The development of abdominal wall hernia surgery has benefited as much from the development of modern surgery as from the advancement of modern anesthesiology, asepsis, materials and other disciplines. Since 1887, when Bassini proposed the first modern, anatomically based treatment of hernia, hernia surgery has undergone a long process of development, and the Bassini repair remains one of the most basic hernia repair procedures performed by surgeons today. Over the next 100 years, there have been more than 200 surgical approaches to hernia repair, including some of the classic approaches that have contributed to hernia surgery, such as the Halsted, Furguson, and McVay approaches. Despite the growing understanding of hernia and the positive effects of various surgical approaches in some aspects, the recurrence rate of inguinal hernia patients after surgery is still 5-10%, and the various complications associated with surgery are still high. This situation until the mid-1980s and early 1990s, with the mature application of synthetic hernia repair materials, Los Angeles Hernia Center hernia surgery experts Lichtenstein equal to the 1989 proposed tension-free hernia repair surgery (Tension-free hernioplasty) concept, followed by a variety of tension-free hernia repair technology and repair material devices continue to develop. Since then, various tension-free hernia repair techniques and devices have been developed. In the mid-1990s, laparoscopic techniques began to be used in hernia repair surgery, allowing surgeons to see the anatomy of the inguinal region more clearly from inside the abdominal cavity, making the posterior approach preperitoneal repair technique gradually recognized by everyone. As a result of the above progress, the treatment effect of hernia has been fundamentally changed, but the surgical treatment of hernia in China still has many deficiencies in general, and compared with the developed countries there is still a large gap between the training of hernia specialists and the concept of hernia has not yet been promoted. This paper discusses some problems in the surgical treatment of abdominal wall hernia. 1, the concept of tension-free hernia repair should be fully understood The concept of tension-free hernia repair should be said to come from two aspects, one is to recognize that tension is an important factor leading to the high recurrence rate of traditional surgery, because these repair methods will be the patient’s existing defects of the adjacent tissues of the forceful suture repair is not easy to produce the true meaning of healing. Another aspect is the emergence of various hernia repair materials since World War II and the continuous reform and innovation, the development of modern material science so that the polypropylene material as a representative of a variety of hernia repair materials in the clinic is widely used, and has achieved great success. Tension-free hernia repair techniques have been accepted by an increasing number of surgeons due to less surgical trauma, less postoperative pain, faster recovery, shorter learning curve for surgical maneuvers, and lower recurrence rates. In 2007, about 2 million cases of tension-free repair were performed in the United States, about 1 million cases in Europe, and according to incomplete statistics in China, it may be around 15-20 million cases. Tension-free hernia repair technology in China continues to promote and popularize, the application of this new technology surgeons gradually increased. However, the popularization and therapeutic effect of tension-free hernia repair in China has not reached an ideal state. Many doctors have not undergone study and training, and do the surgery as a matter of course, with irregular surgery, improper mastery of the indications and choice of materials, which ultimately leads to high complications, high recurrence rate, and unsatisfactory therapeutic effect. To fully understand the concept of tension-free repair one must pay attention to the anatomical structure of the inguinal region, and it is only on the basis of a full understanding of the anatomical structure that the correct repair and the choice of repair material can be performed. Myopectineal orifice (MPO) is a weak area of the human abdominal wall that naturally lacks muscle protection. Previously, the familiar inguinal hernia, rectus hernia, and femoral hernia all occurred within the upper range of the MPO, and therefore can be collectively referred to as the MPO hernia. Recognition of the concept of the pubic foramen is important for proper hernia repair, especially preperitoneal hernia repair, including laparoscopic hernia repair. Strictly speaking, successful hernia repair should be the strengthening of the pubic foramen, which is the anatomical basis for the recognition of preperitoneal and laparoscopic hernia repair. Recognition of the preperitoneal space is a key technical aspect of carrying out preperitoneal repair, and how to establish the preperitoneal space is not something that every surgeon is skilled in. Therefore, it is very important to strengthen the training of surgeons. Our experience is that to correctly understand the basic concepts of modern hernia surgery such as the pubic symphysis foramen, it is necessary to carry out training in about 40 cases of standardized tension-free hernia repair surgery, and at the same time, to have a relatively clear understanding of the basics of laparoscopic hernia repair surgery and the related material science, in order to fully understand the key to modern tension-free repair of hernia repair. 2, individualized treatment of inguinal hernia At present, there are more than 20 methods of tension-free hernia repair that have been clinically applied, and a variety of new repair devices continue to appear, but it can be said that no one method is perfect. Since each repair method has its own characteristics but is not suitable for all types of inguinal hernia, and not every surgeon is skilled in all repair methods, we emphasize that tension-free inguinal hernia repair must follow the principle of individualization, combining the patient’s specific situation and the surgeon’s level of proficiency and training to choose the best surgical method for the patient. The first hernia ring-filling tension-free repair in China has been clinically proven to be an effective method for all types of hiatal hernias and partially rectal hernias, but it must be performed in accordance with the principles of tension-free repair, with adequate freeing of the hernia sac, appropriate placement of mesh plugs, and flat patches to strengthen the posterior inguinal wall must be flatly placed and appropriately secured. The 3DP patch has a small piece that can be spread and fixed in front of the peritoneum and a flat piece that strengthens the posterior wall of the inguinal canal, which alleviates the discomfort caused by the large mesh plug, and makes the surgical operation relatively simple, and is suitable for Gilbert type I and II inguinal hernias with a small hernia ring. Most of the common hernia repair devices are improved on this basis, but fundamentally they are aimed at repairing the hernia ring and the posterior wall of the inguinal canal. The preperitoneal repair represented by Kugul and PHS is theoretically more reasonable, targeting the pubococcygeal foramen in the preperitoneal space to strengthen the repair, which is equivalent to the preperitoneal repair of the anterior approach. It is suitable for all types of inguinal hernia if properly operated, but the difficulty in dissecting the preperitoneal space and placing the patch smoothly during the operation has hindered the popularization of this technique. Our experience is that preperitoneal repair is not mandatory in every case, and it is ideal for inguinal hernias and large hiatal hernias in which it is easy to open the transversal abdominal fascia to create the preperitoneal space, but it is not necessary to perform preperitoneal repair in all cases of smaller hiatal hernias. The key is that the patch used, regardless of size, must unfold flatly over the surgical area, and because the repair material has a certain crumpling ratio, the size of the patch used must exceed the area to be reinforced by more than 1-2 cm. Necessary fixation is needed, the purpose of fixation is not to bear the tension, but to help the patch unfold flatly in the surgical reinforcement area, but at the same time, note that too much fixation is not reasonable, and sometimes it is even the main cause of chronic postoperative pain. 3, the clinical application of local anesthesia in inguinal hernia tension-free hernia repair In China, inguinal hernia repair is routinely performed with epidural anesthesia or general anesthesia, and in recent years, more and more physicians have begun to use local anesthesia to perform tension-free inguinal hernia repair, which has been the mainstream in developed countries such as Europe and the United States. With the gradual aging of China’s population, the incidence of inguinal hernia is also increasing. China’s inguinal hernia patients generally have the characteristics of old age, combined with more basic diseases and heavy, in the past, there are many combined cardiopulmonary diseases and other diseases that can not tolerate epidural anesthesia or general anesthesia patients can not get good treatment. Nowadays, a large amount of clinical data confirms that local block anesthesia in the inguinal region can provide sufficient anesthesia area for tension-free hernia repair. The local infiltration anesthesia used in the past is generally not effective enough because it only targets the cutaneous nerves. Nowadays, most of the local nerve block anesthesia targeting the innervation of the inguinal region, i.e., infiltration anesthesia targeting the cutaneous nerves, ilioinguinal nerve, ilioinflammatory nerve and genitofemoral nerve layer by layer can fully meet the needs of the surgery. Because local anesthesia has little effect on the patient’s body, no special preparation is needed before the operation, generally no preoperative fasting, no need to leave a urinary catheter, and after the operation, the patient can resume eating and getting out of bed, and some patients don’t need to stay in the hospital room, and the operation can be carried out on an outpatient basis. Local nerve block anesthesia has broadened the indications for surgery to a certain extent. Previously, some factors that increase intra-abdominal pressure, such as prostate hyperplasia, chronic constipation, small amount of ascites, etc., are not absolute contraindications, and due to the application of atonic repair, even though these factors can not be completely cured, as long as a little bit of attention is paid to control the improvement of the local anesthesia can be carried out without tension under the patch surgery. At present, local nerve block anesthesia is the main anesthesia method for tension-free inguinal hernia repair, and more than 1,000 surgeries were carried out during the two years of 2006-2007, and there was not a single case of needing to switch to other anesthesia methods in the middle of the operation, so we believe that local anesthesia is the first choice of anesthesia method for tension-free inguinal hernia repair. 4, Laparoscopic technology in the surgical treatment of abdominal wall hernia Laparoscopic technology used in the repair of extra-abdominal hernia is a new technology developed in the early 1990s, belonging to the “posterior approach”, “preperitoneal or intra-abdominal” tension-free repair method. The concept of Myopectineal orifice (MPO) and the preperitoneal space are the anatomical basis for this procedure, and the advancement of modern repair materials and laparoscopic equipment are the prerequisites for the application of this technique. After nearly 20 years of development, the main representative ones are intraperitoneal patch implantation (IPOM), transperitoneal anterior peritoneal patch implantation (TAPP), and total extraperitoneal patch implantation (TEP). Among them, IPOM is mainly used in the laparoscopic treatment of incisional and parastomal hernias as well as intra-abdominal hernias such as esophageal hiatal hernia and diaphragmatic hernia, and TAPP and TEP are optional surgical procedures for the laparoscopic treatment of inguinal hernia. IPOM application in the treatment of incisional hernia has obvious advantages: the application of laparoscopy makes the wound greatly reduced, the separated hernia sac and the placed patch are not directly connected with the outside world, which reduces the infection rate of the wound and the patch; the abdominal wall tissue does not need to be widely free to help maintain the strength of the abdominal wall; the use of the patch has the effect of preventing the intestines and the abdomen from adhering to each other, which reduces the incidence of surgical complications and so on. At present, more and more physicians have begun to use laparoscopic techniques for incisional hernia repair, and this condition is also applicable to the treatment of parastomal hernia, as well as intra-abdominal hernia such as esophageal hiatal hernia and diaphragmatic hernia. However, it is important to note that complications associated within the learning curve are prone to occur in the beginning stages, a situation that has occurred quite a bit, and a similar lesson has been learned in the author’s unit, which must be highly emphasized. The application of TAPP and TEP for inguinal hernia repair is still somewhat controversial, mainly because open tension-free repair itself is already very minimally invasive, has a low recurrence rate, and can be performed under local anesthesia, and the use of laparoscopy is somewhat doubtful. Meanwhile, the relatively high cost is also one of the factors affecting the widespread development of laparoscopic hernia repair. Although some scholars have made some attempts to reduce the cost, it is still higher than open surgery in general. Most scholars believe that laparoscopic techniques have certain advantages in the treatment of bilateral hernia and recurrent hernia: both sides can be performed at the same time to avoid larger incisions, larger patches can be implanted to minimize recurrence, and the effect of recurrent hernia can be better repaired from the abdominal cavity, and so on. In our clinical practice, bilateral hernias and recurrent hernias are prioritized for laparoscopic repair, while unilateral hernias can be selected according to the patient’s condition, willingness, and the experience of the surgeon. How to choose the surgical method is affected by many factors, doctors and patients should fully discuss the various issues related to the selection of appropriate treatment under the guidance of the doctor. Absolutely avoid blindly adopting a specific surgical method without regard to the interests of the patient, which is also one of the basic conditions required by the principle of individualization of tension-free hernia repair surgery. 5, on the development of new hernia repair materials There are three main types of hernia repair materials currently used: polyester patch (also known as polyester patch, polyester mesh, Dacron, mersilene), polypropylene patch (polypropylene mesh, marles, pp) and expanded polytetrafluoroethylene patch (expanded). polypropylene mesh (polypropylene mesh, marles, pp) and expanded polytetrafluoroethylene mesh (e-PTFE), the latter two materials are widely used in clinical practice. Expanded polytetrafluoroethylene mesh (e-PTFE) is widely used in the clinic. Expanded polytetrafluoroethylene mesh has the effect of preventing abdominal adhesion, so it is used as a material for intra-abdominal repair, and it is also a material for some artificial blood vessels, which is mainly used for incisional hernia. Polypropylene material is currently the most widely used patch, in tissue reactivity, compatibility, stability and clinical results have withstood the test. However, with the advancement of tension-free hernia repair technology and the improvement of patient requirements, hernia repair materials need to be continuously improved. The main direction of development is: 1, the material of the patch is required to be more lightweight, under the premise of maintaining sufficient tensile strength, the lighter the patch has a more comfortable patient feeling and better compliance; polypropylene patch mesh required to be large enough to reduce the chances of infection and to provide better compliance, both of which are mainly to make the sense of a smaller foreign body, the subjective feeling of more comfortable. 2, the study of absorbable materials is an important direction of development, the author personally believes that all materials placed in the body, as long as it is not required for permanent support, it should be best to be made of absorbable materials. In hernia repair materials have been related to absorbable materials in the beginning of the use, including partially absorbable composite patches to fully absorbable biological patches have accumulated some experience. The future direction of development should be toward the same or better clinical effect of fully absorbable materials. 3, the anti-infection performance of the patch is also one of the important content, the current research is mainly focused on the material to add a certain amount of antimicrobial material to increase the anti-infection ability of the patch. The application of nanotechnology may be able to improve the anti-infection characteristics from a deeper level, and the further improvement of the patch material will be gradually developed with the progress of modern technology. In the past, abdominal wall hernia surgery was generally regarded as a kind of minor surgery and was performed by low-ranking general surgeons or urologists. In recent years, there have been great changes in both theory and clinical treatment, and although hernia surgery has been gradually standardized in a few large medical centers in China, the overall level of this kind of surgery is still quite backward in China, and there is a big difference between hospitals of different levels. It is necessary to carry out large-scale randomized controlled evidence-based medical research and systematic training of physicians at all levels of medical units to promote the progress of the overall medical level.