CURRENT TREATMENT, RISKS and CONSIDERATIONS IN THE MANAGEMENT OF HERNIAS : An historical approach
Reviewed on 9-2-17
Hernias have been a surgical problem since time immemorial. Many of the great names of the surgical arena are attached to advances made in the anatomical understanding and surgical repair. None more so than the Italian anatomist and surgeon Bassini of Padua who in the late 19th century introduced the then radical concept of herniorraphy thus revolutionized hernia repair. Previously only the sac was excised(herniotomy).This was often fatal and rarely cured the hernia. Instead Bassini repaired the defect as well by suturing the muscles of the inguinal canal and their fascia – internal oblique abdominous, transverse abdominous, transversalis fascia and conjoint tendon down to the inguinal ligament. He immediately achieved a high cure and low short term recurrence rate. However over the next century there still remained a high longer term recurrence rate. The technique was more successful with indirect hernias but less so for direct hernias .with direct hernias because the tissues were already much weakened and the repair placed the sutures under tension.
The technique endured and was the cornerstone of inguinal repair for over 100 years.
A variety of ways to improve the results of Bassini’s sutured repair were introduced. Particularly so for direct inguinal hernia including, what has been termed the Tanner slide. Here the anterior sheath of the rectus muscle was incised so that the tissues of the posterior wall could be approximated to the inguinal ligament with reduced tension. The incidence of recurrence was higher with direct than indirect hernia because a direct hernia is caused by attrition of an extended area of the wall. The indirect hernia was more of a localized defect.
Multiple layers of suturing were often used–the darn repair. One particular method of suturing developed in Toronto in the 1940s was the Shouldice repair.-a 4 layer suturing repair of the posterior wall .Wire had been used for many years.Their results have been excellent but the technique has not been popular world, wide-possibly because the technique has been difficult to emulate and their results difficult to obtain.
Despite all these different measures, world wide the recurrence rates were reported to be up to 20%.
Major advances then occurred in the 1980’s and 90’s with the concept introduced and popularized by Lichtenstein of a” tension free” technique. The muscles and tissues were no longer pulled down to the inguinal ligament. The tension created was felt to be a factor in the sutures cutting out and recurrence occurring.It was considered the tension contributed to the post operative pain. As well it is believed there is a generalized area of weakness and the suturing was of the weakened tissue Thus suturing does not overcome the weakness .
Before the introduction of mesh, surgery with suturing only had also been carried out via a posterior approach. This involved suturing the muscles from behind,—advocated by Stoppa. Later with its introduction a large mesh could also be placed in this posterior position. This technique has been attributed to Nyhus.
THE INTRODUCTION OF MESH
A none absorbable synthetic polypropylene mesh was introduced to reinforce the posterior wall of the inguinal canal [hernioplasty]. This covered the entire area of weakened tissue. Scar tissue ingrowth added to the strength. A variety of synthetic meshes have since been introduced with each claiming advantages over the other in terms of ease of use, POST OPERATIVE or CHRONIC PAIN, risk of infection, meshoma formation and recurrence rate.The mesh manufacture has developed into a whole industry.
As well there have been changes in the way the mesh is fixed into position. The majority sutured these into position, but now as chronic pain remains an issue the meshes are glued in by some..
With laparoscopic surgery some even consider just leaving the mesh in position is adequate.
Of course all these alternatives are the subject of extensive analyses with journals and conferences being devoted to just hernias
Hernias are now being considered a speciality in there own right.
Laparoscopic hernia repair
The then revolutionary Laparoscopic (key hole) hernia repair with mesh was introduced in the 1990s following the success of laparoscopic cholecystectomy ..– This was based on this posterior approach to the posterior aspect of the abdominal wall and inguinal canal
This was achieved by approaching
A.. Through the abdominal cavity (TAPP) trans abdominal pre peritoneal –opening the abdominal cavity
B totally extraperitoneal –abdominal cavity not entered.(TEPP)
Problems occurred initially as surgeons adapted to a completely different anatomical approach with which they were not familiar.
These have been mostly overcome. There is constant evaluation and comparison of these technique with each surgeon having his preferred method claiming advantages of one over the other.. The surgery has become safe with experience but does require a general Anaesthetic
There have been considerable advances in the instrumentation, materials and techniques used , ,
Soon other techniques for open repair using mesh were introduced. These included using mesh plugs with a mesh onlay. THE PLUG AND PATCH METHOD – this became very popular .other mesh formats including placing these deep to the posterior wall of the inguinal canal through an anterior approach. The names of Kugel and Gilbert have been attached to some of these devices and synonymous with their use
Lichtenstein had earlier used mesh plugs for femoral hernia repair and recurrent inguinal hernia repair where the edges of the defect were too scarred and under too much tension to approximate.
With all these advances post operative recovery has improved dramatically. From a hospital stay of many days the majority of patients can now be treated as a day case.In the Bassini era prolonged bed rest was advocated to reduce the tension on suturing and thus recurrence rate.
The widespread introduction of mesh appears to have reduced the recurrence rate and appeared to allow earlier return to activities and work .However chronic pain occasionally associated with a painful lump of mesh and scar tissue leading to the term MESHOMA assumed increased significance
The mesh also has a small risk of becoming chronically infected necessitating removal
Some also said there was a stiffness and reduced mobility
Surgeons rapidly broke up into opposing camps advocating the perceived advantages of one technique over the other
To reduce possible disadvantages of the mesh
; a whole new array of lighter weight partially absorbable meshes have been designed.
Even self adherent meshes.
As well different methods of fixing the mesh have evolved.
From absorbable or non-absorbable suturing, staples to glues and now absorbable staples
Assessing the results of hernia surgery.
Criteria involved in comparing results included ——-
Post op pain *****
Ease of recovery****
Return to activity and work*****
Incidence of chronic pain*****
The issue of chronic pain has assumed such significance, that validated chronic pain questionnaires have been developed to enable comparison of techniques.
IN REVIEW OF OUR PATIENTS AT THE MELBOURNE HERNIA CLINIC
We used the Frannnerby validated pain questionnaire and followed them for 5 years
We reported an insignificant, virtually zero incidence of chronic pain.
In addition there was an incidence of less than 2% recurrence
…………………………Because chronic pain is of such significance risk factors to effecting the possibility include the management of the nerves at operation the type of mesh and the role it may play in the development of scar tissue and the role it plays in chronic inflammation
CAUSES and RISK FACTORS in the prediction and development of CHRONIC POST HERNIA REPAIR PAIN
It could be divided into such groups as:
- The inherent nature of the patient e.g. anxiety, chronic pain syndromes,
- The level of preoperative pain,operative complications,post operative pain
- The materials used sutures , mesh, staples
- The surgical technique itself e.g. open Lichtenstein or Shouldice, laparoscopic, TEPP or TAPP,
Thus chronic pain has been a recent driving force in the search for a techniques and materials which to reduce the incidence this disabling problem.
These many considerations may influence the choice of approach, type of mesh used and method of fixation
From a once feared operation the inguinal hernia repair has evolved into a safe operation,with rapid recovery. It can in most cases be readily performed under local anaesthesia with sedation and the patient treated as a day case. Infection,recurrence and chronic pain remain the major challenges
The developments in inguinal hernia repair have been applied to all other types of hernia surgery
This series will deal with each type in turn. This initial introduction will be followed by an introduction titled
HERNIAS OF THE ABDOMINAL WALL
A/Prof. Maurice Brygel
Director of THE MELBOURNE CLINIC. SYDNEY HERNIA CENTRE. MELBOURNE HAEMORRHOID AN RECTAL BLEEDING CLINIC