Tension-free procedures in the surgical treatment of groin hernias

Abstract

Hernia repair is one of the most common surgical procedures performed in the United States, with 700,000 operations performed each year. Improvements in surgical technique, together with the development of new prosthetic materials and a better understanding of how to use them, have significantly improved outcomes for many patients. These improvements have occurred most notably in centers specializing in hernia surgery, with some institutions reporting failure rates of less than 1%. In contrast, failure rates for general surgeons, who perform most hernia repairs, remain significantly higher. This has important socioeconomic implications, adding an estimated $28 billion or more to the cost of treating the condition, based on calculations utilizing conservative estimates of failure rates and the average cost of a hernia repair. Success of groin hernia repair is measured primarily by the permanence of the operation, fewest complications, minimal costs, and earliest return to normal activities. This success depends largely on the surgeon's understanding of the anatomy and physiology of the surgical area as well as a knowledge of how to use most effectively the currently available techniques and materials. The most important advance in hernia surgery has been the development of tension-free repairs. In 1958, Usher described a hernia repair using Marlex mesh. The benefit of that repair he described as being "tension-eliminating" or what we now call "tension-free". Usher opened the posterior wall and sutured a swatch of Marlex mesh to the undersurface of the medial margin of the defect and to the shelving edge of the inguinal ligament. He created tails from the mesh that encircled the spermatic cord and secured them to the inguinal ligament. Every type of tension-free repair requires a mesh, whether it is done through an open anterior, open posterior, or laparoscopic route. The most common prosthetic open repairs done today are the Lichtenstein onlay patch repair, the PerFix plug and patch repair, the Prolene Hernia System bilayer patch repair and Trabucco's sutureless preshaped herniography. General surgeons today have access to a wider and more sophisticated range of synthetic biomaterials for use in hernia repair than ever before. The advantages and disadvantages of each of these devices must be understood, however, before surgeons select any of these implants. Meanwhile, a 1997 study of various biomaterials used in abdominal wall hernia repair further reported that the risk of infection, seroma formation, biomaterial-related intestinal obstructions, and other complications can be minimized or eliminated by understanding the process underlying these problems and taking proper precautions. The surgeon's choice of the prosthesis used in hernia repair is based on a combination of factors, including patient characteristics; clinical experience, training, interest, and skill; understanding of the range of products available and the clinical studies that may have been performed on each; and the surgeon's familiarity with a particular product and/or surgical approach. Innovations in technique and product design will no doubt continue to spur advances in hernia repair, and it is hoped that they will continue to improve outcomes. The availability of these outcomes data, along with the ongoing accumulation of clinical experience with a broad range of materials and techniques, will help surgeons to better identify the most appropriate prosthesis for the clinician and the patient. It appears that herniology will remain in the realm of the surgeon, since it is doubtful that any medical measures will replace the operative treatment for abdominal wall hernias. Although operative procedures are not yet ideal, important advances have been made in herniorrhaphy resulting in improved outcomes: The use of local techniques has maximized the safety of anesthesia; time needed for care has been minimized, with most procedures now being done on an outpatient basis; and better instruments and prosthetic devices have dramatically improved patient outcomes. However, a greater appreciation for the vulnerability of the entire myopectineal orifice--and the secondary effects of localized mesh grafts--is necessary to avoid iatrogenically created recurrences. An increased awareness of these factors by both general surgeons and hernia specialists alike will improve results for all patients undergoing hernia surgery.