Andrea Morlacchi

Prevention of Pain: Optimizing the Open Primary Inguinal Hernia Repair Technique

The prevention of pain requires that surgeons should take care not only during the entire surgical procedure but also before and after, following these steps: 1. Preoperative patient selection: preoperative pain, preoperative pain response to heat, intraoperative nerve injury, early postoperative pain intensity, younger age, and open surgery are risk factors for postoperative chronic pain. 2. Anesthesia: local anesthesia seems to be followed by less postoperative pain. 3. Approach: open anterior for all primary inguinal hernias. 4. Identification and respect of the three nerves when possible, otherwise pragmatic neurectomy. 5. Choice of the prosthesis: light- or medium-weight polypropylene flat mesh for “normal” patients. 6. Choice of fixation: sutureless or fibrin glue fixation should be advised. 7. Always provide proper postoperative therapy.

Primary Inguinal Hernia: Sutureless Open Anterior, Trabucco Repair

In 1974, Lichtenstein adopted a new “tension-free” approach using a polypropylene prosthesis to improve results [1, 2].

Incisional Hernia: The Open Approach, Introducing MILA Technique (Minimally Invasive Laparotomy Approach)

Before the advent of minimally invasive techniques for ventral hernia surgery, optimal access for an open retromuscular repair (Rives-Stoppa-Wantz technique) could only be achieved at the expense of large high morbidity incisions [1]. It should be the aim of the surgeon to employ the type of incision considered to be the most suitable for that particular hernia repair to be performed. In doing so, three essentials should be achieved: accessibility, extensibility, and security [1]. The incision must not only give ready access to the abdominal wall anatomy to be investigated but also provide sufficient room for the operation to be performed [2]. The incision should be extensible in a direction that allow for any probable enlargement of the scope of the operation, but it should interfere as little as possible with functions of the abdominal wall surgery. The surgical incision and the resultant wound represent a major part of the morbidity of the abdominal wall surgery. The incision must be tailored to the patients need but is strongly influenced by the surgeon’s preference and experience. For any open incisional hernia repair, the best is to go through the previous laparotomy incision, because this minimizes further loss of tensile strength of the abdominal wall by avoiding the creation of additional fascial defects [3]. Care must be taken to avoid “tramline” or “acute angle” incisions, which could lead to devascularization of tissues. Cosmetic end results of any incision in the body are most important from patient’s point of view. Consideration should be given wherever possible, to siting the incisions in natural skin creases or along Langer’s lines. Good cosmesis helps patient morale. Much of the decision about the direction and the length of the incision depends on the type of hernia defect and the previous scar position but also on the shape of the abdominal wall. Traditionally, for an open retromuscular ventral hernia repair, a generous midline laparotomy is required, but there are some cases in which it is possible to adopt our MILA (minimally invasive laparotomy approach) technique with the same excellent results. Elliptical incisions can be used to incorporate previous scars, skin ulcerations, and/or defects. For most, and especially morbidity obese, patients with large midline hernias, an excision of the umbilicus to minimize postoperative wound morbidity is possible.

History and Evolution of Hernia Surgery

Abdominal wall hernia is very common; the prevalence in the general population is about 5% (Basile et al., Int J Surg 11, S20–S23, 2013).

Logistics and Specialised Hernia Units

A Specialised Hernia Unit is a multidisciplinary programme providing state-of-the-art care for all types of hernias, from the most common to the most complex and technically challenging, from the simple primary hernia to multi-recurrent hernia or mesh-related complication (such as infection or post-operative chronic pain), from the small ventral hernia to the swiss cheese with real loss of substance incisional hernia, from the pubic inguinal pain syndrome (the so-called sportsman hernia) to the floppy abdomen postpartum.

Prevention and evaluation of chronic groin pain

In this chapter authors review risk factors for postoperative chronic pain and provide some suggestion in order to prevent it.

Chronic Pain after Inguinal Hernia Repair

Chronic pain is a significant long-term complication that can occur after inguinal hernia repair and can compromise the patient’s quality of life. Although this complication is increasingly recognized, much controversy still exists in the literature regarding its incidence, terminology, pathogenesis and treatment strategies. In an attempt to unify the terminology, the International guidelines for prevention and management of postoperative chronic pain following inguinal hernia surgery [1], in agreement also with the IASP (International Association for the Study of Pain) definition, proposed the following definition: a pain arising as a direct consequence of a nerve lesion or a disease affecting the somatosensory system, in patients who did not have groin pain before their original hernia operation, or, if they did, the postoperative pain differs from the preoperative pain. The pain complex syndrome of postherniorrhaphy inguinodynia includes pain...

Primary inguinal hernia: The open repair today pros and cons

Open anterior repair for inguinal hernia offers several distinct advantages over endoscopic repair, especially when real‐world effectiveness is taken into account. The learning curve for endoscopic techniques is long, whereas the Lichtenstein and other open tension‐free techniques are easier to teach and replicate at all levels. The outcomes of Lichtenstein repairs for primary inguinal hernia as performed by non‐experts and supervised residents are comparable to those of experts. Moreover, open tension‐free repair does not require expensive instruments or dedicated equipment, other than the prosthetic mesh. As such, it is feasible in any operating room anywhere in the world with limited costs. In our opinion, the most important advantage offered by open tension‐free repair is that it can be performed under local anesthesia. Nevertheless, local anesthesia has some disadvantages: it requires training, excellent knowledge of the anatomy and the necessary technique, patience, and gentle handling of the tissues. Open inguinal hernia repair is a procedure that every surgeon should know and be able to perform because it is necessary to treat two conditions, groin hernia recurrence after a posterior approach (both laparoscopic and open) and pubic inguinal pain syndrome.