outcomes have improved so much since the introduction of tension-free prosthetic techniques that a breakdown of the repair is no longer as relevant as it once was. Attention has shifted to other patient concerns: postoperative pain, return to work, satisfaction regarding care received, education about the condition, and overall rehabilitation. Cost is always a factor. The extent of convalescence must be guided by the surgical staff, despite time-honored societal arrangements.

The large Swedish institutional trial of groin herniorrhaphy demonstrated a remarkable reduction in the use of pure tissue repairs from 68% in 1992 to 15% in 1997.75 The data showed the reason; the Lichtenstein procedure had a significantly lower recurrence rate than the Shouldice repair. This difference was reflected in the reoperation rate, which declined by 40%. Several lessons have been learned. Postgraduate education is important for surgeons; team involvement is required. Outcome data must be shared, not only among the many participating hospitals but with patients as well. The costs of prospective auditing should be provided by governing health care authorities. It is not acceptable to propose a particular technique of repair simply because, in its proponent's hands, excellent results are obtained if these cannot be reproduced by others.

It is fortunate that commercial interests have a competitive stake in the prosthetic meshes and the techniques for applying them that are used in the field of herniology. This support has made it possible for several creative surgeons to introduce original operations. Most of these developments have come from private practitioners. The difficulty arises when the techniquesare subjected to critical examination for their efficacy by academia. Vested interests naturally tend to protect their “baby” by vigorously contesting any perceived shortcomings. Their defense is usually that their procedure was not carried out properly. Follow-up is too short or incomplete; sample size is inadequate, or the population that was studied is not representative. These are all reasonable arguments as long as commercial sponsorship does not lead to the inventor failing to support expensive and time-consuming validation. Regardless, now that tension-free repairs have been “on the market” for 40 years, more statistically accurate comparisons are needed. Kingsnorth and colleagues16 are to be commended for recently performing such a study, albeit admittedly a short-term study. They instituted a prospective, double-blind, randomized comparison of the 2 most popular tension-free repairs. Their finding that the plug may require removal because of postoperative pain undoubtedly influenced the development of the bilaminar flat prosthesis.

Grafts and prostheses 

Belams77 in 1832 has been credited with being the first to apply a graft to close the defect of an inguinal hernia. After experimental studies with the air bladders of fish to provoke an adhesive inflammation in 30 dogs, he used the technique in 3 patients with success. As mentioned, Annandale used autogenous hernial sac; Trendelenburg used periosteum, and Rehn used fascia lata. MacArthur pedicled the external oblique aponeurosis. Living tissue must be harvested, which usually requires a second operation to close the donor site with its potential consequences. Grafts often are absorbed by the recipient, which leaves only a foreign body reaction. These grafts may also be “damaged goods”because they can be affected by the same metabolic defects that led to the development of herniation in the first place. Foreign grafts can transmit disease or be rejected. Techniques of preservation may induce a response from the recipient or cause wound infection. These disadvantages encouraged the development of artificial prostheses that could be easily manufactured, sterilized, standardized for quality, and made available in the operating room.78

Metals were first used by Phelps (silver wire, 1894),79 but their use gradually faded because of problems with fixation to surrounding tissues, lack of inertness, stiffness, fatigue, fragmentation, and patient discomfort with seromata and sinus formation. Annealed stainless steel was the best, but it perforated the surgeon's fingers and prevented the use of magnetic resonance imaging. Knitted plastic weave meshes were investigated in the 1940s at the beginning of this commercial innovation, the greatest of the 20th century. Unfortunately, most of these meshesbecame foreign bodies in the presence of infection (eg, Fortisan, Vinyon,polyvinyl, nylon, Teflon) as did their predecessor, rubber sponge.

Dacron mesh, which was formulated originally in England in 1941, was tolerated. It replaced cotton or wool in many applications and eventually became DuPont's biggest product. It was first used in surgical procedures as a blood vessel substitute. Some in vivo degradation does occur, but it has been used in the field of herniology since 1954. Rarely, ventral prostheses have ruptured. Its fibers evoke a complement and macrophage-mediated inflammatory response.

In 1965, Mersilene was introduced to France, where it has become popular. Its pliability and adhesiveness are in demand. However, it has not been widely marketed in the United States, despite Wantz's championing. A recent study was critical and advised against its use.80

Polypropylene mesh, the most popular prosthesis used in the field of herniology, was introduced to medicine by Usher in 1962.53 Earlier, Usher had used polyethylene but preferred the polypropylene, which he had made for his own use because, unlike polyethylene, it did not fray when cut and could be autoclaved rather than just boiled. He spanned inguinal defects with preperitoneal placement and overlap. He also parietalized the spermatic cord without keyholing the patch. His results were so outstanding that, 3 years after their publication, 20% of general surgeons in the United States were using Marlex (Marlex Bard Implants, Billerica, Mass). He never received the credit he deserved for his revolutionary contribution to the field of herniology. It was he who put tension-free preperitoneal prosthetic repair on the map. This disdain resulted from the fact that, at the time, the field of herniology was held in little regard by the surgical elite, who were busy applauding recent advances in open heart surgery. Furthermore, the “old guard,” who had been stung repeatedly by 2 decades of problems with prostheses that were either rejected or infected, wanted to stay with their modified Bassini operations (ie, pure tissue repair).

Polypropylene fibers have a tensile strength similar to that of steel. Although resistant to degradation, they do shrink by 30% over time. Therefore, prostheses must be inserted with some slack. The mesh does not have to be removed with sepsis, which can be treated successfully by drainage, with or without antibiotic therapy. Peacock, nearly 20 years after this mesh had been introduced, concluded that suture repair of direct inguinal herniation should be abandoned. He based this view on the excellent results obtained by Lichtenstein and evidence of biochemical damage to groin tissues that must be brought together under tension.81 Nine years later, Korenkov and colleagues82 documented the surprisingly disastrous results that were achieved with the time-honored overlap suture repair of umbilical herniation (imbrication). Their findings presumably relate to the lack of incised edges interposing, which is required for proper wound healing.

Polytetrafluorethylene (PTFE) was discovered accidentally in 1938 at Dupont(Wilmington, Del). Nothing will adhere to it. In 1949 LeVeen and Barberia83 found tissue reaction to be minimal.However, it is not incorporated and is intolerant of infection. Wound complications (ie, sinuses and fistulization) deterred its use. Nevertheless, in 1963a process for expanding PTFE was discovered in Japan, which resulted in a strong porous material. This material was introduced to medicine as a vascular prosthesis in 1975. Subsequently 1- to 2-mm sheets were prepared for use in the field of herniology (1981). Numerous studies since then attest to its value.

PTFE has been preferred over polypropylene, by some, for intraperitoneal placement because there are fewer adhesions and because a mesothelial layer reperitonealizes the patch. Double overlap fixation is required to avoid button-holing, which gives rise to hernias. The size of its interstices (less than 10 microns compared with more than 75 microns) was earlier considered to be too small for adequate incorporation and resistance to infection. But the intersticeshave been enlarged. Recently, tissue reactive sandwiches that are constructed with polypropylene, polyester, or gelatin have been crafted to enhance attachment externally to the abdominal wall. Recent data question long-term stability, because a splitting of its layers may occur. This material must be removed if infection supervenes. More comparative data are needed to define its exact role, vis a vis polypropylene.

Absorbable meshes developed as an outgrowth of their successful use as sutures. The polymer, polyglycolic acid (Dexon; introduced in 1983 by Davis and Geck Inc. Manati PR),and polyglactin 910 mesh (Vicryl; introduced in 1985 by Ethicon, Inc Somerville NJ)are absorbed within 90 to 150 days, which is less time than the 6 to 9 months that are required for incorporation. Fibrous infiltration is inadequate; therefore, neither of these absorbable meshesis suitable for permanent repair. These materials are useful for reconstruction of the peritoneum (Delaney and colleagues 1985)or temporary coverage in the presence of infection (Dayton and colleagues 1986),because they evoke fewer adhesions than does polypropylene. In an important study, Amid and colleagues84 showed that, unfortunately, a visceral layer of absorbable mesh does not protect against bowel fistulae.

At the present time, polypropylene, Mersilene, and expanded PTFE are all being used in the repair of groin herniation with satisfactory results. Most research at this juncture is centered on their use within the peritoneal cavity, in the repair of large incisional hernias. Prosthetic sandwiches are being developed to allow visceral contact without transmigration or fistulization, which ensures incorporation. Happily, infection rates have fallen dramatically, despite the work of Elek and Conen85 in 1957 that pointed out that the number of Staphylococcus pyogenes organisms that are required to produce sepsis in human volunteers was reduced 10,000 times if a foreign body was present. Strict asepsis is essential when any prosthesis is inserted. Today, most surgeons do not prescribe antibiotics routinely for tensionless repair because statistically valid data are unavailable regarding their efficacy. Similarly, interest in permeating mesh prophylactically with antibiotics has diminished also.

Schumperlick and colleagues86 at the University of Aachen have pointed out recently, in extensive engineering studies, that the prosthetic mesh that is presently in use is too strong. It is therefore unnecessarily bulky. The abdominal wall becomes stiff, unbending, and loses needed flexibility. This, again, is a problem primarily with ventral hernias for which extensive coverage is required. Other lighter products have been developed by impregnation with absorbable gelatin, collagen, polyglycolic acid, polyglactin, or carboxymethylcellulose. The goal is to provide a thinner, pliant, lighter product that has larger porosity to improve incorporation and biocompatibility. Fortunately, most patients do not realize that they are carrying a prosthesis. Elderly and asthenic patients are most aware.

Occult findings 

Most occult findings arise in patients with pain in the groin of uncertain cause. There are 2 or 3 main causes of such pain: indirect inguinal or femoral herniation, and tenoperiostitis, usually adductor.87 It is amazing that it has been only in the last decade that the magnitude of the problem of tendonitis as a cause of chronic intermittent pain in this area has been appreciated. The hernias are small and are seen often as a sliding lipoma without a sac. They are particularly difficult to diagnose in women, especially if the woman is obese, because the inguinal canal cannot be fingered. Many of these patients are young. Their pain is thought to arise from an increased tone in the transversus abdominis and internal oblique musculature. This traps the ilioinguinal or iliohypogastric nerve as they pass obliquely, inferiomedially to the internal inguinal ring. Hyperesthesia to pinprick may be elicited, and in some patients, point tenderness over the internal inguinal ring may be present. Valsalva maneuvers may bring on the pain.

The best way to exclude occult herniation, not revealed by physical examination, has been shown by Starling to be herniography (v infra).This procedure was introduced in 1967 by Ducharme.72 Its use has become widespread. Because contrast media are now isotonic, peritoneal reactions have been eliminated. False negatives may occur, but the overall accuracy is high. Lipomatous herniation is best identified by computed tomography or magnetic resonance imaging. Ultrasonography is more accurate with femoral protrusion. The opposing asymptomatic side should also be examined. Ultrasonographyis not as useful in inguinal herniation. The supine position, commonly used for the test, makes it difficult to demonstrate small hernias that may become evident only in the upright posture with straining. However, direct defects, from posterior wall deficiency, may be identified. In children, the enlargement of the internal inguinal ring on the asymptomatic side is found to be associated with herniation in over 98% of cases.88 Pubalgia in adults is encountered predominantly in men (98%).87

Chronic pelvic pain in women has been associated, similarly, with occult small hernias, which are located in unusually rare sites. The ovary may be impinged with or without a fallopian tube in a sciatic, obturator, or perineal foramen. Similarly, rare groin hernias have been discovered when pubalgia is investigated: parapubic, prevesical, prefemoral, para- or retrofemoral, retropsoas, and Spigelian. Several of these have been identified after diagnostic laparoscopy, which has replaced exploratory procedures, undertaken through the classic open anterior approach. Again, judgment must be exercised as to whether a small sac, dilated under carbon dioxide pressurization, is responsible for the pain or whether it is indeed herniation. Lytle has insisted that only those herniasthat pass down the femoral canal to the cribriform fascia should be considered ruptures. Similarly, in the inguinal canal, an open processus vaginalis may be a normal finding. Passage of peritoneal content to the intermediate ring of Gallaudet may be a requisite (v infra).Nevertheless, many herniologists at the operating table would favor prophylaxis, given the presence of a defined sac.

Adductor tenoperiostitis (ATP)is encountered primarily in men, particularly in elderly patients and in those patients who participate in sports or other vigorous exercise. This condition is usually intermittent but chronic. Sudden onset in the absence of signs of herniation on physical examination raises questions about this diagnosis. This condition may be associated with a change in the usual activities. Radiation is down the medial side of the thigh. Rectus abdominis tendonitis causes similar pubalgia that spreads superolaterally. Compression of the lateral cutaneous nerve of the thigh by the iliopubic tract or inguinal ligament produces meralgia paresthetica. Arthritis of the hip joint is another possibility. One or more of the many musculotendonous layers in the groin may be disrupted.

The physical examination is frequently of little value. However, point tenderness over the pubic spine or more laterally may be elicited. Coughing or abduction of the thigh may reproduce the pain. Unexplained pubalgia should be investigated further by neurologic examination of the groin for tenderness or anesthesia, supplemented by nerve blocks for the dermatomes that are supplied by the ilioinguinal, iliohypogastric, and genitofemoral nerves. Banishment of the pain by nerve blocks that are performed close to the anterior superior iliac spine is attempted. A rectal examination may reveal the rare obturator hernia. Reaching a diagnosis of tendonitis is one half of the battle. In severe cases, especially in young patients, anterior exploration has been undertaken to repair tears that were noted on magnetic resonance imaging. Occult direct or lipomatous indirect hernias may be discovered.

Unexpected findings discovered at herniotomy mainly relate to the hernial sac, which may provide evidence of peritoneal lesions. Classically, these lesionsare related to tuberculosis, which, with immunologic failure from human immunodeficiency virus infection has become more prevalent in the younger adult. Increased air travel and immigration have also played their roles. Extrapulmonary infection is more common in the adult with acquired immunodeficiency syndrome. Infection extends to the hernial sac from ascites, the bowel, mesenteric or inguinal nodes, and the fallopian tubes. Usually, it reflects diffuse involvement. There are 3 forms: miliary or ascitic, ulcerocaseous, and fibrous. The fibrous form is the healing form of the miliary or ascitic form.Incarceration of the bowel is frequent. Diagnosis depends on biopsy specimens and cultures. Ulceration, stricture, or strangulation may necessitate resection which, otherwise, is avoided. Patients are treated with drug regimens. Hematogenous spread occasionally involves inguinal nodes (buboes), which can be mistaken for incarcerated hernias.89

Inflamed hernial sacs usually are related to strangulation or appendicitis. Hematogenous spreadis generally found with longstanding incarceration and bowel obstruction. An inflamed hernial sacwas responsible for the first appendectomy (Amyand's hernia). The appendix may be in the sac or associated with a periappendiceal abscess that has drained therein. Occasionally, a chronic cecal fistula is discovered when, at herniorrhaphy, fecal content or contrast material from a previous barium enema is found. The sac itself may be destroyed by the infection, with inflammation extending into the groin itself. Foreign bodies may be found as a result of visceral perforation or “leftovers” from previous laparotomy. Peritoneal free bodies, usually appendices epiploicae, are described.

Tumors of the hernial sac can be benign or malignant; malignant tumors are more common. These are almost always metastatic, although sarcomata arising from preperitoneal fat (lipomata) are primary as are the even more rare mesotheliomata or fibrosarcomata. Carcinoma of the colon (Foster Dulles' tumor) is the most common metastatic lesion. Irreducibility of the hernia is an ominous development, but implants are present more often. Bloody ascitic fluid is a frequent accompaniment. Pseudomyxoma peritonei, which arises from rupture of a pseudomucinous cystadenoma of the ovary or appendix, causes “jelly-belly,” abdominal girth that increases with the protrusion. Treatment is controversial. Finally, melanoma may be a surprising finding.

Anesthesia 

Spanish conquistadores discovered coca in the 16th century. Niemann isolated its active alkaloid, cocaine, in 1858. It was used in surgical procedures in 1884. Bassini agreed it should be used if the patient was unfit for general anesthesia. Halsted investigated its effects on himself and became addicted.Cushing in 1900 reported his experience with its use in 49 herniorrhaphies. This agent (or its homologues) is now widely used because it reduces hospital stay and allows the repair to be tested intraoperatively. Patients recover more quickly from the operation. Because elderly patients comprise an increasingly large proportion of those in need of care, the fact that local anesthesia does not cause urinary retention is an important asset. Postanesthetic delirium or agitation is encountered much less than when general anesthesia is used. Aspiration pneumonia or postoperative vomiting is eliminated essentially. However, intraoperative sedation, administered skillfully, is required. Yet it should not be used to substitute for inadequate local anesthesia. Interestingly, some but not all recent studies (v infra)indicate that the local anesthesiamay provide delayed pain relief, even after its immediate effects have worn off.45

Some surgeons do not like using local anesthesia for herniorrhaphy. Regional blocks are difficult to perform and are often inadequate; then, local injection into the tissues is required at the behest of the patient. The patient must feel the pain before further anesthetic is provided. Local planes become edematous, which obscures the anatomy. These herniologists follow Rutkow in the use of epidural blocks. The patient can walk within an hour after the procedure. He can move his legs, cough, and strain on command usually, while the operation proceeds with the surgeon's undivided attention. Local anesthesia requires the cooperation of the patient and is therefore unsuitable for children. Death with local anesthesia has been shown to be significantly less than with general anesthesia. Toxicity relates to overdosage or intravascular injection. Cost is reduced because an anesthesiologist is not required to be present throughout the operation.

Certain debilitated individuals, obese individuals, and individuals with cardiovascular or pulmonary disease obviously need special consideration before the operation, because monitoring may be necessary. Emergency relief of incarceration or strangulation is undertaken usually with the use of general anesthesia. The same is true for laparoscopic repair. Fortunately, advances with the laryngeal mask airway obviate the use of muscle relaxants. Newer inhalation agents have sped recovery. Spinal anesthesia has been used, instead of local, to replace general anesthesia. However, the recovery is delayed, and hypotension may supervene, especially in elderly patients. Similarly, paravertebral nerve block is not used widely today. The technique is difficult and unpleasant for the patient because it requires that 5 nerve roots be injected. Identifiable landmarks must be available because accurate placement is essential for optimal anesthesia. Failure rates are high, and failures are time consuming.

Infection90 

Surprisingly, infection is now remarkably uncommon, considering the widespread use of prostheses and the proximity of the groin to the perineum.46 When infection does occur after herniorrhaphy, one can assume that contamination occurred at the operating room table either from skin, instruments, gloves, supplies, or the air. Some bacteria are present in every wound but do not cause infection. The threshold is considered to be 100,000 organisms per gram of tissue. This concentration is almost impossible to achieve in modern operating rooms, so other factors contribute. Thus, the most common pathogen (S aureus) produces coagulase as its virulent factor. The fibrin that is precipitated protects the organism from host resistance. Group A streptococcus infection is now rare but catastrophic, with high fever, septicemia, and intense pain. Gram negative infection, which is encountered in the abdomen, is also rare after groin repairs. Women are infected twice as often as men.

The wound environment can foster growth; therefore, hematomata and seromata must be avoided by the elimination of dead space. Tissue necrosis because of cauterization, along with undermining, encourage sepsis. The perimeter of the mesh, which should be woven coarsely, is at risk of infection from redundancies, sutures, and their knots that create dead spaces and nests. The integrity of host defenses is probably a significant factor that is difficult to evaluate.

Like recurrence, what constitutes a wound infection has not been standardized. Reports from Europe tend to show higher rates, but along with hospitalization, the incidence has fallen in the last few years. Groin herniorrhaphies are less likely to be associated with sepsis than incisional repairs. Similarly, laparoscopic procedures are less often associated with this complication than open repairs, partly because the prosthesis is placed further away from the skin. Wound drainage promotes infection and has not been used in the groin since Bassini gave it up.The recent predominance of ambulatory surgery means that infection is an outpatient phenomenon that demands careful follow-up. Fortunately today, the incidence, even with excellent surveillance, is less than 2%. In the past, this complication occurred in up to 10% of patients. Most cases respond to the removal of a few skin staples and do not require antibiotics. The prosthesis does not need to be removed. Its presence has been shown recently not to increase the rate of infection.

Repairs of recurrent herniation are more likely to become infected than primary defects, presumably because the wound environment is harsher, because hematomata are common, and because scar tissue is devascularized. Coexistent contamination may also be present. The usefulness of cultures is controversial because small pockets of infection fare well, regardless, if drained. If the process is severe enough to require antibiotics then identification of specific organisms is useful. Occasionally, signs of sepsis are delayed for months at which time a sinus drains, generally at the limits of the mesh. These are walled off usually, and the patient fares well. Incarcerated, strangulated, and femoral herniorrhaphies tend to take longer to repair and are more likely to become infected.

Prevention is better than cure. The patient is instructed to shower with antiseptic soap on the morning of surgery. The groin is shaved in the operating room. Extraneous infections, even if minor, should cause postponement. The surgical site is scrubbed and cleaned with antiseptic. Pedestrian traffic in the operating room should be kept to a minimum. As emphasized by Bassini, good surgical technique protects against sepsis.Hemostasis, limited use of the electrocautery, ligation of veins, elimination of dead space, no drainage, excision of scar, few knots, smoothing out the prosthesis, and avoidance of redundancy but allowance for adequate overlap have all been cited as desirable features. The use of prophylactic antibiotics is controversial in groin repair. Unfortunately, the largest randomized trial was combined with breast surgery cases. Also, given the low incidence of infection, the number of patients was inadequate. Furthermore, the severity was not stratified. Pulmonary and urinary infection were included. Therefore, at present, most surgeons do not administer prophylactic antibiotics routinely. Cases of recurrence or those patients with diabetes mellitus, obesity, or other comorbidities receive cefazolin (1 g) intravenously on the operating room table. A recent large retrospective study failed to identify a reduction in postoperative infection with prophylactic antibiotics.91

The treatment of infection varies with extent. Most infections are superficial and require little attention. More extensive involvement is rare and requires debridement with removal of suture material. Antibiotic treatment is only considered if there is necrosis or cellulitis. The rare Escherichia coli infection is treated with oral quinolone therapy or intravenous cephalosporine. Necrotizing fasciitis is associated with tenderness, fever, and leukocytosis. Patients with diabetes mellitus are particularly at risk. The wound requires debridement, but mesh removal is required rarely. Many surgeons will use antibiotics when performing operations in elderly patients, patients with diabetes mellitus, patients with prosthetic heart valves or prolapse, and patients with artificial joints.

Techniques of open repair 

Tension-free prosthetic repair (open) 

Elimination of tension from the repair of groin herniation is the greatest advance in herniology during the 20th century. This was made possible by the enormous commercial development of plastics since World War II. Happily, 3 of these (polypropylene, Dacron, and expanded PTFE) are well tolerated by the body. Usher, who introduced the former prosthetic, which is most popular, deserves enormous credit. He inserted it into the preperitoneal plane, with overlap, to span the inguinal defect. He was also the first to operate on a large series of patients with a tension-free technique. Other surgeons followed. As indicated earlier, he introduced parietalization of the spermatic cord as well.53

Originally introduced anteriorly, then posteriorly, unilaterally, or bilaterally with an open technique, prostheses in the past decade have also been applied laparoscopically. Approximately 2 dozen named operations have been described. Because these can be grouped into variations of approximately 6 different procedures, these latter will be discussed. All are based on the understanding that the mesh is not to be used to reinforce or “buttress” a sutured repair under tension but that it is itself the repair.

Laparoscopic repair 

Laparoscopic repair was first undertaken by Ger115 in 1982.They closed an indirect hernial sac with a metal clip. The potential advantages of laparoscopy were outlined: concurrent repair of bilateral protrusions, diagnosis of asymptomatic or rare multiple hernias, and earlier return to work. Schultz116 in 1990conducted the first series of intraperitoneal onlay mesh repairs with the use of plugs and patches that were sutured in place to avoid migration. This did take place, however, and resulted in a high recurrence rate (25%). He then began to divide the peritoneum that overlays the defect and dissected in the posterior preperitoneal space of Bogros where he placed the prosthesis (Transabdominal Preperitoneally [TAPP]). Soon thereafter, Spitz and Arregui117 in 1991 published their technique, which uses a large prosthesis (polypropylene). They followed the precepts that Stoppa had laid down, which included parietalization of the spermatic cord, considerable overlap of Fruchaud's myopectineal gateway, and sutureless placement into the pelvis. Failure to follow this last recommendation damaged the reputation of laparoscopy initially because staples compromised many of the inguinal nerves. Phillips,118 and McKernan and Laws119 independently introduced total extraperitoneal placement (TEPP) techniques.

The extension of laparoscopy to the field of herniology takes advantage of surgical skills that were derived from cholecystectomy. It delivers the advantages of the GPRVS procedure, while reducing postoperative pain and hospitalization. It has advantages with incarceration because, as the enthusiasts of open intraperitoneal herniorrhaphy found a century before, it is easier to pull the bowel or omentum out than push these structures back in. Perhaps its greatest application has been with hernias that recur after classic anterior repair. Laparoscopy enables the scarred inguinal canal that encases nerves, blood vessels, and the vas deferens to be bypassed. Thereby, postoperative neuralgia, testicular atrophy, dysejaculation, hypospermia, infection, and seromata can be reduced. There is little cosmetic advantage because much of the open surgical procedures of the groin today are being conducted through keyhole incisions.

Disadvantages of laparoscopy include the need for general anesthesia, a problem particularly in our increasingly aged population. Similarly, there are disadvantages with carbon dioxide insufflation. Costs increase, and special surgical skills, which can be obtained only after a long learning curve, limit its use to larger clinics. The intraperitoneal route with placement of the prosthesis (intraperitoneal onlay mesh repair) is used by only a few surgeons when groin defects are repaired. Most surgeons are concerned about adhesions, migration, and visceral damage and therefore advise against its use. However, Franklin and Diaz-Elizondo120 continue to obtain good results, even after having had, initially, a bad experience with expanded PTFE in 1 patient. Despite widespread use of expanded PTFEin incisional herniorrhaphy, he switched to polypropylene.

A criticism of the TAPP procedure, the second most popular, is the need to enter the peritoneal cavity before dissecting and placing the mesh retroperitoneally. This can be an advantage because it provides an opportunity to look around before proceeding further. Thereby, contralateral, rare, incarcerated, or multiple hernias can be diagnosed. Furthermore, unusual causes of groin pain may be discovered, which includes, in women, endometriosis. However, accidents that involve the viscera from the trocar insertion are more likely. After the operation, intestinal obstruction from adhesions or a breakdown of the peritoneal or trocar site closure may supervene. Early experience with laparoscopy led to such complications, which sometimes resulted in death. These, again, damaged the reputation of this new field.

TEPP has become the most popular technique for the application of laparoscopic technology to groin repair. The use of a balloon device, to open up the preperitoneal space initially, facilitates its dissection. Previous lower abdominal surgical procedures or irradiation may scar the space of Retzius sufficiently so that the peritoneal cavity is entered. Such tearing of the peritoneum should be anticipated, and TAPP should be used. TAPPis still used in certain complex hernias (eg, large or incarcerated). Several nonrandomized series of cases have indicated that TEPP takes less time, has a decreased number of complications, and allows the patient a quicker return to normal activities. This technique is being used more and more for the small, simple, primary groin hernia. Kald and colleagues121 declared that TEPP “may be the method of choice in laparoscopic hernia repair.”

Several prospective, randomized studies that compared laparoscopic repair with open repair now have been completed. Some of the earlier ones are less valuable because they used tissue repairs under tension as the control. Nevertheless, in a triple study, Zieren and colleagues122 found that the Rutkow plug and patch operation gave excellent results, as did laparoscopy. The results were significantly better than those results that were obtained with the Shouldice procedure. Payne and colleagues123 and Wellwood and colleagues124 compared the Lichtenstein operation with TAPP repairs.They concluded that the latterhad advantages in the short term but were more expensive. Overall, laparoscopic herniorrhaphy took longer but resulted in less pain, with a correspondingly reduced need for analgesics after the operation. Patients returned to work earlier. Seromas and urinary retention were more frequent, but other complications decreased. More long-term data are needed.

The surgical technique used with laparoscopy is almost identical to that used by Stoppa with his GPRVS. Obviously, special skills and instruments are required along with carbon dioxide pressurization to 12 mm Hg. Polypropylene mesh is usually used. However, most laparoscopists secure the mesh below (and above) with staples. Fixation is avoided posterior to the iliopubic tract to avoid nerve damage. The staples are inserted bimanually, parallel to the paths of the femoral nerve, lateral cutaneous of the thigh, and ilioinguinal, iliohypogastric, and genitofemoral nerves. Wider exposure, achieved quickly by balloon dissectors, has also helped.

The increased costs of laparoscopic techniques compared to open procedures continues to be an issue. The costs are being reduced in various ways. Thus, disposable instruments are being used less as reusable instruments are used. Instrument dissection is being adopted instead of the use of expensive balloon dissectors. Indications for laparoscopic surgery are being restricted to recurrent, bilateral, or incarcerated hernias in some clinics. Such surgery is now almost 100% ambulatory. Furthermore, attempts are being made to use regional anesthesia because the peritoneal cavity is no longer violated by necessity. Patient selection has been stepped up. Thus, elderly patients and patients with significant morbidity who may well require monitoring after the procedure are being advised to undergo open tension-free repair with local anesthesia. These recommendations apply similarly to young patients and patients with small, simple primary defects. Nevertheless, the fact that general anesthesia is required usually for laparoscopy with its own morbidity means that, for the immediate future, it is likely to remain more expensive. Rutkow's spartan preoperative testing regimen is not going to be duplicated.56

In conclusion, the introduction of laparoscopic technology during the past decade has enriched the whole field of herniology. Competition with open techniques has improved both approaches. At the present time, unlike at the diaphragm and increasingly with ventral herniation, laparoscopy remains the junior partner in the groin. However, it has only been available for a few years. Further developments in the future may well lead to an increase in a role that has already earned respect.

Postoperative pain 

One of the greatest advances in the repair of groin herniation in the past decade has been a marked fall in the rates of recurrence. The development and refinement of various techniques for accomplishing tension-free prosthetic placement have been responsible largely. Their use has spread worldwide. Improved surgical skills, stricter control of infection, and a better understanding of the field of herniology have contributed. This happy sequence of events has shifted the focus after the operation from concerns regarding surgical failure to other patient considerations. Pain, which earlier was underappreciated, is the main consideration. Some herniologists say that it is the most frequent complaint after a Lichtenstein procedure. This symptom is of prime importance because it prevents normal recovery from the operation, rehabilitation, and return to work. It also has legal, insurance, and other societal implications. Being subjective, it is difficult to characterize and can damage the doctor-patient relationship. Whereas some immediate pain and tenderness is to be expected after the operation, it is severe or chronic pain that is difficult both to live with and to treat. Whenever possible, prevention is the best cure. Unfortunately, there are few prospective studies.125

The good news is that most individuals who undergo operation for groin herniation do not experience pain after the immediate postoperative period. The prevalence of inguinodynia is 2% to 17%,126 regardless of technique. These figures include testicular pain, which seems to be an unusual variant. Severe pain arises in 1% to 4%.127 Inguinodynia is mainly short term; only 10% of patientsexperience it for more than a year.128 There are 3 types of inquinodynia: continuing pain in the groin after the operation, immediate and intense postoperative pain, and delayed onset of pain after herniorrhaphy.

Sexual dysfunction 

The proximity of the groin to the genitalia triggers patient concerns, especially in men, of sexual sequelae to hernia repair. Psychogenic impotence may follow, at least for a while. Dysejaculation (0.04%)132 can occur immediately or be delayed (mean, 9 months). Most patients recover completely, within a year or two. Atrophy of the testicle (0.34%), which is more frequent (0.5%) after repair of recurrences, not only reduces the sperm count but also the libido and therefore erectile function. This rare complication is due to ischemic orchitis, which is characterized by a painfully swollen spermatic cord and testis occurring 2 to 3 days after the operation and is accompanied by fever and leucocytosis. Doppler studies confirm the loss of blood flow; hematoma or infection must be ruled out. This condition may take several months to disappear. Atrophy is a sequel in one third of such cases. Wantz136 ascribed these cases to venous infarction rather than to arterial insufficiency. It was he who recommended that scrotal dissection should not accompany hernioplasty unless incarcerations could not be released otherwise. A large hernial sac should be transected, with the distal end left open to drain to prevent hydrocele formation, and the collateral testicular blood supply should be left alone. It is worth harking back to Halsted's problems after skeletonization of the cord. Infertility arises because antibodies can develop to the patient's sperm.137

In the infant, testicular infarction may be caused by strangulation, which occurs in 28% of hernias arising before three months of age. Torsion of the spermatic cord, encountered in children, is another cause.138 Venous infarction rarely is produced by overly tight closure of the hernial defect around the spermatic cord, and this has prompted the time-honored advice to allow for the insertion of the tip of a hemostat (Kelly clamp). Transection of the vas deferens is almost never encountered as an intraoperative complication; reanastomosis under a microscope is recommended as it is after purposeful vasectomy. The posterior preperitoneal approach with parietalization, as practiced with GPRVS or laparoscopic repair, involves less handling of the spermatic cord. However, separation of the indirect sac at its true neck may cause problems with the vas deferens. To minimize patient concerns, the herniologist should obtain a sexual history before the operation. Reassurance then should be coupled with an inquiry after the operation.

Emergency repair 

Emergency repair takes place in patients whose groin hernias develop signs of incarceration with bowel obstruction, melena, or frank strangulation. These complications raise the question of contamination, which can infect the standard tension-free prosthetic repair. Most of these patients will undergo operation through the posterior preperitoneal approach so that incarceration can be relieved by pulling bowel or omentum out of the defect after the peritoneum has been entered. Aberrant obturator arteries can be avoided, and, if necessary, intestinal resection can be performed. Until recently, the standard practice was to avoid the use of prosthetic mesh. Thus, Stoppa and Warlaumont139 stated that “The use of a prosthesis must be reserved for cases in which the viability of the intestine is assured, where the operation takes place in an aseptic setting.” However, during the past decade, this policy has been relaxed.

Few patients with groin herniation have an emergency. Femoral hernias are more likely than inguinal to incarcerate and strangulate, which is the reason that they necessitate operation once diagnosed. Indirect inguinal defects strangulate much more frequently than direct inguinal defects. Elderly patients and infants particularly are prone to indirect inguinal defects.Richter's herniation (first reported by Hildanus in 1606) is rare,140 but significant, because necrosis of an intestinal wall occurs without bowel obstruction, simply with melena. It most frequently affects the ileum at the internal inguinal ring. Emergencies arise mainly acutely, whereas incarceration itself, especially with femoral herniation, can exist for a long time because of adhesions or an unyielding femoral ring.

In developed countries, the incidence of emergency herniorrhaphy has fallen with better care, but this is counterbalanced by the aging of the population. Modern thought is against taxis to relieve incarceration. There is always the threat of reductio en masse,and the hernia must be attended to anyway. Nevertheless, in the acute situation with vomiting and fluid depletion, resuscitation is mandatory before operation. Postoperative monitoring in the intensive care unit is indicated, especially in elderly patients. “The attention paid to the correction of metabolic abnormalities associated with intestinal obstruction and surgical judgment related to the timing of operation will determine the mortality of the disease.”141

Pans and colleagues142 were the first to perform operation, with a variation of Stoppa's GPRVS, for a series of patients in whom prostheses were used in emergency repair of groin herniation. Recently, they have updated their experience, which extends back to 1985.143 Forty-five adults (19 men and 26 women) with strangulated femoral and inguinal hernias have been so treated. The mean ages of the men and women were 64 years and 74 years, respectively. Whereas inguinal hernia predominated in men, women had an equal number of femoral defects. There were 3 strangulated hernias of the appendix and 24 strangulated hernias of the small and large bowel. General anesthesia was used in 38 procedures; spinal anesthesia was used in 6 procedures, and epidural anesthesia was used in 1 procedure. Incarceration and strangulation were addressed intraperitoneally with the use of antiseptic packs. Gloves and instruments were then changed before the redraping procedure for the extraperitoneal dissection.

All patients received intravenous antibiotics prophylactically for 24 to 48 hours. Those who had intestinal resection continued to receive antibiotics for 5 days. Interestingly, most patients had polypropylene mesh inserted. In one third of the patients, the hernial sac contained necrotic small bowel, appendix, or omentum. One patient, who was 96 years old, did not require intestinal resection, but he died 3 weeks later after an unsuccessful gastrectomy for hematemesis. Two abscesses (1 was superficial) occurred after the operation in patients who had not required bowel resection. The mesh did not need to be removed. These excellent results have prompted others to follow. The alternative is to forego repair or to try a Shouldice operation. A combined series of 106 patients is now available with an infection rate of 1.88%, which compares with an incidence of 4% in a group of 174 patients who underwent operation for strangulation of groin herniation without prosthetic repair.144

In conclusion, Pans and colleagues143 state that the risk of sepsis after the relief of strangulation with prosthetic repair of the groin has been overestimated. They also tout the advantages of the posterior intra- and preperitoneal routes to the hernia under these circumstances. Localized abscess, bowel perforation, and colon resection remain contraindications to this approach. The greatest care should be taken by the surgeon to minimize sepsis. Contralateral defects should not be repaired unless, rarely, they are also involved with strangulation. One could add with Bendavid145 that “femoral hernias have not received the respect they deserve as a surgical entity, because they strangulate ten times more than inguinal.” Finally, every effort should be made to operate within 4 hours of onset in cases of acute strangulation.

Pediatric repair 

The modern approach to the repair of inguinal herniation in children (high ligation of the hernia sac) was introduced by both Czerny and Banks in 1877. Herzfeld in 1938 recommended outpatient care, and Ladd in 1941 advocated early repair. These hernias arise from persistence of the processus vaginalis or canal of Nuck. Boys are affected more often than girls. The right groin is implicated in 60%, the left in 30%, and both in 10% of cases. Direct inguinal and femoral defects are uncommon. Inguinal herniation in this age bracket is more likely with a positive family history, cryptorchidism, other abdominal wall defects, cystic fibrosis, connective tissue disorders, ascites, and intersex changes. Prematurity also increases the risk and the incidence of bilaterality. Characteristically, a bulge is noted over the external inguinal ring when the child cries or coughs. Differential diagnosis includes testicular torsion, hydrocele, varicocele, lymphadenopathy, and epididymitis. Incarceration occurs predominantly with prematurity and during the first months after birth.146

Laparoscopic repair without prostheses, introduced widely in 1992, has not gained acceptance.147 However, during standard open anterior repair, it has been used to evaluate the contralateral asymptomatic side. The presence of a patent processus vaginalis there does not predict the presence of a clinically relevant inguinal hernia. Tackett and colleagues148 studied the incidence of metachronous hernia prospectively for 2 years. This period should capture most occurrences. Of 656 children, 16.5% had bilateral defects, and 7.3% who had undergone unilateral repair did have a new hernia on the opposite side. This result, along with numerous retrospective studies, has reduced markedly the support for routine, contralateral exploration, which was adopted in the 1950s (Rothenburg and Barnett).149 Bilateral exploration remains appropriate for a child with risk factors for anesthesia or with a predisposing condition for the development of herniation and incarceration.

The main reason for operating early for inguinal herniation, in the infant, is the risk of incarceration in the first few months (30%), which can be complicated by strangulation or vascular compromise of the testicle that can go on later to atrophy in a reported 20% of such cases. Taxis may well reduce the hernia and quiet the child. The procedure usually requires sedation. To reduce the risk of incarceration, elective operation is carried out within weeks of the diagnosis. Premature infants undergo operation before discharge. Exceptions are made in the very tiny infant or infants with medical problems. To prevent recurrent incarceration, most hernias with irreducibility are repaired within 48 hours. The technique has been standardized. Many surgeons now use magnifying glasses. The sac is identified beneath the external oblique aponeurosis, close to the external inguinal ring; the ilioinguinal nerve is avoided. Proximal anteromedial dissection, by avoiding the contents of the spermatic cord, reaches preperitoneal fat where the hernial sac is tied and divided with a nonabsorbable suture. The basic steps are similar in girls. However, to avoid injury to the fallopian tube, which is encountered as a sliding hernia in 20%, the sac is always opened and examined before it is tied. Incarcerations are repaired through the same approach. Resection can be undertaken if ischemia of the bowel so indicates.

Complications of hernia repair in children relate to associated morbidity and whether the operation is elective or urgent. The premature infant and infants who are less then 3 months old pose special anesthetic problems. Wound infection, hydrocele, testicular atrophy, injury to the vas deferens, and recurrence may follow an operation, as in adults. Iatrogenic cryptorchidism is peculiar to these patients. Prophylactic antibiotics are indicated rarely. Atrophy or diminution in the size of the testicle has been found in extended follow-up in 3.7% of the male infants, a higher incidence with incarceration. Injury to the vas deferens, which is associated with microdissection, correlates with a greater incidence of infertility in men who underwent inguinal herniorrhaphy in childhood. The rate of recurrence (1%-3%) is again higher with prematurity (20%). Laparoscopic repair of these failures is recommended. The complication rate rises markedly in those who have incarcerations repaired (1.7% to 22%), especially in infants soon after birth. The main sequel is gonadal loss (20%).138

Anesthetic treatment during the past decade has evolved into less invasive techniques. Laryngeal mask airways, which circumvent intubation, have been used in the young child. Nevertheless, treatment of the immature respiratory responses and dealing with the respiratory tract of premature infants continue to pose challenges to the pediatric anesthesiologist. Postoperative apnea after general anesthesia is a big problem, considering that 10% to 20% of pediatric herniorrhaphies are performed in these small babies. Anemia and previous breathing difficulties were considered warning signs by Cote and colleagues.150 Somri and colleagues,151 in a prospective study of high-risk infants, concluded that the need for mechanical ventilation and the length of hospitalization could be reduced with the use of spinal anesthesia. However, this is difficult to administer, and some sedation is required anyway. The availability of new volatile short-acting agents may provide an opportunity to provide safer anesthesia. An important randomized study in older children showed that 10% lidocaine aerosol that was applied to the wound provided only short and clinically insignificant pain relief, despite repeated claims to the contrary.152

Elderly patients 

More than one half of adult groin herniorrhaphies today are undertaken in patients over the age of 50 years. Elderly patients have muscle atrophy with similar changes in the fasciae and aponeuroses. These effects are “normal” over and above any genetic or environmental damage to connective tissue. This loss of tone in the groin degrades the shutter effect; it is aggravated by associated morbidity, gout, arthritis, sciatica, and changes in the preperitoneal fat pad. Prostatism, in this predominantly male population, may cause straining and subsequent herniation. Urinary retention may follow general anesthesia and vagolytic medications. Direct herniation, especially bilateral, is more common; however, ideally, a short procedure is indicated. Circulating proteolytic activity is elevated in elderly patients and, because this is increased by smoking, this addiction should be stopped before the operation. The transversalis fascia is affected particularly by these proteases.

Cardiovascular or pulmonary insufficiency may mandate local anesthesia.153 Incarceration and strangulation are encountered more in elderly patients. Morbid conditions (eg, American Society of Anesthesia class IV) may mandate some form of regional anesthesia. Elderly women have femoral hernias 3 times as often as inguinal hernias, and bowel necrosis occurs in most of these hernias. An older woman with vomiting and a groin mass is the archetype, similar to its rarer sister, obturator herniation. Sliding herniation affects one third of inguinal defects in this age group. Herniography may be required to elucidate groin pain of unclear origin in elderly women. All elderly patients with femoral hernias should undergo operation as soon as possible. Multiple hernias are present in 12% and must be sought actively, both before and during operation.

Given the associated morbidity and increased postoperative risk in elderly patients, there has been renewed interest in the question of whether treatment is indicated, especially with asymptomatic direct inguinal defects. Leaving a hernia alone in elderly patients runs the risk that it may expand later and then be complicated. The answer may come from prospective, randomized studies, which are presently underway. Regardless, at operation, most surgeons today use standard tension-free prosthetic techniques. The short-term results are very good. Usually there is no death, and the morbidity rate is low. These cures are obtained with elective procedures. In urgent operations, the mortality and morbidity rates are considerable. It is for this reason that many surgeons, wherever possible, operate for all groin hernias in elderly patients.

Summary 

There have been several recent advances in the repair of groin herniation. Perhaps the greatest has been the eclipse of pure tissue repairs by tension-free hernioplasties, which are performed open or laparoscopically. Two “right” ways have emerged. Preperitoneal prosthetic covering of Fruchaud's myopectineal orifice, from above or below is one. A subaponeurotic prosthetic keyhole, tightened to restore the musculofascial shutter mechanisms of the intermediate and compress the internal inguinal rings, while, medially, reinforcing the transversalis fascia is the other. This latter technique, with or without a preperitoneal plug, is now the gold standard worldwide.

Modern prosthetic meshes incorporate rapidly, are well tolerated, and resist infection, even after strangulation. Their widespread adoption has been accelerated by the perceived need to resist wound tension. Furthermore, we now realize that muscle atrophy and damage to connective tissue, which are acquired by smoking or other insults to genetic expression, not only cause groin herniation but also interfere with its repair. Happily, these new concepts have reduced the main “bugaboo,” recurrence, significantly. Other patient concerns therefore have received much needed attention. These include pain, rehabilitation, cost, education, and continuing access countrywide to the latest advances in care. Other “minor” issues are also being examined. Ambulatory surgery, wherever possible with the use of local anesthesia, is the latest paragon, especially for elderly patients who now account for more than one half of the patients who are treated.92