LAPROSCOPY IN HERNIA REPAIR

Hernia Repair

Introduction

An inguinal hernia has 2 components: the peritoneal sac and the defect in the abdominal wall. If one treats only the peritoneal sac, e.g. by high ligation, a definite risk of recurrence is present because the peritoneum will have the tendency to bulge through the opening in the abdominal wall. This is common knowledge since the Middle Ages, and very early on, attempts were made to close the "hole in the wall". Simple closure of the defect, however, caused an unacceptably high recurrence rate.

More complex repair techniques were necessary and over 100 years ago the Italian surgeon Bassini designed a muscular plasty, in which the muscles in the inguinal canal were stitched together in order to build a screen that could withstand the intra-abdominal pressure. This technique gave good results as compared to others, and carried a recurrence rate of 10 to 20 %. Morbidity was not negligible, however, because of the high infection rate and the postoperative pain. Pain was not caused by the surgical incision, but by the traction created by the repair.

This traction was also responsible of the high recurrence rate. Modified versions of the Bassini repair were therefore attempted. The most famous one was the Shouldice technique, in which a progressive build up of tension was carried out by suturing successive layers of the inguinal canal. Morbidity in this excellent technique was improved and the clinical results were far better. Depending on the surgeon, recurrence rates of 1 to 10 % were reported.

Progress in medical technology encouraged some to use foreign material in order to reinforce the repair. Dacron, popypropylene and PTFE appeared to be useful material for that purpose, as opposed to silver mesh, tantalum or carbon. Thanks to the use of mesh material, a true tension free repair was finally achieved. The recurrence rate dropped dramatically and approached 1 %. The pain that patients still suffered after open mesh repair was no longer caused by tissue traction but by the dissection performed to reduce the hernia and to place the reinforcement in the correct position.

Some, like Lichtenstein, using an anterior approach, placed the mesh superficially to the defect in the abdominal wall. Biomechanically, however, it seems better to insure the reinforcement deep to the defect, between peritoneum and muscle, i.e. between the defect and the pushing force. This "posterior approach" as described by Rives, however, necessitated a far more extensive dissection and created pain. Healthy tissues had to be incised in order to gain access to the target area.

This latter drawback was partially avoided by Stoppa, who used a midline incision so as not to damage healthy muscle. Closure of this incision, however, created traction and hence pain.
In the search for reduction of unnecessary tissue damage, the laparoscopic approach was an obvious and welcome alternative. Considerable gain in recovery time after gallbladder surgery and hiatal hernia treatment performed laparoscopically prompted surgeons to attempt this new approach in the treatment of inguinal hernia, as early as 1985 (Ger).

In laparoscopy, however, the peritoneum must be perforated and manipulations are performed intraperitoneally whereas in the Stoppa approach the peritoneal cavity remains unviolated. Despite this drawback, the laparoscopic treatment soon became very popular. All kinds of mesh were inserted in order to "patch" or to "plug" the defect in the abdominal wall. The availability of staples facilitated easy fixation of the mesh to the hernia edges and, in case of preperitoneal placement, permitted closure of the peritoneum over the foreign material.

High recurrence rates with this technique proved that Stoppa's theory - the need to insert a very large mesh rather than to perform a patch repair - was correct. The preperitoneal dissection obviously had to be more extensive. More extensive dissection performed laparoscopically soon generated unexpected problems.

Three percent of the patients presented neuralgias, caused by either blind electrical dissection or by nerve entrapment due to stapling. Moreover, approximately 1 % of the patients presented prolonged ileus or even intestinal obstruction, which necessitated re-operation in several cases. The reason of this latter complication was dehiscence of the peritoneal staple line, followed by entrapment of small bowel in the thus created gap. Small bowel resections and even fatalities were reported. These complications put the procedure in an unfavorable light.

New ways to avoid this unexpected morbidity were explored and the preperitonescopic approach was developed. The plane of dissection in this latter technique was exactly the same as with the Stoppa procedure.Moreover, the procedure itself could now be exactly mimicked by endoscopic means and a big prosthesis be inserted in exactly the same plane as described by Stoppa.

Stoppa 's space was no longer created by the surgeon's finger but by a simple tool that combined safety and efficacy with an unsurpassed visual acuity.

Stoppa's technique is basically unchanged : a large mesh is inserted between the abdominal wall and the peritoneum. Tissue damage is minimal, the risks are small and more acceptable. There is hardly any pain, whereas the excellent functional results of the open technique can be matched. Recurrence rates of less than 1 % are reported.