**4. Personal case**

#### **4.1. Population**

We considered a cohort of patients suffering from primary unilateral inguinal hernia that underwent the "all-in-one" mesh hernioplasty technique consecutively, at our institution. Hernias were divided according to the European Hernia Society criteria (**Table 1**). The work described has been carried out in accordance with the code of ethics of the World Medical Association. Written informed consent was obtained from each patient included in the study. All data of the cohort were registered in a specific database. Spinal anesthesia was adopted, and 2.0 g cefazolin was administrated intravenously over 30 minutes before the incision for all patients, and the procedure was performed on a 1-day surgery basis. From September 2012 to August 2015, we treated 250 adult patients for primary inguinal hernia, 241 males and 9 females with an average age of 61.7 years (range, 22–90).

#### **4.2. Follow-up**

Postoperative pain was gauged on the ward by a surgeon of the team. At discharge, all patients received a data sheet designed for the evaluation of postoperative pain using visual analogue scale (VAS) score, quantity of pain medication, and any postoperative discomfort. The patient's discomfort was assessed in terms of limitation of daily activities during the postoperative period, and return to work, and sports. Patients were asked for an overall opinion on the operation, on the postoperative period, and on the final result. These data were recorded by patients themselves on data sheet after 1, 2, and 3 weeks from discharge. The first clinical evaluation was made 7 days after surgery by a member of the surgical team. The second and third week interviews were made on the phone. The postoperative data registered by patients were collected. Follow-up, made to evaluate local signs, any kind of chronic pain, any sensation of foreign body, and recurrence, took place at 3, 6, 12, 18, and 24 months after surgery in the outpatient clinic by a surgeon of the team. All patient data were collected in a database of our institution.


(average VAS score = 0.06). None of the patients took medication (**Table 3**). During the third postoperative week, only 0.4% (1) of patients complained of slight pain (average VAS score 0.01) which needed no medication (**Table 4**). Only 23 (9.2%) subjects experienced slight limitations of normal activities during the first week (**Table 5**). Thirty (20.1%) patients were able to engage in sports as early as 1 week from surgery, while 46 (30.9%) started between 7 and 21 days after surgery. Patients underwent to planned follow-up at 3 months (50 patients), 6 months (35 patients), 12 months (25 patients), 18 months (35 patients +1 patient lost), and 24 months (104 patients). Average follow-up is 15 months. None of our patients suffered from postoperative neuralgia, sensation of foreign bodies, or even simply discomfort. One recurrence was seen. All patients seemed satisfied with the operation, the recovery, and the

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Tension-free techniques dramatically reduced recurrence rates making them the standard in hernia surgery. A not negligible incidence of postoperative chronic neuralgia [8, 26, 27] brought the attention of surgeons to new precautions even with the use of meshes [28].

Postoperative pain is temporary, usually controlled by medication. When persistent after 3–6 months from surgery, pain becomes disabling and may compromise the patient's quality of life. Pain may be related to the presence of the mesh that, because of size and location, takes contact with muscular structures or caused by fibrotic entrapment of nerves by a subfascial prosthesis [4, 13]. Studies conducted on animals also showed perineural alterations with myelinic degeneration due to contact between nervous structures and mesh [29]. Therefore, there is a necessity of identifying and dissecting subfascial nerves [30] and even of dividing them to avoid chronic pain [5, 6]. New surgical techniques and numerous kinds of meshes were proposed in the past years in the attempt to reduce postoperative neuralgia; neverthe-

less, the results of these new procedures were not completely satisfactory [7–10].

final result [25].

VAS 0 96.8% (242 pts) VAS 1 0.8% (2 pts) VAS 2 1.2% (3 pts) VAS 3 1.2% (3 pts)

**Table 3.** Postoperative pain in the second week.

VAS 0 99.6% (249 pts) VAS 1 0.4% (1 pt)

**Table 4.** Postoperative pain in the third week.

Average pain VAS 1.2; SD 1.5.

Average pain VAS 0.06; SD 0.4.

**4.4. Discussion**

**Table 1.** Hernias were divided according to the European hernia society classification.

#### **4.3. Results**

Three (1.2%) patients complained of urinary retention, 2 (0.8%) of orchitis, and 14 (5.6%) showed bruising of the external genitalia. No other early complications were reported. Pain reported by patients in the immediate postoperative period was slight (mean VAS score = 2.1). A total of 79 (31.6%) patients required no pain medication, while the remaining 171 (68.4%) were given nonnarcotic analgesics. Average VAS score during the first postoperative week 171 was 1.2, and 119 (47.6) patients took no medication (**Table 2**). During the second postoperative week, 8 (3.2%) subjects still complained of slight pain referred to the wound


**Table 2.** Postoperative pain in the first week.


**Table 3.** Postoperative pain in the second week.

(average VAS score = 0.06). None of the patients took medication (**Table 3**). During the third postoperative week, only 0.4% (1) of patients complained of slight pain (average VAS score 0.01) which needed no medication (**Table 4**). Only 23 (9.2%) subjects experienced slight limitations of normal activities during the first week (**Table 5**). Thirty (20.1%) patients were able to engage in sports as early as 1 week from surgery, while 46 (30.9%) started between 7 and 21 days after surgery. Patients underwent to planned follow-up at 3 months (50 patients), 6 months (35 patients), 12 months (25 patients), 18 months (35 patients +1 patient lost), and 24 months (104 patients). Average follow-up is 15 months. None of our patients suffered from postoperative neuralgia, sensation of foreign bodies, or even simply discomfort. One recurrence was seen. All patients seemed satisfied with the operation, the recovery, and the final result [25].

#### **4.4. Discussion**

**4.3. Results**

VAS 0 46.8% (117 pts) VAS 1 17.6% (44 pts) VAS 2 17.6% (44 pts) VAS 3 10.8% (27 pts) VAS 4 3.2% (8 pts) VAS 5 3.2% (8 pts) VAS 6 0.8% (2 pts)

**Type No. of patients**

P L1M0F0 53 P L2M0F0 53 P L3M0F0 33 P L2M2F0 24 P L1M1F0 20 P L0M2F0 16 P L0M1F0 12 P L3M3F0 12 P L1M2F0 12 P L0M3F0 8 P L1M3F0 3 P L2M1F0 2 P L2M3F0 1 P L3M2F0 1

54 Hernia Surgery and Recent Developments

Average pain VAS 1.2; SD 1.5.

**Table 2.** Postoperative pain in the first week.

Three (1.2%) patients complained of urinary retention, 2 (0.8%) of orchitis, and 14 (5.6%) showed bruising of the external genitalia. No other early complications were reported. Pain reported by patients in the immediate postoperative period was slight (mean VAS score = 2.1). A total of 79 (31.6%) patients required no pain medication, while the remaining 171 (68.4%) were given nonnarcotic analgesics. Average VAS score during the first postoperative week 171 was 1.2, and 119 (47.6) patients took no medication (**Table 2**). During the second postoperative week, 8 (3.2%) subjects still complained of slight pain referred to the wound

**Table 1.** Hernias were divided according to the European hernia society classification.

Tension-free techniques dramatically reduced recurrence rates making them the standard in hernia surgery. A not negligible incidence of postoperative chronic neuralgia [8, 26, 27] brought the attention of surgeons to new precautions even with the use of meshes [28].

Postoperative pain is temporary, usually controlled by medication. When persistent after 3–6 months from surgery, pain becomes disabling and may compromise the patient's quality of life. Pain may be related to the presence of the mesh that, because of size and location, takes contact with muscular structures or caused by fibrotic entrapment of nerves by a subfascial prosthesis [4, 13]. Studies conducted on animals also showed perineural alterations with myelinic degeneration due to contact between nervous structures and mesh [29]. Therefore, there is a necessity of identifying and dissecting subfascial nerves [30] and even of dividing them to avoid chronic pain [5, 6]. New surgical techniques and numerous kinds of meshes were proposed in the past years in the attempt to reduce postoperative neuralgia; nevertheless, the results of these new procedures were not completely satisfactory [7–10].


**Table 4.** Postoperative pain in the third week.


In our technique, the prosthesis is positioned and remains on the transversalis fascia because it is coated with the fibro-cremasteric sheath and it remains anchored on the inguinal floor with a single fixing point at the pubic level and with the prosthetic conical ring on the deep inguinal ring. It is not directly under-aponeurotic at any point, and it stays in place and there-

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In addition, the prosthesis is not in contact with the ilioinguinal and iliohypogastric nerves. Our paper is an observational cohort study with only midterm (2 years) follow-up. Clinical trials comparing the "all-in-one mesh" hernioplasty to the most common surgical techniques are required to obtain a validation of our procedure. Indeed, a much longer follow-up could

This new procedure claims many technical advantages and helps the less experienced surgeon to avoid pitfalls in dealing with nerves. According to our series, "all-in-one mesh" hernioplasty presents a low rate of long-term complications. Employing a smaller amount of prosthetic material, placed where no contact with nerves occurs, avoids neuralgia and sensation of foreign body. A multicenter study is underway to compare this new procedure with the most common

, Nicoletta Pecora<sup>1</sup>

1 Department of Medicine and Surgery, General Surgery Unit, Istituti Clinici Zucchi,

[1] Lichtenstein IL. Herniorrhaphy. A personal experience with 6321 cases. American

[2] Trabucco E, Trabucco A, Rollino R, et al. L'ernioplastica inguinale tension-free con rete

presagomata senza suture secondo Trabucco. Chirurgia. 1998;**11**:142-148

3 Department of Medicine and Surgery, University of Milano-Bicocca, Italy

, Marco Chiarelli<sup>2</sup>

,

fore does not require lateral fixation.

**5. Conclusion**

techniques.

**Author details**

Angelo Guttadauro<sup>1</sup>

Valentina Riggio<sup>3</sup>

**References**

highlight the actual recurrence rate of the new procedure.

\*, Matteo Maternini<sup>1</sup>

and Francesco Gabrielli1

University of Milano-Bicocca, Monza, Italy

2 General Surgery Unit, Ospedale di Lecco, Italy

Journal of Surgery. 1987;**153**(6):553-559

\*Address all correspondence to: angelo.guttadauro@unimib.it

**Table 5.** Restriction in daily activities.

This led to the setting of guidelines for prevention and treatment of this situation [31].

If we consider the areas of weakness within the inguinal canal from which the three types of hernia arise, we see an oval-shaped surface surrounded by known muscular and fascial structures on the canal's floor and a further weak zone in proximity to the deep inguinal ring (**Figure 2**).

The transversalis fascia is an important restraining element for both structure and functionality in a region lacking overlying muscular structures. Then, the idea of a prosthesis specifically shaped to obtain containment by acting directly on the weak areas of the transversalis fascia without involving muscular or nervous structures avoiding to place a subaponeurotic mesh. This allows the procedure more anatomical with minimal foreign body implantation.

The prosthesis size, defined after numerous measurements of the inguinal canal made at the operating table, is notably smaller than the ones used as of now, allowing a precise and smooth positioning in a different plane to where the nerves lie.

The weak areas along the transversalis fascia are strengthened, all at once, by the prosthesis (all-in-one mesh), so that losing a hernia sac can no longer happen [2].

Polypropylene was chosen because of its capacity of inducing a lively inflammatory and fibrotic response with quick and strong adhesion to adjacent tissues. A prompt fibroblastic reaction between transversalis fascia and mesh immediately takes place because of the absence of any dead space and quickly forms a new wall.

This new technique is simple to perform and guarantees quick discharge and return to normal activities without any long-term discomfort. The average operative time was 25 min. The surgeon needs not dissect the cremaster, which may cause damage to the nerves, nor create a subfascial "nest," because no mesh is inserted at that level.

Furthermore, no plugs nor mesh trimming are necessary, and the prosthesis does not have to be sutured to adjacent structures. The use of a smaller quantity of prosthetic material allows the envelopment of the mesh by the fibro-cremasteric sheath, avoiding contact with surrounding nerves. Because of its shape, the mesh is placed in a deeper site directly over the weak areas of the floor of the inguinal, canal and, although smaller, it seems not to increase rate of recurrence.

The most common technique of Lichtenstein provides a prosthesis which, to remain on the transversalis fascia, must be fixed to the sides and becomes necessarily under aponeurotic in the upper third.

In our technique, the prosthesis is positioned and remains on the transversalis fascia because it is coated with the fibro-cremasteric sheath and it remains anchored on the inguinal floor with a single fixing point at the pubic level and with the prosthetic conical ring on the deep inguinal ring. It is not directly under-aponeurotic at any point, and it stays in place and therefore does not require lateral fixation.

In addition, the prosthesis is not in contact with the ilioinguinal and iliohypogastric nerves. Our paper is an observational cohort study with only midterm (2 years) follow-up. Clinical trials comparing the "all-in-one mesh" hernioplasty to the most common surgical techniques are required to obtain a validation of our procedure. Indeed, a much longer follow-up could highlight the actual recurrence rate of the new procedure.
