Parviz K. Amid

The tension-free hernioplasty

Since the first true herniorrhaphy was performed by Bassini over 100 years ago, all modifications and surgical techniques have shared a common disadvantage: suture line tension. The anatomic, physiologic, and pathologic characteristics of hernia recurrence are examined. The prime etiologic factor behind most herniorrhaphy failures is the suturing together, under tension, of structures that are not normally in apposition. With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity.

Lichtenstein tension-free hernioplasty: Its inception, evolution, and principles

To circumvent the degenerative nature of inguinal hernias and adverse effect of suture line tension, the Lichtenstein tension-free hernioplasty began in 1984 and evolved (between 1984 and 1988) to a procedure that is now considered the gold standard of hernia repair by the American College of Surgeons. The objective of this paper is to outline the reasons behind the minor changes made during the short, 4-year evolution of the technique, describe the key principles of the operation, and introduce a new mesh that, if elected to be used, automatically satisfies all the key principles of the procedure and guides the surgeon to perform the operation correctly. The worldwide reported result of the operation by experts and nonexperts alike is a recurrence and complication rate of less than 1%. When the key principles of the procedure, which, as reported by many authors, are easy to learn, perform, and teach, are respected, the operation results in an effectiveness (external validation) that is virtually the same as its efficacy (results of the experts), attesting to the simplicity of the procedure.

Critical scrutiny of the open “tension-free” hernioplasty

Tension-free hernioplasty is rapidly gaining worldwide acceptance. Since June 1984, 3,125 consecutive adult male primary inguinal hernias have been repaired by employment of an open tension-free prosthetic repair without approximation of the margins of the defect. Since the original publication of our technique in the 1989 February issue of The American Journal of Surgery, we have encountered four recurrences. These recurrences were caused by technical errors early in our experience and have since been corrected. The purpose of this paper is to bring those errors to the attention of surgeons, as well as to suggest certain modifications to further simplify the operation. Three of the recurrences occurred at the pubic tubercle and were caused by placing the mesh in juxtaposition to the tubercle. This error has since been corrected by overlapping the mesh at the pubic bone. One recurrence was caused by disruption of the lower edge of the mesh from the shelving margin of Pouparts ligament. The error here was utilization of a patch that was too narrow and therefore under tension. It became apparent that a wider patch, fixed in place with an appropriate degree of laxity, was required.

Local anesthesia for inguinal hernia repair step-by-step procedure.

ObjectiveThe authors introduce a simple six-step infiltration technique that results in satisfactory local anesthesia and prolonged postoperative analgesia, requiring a maximum of 30 to 40 mL of local anesthetic solution. Summary Background DataFor the last 20 years, more than 12,000 groin hernia repairs have been performed under local anesthesia at the Lichtenstein Hernia Institute. Initially, field block was the mean of achieving local anesthesia. During the last 5 years, a simple infiltration technique has been used because the field block was more time consuming and required larger volume of the local anesthetic solution. Furthermore, because of the blind nature of the procedure, it did not always result in satisfactory anesthesia and, at times, accidental needle puncture of the illoinguinal nerve resulted in prolonged postoperative pain, burning, or electric shock sensation within the field of the ilioinguinal nerve innervation. MethodsMore than 12,000 patients underwent operations in a private practice setting in general hospitals. ResultsFor 2 decades, more than 12,000 adult patients with reducible groin hernias satisfactorily underwent operations under local anesthesia without complications. ConclusionsThe preferred choice of anesthesia for all reducible adult inguinal hernia repair is local. It is safe, simple, effective, and economical, without postanesthesia side effects. Furthermore, local anesthesia administered before the incision produces longer postoperative analgesia because local infiltration, theoretically, inhibits build-up of local nociceptive molecules and, therefore, there is better pain control in the postoperative period.

Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia: Triple neurectomy with proximal end implantation

The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy has been a two-stage operation including: (a) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (b) genital nerve neurectomy through a flank approach. Two hundred twenty-five patients underwent triple neurectomies with proximal end implantation to treat chronic postherniorrhaphy neuralgia. Four patients reported no improvement. Eighty percent of patients recovered completely, and 15% had transient insignificant pain with no functional impairment. These results are comparable to the results of the two-stage operation. Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves without mobilization of the spermatic cord is an effective one-stage procedure to treat postherniorrhaphy neuralgia. It can be performed under local anesthesia and avoids testicular complications. Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structures of the groin, which can result in recurrence of the pain. A one-stage surgical procedure resecting all three nerves from an anterior approach avoids a second operation through the flank and successfully treats chronic neuralgia.

Biomaterials for abdominal wall hernia surgery and principles of their applications

This article focuses special attention on the porosity, cellular permeability and molecular permeability of biomaterials and their effect on infection, host tissue incorporation and seroma formation when mesh is used for the repair of abdominal wall hernias. Furthermore, the general principles of the application of biomaterials, regardless of the technique used for their employment, is discussed.ZusammenfassungDiese Arbeit befaßt sich mit der Durchlässigkeit sowohl zellulär als auch molekular von Biomaterialien und ihre Auswirkungen auf Infektion, Serombildung und Akzeptanz in Empfängergewebe bei der Implantation von Netzmaterialien in der Hernienchirurgie. Darüber hinaus werden die allgemeinen Prinzipien der Anwendung von Biomaterialien unabhängig von der jeweiligen Implantationstechnik diskutiert.

The Cause, Prevention, And Treatment Of Recurrent Groin Hernia

At present, groin hernia repair is associated with a 10% recurrence rate. Despite innumerable modifications of the Bassini technique, this depressing figure remains essentially unimproved. This article documents the two major reasons for failure and presents techniques that are simple, can be performed under local anesthesia in an outpatient setting, allow patients to return home within hours of their surgery, encourage rapid return to unrestricted activity, and are associated with a recurrence rate approaching 0%.

Long-term result and current status of the Lichtenstein open tension-free hernioplasty

SummaryThe tension-free hernioplasty project began in 1984 at the Lichtenstein Hernia Institute. The method consists of complete reinforcement of the inguinal floor with a large sheet of mesh, with adequate mesh tissue interface beyond the boundary of the inguinal floor and creation of a new internal ring made of prosthesis. The preliminary report of this operation was published in 1989, with no recurrence at that point in time. Shortly after the submission of the report, several recurrences were encountered. Based on the lesson learned from those recurrences, the operation was slightly modified and reported in 1991 [Amid 1993]. Since then, the Lichtenstein technique has gained world-wide popularity. Outcome measures identical to ours and other authors have been achieved by even those surgeons who have no special interest or expertise in herniology. The purpose of this article is to report the current state of the open tension-free hernioplasty for the repair of primary and recurrent inguinal hernias.

Cause and prevention of postherniorrhaphy neuralgia: A proposed protocol for treatment

The cause of severe and persistent neuralgia after hernia surgery is due to sensory nerve crushing. An operative technique has been described that prevents inadvertent crushing or division of the sensory nerves to the groin. With persistent postoperative pain, the offending nerve is usually difficult to identify. A protocol has been suggested to differentiate ilioinguinal from genitocrural causalgia. When the particular nerve is incriminated, its division will ordinarily cure the problem.

Groin Hernia Repair: Open Techniques

Since the introduction of the Bassini method in 1887, more than 70 types of pure tissue repair have been reported in the surgical literature. An unacceptable recurrence rate and prolonged postoperative pain and recovery time after tissue repair along with our understanding of the metabolic origin of inguinal hernias led to the concept of tension-free hernioplasty with mesh. Currently, the main categories of inguinal hernia repair are the open repairs and the laparoscopic repairs. In the open category, repair of the hernia is achieved by pure tissue approximation or by tension-free mesh repair. The most commonly performed tissue repairs are those of Bassini, Shouldice, and to a lesser extent McVay. In the tension-free mesh repair category, the mesh is placed in front of the transversalis fascia, such as with the Lichtenstein tension-free hernioplasty, or behind the transversalis fascia in the preperitoneal space, such as during the Nyhus, Rives, Read, Stoppa, Wantz, and Kugel procedures. Numerous comparative randomized trials have clearly demonstrated the superiority of the tension-free mesh repair over the traditional tissue approximation method. Placing mesh behind the transversalis fascia, although a sound concept, requires extensive dissection in the highly complex preperitoneal space and can lead to injury of the pelvic structures, major hematoma formation, or both. In addition, according to the prospective randomized comparative study of mesh placement in front of versus behind the transversalis fascia, the latter offers no advantage over the former, and it is more difficult to perform, learn, and teach. More importantly, preperitoneal mesh implantation (via open and laparoscopic procedure) leads to obliteration of the spaces of Retzius and Bogros, making certain vascular and urologic procedures, in particular radical prostatectomy and lymph node dissection, extremely difficult if not impossible. In conclusion, according to level A evidence from randomized comparative studies, (1) mesh repair is superior to pure tissue approximation repairs, and (2) mesh implantation in front of the transversalis fascia is superior, safer, and easier than open or laparoscopic mesh implantation behind the transversalis fascia.