International Journal of Surgery 6 (2008) S26–S28

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International Journal of Surgery

journal homepage: www.theijs.com

Inguinal hernia: State of the art

Giampiero Campanelli a, b, *, Marco Canziani a, b, Francesco Frattini a, b, Marta Cavalli a, b, Sonia Agrusti a, b
a
Department of General Surgery, University of Insubria, Varese, Italy
b
Department of General Surgery, Multimedica Santa Maria Hospital, Italy

a r t i c l e i n f o a b s t r a c t

Article history: A review of the history of inguinal hernia repair from the far surgical approach performed by Celso,
Available online 13 December 2008 trought the physiological reconstruction of inguinal canal by Bassini and the introduction of the concept
of tensionfree repair, to the newest find in this specialist surgery.
Keywords: Nowadays in addition to the choice of approach (open vs laparoscopic, anterior vs preperitoneal), the
Inguinal hernia plane where placing the mesh (in front of the trasversalis fascia vs preperitoneal space), and the fixation
History
device (suture vs sutureless vs glue), surgeons can select among a wide range of prosthesis.
Gold standard
Choosing the proper biomaterial can determine the success of an operation and prevent biomaterial-
Newest
related complications. Indepth knowledge and understanding of the physical properties of the pros-
thesis, porosity, and pore size in particular are required.
Modern advances in hernia repair are credited with reduced recurrence rate, so surgeons’ attention is
shifted from preventing recurrence to the new topic of chronic pain after surgery.
Ó 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Early description of surgical approach is performed by Celso in
De Re Medica (I century): ‘‘for a medium-size swelling one incision
is enough, for bigger size two linear incisions are necessary and the
cord is removed. Vessels are identified, tied and cut’’. Lack of
anatomical knowledge is clear in that age.
Galeno (129–199) in ‘‘De Semine’’ describes the correct anatomy
of the inguinal canal.
After 500 years Paolo D’Egina (625–690) suggests the cauter-
ization and proposes to tie and dissect the whole sac: this means
that the cord is tied. Maestro Rolando supports strongly the
necessity of the cord section.
Guy De Chauliac (1300) prescribes a fifty-day bed rest after the
surgery: nowadays, finally after seven centuries, hospitalization is
reduced to one hour.
Guido Lanfranchi (1250–1306) suggests to avoid cord section,
but it is necessary to wait until the XVI century when surgeons,
supported by improved anatomy knowledge, pursue cord preser-
vation during inguinal hernia repair.
Girolamo Fabrici d’Acquapendente (1533–1619) describes the
cord dissection and the division of spermatic vessel from the sac:
this one is sutured with golden stitches.
* Corresponding author. Department of General Surgery II – Day and Week
Surgery, Multimedica Santa Maria Hospital, Viale Piemonte 70, 21053 Castellanza
(VA), Italy.
E-mail address: giampiero.campanelli@uninsubria.it (G. Campanelli).
After about two centuries without evolution in surgery tech-
nique, August Gottlieb Richter (1742–1812) remarks that it is
necessary to close the sac but also to repair the wall defect.1,2
Bassini (1844–1924) is credited with developing the precursor to
the modern inguinal hernia operation at the end of the 19th century.
Bassini’s essential discovery was that the transversal fascia plays
a key role in the pathophysiology of inguinal hernias. Bassini creates
a physiologic reconstruction of the inguinal canal, suturing conjoint
tendon and the trasversalis fascia with inguinal ligament. Bassini’s
operation was considered the gold standard for nearly a century.3
Some modified versions are suggested (Mugnai, Ferrari, Post-
emski, Mc Vay) until Shouldice Hospital surgeons propose their
tissue variant repair, evolution of Bassini procedure, in order to
reduce recurrent rate. The acknowledgement that excessive suture-
line tension was primarily responsible for high recurrence rates and
significant postoperative pain following tissue-based repairs leads
to the introduction of the concept of tension-free hernia surgery.4
The first mesh repair was performed by Usher in 1958.1,2
Then numerous surgeons helped to write hernia repair history:
Nyhus, Mahorner, Goss, Reed, Rives, Stoppa, Wantz. The develop-
ment of prosthetic materials ushers in the current era of hernia
surgery, allowing a tension-free repair to be performed even for the
largest defects and the most difficult procedures. Tension-free
mesh-based repairs begin to increase in number in the late 1980s.4
Many surgical procedures and devices have been marketed in
the last twenty years, some of them evolved and now they are
accepted worldwide and used (for example Lichtenstein technique)

1743-9191/$ – see front matter Ó 2008 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2008.12.021
 G. Campanelli et al. / International Journal of Surgery 6 (2008) S26–S28
while some of them are used by a limited number of hernia experts
(Stoppa or Wantz technique).
The techniques for inguinal hernia mesh repair can be grouped
in three classes:
- sublay: the mesh is placed in the preperitoneal space (Rives,
Stoppa, Wantz, Kugel);
- onlay: the mesh is placed in front of the trasversalis fascia
(Lichtenstein Trabucco.);
- plug inserted in the wall defect (Gilbert, Rutkow, Hugahary).
Implantation of mesh behind the trasversalis fascia via open
approach can be achieved through a transinguinal method such as
the Rives operation (introduced in 1965), a lower midline abdom-
inal incision (Stoppa GPRVS method, 1967), a slit made in the broad
abdominal muscles (Wantz repair, 1988).5
Even if preperitoneal approach covers the entire groin region
and reduce the risk of recurrence or missed hernias, they were
limited to repair recurrent inguinal hernia in the hands of a limited
number of hernia experts.
Lichtenstein, introduced in 1984, now is the most commonly
used technique probably because it does not need a long learning
curve to obtain highly acceptable results and its recurrence and
complication rate are 1% (less in hands of experts).6
The original technique requires a polypropylene mesh fixed
with unabsorbable suture on the inguinal ligament and with
absorbable stitch on the conjoint tendon.
Trabucco in 1989 proposes a tension-free sutureless technique:
a flat preshaped memory mesh with proper rigidity is placed on the
posterior wall of the inguinal canal without suture fixation on the
surrounding tissue: such mesh better adapts to a patient move-
ments postoperatively. This technique, despite of his simplicity, is
not so common as Lichtenstein technique, due to the lack of
scientific information.
Lichtenstein and Trabucco techniques are often the first choice
by residents and nonexperts because anterior anatomy is more
familiar and feasible, whereas preperitoneal approach did not have
widespread success because of their hard performing and fea-
sibleness under local anaesthesia.
During the early 1990s the laparoscopic method of mesh
implantation in the preperitoneal space was introduced.5
Endoscopic inguinal hernia operations result in a quicker post-
operative recovery and a lower risk of chronic pain symptoms than
open techniques, but they require general anaesthesia, they are
more expensive and they have a long learning curve which can
include potentially serious yet rare complications.7–10
So since laparoscopic technique is introduced, more attention
has been focused on using the preperitoneal space for mesh
placement also during open approach.
Gilbert, followed by other surgeons as Rutkow and Robbins, tries
to take advantages from the placement in the preperitoneal space
and combines them with a simple anterior approach: after some
modifications of the original techniques, Gilbert creates the ‘‘Pro-
lene Hernia System’’, comprising a superficial layer for placement
in front of the trasversalis fascia, a connector and a deep layer for
placement behind the trasversalis fascia. In case of indirect hernia,
the deep layer is introduced in the internal inguinal ring, in case of
direct hernia, the trasversalis fascia is divided and a pocket for the
deep layer is created.2
Kugel hernia patch aims to combine the utility of the open
operation with a minimal access (3–4 cm-incision): it consists of
a self-expanding two polypropylene patch with a memory recoil
ring which helps patch spring open and maintain shape. It does not
require special instrumentation and thus contains expense, but it
requires regional or general anaesthesia.
S27
Again, Polysoft patch is placed in the preperitoneal space but with
an open anterior approach that allows a visual and tactile exposure of
the space and it can be performed under local anaesthesia.
Modern advances in hernia repair are credited with reduced
recurrence rate, so surgeons’ attention is shifted from preventing
recurrence to chronic pain after hernia surgery. A systematic review
reports that 11% of patients suffer chronic pain,11 but estimates in
literature range from 0 to 53%.12
Chronic inguinal pain is defined as pain arising 3 months after
hernioplasty; it is a significant complication that can compromise
the patient’s quality of life. The pain complex syndrome of post-
herniorrhaphy neuropathic inguinodynia includes pain (neuralgia),
burning sensation (paresthesia), hypoesthesia, hyperesthesia, with
radiation of the pain to the skin of the corresponding hemiscrotum,
labium majus, and Scarpa’s triangle. The symptoms are frequently
triggered or at least aggravated by walking, stooping, or hyperex-
tension of the hip and can be decreased by recumbency and flexion
of the thigh, suggesting that traction of the involved nerve plays
a major role in the postherniorrhaphy pain syndrome.13,14
The risk of chronic pain after laparoscopic hernia repair is lower
than after open hernia repair and is lower after mesh repair than
suture repair.11,15
Following the idea that Pain Complex Syndrome could be caused
by use of suture13 and fixation devices, some authors look for an
alternative method for mesh fixation.
Observational studies proved that chronic pain rate is reduced
after glue mesh fixation in different techniques during both open
and laparoscopic approach.16–22
Final results are attending from a prospective, controlled,
randomized, patient and evaluator blinded study to evaluate pain
in patients undergoing Lichtenstein technique for primary inguinal
hernia repair by fixing the mesh with fibrin sealant vs sutures
(TI.ME.LI. study).14
Looking for an alternative fixation device, Progrip patch is real-
ized: it is a mesh provided with absorbable draws that anchor it to
the above plane, so that no suture is necessary to secure prosthesis.
Today there is no consensus opinion about cause and treatment
of chronic postoperative pain. What it is clear is that it is important
the prevention: this is possible performing local anaesthesia,
identifying nerves of the region, leaving nerves in the position if
possible, limiting sutures and fixation devices and, in case of nerve
injury, doing selective neurectomy.13,23
Nowadays in addition to the choice of approach (open vs lapa-
roscopic, anterior vs preperitoneal), the plane where placing the
mesh (in front of the trasversalis fascia vs preperitoneal space) and
the fixation device (suture vs sutureless vs glue) surgeons can select
among a wide range of prosthesis.
Choosing the proper biomaterial can determine the success of
an operation and prevent biomaterial-related complications. In-
depth knowledge and understanding of the physical properties of
the prosthesis, porosity, and pore size in particular are required.
Classification of biomaterials for hernia surgery is essential for
everyday practical use of prosthesis.
The most frequently used prosthetic materials for hernia
surgery can be grouped into absorbable and nonabsorbable
materials.
Absorbable materials can be divided into synthetic materials
(e.g. Dexon and Vicryl) and biological materials (e.g. acellular
dermis, porcine dermal collagen and porcine small intestinal
submucosa). All absorbable biomaterials are totally replaced by the
host tissue; however, there is no scientific evidence that the new
tissue has the integrity of normal collagen or the normal typeI/
typeIII collagen ratio to withstand the intraabdominal pressure and
thus avoid future recurrence. Therefore the only possible recom-
mended use of absorbable materials (synthetic or biological) is for
S28 G. Campanelli et al. / International Journal of Surgery 6 (2008) S26–S28
repairing a hernia in a contaminated setting, where nonabsorbable
materials would present an unacceptable risk of chronic infection.
Nonabsorbable materials can be grouped in base on pore size:
totally macroporous, totally microporous, macroporous with mul-
tifilamentous or microporous component, biomaterials with sub-
micrometer pore size. Currently the most frequently recommended
type of biomaterial for open and laparoscopic inguinal hernia
repairs is the totally macroporous monofilament polypropylene
meshes: large pores are required for easy passage of fibroblasts,
collagen fibres, blood vessels and macrophages.5
Although very little data are available the material reduced
meshes seem to have some advantages with respect to post-
operative discomfort and foreign body sensation and postoperative
well-being but possibly they are associated with an increase risk for
hernia recurrence.24–28
Today the gold standard for primary inguinal hernia repair is an
open tension-free technique performed in local anaesthesia in
a Day-Surgery Unit.
Local anaesthesia provides various advantages: less post-
operative pain, less anaesthesia related complaints, less micturition
difficulties, faster discharge and faster short term recovery.29,30
Hernia surgery can easily be performed as a day surgery, irrespective
of the technique used; day surgery is safe (also for selected older and ASA
III patients), effective and also cheaper then ordinary recovery.31–33
All modern advances reported above, permit surgeons to select
the right approach, the proper technique, the suitable mesh fixed in
the best manner among others so that the procedure is tailored for
that hernia in that patient.
Conflict of interest
None declared.
Funding
None.
Ethical approval
None.
References
1. Campanelli G, Annibali R. Storia dell’ernia inguinale. Notiz Chir 1990;11(1):
27–30.
2. Campanelli G, Pettinari D, Cavalli M. Chirurgia. IV ed.. In: Dionigi R, editor.
Parete addominale ed ernie. Masson; 2006
3. Bekker J, Keeman JN, Simons MP, Aufenacker TJ. A brief history of the inguinal
hernia operation in adults. Ned Tijdschr Geneeskd 2007 April 21;151(16):924–31.
4. Nathan JD, Pappas TN. Inguinal hernia: an old condition with new solutions.
Ann Surg 2003 Dec;238(Suppl. 6):S148–57.
5. Parviz KA. Groin hernia repair: open techniques. World J Surg 2005;29:1046–51.
6. Parviz KA. Lichtenstein tension-free herioplasty: its inception, evolution, and
principles. Hernia 2004;8:1–7.
7. Collaboration EH. Laparoscopic compared with open methods of groin hernia
repair: systematic review of randomized controlled trials. Br J Surg
2000;87:854–9.
8. The EU Hernia Trialists Collaboration. Laparoscopic versus open groin hernia
repair: meta-analysis of randomised trials based on individual patient data.
Hernia 2002;6:2–10.
9. McCormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques
versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev
2003;(1): CD001785 [Review].
10. McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E, et al. Laparoscopic
surgery for inguinal hernia repair: systematic review of effectiveness and
economic evaluation. Health Technol Assess 2005 April;9(14):1–203 [iii–iv].
11. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic
pain after mesh repair of inguinal hernia: a systematic review. The American
Journal of Surgery 2007;194:394–400.
12. Poolbalan AS, Bruce J, Cairns W, Smith S, King PM, Krukowski ZH, et al. A review
of chronic pain after inguinal herniorrhaphy. The Clinical Journal of Pain
2003;19:48–54.
13. Amid PK. Causes, prevention, and surgical treatment of postherniorrhaphy
neuropathic inguinodynia: triple neurectomy with proximal end implantation.
Hernia 2004 Dec;8(4):343–9.
14. Campanelli G, Champault G, Pascual MH, Hoeferlin A, Kingsnorth A,
Rosenberg J, et al. Randomized, controlled, blinded trial of Tissucol/Tisseel for
mesh fixation in patients undergoing Lichtenstein technique for primary
inguinal hernia repair: rationale and study design of the TIMELI trial. Hernia
2008;12(2):159–65.
15. The EU Hernia Trialists collaboration. Repair of groin hernia with synthetic
mesh: meta-analysis of randomised controlled trials. Ann Surg 2002;235:
322–32.
16. Canonico S, Santoriello A, Campitiello F, Fattopace A, Della Corte A, Sordelli I,
et al. Mesh fixation with human fibrin glue (Tissucol) in open tension-free
inguinal hernia repair: a preliminary report. Hernia 2005;9:330–3.
17. Helbling C, Schlumpf R. Sutureless lichtenstein: first results of a prospective
randomised clinical trial. Hernia 2003;7:80–4.
18. Hidalgo M, Castillo MJ, Eymar JL, Hidalgo A. Lichtenstein inguinal hernioplasty:
sutures versus glue. Hernia 2005;9:242–4.
19. Benizri EI, Rahili A, Avallone S, Balestro JC, Caı̈ J, Benchimol D. Open inguinal
hernia repair by plug and patch: the value of fibrin sealant fixation. Hernia
2006;10:389–94.
20. Lau H. Fibrin sealant versus mechanical stapling for mesh fixation during
endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective
trial. Ann Surg 2005;242:670–5.
21. Topart P, Vandenbroucke F, Lozac’h P. Tisseel versus tack staples as mesh
fixation in totally extraperitoneal laparoscopic repair of groin hernias: a retro-
spective analysis. Surg Endosc 2005;19:724–7.
22. Schwab R, Willms A, Kroger A, Becker HP. Less chronic pain following mesh
fixation using a fibrin sealant in TEP inguinal hernia repair. Hernia
2006;10:272–7.
23. Alfieri S, Rotondi F, Di Giorgio A, Fumagalli U, Salzano A, Di Miceli D, et al.
Influence of preservation versus division of ilioinguinal, iliohypogastric, and
genital nerves during open mesh herniorrhaphy: prospective multicentric
study of chronic pain. Ann Surg 2006;243:553–8.
24. Bringman S, Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, et al.
Three-year results of a randomized clinical trial of lightweight or standard
polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg
2006;93:1056–9.
25. Horstmann R, Hellwig M, Classen C, Rottgermann S, Palmes D. Impact of
polypropylene amount on functional outcome and quality of life after inguinal
hernia repair by the TAPP procedure using pure, mixed, and titanium-coated
meshes. World J Surg 2006;30:1742–9.
26. Khan LR, Kumar S, Nixon SJ. Early results for new lightweight mesh in
laparoscopic totally extra-peritoneal inguinal hernia repair. Hernia
2006;10:303–8.
27. O’Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers B, Horeyseck G.
Randomized clinical trial assessing impact of a lightweight or heavyweight
mesh on chronic pain after inguinal hernia repair. Br J Surg 2005
February;92(2):166–70.
28. Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of
lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg
2004;91:44–8.
29. Nordin P, Zetterström H, Gunnarsson U, Nilsson E. Local, regional, or general
anaesthesia in groin hernia repair: multicentre randomised trial. Lancet 2003
Sep 13;362(9387):853–8.
30. O’Dwyer PJ, Serpell MG, Millar K, Paterson C, Young D, Hair A, et al. Local or
general anesthesia for open hernia repair: a randomized trial. Ann Surg 2003
Apr;237(4):574–9.
31. Engbaek J, Bartholdy J, Hjortsø NC. Return hospital visits and morbidity within
60 days after day surgery: a retrospective study of 18,736 day surgical proce-
dures. Acta Anaesthesiol Scand 2006 Sep;50(8):911–9.
32. Jarrett PE. Day care surgery. Eur J Anaesthesiol Suppl 2001;23:32–5.
33. Prabhu A, Chung F. Anaesthetic strategies towards developments in day care
surgery. Eur J Anaesthesiol Suppl 2001;23:36–42.