Open repair (Lichtenstein, Shouldice, Bassini)
The most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect.
It is a "tension-free" repair that does not put tension on muscles, contrary to Bassini and Shouldice suture repairs (but there are also tension-free suture repairs, like Desarda). It involves the placement of a mesh to strengthen the inguinal region. Patients typically go home within a few hours of surgery, often requiring no medication beyond paracetamol (Tylenol/acetaminophen). Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation. Complications include chronic pain (varying from 10-50% depending on source), foreign-body sensation, stiffness, ischemic orchitis, testicular atrophy, dysejaculation, anejaculation or painful ejaculation in around 12%. They are often under-reported. Recurrence rate is low, <2%.
Intraoperative view by TEP Operation. 1. Genital ramus of genitofemoral nerve. 2. Preperitoneal lipom and spermatic cord.
There are mainly two methods of laparoscopic repair: transabdominal preperitoneal (TAPP) and totally extra-peritoneal (TEP) repair. When performed by a surgeon experienced in hernia repair, laparoscopic repair causes fewer complications than Lichtenstein, particularly less chronic pain. However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. Indeed, the TAPP approach needs to go through the abdomen. All that said, many surgeons are moving to laproscopic methodologies as they are more lucrative and cause smaller incisions, resulting in less bleeding, less infection, faster recovery, reduced hospitalization, and reduced chronic pain.
Laparoscopic mesh surgery, as compared to open mesh surgery
There is no difference in cost between laparoscopic and open repair as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical when laparoscopy is performed by an experienced surgeon. When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein.
Polypropylene mesh used for inguinal hernia surgery
Commercial meshes are typically made of prolene (polypropylene) or polyester. Marlex, Gore-Tex or Teflon meshes are sold by some companies. Lightweight meshes seem to cause less discomfort than heavyweight meshes. Some repair kits combine a plug and a patch. Some plug-and-patch kits combine an absorbable plug with a nonabsorbable patch, like Bio-A, manufactured by W. L. Gore.
Cases of obstructive azoospermia have been related with the use of polypropylene mesh, due to the obstruction of the vas deferens as a result of the fibroblastic reaction to the mesh. However, a recent study finds that this risk seems to be less than 1%  and therefore, it does not need to be notified in an informed consent.
The first efficient inguinal hernia repair was described by Edoardo Bassini in the 1880s. The Bassini technique is a "tension" repair, in which the edges of the defect are sewn back together, without any mesh. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis and internal oblique muscles) is approximated to the inguinal ligament and closed. Today, Bassini's main interest is historical. It remains performed in some developing countries, if surgeons do not have knowledge of the mosquito-net alternative to commercial meshes in Lichtenstein repair, or if they ignore more efficient suture-based repairs.
The floor of the canal is reinforced by approximating the transversus abdominal aponeurosis and transverse fascia to pectineal (Cooper's) ligament medially from the pubic tubercle to the femoral vein. Lateral to this the floor is restored by approximating the femoral sheath to the inguinal ligament. It is also used in femoral hernia repairs.
The Shouldice technique is the mainstream suture-based repair. It is a relatively difficult four layer reconstruction of fascia transversalis; however, it has relatively low reported recurrence rates in the hand of a surgeon experienced with this method.
Shouldice repairs are less commonly used today than in previous years, especially in developed countries. This is mostly due to the fact that mesh-based Lichtenstein method is easier to perform. The Shouldice repair has a higher rate of hernia recurrence in the hands of surgeons inexperienced with them (<200 operations/year). Another drawback is the post-operative pain due to the tension on muscles, which generally lasts some weeks. However, this pain is well-managed with analgesics, and this short-term pain must be balanced with the much lower risk of long-term pain of the Shouldice technique, which is half Lichtenstein (but similar to laparoscopic). This is why few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVay repair.
The main advantage of the Shouldice technique remains the relatively low report of chronic pain (10% incidence), as compared with mesh-based open repair (Lichtenstein) (20% incidence). However, the risk of chronic pain with this method is comparable to a laparoscopic repair performed by a surgeon experienced with inguinal hernia repair (i.e. >200 hernias/year) (8% incidence) (and not simply a surgeon experienced with laparoscopy. This difference is important).
Moreover, if the surgeon is not experienced enough with the Shouldice technique, as is the case for most surgeons nowadays, mesh-based repair can be advised. For example, in developing countries, where commercial meshes are expensive, but where surgeons might also be less qualified, a mosquito-net mesh open repair can be better than Shouldice. Indeed, both have a similar cost (a mosquito-net mesh costs less than $0.01. Its sterilization costs less than $1), and mesh repair is easier to perform than Shouldice. Desarda repair is also another option, but it is less widely known.
Another advantage of suture-based repairs over permanent mesh repairs is that they do not introduce significant permanent foreign-body material, at worst, only polypropylene non-absorbable sutures. Permanent meshes can cause additional long-term complications due to this fact.
The Desarda technique is an emerging suture-based technique. It can be performed with absorbable sutures. It is simpler and faster to perform than Shouldice and Lichtenstein. It also gives similar results to Lichtenstein in terms of recurrence, with the significant benefit of not introducing permanent foreign-body material. Moreover, this technique is tension-free, mesh-free, and it pays attention to the physiology. Other techniques using a flap from the external oblique aponeurosis were proposed independently by other surgeons.
Guarnieri technique appeared in 1988. It can be used with or without mesh. Like Desarda technique, the Guarnieri method pays attention to the physiology, and it is also tension-free.
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