Piero Giovanni Bruni

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.

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.

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.