Introductory Chapter: State of the Art in Hernia Surgery

*Angelo Guttadauro*

#### **1. Introduction**

After the introduction of prostheses, wall surgery has undergone a progressive evolution aiming both at the development of new techniques and at the study of new and more comfortable prosthetic materials. Until recently the repair of a wall defect was carried out by direct suture of the muscle-aponeurotic structures and related to a high incidence of recurrence and postoperative pain. With the use of prostheses, surgeons are now able to adopt techniques and technologies more respectful of the original anatomy and physiology, avoiding tension between the muscle and tendon structures. This allows to reduce drastically the incidence of recurrence. Laparoscopy and robotic surgery, when used with the correct indications, are less traumatic and invasive and reduce postoperative pain. The higher costs allegated to these procedures are, in some cases, at least partially mitigated by the patient's better postoperative course and to a more rapid resumption of his work.

#### **2. Tailored surgery**

Today there are numerous open and laparoscopic surgical techniques available for the treatment of the various types of wall defects. The choice of the most appropriate technique for a specific patient remains fundamental. The concept of "tailored surgery" is new in this field and is based on the fact that each type of hernia and each patient are different from the other. Therefore surgical procedures should not be chosen according to the normal protocols but based on the needs and characteristics of that specific patient such as age, physical constitution, life habits, and work activity, but above all the size and type of the hernia should be considered. This would allow an effective treatment with the best comfort for the patient, minimal hospitalization, and most rapid resumption of normal activities.

#### **3. Problems**

Among abdominal wall hernias, inguinal hernia repair is the most frequently performed surgical operation in all operating rooms around the world. Since the 1970s, one of the priorities in inguinal hernia surgery was that of minimizing postoperative chronic pain [1, 2]. All surgical techniques proposed during the few past years to improve patient's comfort reported a variable incidence of neuralgia [1–4] that, when persistent after 3–6 months from surgery, may compromise significantly the patient's quality of life. Pain may be related to the presence of the mesh that, depending on its size and location, may take contact with muscular structures or cause fibrotic entrapment of nerves when in subfascial position [5–7]. Studies

conducted on animals also showed perineural alterations with myelinic degeneration due to contact between nervous structures and the mesh [8], hence the necessity of identifying and dissecting subfascial nerves [9] and even of dividing them to avoid chronic pain [9, 10]. This led to the setting of guidelines for the prevention and treatment of chronic neurotic pain following inguinal hernioplasty [11, 12].

The all-in-one mesh hernioplasty technique [13], proposed by myself a few years ago, is a procedure that employs a smaller precut single mesh that covers all weak areas of the inguinal canal and is enveloped in the fibro-cremasteric sheath, avoiding the contact of the prosthesis with neural structures. Because of its shape, the mesh is placed in a deeper site directly over the weak areas of the floor of the inguinal channel, and, although smaller, it doesn't seem to increase the rate of recurrence. The more common Lichtenstein technique provides that the prosthesis is laid on the transversalis fascia and fixed to the sides becoming necessarily underaponeurotic in the upper third. In our technique, the prosthesis is positioned and remains on the transversalis fascia being covered with the fibro-cremasteric sheath. The mesh is anchored to the inguinal floor by a single point at the pubic tubercle and comprises a section that is introduced inside the deep inguinal ring. Therefore the mesh is not directly underaponeurotic at any level, stays in place, and therefore does not require lateral fixation. In addition, the prosthesis is not in contact with the ilioinguinal and iliohypogastric nerves. This new procedure may have technical advantages and help 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.

#### **4. Conclusion**

The task of a good surgeon today is to know how to choose, based on your experience and taking into account innovation. The best technique correctly tailored on the patient guarantees the best results.

#### **Author details**

Angelo Guttadauro1,2

1 Department of Medicine and Surgery, University of Milan-Bicocca, Italy

2 Hernia Center Monza-Brianza, Clinical Unit of General Surgery, Zucchi Clinical Institutes of Monza, Italy

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

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**5**

*Introductory Chapter: State of the Art in Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.91766*

> repair of groin hernia. Journal of Surgical Research. 2006;**131**:175-181

[9] Alfieri S, Rotondi F, Di Miceli D, et al. Chronic pain after inguinal hernia mesh repair: Possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases. Chirurgia Italiana. 2006;**58**:23-31

[10] Mui WL, Ng CS, Fung TM, et al. Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: A doubleblind randomized controlled trial. Annals of Surgery. 2006;**244**:27-33

[11] Alfieri S, Amid PK, Campanelli G, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;**15**:

[12] Graham DS, MacQueen IT, Chen DC. Inguinal neuroanatomy: Implications for prevention of chronic postinguinal hernia pain. International Journal of Abdominal Wall and Hernia

[13] Guttadauro A, Maternini M, Frassani S, De Simone M, Chiarelli M, Macchini D, et al. "All-in-one mesh" hernioplasty: A new procedure for primary inguinal hernia open repair. Asian Journal of Surgery. 2018;**41**(5):473-479. DOI: 10.1016/j.

Surgery. 2018;**1**(1):1-8

asjsur.2017.07.003

239-249

**References**

2016;**29**:165-170

2012;**22**:134-139

210-214

[1] Pierides GA, Paajanen HE,

et al. Reducing postoperative pain: The use of Tisseel for mesh fixation in inguinal hernia repair. Surgical Technology International.

Vironen JA. Factors predicting chronic pain after open mesh based inguinal hernia repair: A prospective cohort study. International Journal of Surgery.

[2] Campanelli G, Sfeclan C, Cavalli M,

[3] Kehlet H, Roumen RM, Reinpold W, et al. Invited commentary: Persistent pain after inguinal hernia repair: What do we know and what do we need to know? Hernia. 2013;**17**:293-297

[4] Bueno J, Serralta A, Planells M, et al. Inguinodynia after two inguinal herniorrhaphy methods. Surgical Laparoscopy Endoscopy &

Percutaneous Techniques. 2004;**14**:

Oct 2013;**206**(4):619-623

Surgery. 2007;**92**:344-350

1998;**187**:514-518

[7] Heise CP, Starling JR. Mesh

[5] Fischer JE. Hernia repair: Why do we continue to perform mesh repair in the face of the human toll of inguinodynia? The American Journal of Surgery.

[6] Karakayali F, Karatas M, Ozcelik U, et al. Influence of synthetic mesh on ilioinguinal nerve motor conduction and chronic groin pain after inguinal herniorrhaphy: A prospective

randomized clinical study. International

inguinodynia: A new clinical syndrome after inguinal herniorrhaphy? Journal of the American College of Surgeons.

[8] Demirer S, Kepenekci I, Evirgen O, et al. The effect of polypropylene mesh on ilioinguinal nerve in open mesh

*Introductory Chapter: State of the Art in Hernia Surgery DOI: http://dx.doi.org/10.5772/intechopen.91766*

#### **References**

*Techniques and Innovation in Hernia Surgery*

conducted on animals also showed perineural alterations with myelinic degeneration due to contact between nervous structures and the mesh [8], hence the necessity of identifying and dissecting subfascial nerves [9] and even of dividing them to avoid chronic pain [9, 10]. This led to the setting of guidelines for the prevention and treatment of chronic neurotic pain following inguinal hernioplasty [11, 12]. The all-in-one mesh hernioplasty technique [13], proposed by myself a few years ago, is a procedure that employs a smaller precut single mesh that covers all weak areas of the inguinal canal and is enveloped in the fibro-cremasteric sheath, avoiding the contact of the prosthesis with neural structures. Because of its shape, the mesh is placed in a deeper site directly over the weak areas of the floor of the inguinal channel, and, although smaller, it doesn't seem to increase the rate of recurrence. The more common Lichtenstein technique provides that the prosthesis is laid on the transversalis fascia and fixed to the sides becoming necessarily underaponeurotic in the upper third. In our technique, the prosthesis is positioned and remains on the transversalis fascia being covered with the fibro-cremasteric sheath. The mesh is anchored to the inguinal floor by a single point at the pubic tubercle and comprises a section that is introduced inside the deep inguinal ring. Therefore the mesh is not directly underaponeurotic at any level, stays in place, and therefore does not require lateral fixation. In addition, the prosthesis is not in contact with the ilioinguinal and iliohypogastric nerves. This new procedure may have technical advantages and help 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

**4**

**Author details**

foreign body.

**4. Conclusion**

Angelo Guttadauro1,2

the patient guarantees the best results.

Institutes of Monza, Italy

provided the original work is properly cited.

1 Department of Medicine and Surgery, University of Milan-Bicocca, Italy

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

2 Hernia Center Monza-Brianza, Clinical Unit of General Surgery, Zucchi Clinical

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

The task of a good surgeon today is to know how to choose, based on your experience and taking into account innovation. The best technique correctly tailored on [1] Pierides GA, Paajanen HE, Vironen JA. Factors predicting chronic pain after open mesh based inguinal hernia repair: A prospective cohort study. International Journal of Surgery. 2016;**29**:165-170

[2] Campanelli G, Sfeclan C, Cavalli M, et al. Reducing postoperative pain: The use of Tisseel for mesh fixation in inguinal hernia repair. Surgical Technology International. 2012;**22**:134-139

[3] Kehlet H, Roumen RM, Reinpold W, et al. Invited commentary: Persistent pain after inguinal hernia repair: What do we know and what do we need to know? Hernia. 2013;**17**:293-297

[4] Bueno J, Serralta A, Planells M, et al. Inguinodynia after two inguinal herniorrhaphy methods. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2004;**14**: 210-214

[5] Fischer JE. Hernia repair: Why do we continue to perform mesh repair in the face of the human toll of inguinodynia? The American Journal of Surgery. Oct 2013;**206**(4):619-623

[6] Karakayali F, Karatas M, Ozcelik U, et al. Influence of synthetic mesh on ilioinguinal nerve motor conduction and chronic groin pain after inguinal herniorrhaphy: A prospective randomized clinical study. International Surgery. 2007;**92**:344-350

[7] Heise CP, Starling JR. Mesh inguinodynia: A new clinical syndrome after inguinal herniorrhaphy? Journal of the American College of Surgeons. 1998;**187**:514-518

[8] Demirer S, Kepenekci I, Evirgen O, et al. The effect of polypropylene mesh on ilioinguinal nerve in open mesh

repair of groin hernia. Journal of Surgical Research. 2006;**131**:175-181

[9] Alfieri S, Rotondi F, Di Miceli D, et al. Chronic pain after inguinal hernia mesh repair: Possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases. Chirurgia Italiana. 2006;**58**:23-31

[10] Mui WL, Ng CS, Fung TM, et al. Prophylactic ilioinguinal neurectomy in open inguinal hernia repair: A doubleblind randomized controlled trial. Annals of Surgery. 2006;**244**:27-33

[11] Alfieri S, Amid PK, Campanelli G, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011;**15**: 239-249

[12] Graham DS, MacQueen IT, Chen DC. Inguinal neuroanatomy: Implications for prevention of chronic postinguinal hernia pain. International Journal of Abdominal Wall and Hernia Surgery. 2018;**1**(1):1-8

[13] Guttadauro A, Maternini M, Frassani S, De Simone M, Chiarelli M, Macchini D, et al. "All-in-one mesh" hernioplasty: A new procedure for primary inguinal hernia open repair. Asian Journal of Surgery. 2018;**41**(5):473-479. DOI: 10.1016/j. asjsur.2017.07.003

**7**

Section 2

Ventral Hernia
