Marta Cavalli

Surgical treatment of chronic pain after inguinal hernia repair.

BackgroundChronic groin pain is defined as pain arising 3–6xa0months after inguinal hernia repair that can compromise the patient’s quality of life. Many articles in the literature report clinical presentation, but there are no well-defined indications and protocols of treatment.MethodsForty-six patients underwent surgical treatment for chronic groin pain that consisted of a simultaneous double approach, anterior and posterior, to the inguinal region, with 44 triple neurectomies and 2 iliohypogastric neurectomies. Ilio-inguinal and ilio-hypogastric nerves were resected by anterior approach, while genitofemoral trunk was resected by a posterior pre-peritoneal approach. Mesh was removed in 24 cases, and mesh and plug were removed in 16 cases. A new mesh repair was performed in 42 cases. All the patients were examined 1xa0week, 1xa0month and 1xa0year postoperatively.ResultsIn 40 patients, the surgical treatment has obtained good response with improvement or complete resolution of the pain. Two patients referred persistent groin pain different from preoperative and in 4 cases the pain persisted without substantial benefit. Mean VAS value was 7.89 before surgery and 1.89 after surgery.ConclusionsChoice of the adequate therapy of chronic groin pain after inguinal hernia repair is still controversial. Our surgical approach turned out to be a safe and effective procedure. In this way, an accurate exploration of the whole inguinal region can be performed along with the identification of the nerves involved. Anyway in a certain number of cases, the resolution of pain cannot be achieved; this suggests a possible involvement of differences in the single personality and tolerances of pain in the different patients.

Sutureless mesh fibrin glue incisional hernia repair.

PurposeThe aim of this study is to evaluate the usefulness of sutureless incisional open hernia repair with mesh fixation only using a fibrin glue sealant.MethodsFrom 2002 to 2007, 40 patients underwent surgical recurrent incisional hernia repair, consisting of a sutureless positioning of a retromuscolar-preperitoneal polypropylene stiff mesh, fixed only with 2xa0ml of human fibrin glue.ResultsThe average hospitalization period was 3 days; postoperative complications occurred in seven patients: wound infection in four patients and hematoma in three patients. Seroma was not observed. Postoperative pain occurred in two patients, while chronic pain occurred in one patient; the remaining 37 patients were pain-free.ConclusionsThe use of an open retromuscolar mesh is an easy, inexpensive and relatively safe method to repair large incisional hernias. In our study the use of fibrin glue sealant demonstrated a low incidence of postoperative pain and short hospitalization.

Inguinal hernia: State of the art

A review of the history of inguinal hernia repair from the far surgical approach performed by Celso, trought the physiological reconstruction of inguinal canal by Bassini and the introduction of the concept of tensionfree repair, to the newest find in this specialist surgery. Nowadays in addition to the choice of approach (open vs laparoscopic, anterior vs preperitoneal), the plane where placing the mesh (in front of the trasversalis fascia vs preperitoneal space), and the fixation device (suture vs sutureless vs glue), surgeons can select among a wide range of prosthesis. Choosing the proper biomaterial can determine the success of an operation and prevent biomaterial-related complications. Indepth knowledge and understanding of the physical properties of the prosthesis, porosity, and pore size in particular are required. Modern advances in hernia repair are credited with reduced recurrence rate, so surgeons attention is shifted from preventing recurrence to the new topic of chronic pain after surgery.

Primary Inguinal Hernia: TAPP

Transabdominal preperitoneal patch (TAPP) is indicated in bilateral primary hernia and recurrent inguinal hernia after the previous anterior approach.

Pubic Inguinal Pain Syndrome (PIPS)

Pubic inguinal pain syndrome commonly presents as a painful groin in those sports that involve kicking and twisting movements while running such as football, rugby, and soccer. The pain experience is recognized at the common point of origin of the rectus abdominis muscle and the adductor longus tendon on the pubic bone. Although it is usually known as “sportsman’s hernia,” it may also appear in normally physically active people. Moreover it is accepted that this chronic pain caused by abdominal wall weakness occurs without a palpable hernia. For all this reason, we proposed the new name “pubic inguinal pain syndrome (PIPS).”

Postoperative Chronic Pain Assessment and THOPA Philosophy

PCP (postoperative chronic pain) was formally defined as a new or different quality of pain (if pain existed before hernia repair) arising as a direct consequence of a nerve lesion or disease affecting the somatosensory system after inguinal hernia repair. The etiology of PCP includes non-neuropathic and neuropathic causes, visceral and somatic pain.

Local Anesthesia in Inguinal Hernia: Indications and Techniques

Large epidemiologic and consecutive series and several retrospective and randomized controlled trials have shown the superiority of local anesthesia over general and regional anesthesias for primary inguinal hernia repair in terms of less postoperative pain, less anesthesia-related complaints, less micturition difficulties, faster discharge, and faster short-term recovery.

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].

Giant Hernia: Hug and TOP Technique

Giant inguinoscrotal hernias have been defined as those that extend below the midpoint of the inner thigh with the patient in the standing position [1]. Giant inguinoscrotal hernias, with a significant secondary abdominal cavity, are infrequent in developed countries; nevertheless, on rare occasions, patients visit their clinician after years of neglect and refusing to admit their problem. Even among underserved populations, the incidence of giant inguinoscrotal hernias is less than that of large inguinoscrotal hernias: indeed, this evidences the real distinction between giant and large inguinoscrotal hernias. Giant inguinoscrotal hernias are not only those that extend below the midpoint of the inner thigh when the patient is standing but also those with an anteroposterior diameter of at least 30 cm and a laterolateral diameter of about 50 cm and have been not reducible for more than 10 years (Figs. 37.1 and 37.2).

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.