Preface to Module 2 – Herniae

Historical Background

Hernias have been a surgical problem since time and more. Many of the great names of surgeons from bygone eras including Bassini, Halstead, Tanner, are attached to advances made in the anatomical understanding and surgical repair.

In those bygone years inguinal and femoral hernia surgery was carried out through what was termed the open anterior approach.

That is for an inguinal hernia an incision was made over the inguinal canal – the hernia dealt with and then the repair of the posterior wall carried out. There were numerous techniques and modifications to this repair – the commonest being the Bassini and Italian surgeon.

Another method described and popularized by Stoppa (and Nyhus) was to approach the hernia from behind by making an incision higher in the abdominal wall and then dissecting behind the muscle into the pre-peritoneal space between the peritoneum and the posterior wall of the inguinal canal. Sutures and mesh were placed behind the posterior wall.

One of the foremost modern components of the open anterior approach was the Shouldice Clinic Toronto, Canada – they used 4 layers of non absorbable suture to repair the posterior wall and reported amazing results for that time. The procedure was carried out under local anaesthesia and their clinic attracted patients from all over Canada and the United States. This was a unique centre where thousands upon thousands of cases were treated in a hospital devoted solely to hernia surgery.

Then along came mesh and Dr Lichtenstein of Los Angeles. He also used local anaesthesia and advocated the use of polypropylene mesh and made the “TENSION FREE” repair almost a household name. He rejected the Bassini concept of suturing the posterior wall down to the inguinal ligament, because of the tension involved.This tension when the patient strains of coughs causes the sutures to cut out. The Bassini repair reported as having very high recurrence rate whilst Lichtenstein results matched those of the Shouldice Clinic. Lichtenstein technique was to imbricate the posterior wall and narrow the internal ring, but not suture down to the inguinal ligament. The strength of the repair is obtained by the use of a permanent mesh.

Other surgeons were using what was termed the darn technique. Here multiple layers of suturing are use to almost replicate a mesh. In addition many of these techniques used an extensive relieving incision in the anterior sheath of the rectus muscle to reduce the tension required to pull the muscle together in the repaired. The ability of the patient to cough and strain during the procedure under local anaesthesia seemed to give a new understanding to the philosphy of the posterior wall of the inguinal canal and the way it should be repaired.

At this stage hernia repairs could be divided into;

Anterior approaches:

(1) The Bassini repair conservative suturing style of the posterior wall of inguinal canal.
(2) The Shouldice suturing technique of the posterior wall of inguinal canal.
(3) The Darning technique of posterior wall of inguinal canal.
(4) The Lichtenstein Mesh and Plug “tension free” repair technique. Using minimal suturing.

Posterior approaches:

(5) The posterior approach of Nyhus or Stoppa.

Just as everyone was getting comfortable with these icons a revolution occurred in the late eighties “LAPAROSCOPIC HERNIA REPAIR”.

This was a posterior approach similar in some ways to that of those of Nyhus. It was carried out laparoscopically though either an extra- peritoneal approach (TEPP) or a trans abdominal approach (TAPP) .

This initial surgery looked very clumsy and there were many disasters as surgeons adapted and developed their techniques. It was felt by the proponents that the “keyhole” technique would replace the open technique rapidly and leave those surgeons who did not adapt in their wake. But this has not occurred for a variety of reasons including;

• The difficulty in learning the technique.
• The more than occasional serious complication.
• The need for a general anesthetic.
• The costs involved.
• It has not been proven to cause less post operative pain than the local anaesthetic technique or indeed that return to work is quicker.
• Discussion as to whether the recurrence rate has improved.

An extensive series in the recent (2004) New England Journal of Medicine showed a higher recurrence rate in some – 8% in 2 years as opposed to 4% in 2 years for the open techniques. Both these rates are in excess of the previous report with good results, (Shouldice and Lichtenstein). The objectives of the open tension free technique and the laparoscopic technique were to reduce the recurrence rate, promote early return to normal activities and work, because of the “absence of tension” on the repair. The mesh gives immediate strength. The absence of tension is said to reduce the severity of post-operative pain allowing earlier mobilitity and activity.

A stalemate was reached as over the last couple of years in most centers laparoscopic hernia repair has decreased for example from 12% of repairs to 6% of repairs. It seems that most surgeons are doing the open repair and the laparoscopic repair is being concentrated in the hands of fewer surgeons who have more extensive experience. In a similar manner Lichtenstein technique became more popular because it seems to be agreed by most that it is much easier to learn and replicate than the Shouldice technique.

However laparoscopic repair stimulated a new approach combining anterior local anesthetic approach but placing the mesh behind the muscles, like Stoppa, Nyhus and laparoscopic techniques as through a inguinal incision. A variety of materials, indifferent shape has been promoted by different highly reputable surgical material companies. These include kugel patch or the prolene hernia system.

These mostly rely on the developing plain between the peritoneal and the muscles with finger or blunt dissection.

This is done through the deep inguinal ring in the case of indirect hernias, and by dividing the transverse fascia with direct inguinal hernias. The sac need not be excised after the mesh is placed and fixed into position. With minimal suturing a layer of mesh is then placed superficially to the muscles. This mesh may only require one suture to sustain it into position.

Another popular modification to this last technique is the use of self-expanding mesh. The muscles are split above the lateral to the deep ring and this expanding sheet of mesh based deep to the muscles after the hernia has been reduced (kugel patch).

The Bassini repair, which excised the indirect sac and pulled the posterior muscles down to the inguinal ligament, has lost popularity. This still has its component, especially those who abdicate the use of relieving incision with this.

My experience in Fiji showed that many countries cannot afford mesh or do not have the mesh available for use. While most would consider mesh to be a significant cost benefit – lower recurrence rate – this will not necessarily alter the situation.

Over the last 30-40 years we have seen the hospital stay of hernia repair plummet from 5-14 days, where now most of the patients can be discharged home the same day.

It is difficult to attribute this to any single factor.

As all these improvements have occurred more emphasis being placed on the incidence of chronic pain following hernia surgery. This is said to occur in up to 5% of hernia patients in some series. Some attribute this to the increasing use of mesh and new words have have crept into the English language “ meshoma”. A variety of meshes are being designed to be of lighter weight, less reactive and to reduce symptoms of adhesions where used for incisional hernia repair.

Laparoscopic hernia repair appears to have gained a significant place in the repair of incisional hernias. Maybe the laparoscopic hernia repair or incisional hernias will increase. The use of laparascopic hernia repair for recurrent inguinal or femoral hernias seems to have a reasonable place which is still being evaluated.