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What’s New in Hernia Repair?

Since Dr. Bassini’s description of inguinal hernia repair in the 1880s there have been many variations and techniques used to address this common yet complex surgical problem. This trend has continued in the modern era, with multiple options for repair, and many materials available.

The original tissue repairs of Bassini and Cooper are rarely if ever indicated today, as the use of mesh reduces tension and therefore results in a superior repair. Patients recover faster, have less pain, and have a reduced chance of recurrence with these techniques. There are several commonly used mesh configurations. Polypropylene plastic mesh used as an onlay patch (the Lichtenstein repair) has declined in popularity due to the small degree of tension this technique produces and because it does not allow for significant extension of the mesh beyond the confines of the inguinal canal. Similar material used as a plug and patch combination still has some advocates, however I have observed plug migration and displacement of the pre-peritoneal plug due to poor fixation. I no longer use these techniques.

The material used to make the mesh has also evolved. The original stainless steel is long out of use, although I still see the rare patient with steel mesh reinforced repairs. Polypropylene is the most common material in use, and recently studies have supported use of the lightweight configurations. This decreases mesh burden but maintains tensile strength, resulting in a more comfortable repair for our patients with minimal recurrence. Polyester has recently shown potential for superiority over polypropylene due to better incorporation into the tissues.

Laparoscopic inguinal herniorraphy perhaps best addresses the repair of the anatomic defect with zero tension and generous overlap of the mesh on the fascia. I have performed thousands of these repairs with excellent results. The main disadvantages of the approach are the rare possibility of injury to pelvic and intra-abdominal structures, the need to use a Foley catheter, and the possibility (although rare) of hemorrhage.

The open approach to inguinal hernia repair has also improved, incorporating the benefits of several of the popular operations. This technique uses a bilayer configuration of lightweight polypropylene with a central connector. The internal component is placed into the preperitoneal space (inside), the central portion passes through the defect, and the onlay portion is placed over the repair. Minimal fixation with several sutures is used, with the repair being performed through a two inch incision. This results in a tension-free repair with generous mesh overlap in the preperitoneal space with immovable fixation of the mesh due to the connector. The result is an excellent repair with the lowest reported recurrence rate. I have observed high patient satisfaction due to minimal post-operative pain and the comfort of the mesh. This combines the advantages of a laparoscopic repair with the safety of an open repair that can be done under local or general anesthesia. Possibility for injury to pelvic and intra-abdominal structures is all but eliminated.

The robotic approach to hernia repair has gained popularity in recent years, utilizing a technique similar to laproscopic hernia repair with a more delicate approach. The result may be a more comfortable recovery with excellent repair.

Ultimately, the decision regarding which procedure will be used is made between the patient and the surgeon. Tailoring the procedure to the patient individualizes care and the result is a happy patient with an excellent long-term result.

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"Nineteen years ago, Connie had veins in her left leg surgically stripped. “I was in the hospital for a week, wrapped and bandaged, then off my feet for another three weeks.” Years later, Connie had the problematic veins in her right leg…" -- Connie K.