Hernia and abdominal wall surgery has become a veritable subspecialty of general surgery, and the Chinese Medical Association Surgery Branch has established a special group on hernia and abdominal wall surgery, which shows the importance of its academic status. With the deepening understanding of the anatomy and etiology of this disease, the concept of repair has changed dramatically, and the surgical approach to repair is also undergoing rapid changes, which is vividly reflected in the transformation of the operator’s perspective during surgery: overhead view – flat view – elevated view ( open repair – complete extraperitoneal patch implantation – transabdominal repair). It is this change in perspective that has witnessed the revolutionary development and enhancement of abdominal wall hernia repair techniques, and it is not an exaggeration to say that it is one of the most rapidly developing and changing surgical procedures among the various general surgery modalities.
I. Overhead view (open repair)
1. Tension repair
Since the first hernia repair by Bassini in 1887, with the increasing understanding of the mechanism of inguinal hernia occurrence and the accumulation of experience in treatment, various different procedures have been created. These include Furgwson’s hair, which strengthens the anterior wall, and Bassini, Halstecl, and Mcvay, which strengthen the posterior wall. However, because the anatomy of the groin is both delicate and complex, which was not yet well understood, these classical procedures have significant shortcomings. These surgical approaches use the patient’s adjacent tissue for repair, forcing together tissue that is not in the normal anatomic area or suturing the tendon and inguinal ligament, resulting in high tension during repair, significant postoperative pain, and a recurrence rate of 10%-20%.
2.Low tension repair
Since the classical inguinal hernia repair had the problem of high tension leading to high recurrence rate, in 1953, doctors at the Shoudice Hospital in Canada innovated and improved the method by using overlapping sutures of the transverse abdominal fascia to achieve a low-tension repair, which had a recurrence rate of 0.8%-3% after surgery and was called the second milestone of inguinal hernia repair. However, because the procedure focuses on repairing the transverse abdominal fascia, it is not suitable for those with severe transverse abdominal fascia defects and requires high surgical skills, so we expect a more advanced and practical repair method.
3.Tension-free repair
The concept of “tension-free repair” was first introduced by Lichtenstein in 1989 [5]. Tension-free repair is a patch using artificial or biological materials to repair and strengthen the posterior wall of the inguinal canal to achieve the purpose of hernia repair, which has the advantages of mild postoperative pain, rapid recovery, wide surgical indications, and low recurrence rate. After years of clinical research and discussion, a variety of different procedures have been developed for tension-free repair, and a series of lumpectoscopic tension-free inguinal hernia repair procedures have been derived with the wide application of modern lumpectoscopic techniques.
3.1 Open surgery
The main open surgical procedures are the flat patch repair, the hernia ring filling procedure, the giant patch reinforced visceral capsule procedure, and the Prilling system method. Among them, flat patch repair and hernia ring filling surgery are the most popular.
(1) Flat patch repair surgery.
This is the tension-free repair procedure proposed by Lichtenstein, in which a Marlex patch is sutured to the posterior wall of the inguinal canal, and fibrous tissue proliferates within the mesh after the patch is implanted to repair and strengthen the posterior wall. 1993 Lichtenstein summarized 3125 columns of adult primary inguinal hernia patients using this procedure, and four columns later recurred, and this procedure was This procedure has been further improved. The flat-piece repair procedure does not disrupt the normal anatomy, and the sutures are low tension and technically simple to perform.
(2) Tension-free hernia ring filling repair (Rutkolo procedure).
It is a conical hernia ring filling stuffed into the inner ring or defect and then repaired with patch sutures to the posterior wall of the inguinal canal, which reduces the local pressure of abdominal pressure at the mouth of the inner ring and has a better effect on preventing hernia recurrence. This method has a lower recurrence rate than flat patch repair, but there are reports in China that postoperative pain and foreign body sensation in patients are more obvious than flat patch repair, and the second may be related to more filled patches and a large number of fibroblasts proliferating to form tissue masses. Later, someone modified the Millikan procedure on this basis. Millikan improved the placement depth (position) of the mesh plug and the suture site by suturing the inner flap of the mesh plug at the edge of the defect, so that the outer flap of the mesh plug spreads in the anterior abdominal space and completely covers the defect. Since abdominal pressure causes the bardic mesh plug made of round mesh set to open like an umbrella, the umbrella-shaped outer flap has a tendency to restore the round mesh and protect the defect better, so it is more reasonable than the filling type, and the postoperative pain and foreign body sensation are significantly improved.
(3) Giant patch reinforced visceral capsule surgery.
This involves replacing the transversus abdominis fascia with a large patch in the groin that should exceed the musculo-pubic foramen (MPO) in area. The large patch covers the visceral sac and is kept in place by abdominal pressure. Later, as the connective tissue grows into the patch and adheres to the abdominal cavity, a dense tissue is formed so that the viscera cannot protrude from the abdominal wall defect for the purpose of hernia repair. However, this method involves a large anatomical area, extensive separation, great damage and huge patch used, so postoperative complications such as infection and pain are obvious, and therefore it is only suitable for repair of some huge and complicated hernias.
(4) Priligy system method.
During surgery, the “bottom piece” of the repair device is placed flatly in the gap between the peritoneum and the transverse abdominal fascia, the middle layer of the connecting plug is automatically located at the hernia ring to fill the hernia ring, and the upper layer is fully flattened under the spermatic cord to repair the defect between the joint tendon and the inguinal ligament. The upper lamina is sufficiently flattened below the spermatic cord to repair the defect between the joint tendon and the inguinal ligament. This procedure is simple, with quick recovery and low recurrence rate, and is a widely used method for hernia repair.
II. Plain view (complete extraperitoneal patch implantation)
Totally extraperitoneal patch implantation (TEP): the technical point of this procedure is to enter the anterior peritoneal space, parallel expansion, freeing the hernia sac, vas deferens and genital vessels ventralization, and covering the area of the musculo-pubic foramen with a large enough patch centered on the inner opening of the hernia ring, without entering the abdominal cavity, which maintains the integrity of the peritoneum and thus reduces intra-abdominal The operation does not enter the abdominal cavity and maintains the integrity of the peritoneum, thus reducing the possibility of intra-abdominal organ damage and intra-abdominal adhesions. In China, it has been reported in the literature that there is no significant difference between the results of transabdominal preperitoneal patch implantation (TAPP) compared with the two procedures, but TEP is more economical and has shorter operative time, and should be the preferred procedure for laparoscopic inguinal hernia repair, but has the disadvantage of higher technical requirements and more stringent requirements for operator experience.
III. Supine view (transabdominal repair)
1. Transabdominal preperitoneal patch implantation (TAPP).
During surgery, the laparoscope is used to separate and expose the inguinal structures, separate and establish the extraperitoneal space, peel back the small hernia sac, close the large hernia sac proximally after cutting it off, and leave the distal end open. TAPP is a widely used laparoscopic inguinal hernia repair procedure, which is simple to perform and has a low recurrence rate.
2, Intra-abdominal mesh repair.
This procedure involves direct laparoscopic placement of a patch into the abdominal cavity to strengthen the posterior wall of the inguinal canal. However, because the patch is placed directly in the abdominal cavity, it is easy to cause serious adhesions, leading to intestinal obstruction, intestinal adhesions and other complications, so it has been largely abandoned. The modified procedure, laparoscopic intraperitoneal implantable inguinal hernia repair (IPODM), takes advantage of the features of the Bard double-sided patch to reduce postoperative pain, adhesions and other complications, and is an option for laparoscopic hernia repair.
3 .Patch placed intraperitoneally in close proximity to the peritoneum.
Laparoscopic anti-adhesion patch repair of incisional hernia of the abdominal wall and parastomal hernia is characterized by less injury, faster recovery, and exact and reliable results.
4.Laparoscopic simple hernia sac ring suture method and various improved laparoscopic repair methods.
The traditional hernia repair is mainly based on human anatomy, and the concept of repair is necessarily limited to the intervention of the anatomical structure of the defective area and inguinal canal. Since the 1970s, a large number of facts have proven that the etiology of hernia is a systemic connective tissue disease, i.e. a disease with abnormal collagen fiber metabolism. Therefore the repair and strengthening of the transversus abdominis fascia received greater attention in inguinal hernia repair, which led to the promotion and popularity of the Shouldice repair method, the key to which is the incision of the transversus abdominis fascia between the pubic symphysis and the internal ring and the overlapping suturing of its upper and lower lobes. Lichtenstein was the first to introduce the concept of “tension-free repair” in 1989.
This led to the emergence of tension-free repair, which is a general term for a type of surgery that uses artificial or biological materials as patches to repair and strengthen the posterior wall of the inguinal canal for the purpose of hernia repair. The advantages of these procedures include less postoperative pain, faster recovery, wider surgical indications, and lower recurrence rate, so patch repair has developed considerably and Lichtenstein’s tension-free repair once became a classic procedure.
The formation of the modern concept of “hernia” and the deepening of the understanding of the etiology and pathogenesis have led to revolutionary progress in inguinal hernia repair surgery, and the development and application of new materials and instruments (such as laparoscopy) have made it possible not only to have reliable repair materials for abdominal wall hernia repair, but also to enable the surgeon to view the hernia from multiple perspectives and perform the repair operation. observation and perform repair operations, thus greatly improving the quality of surgery, reducing patient injury and pain, and improving the quality of life of patients after surgery.
However, the real way out for the eradication of hernia is to remove the cause of hernia and correct the decreased strength of the abdominal wall in the inguinal region, and lumpectomy hernia repair is not the ultimate repair method for hernia. Currently, there are data with 13 years of follow-up showing that the recurrence rate within 5 years after inguinal hernia repair is significantly higher for suture repair than patch repair, but the recurrence rate after 5 years increases gradually for both, i.e., it is biological recurrence, and the better results are maintained after patch repair This reminds us that it is not enough to focus only on anatomical recovery and mechanical strengthening of the abdominal wall when repairing inguinal hernias, but the real way out of hernia repair also lies in treating the patient’s systemic connective tissue disease and correcting abnormalities in collagen fiber metabolism.