Emerging Technology: Open Approaches to Preperitoneal Inguinal Hernia Repair
Over the years and most probably influenced and stimulated by the introduction of the laparoscopic inguinal hernia techniques, the open preperitoneal techniques had their revival. Historically, many of the nowadays more popular open preperitoneal techniqu
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Frederik Christiaan Berrevoet
14.1 Introduction Up until late in the nineteenth century, treatment of inguinal hernias consisted of reducing protrusions through the external inguinal ring or femoral canal, and applying a truss for maintenance. Bassini’s repair, which failed to divide the transversalis fascial floor of the inguinal canal, became the standard of care in the 1890s for inguinal herniae. Preperitoneal approaches to the groin began a century earlier. Already as early as in 1823 the anatomist Bogros [1] described a transverse 5-cm incision, above the inguinal ligament, midway between the anterior superior iliac spine and the pubic tubercle to use an anterior preperitoneal repair of inguinal and femoral herniation. The posterior preperitoneal approach to the groin was described by Cheatle in 1920 [2], who introduced the transabdominal paramedian approach to the space of Bogros. His operation was ignored until 1936, when Henry [3] used it to treat a femoral hernia, while operating extraperitoneally on the pelvic ureter for stones. In 1950 McEvedy [4] reported an oblique lateral incision, dividing both the rectus sheath and transversalis fascia with medial retraction of the rectus muscle and in that way used the lateral transverse incision to reach the preperitoneal space. Using the preperitoneal approach to repair groin herniation facilitates entry into the retro-fascial transversalis space, providing direct access to the posterior inguinal structures. Hernial protrusions are exposed along with the myopectineal orifice of Fruchaud. Using a mesh in this preperitoneal space, a strong barrier is created against the continuous intra-abdominal pressure. F.C. Berrevoet, M.D., Ph.D., F.E.B.S., F.A.C.S. (*) Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital and Medical School, De Pintelaan 185, 2 K 12 IC, Ghent 9000, Belgium e-mail: [email protected]
The prosthesis, pressed by intra-abdominal pressure against the parietal wall, replaces the damaged floor of the inguinal canal to which it quickly becomes attached as connective tissue infiltrates its pores. The need for fixation devices, which can cause postoperative pain, might be reduced, as abdominal pressure, according to Pascal’s hydrostatic principles, stabilizes the prosthesis. When we discuss the current emerging technologies and techniques for open preperitoneal approaches to the groin, its historical background is essential to understand and interpret the evolutions correctly. Jean Rives [5] described his unilateral inguinal hernia repair using the preperitoneal space already in 1967. He approached the hernia initially as in the Bassini technique, ligated the sac, and incised the transversalis fascia transversely. Dissection of the preperitoneal space was performed with the finger, first at the top behind the wall and thereafter down behind the horizontal ramus of the pubis. A prosthesis of dacron 10 × 10 cm was used and split laterally for passage of the cord structures. He then sutured the
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