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TYPES OF THE OPERATIONS FOR INGUINAL HERNIA

The goal of all hernia repairs is to eliminate the peritoneal sac in the
case of an indirect hernia) and to close the fascial defect in the inguinal
floor. Traditional repairs approximatednative tissuesusing
permanentsutures. More recently, a permanent mesh has been used
with greater frequency to decrease tension on the repais. As surgeons
have gained more experiencewith the technique, laparoscopic
approaches have increased in frequency as well as in their success.
Simple high ligation of the sac through an inguinal incision is the key to
repair of indirect hernias in infants and children. Combined with
athightening of the internal ring, it is called Maercy repair.
Inguinal hernia in adults can ne repaired successfully through an inguinal, preperitoneal, or abdominal
approach, though inguinal repairs are most widely use today. While a given repair may be championed
by a particular surgeon or group, comparative studes do not conclusively demonstrate the superiority of
any one tye; inn fact, it seems likely that all the methods in common use give aquivalent results when
properly performed. Details of technique and the experience and skill of the surgeon are more likely to
account for the success of the procedure than is the type of the repair.
Thought most methods of repairing indirect inguinal hernias in
adults emphasize high ligation of the sac, as in children, elimination
of the sac by reducing it may suffice. The factor common to all
succsesfull methods of inguinal hernia repairs in adults is repair of
the inguinal floor. Over the past 15-20 years, mesh repairs have
gradually gained in popularity and have become the most commonly
employed methods. Comparative studies show a clear superiority of
open mesh repairs over the most traditional repairs using native
tissue alone.
Over the past decade, increased wxperience has been gained with the laparoscopic and other minimally
invasive techniques. Althought laparoscopic approaches offer less pain and more rapid return to work or
normal activities, no long term studies are yet available to assure that hernia recurrence rates are as low
as tose seen with open mesh hernia repairs. Operative time and procedutre costs are generally highwr
for laparoscpic hernioraphies have lower hernia recurrence rates,
Among the traditional autologous tissue repairs, the Bassini repair was the most widely use method. In
this repair : the conjoined tendon is approximated to Pauparts ligament and the spermatic cord remains
it is normal anatomic position under the external oblique aponeurosis.
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The Halsted repair placed the external oblique beneath the cord but otherwise resembles the Bassini
repair. Cooper`s ligament (Lotheissen-McVay) repair brings the conjoined tendon farther posteriorly
and inferiorly to Coopers ligament.

Unlike the Bassini and Halsted methods, MacVays repair is effective for femoral hernia but always
requires a relaxing incision to relieve tension. Reccurense rates after these open nonmesh repairs vary
widely according to skill and experience of the surgeon, but range around 10%.

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Thought the Shouldice repair has a low reported reccurance rate, it is not widely used, perhaps because
of the more extensive dissection required and belief that the skill of the surgeon may be as important as
the method itself. In the Shouldice repair, the transversalis fascia is first divided and then imbricated to
Pouparts ligament. Finally, the conjoined tendon and internal oblique muscle are also approximated in
layers to inguinal ligament.


The preperitoneal approach exposes the groin from between the transversalis fascia and peritoneum via
a lower abdominal incision to effect closure of the fascial defect. Because it requires more initial
dissection and is associated with higher morbidity and recurrence rates in less experience hands, it has
not been widely favored. For recurrent or large bilateral hernias, a preperitoneal approach using a large
piece of mesh to span all areas of potential herniation has been described by Stoppa. Laparoscopic
preperitoneal approaches have demonstrated excellent success, with low recurrence and complication
in experienced hands.
A desire to decrease the recurrence rate of hernias has prompted in ancreased use of prosthetic
materials in repair of both recurrents and first-time
hernias. Methods include plugs of mesh inserted
into the internal ring and sheets of mesh to create a
tension free repair. The most widely used
technique is that of Lichtenstein, an open mesh
repair that allows and early return to normal
activities and a low complication and recurrence
rate.



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Virtually all laparoscopic approaches utilize mesh in the repair. Several methods have been explore
from
- a transabdominal intraperitoneal onlay of mesh (IPOM)





- transabdominal preperitoneal mesh technique (TAPP)


- total extraperitoneal (preperitoneal) mesh placement (TEP).

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The high incidence of complications that occurred in early studies prompted revisions in operative
technique to avoid injury to lateral nerves. Several prospective
randomized trials have demonstrated decrease pain and faster
return to work with the minimally invasive techniques but at
increased cost of the procedures has not yet been established.
Spesific situations in which minimally invasive procedures may
be particularly advantageous include the repair of bilateral
hernias simultaneously, and repair in patients who must return
to work particularly quickly.