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Surgery_Schwartz. vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended medially up to the pubic symphysis and laterally 1 to 2 cm beyond the reconstructed abdominal ring.The free border of the strip of the EOA is now sutured to the internal oblique or conjoined tendon lying close to it with 1–0 Ethilon or Prolene interrupted sutures. This is followed by closure of the superficial fascia and the skin as usual.39-41Prosthetic Repairs. The popularization of tension-free pros-thetic mesh repairs signified a paradigm shift in the surgical concept of inguinal hernia pathophysiology. Mesh-based her-nioplasty is the most commonly performed general surgical procedure, owing to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein


Surgery_Schwartz

Surgery_Schwartz. to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein technique allows for a tension-free repair of the inguinal floor by buttressing the floor with a prosthetic mesh (Fig. 37-18). Initial exposure and mobilization of cord structures is identical to other open approaches. The inguinal canal is dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for mesh. The most commonly used mesh is “flat iron” shaped with a keyhole for cord egress, it is available in several sizes. It should be noted that when selecting the size, it must be large enough to extend 2 to 3 cm superior to Figure 37-18. The Desarda repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3


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Surgery_Schwartz. repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 pubic tubercle, 4 abdominal ring, 5 spermatic cord, 6 lateral leaf B. Undetached strip of the external oblique aponeurosis forming the posterior wall. 1 Reflected medial leaf after a strip has been separated, 2 internal oblique muscle seen through the splitting incision made in the medial leaf, 3 interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle, 4 interrupted sutures between the lower border of the strip and the inguinal ligament, 5 pubic tubercle, 6 abdominal ring, 7 spermatic cord, 8 lateral leaf.64123568751234Hesselbach’s Triangle. The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial


Surgery_Schwartz

Surgery_Schwartz. The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial recurrence.42For fixation of the inferior margin of the mesh, a per-manent, synthetic, monofilament suture is used taking care to avoid placing sutures directly into the periosteum of the pubic tubercle. Fixation is continued along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring. The upper tail of the mesh is then fixed to the internal oblique aponeurosis and the medial edge to the rectus sheath using a synthetic, absorbable suture.In the case of a femoral hernia, a triangular extension of the inferior aspect of the mesh is sutured to Cooper’s ligament medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are


Surgery_Schwartz

Surgery_Schwartz. medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are then sutured to the inguinal ligament with an interrupted stitch and placed beneath the external oblique aponeurosis.Plug and Patch Technique. A modification of the Lichtenstein repair, the Plug and Patch technique was developed by Gilbert and later popularized by Rutkow and Robbins.43 Prior to placing the prosthetic mesh patch over the inguinal floor, a three-dimensional prosthetic plug is placed in the space previously occupied by the hernia sac (Fig. 37-19). In the case of an indirect hernia, the plug is placed alongside the spermatic cord through the internal ring. Prosthetic plugs of various sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s


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Surgery_Schwartz. sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and Brunicardi_Ch37_p1599-p1624.indd 161229/01/19 2:03 PM 1613INGUINAL HERNIASCHAPTER 37Figure 37-19. Lichtenstein tension-free hernioplasty. m. = muscle; n. = nerve; v. = vein.the internal oblique aponeurosis. While the technique has good overall outcomes, there have been some isolated case report series of complications involving the presence of the plug, including bowel obstruction and chronic pain.Wound Closure Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic posi-tion. The external oblique aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the


Surgery_Schwartz

Surgery_Schwartz. aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the appearance of recurrence on future examination. Scarpa’s fascia and skin are appropriately closed.Laparoscopic ApproachLaparoscopic inguinal hernia repairs have become increas-ingly popular given the noninferiority studies, improved aes-thetics, and increased surgeon experience with the procedure. Principal endoscopic methods include the transabdominal preperitoneal (TAPP) repair, the totally extraperitoneal (TEP) repair, and the less-commonly performed intraperitoneal onlay mesh (IPOM) repair.Of note, awake patients do not tolerate abdominal insuffla-tion well; therefore, laparoscopic repair necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair.


Surgery_Schwartz

Surgery_Schwartz. necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. Occasionally, induction of general anesthesia may result in reduction of an incarcer-ated or strangulated inguinal hernia. If the surgeon suspects this might have occurred, the abdomen should be explored for non-viable tissue either via laparoscopy or upon conversion to an open laparotomy.The indications for laparoscopic inguinal hernia repair are similar to those for open repair. Most surgeons would agree that the endoscopic approach to bilateral or recurrent inguinal hernias is superior to the open approach.45 Concurrent inguinal hernia repair can be considered if a hernia patient is scheduled to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP


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Surgery_Schwartz. to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP are preferred alternatives to Lichtenstein repair for recurrent hernias after open anterior repair.48,49 The possibility of bilateral repair should be discussed with all patients undergoing endoscopic inguinal hernia surgery.The operating room configuration is identical for TAPP, TEP, and IPOM procedures. The patient is placed in the Trendelenburg position, and video screens are placed at the foot of the bed. The surgeon stands contralateral to the hernia, and the assistant stands opposite the surgeon. The patient’s arms are tucked to the sides. Figure 37-20 demonstrates a typical operating room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The


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Surgery_Schwartz. room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The transab-dominal approach confers the advantage of an intraperitoneal perspective, which is useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery. The abdominal cavity is accessed using a dissecting trocar or open Hasson technique. Pneumoperitoneum to a level of 15 mmHg is achieved. Two 5-mm trocars are placed lateral and slightly inferior to the umbilical trocar, avoiding injury to the inferior epigastric vessels (Fig. 37-21). The patient is then placed in the Trendelenburg position, and the pelvis is inspected.The bladder, median and medial umbilical ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and


Surgery_Schwartz

Surgery_Schwartz. ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and it is carried lat-erally to the anterior superior iliac spine. For bilateral inguinal hernia repair, bilateral peritoneal incisions are advisable, leav-ing a midline bridge of tissue to avoid injuring a potential patent urachus. The inferior edge of incised peritoneum is retracted, and the preperitoneum is dissected to expose the spermatic cord. If a direct hernia is encountered, the sac is inverted and fixed to Cooper’s ligament to prevent development of hematoma or seroma. An indirect hernia sac will usually protrude anterior to the spermatic cord. In this case, the sac is grasped and elevated superiorly from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm


Surgery_Schwartz

Surgery_Schwartz. from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm to completely cover the myopectineal orifice (Fig. 37-22). It is rolled length-wise and placed through the 12-mm trocar. It is unrolled in the preperitoneal space and secured medially to Cooper’s ligament using an endoscopic tacker. During this fixation, the surgeon palpates the end of the tacker from the abdominal surface to ensure its proper angle and to stabilize the pelvis. The mesh is then pulled taut and fixed laterally to the anterior superior iliac spine. Tacks are placed above the iliopubic tract to avoid injury to the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh


Surgery_Schwartz

Surgery_Schwartz. nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh and the intestine. The abdomen is desufflated, and the trocars are removed. The fascial defect of the 12-mm port and the skin incisions are appropriately closed.Totally Extraperitoneal Procedure. The advantage of the TEP repair is the access to the preperitoneal space without intra-peritoneal infiltration. Consequently, this approach minimizes the risk of injury to intra-abdominal organs and port site hernia-tion through an iatrogenic defect in the abdominal wall. As with TAPP, TEP is indicated for repair of bilateral inguinal hernias or Brunicardi_Ch37_p1599-p1624.indd 161329/01/19 2:03 PM 1614SPECIFIC CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal


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Surgery_Schwartz. CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal incision is made inferior to the umbi-licus. Subcutaneous tissue is dissected to the level of the ante-rior rectus sheath, which is then incised lateral to the linea alba. The rectus muscle is retracted superolaterally, and a dissecting balloon is advanced through the incision toward the pubic sym-physis. Under direct visualization with a 30° laparoscope, the balloon is inflated slowly to bluntly dissect the preperitoneal space (Fig. 37-23). The dissecting balloon is replaced with a 12-mm balloon trocar, and pneumopreperitoneum is achieved by insufflation to 15 mmHg. A 5-mm trocar is placed suprapubically in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion


Surgery_Schwartz

Surgery_Schwartz. in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion to TAPP. No modifications are necessary to repair bilateral ingui-nal hernias with the TEP approach. Any peritoneal rents should be repaired prior to desufflation to prevent mesh from contact-ing intraperitoneal structures. Following mesh placement, the preperitoneal space is desufflated slowly under direct vision to ensure proper mesh positioning. Trocars are removed, and the anterior rectus sheath is closed with an interrupted suture. If there Brunicardi_Ch37_p1599-p1624.indd 161429/01/19 2:03 PM 1615INGUINAL HERNIASCHAPTER 37BA Figure 37-21. Trocar placement for (A) transabdominal preperitoneal repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the


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Surgery_Schwartz. repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the preperitoneal space in a totally extraperitoneal inguinal hernia repair.Brunicardi_Ch37_p1599-p1624.indd 161529/01/19 2:04 PM 1616SPECIFIC CONSIDERATIONSPART IIis violation of the peritoneum during insufflation of the dissec-tion balloon and subsequent pneumoperitoneum, visualization can be compromised. To address this, a Veress needle or angio-catheter can be placed in the LUQ, which will allow desufflation of the peritoneum and restore visualization.Intraperitoneal Onlay Mesh Procedure. In contrast to TAPP and TEP, the IPOM procedure permits the posterior approach without preperitoneal dissection. It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would


Surgery_Schwartz

Surgery_Schwartz. It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would make TEP or TAPP challenging. Port placement and inguinal hernia identification are identical to TAPP. Hernia sac contents are reduced; however, the sac itself is not inverted from the preperitoneal space. Instead, mesh is placed directly over the defect and fixed in place with sutures or spiral tacks. Because these anchors are placed through the peritoneum without preperitoneal inspection, the lateral cutane-ous nerve of the thigh and the genitofemoral nerve are especially prone to injury. Furthermore, intraperitoneal mesh migration is a documented phenomenon that can lead to postoperative mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist


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Surgery_Schwartz. mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist capabilities provides greatly improved manual dexterity and a relatively short learning curve. Though both total extraperito-neal repair and transabdominal preperitoneal repair can be adapted to a robotic platform, the latter has gained more traction among surgeons.Many papers have explored the efficacy and cost-effectiveness of robot-assisted herniorraphy. Retrospective data have had mixed results when comparing robot-assisted surgery vs. laparoscopy. One recent study has shown longer operative time,50 another analysis has shown increased cost.51 It should be noted, however, that there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A


Surgery_Schwartz

Surgery_Schwartz. there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A retrospective, single-institution study has shown greatly reduced complication rates with robotic assisted surgery in obese patients; however, this was compared against open inguinal hernia repair (10.8% vs. 3.2%, P = 0.047), the two groups were covariate matched for preoperative risk.52 Studies have also shown excellent long-term (36-month) quality of life indicators in robot-assisted TAPP, though this was a single surgeon survey.53 Further randomized trials will shed more light into cost issues as surgeons gain more experience with robotic application that would lead to shorter operative time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias.


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Surgery_Schwartz. time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias. Contraindications to robotic her-nia repair are the same as for laparoscopic repair and include coagulopathy and/or severe cardiopulmonary disease precluding induction of general anesthesia and pneumoperitoneum. Previ-ous preperitoneal repair is a relative contraindication along with the presence of a large incarcerated inguinal hernia.Patient evaluation should proceed similarly to workup for laparoscopic inguinal herniorraphy.Technique. Patients are instructed to void in preoperative area to avoid Foley catheter placement, though some surgeons advocate 4routine Foley catheter placement. Ideally, the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position


Surgery_Schwartz

Surgery_Schwartz. the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position with arms tucked at both sides. Appropriate padding of extremities is important to avoid neuropraxia and trauma from robotic arm movements. Three trocars are typically used for TAPP repair. Open Hasson technique is employed for initial trocar placement at umbilicus; this can be an 8-mm trocar or alternatively a 12-mm with a tele-scoped 8-mm trochar. Additionally, two 8-mm trocars are placed in each side of the mid-abdomen, slightly above the level of umbi-licus. After trocar placement, the robot is docked and targeted, and the patient is placed in Trendelenburg position. Typically, the surgeon will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the


Surgery_Schwartz

Surgery_Schwartz. will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the cost associated with robotic application is due to disposable instruments. Exposure starts with incising the parietal peritoneum from the medial umbilical ligament to the anterior superior iliac spine. A peritoneal flap is developed by blunt and sharp dissection with robotic shears in the prepreitoneal space. Special care is taken to leave the preperitoneal fat pad contain-ing nerves and vessels with the anterior abdominal wall. Small vessels can be coagulated with application of electrocautery with scissors. With the aid of pneumoperitoneum, the preference is first to perform a lateral dissection in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement


Surgery_Schwartz

Surgery_Schwartz. in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement at the end. Then the space of Retzius is entered medially exposing the pubic symphysis. In the absence of haptic feedback, visual recognition of the pubic symphysis is crucial as this serves as an important landmark for further dis-section. Inferior epigastric vessels are readily identified. Next, an inferior peritoneal flap is developed to avoid rolling of mesh during closure. Direct, indirect, and femoral spaces are carefully examined. Cadiere forceps are then used to grasp the hernia sac to provide traction. Any cord lipoma is carefully dissected free from the cord structures, and the testicular vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced


Surgery_Schwartz

Surgery_Schwartz. vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced after traction is released. The next step is placement of the mesh. Lightweight barbed mesh and anatomically preshaped mesh are routinely used. Mesh should be an appropriate size to cover the myopectineal orifice entirely, and the peritoneal dissection will need to be large enough to accommodate this size mesh. It is rolled and placed through one of the ports by the bedside assistant. Then it is unrolled and placed in the pelvis overlapping the pubic symphysis by several centimeters medially; this is essential as the majority of recur-rences occur in this area. Utilization of tacking devices are not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running


Surgery_Schwartz

Surgery_Schwartz. not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running locking suture that is facilitated by the increased intracorporeal dexterity of the robotic instruments. Then the fascia of the umbili-cal trochar site is closed with 0-absorbable suture (Fig 37-24), and the skin is closed with absorbable monofilament suture.Prosthesis ConsiderationsThe success of prosthetic repairs has generated considerable debate about the desirable physical attributes of mesh and their fixation. An ideal mesh should be easy to handle, flexible, Brunicardi_Ch37_p1599-p1624.indd 161629/01/19 2:04 PM 1617INGUINAL HERNIASCHAPTER 37Figure 37-24. Steps in robotic TAPP repair. A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of


Surgery_Schwartz

Surgery_Schwartz. A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of mesh E. Satisfactory placement of mesh. F. Closure of peritoneum. G. Completed repair of hernia with comparison to contralateral side.ABCDEFGBrunicardi_Ch37_p1599-p1624.indd 161729/01/19 2:04 PM 1618SPECIFIC CONSIDERATIONSPART IIstrong, immunologically inert, contraction-resistant, infection-resistant, and inexpensive to manufacture.54 The following section reviews the most common types of mesh and fixatives currently available.Synthetic Mesh Material. Polypropylene and polyester are the most common synthetic prosthetic materials used in her-nia repair. These materials are permanent and hydrophobic, and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with


Surgery_Schwartz

Surgery_Schwartz. and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with the goals of minimizing postoperative pain and preventing infection or recurrence. In selecting mesh material, considerations include mesh absorbability, thickness, weight, porosity, and strength.Variations in the fiber diameter and fiber count of mesh materials categorize them as heavyweight or lightweight in den-sity, though there does not seem to be a universally agreed upon set of criteria for either. Commonly used lightweight mesh materi-als include β-d-glucan, titanium-coated polypropylene, and poly-propylene–poliglecaprone. These materials have greater elasticity and less theoretical surface area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of


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Surgery_Schwartz. area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of lightweight mesh use in TEP and TAPP repairs is associated with fewer 3-month cumulative mesh-related complications.54 A 2012 meta-analysis of 2310 patients undergoing open or laparoscopic hernia repairs found a lower incidence of chronic pain (relative risk [RR] 0.61, CI 0.50–0.74) following use of lightweight mesh versus heavyweight mesh and no significant difference in rates of recurrence.55When available, lightweight mesh should be considered for all prosthetic repairs to minimize postoperative chronic pain. A disadvantage of currently available commercial pros-theses is their high cost. In settings where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and


Surgery_Schwartz

Surgery_Schwartz. where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and India, and they have similar mechanical properties to commercially available hernio-plasty meshes. Meta-analysis of 577 hernioplasties performed using sterilized mosquito nets demonstrated similar rates of short-term mesh-related complications (6.1%) and recurrence (0.17%) to those using commercial meshes.56 Furthermore, the disability-adjusted life years (DALYs) prevented by inguinal hernia repair signify a comparable impact to that of vaccination in sub-Saharan Africa.57,58 Expensive prostheses are not neces-sarily needed for hernia surgery, whether in resource-limited or in resource-abundant settings, and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined,


Surgery_Schwartz

Surgery_Schwartz. and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined, they are commonly reserved for contaminated cases or when domain expansion is necessary in the face of high infection risk. This is partially on account of their high cost and high recurrence rates. There are numerous biologic materials available with differing properties, but in general, they have a lower tensile strength and subse-quently higher rates of rupture than synthetic prostheses.59 They also have varying degrees of tensile strength and tissue biocom-patibility between them. In ventral hernia repairs, xenograft material was associated with a lower rate of recurrence than allograft material.60 A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel


Surgery_Schwartz

Surgery_Schwartz. A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel adversely affects rates of infec-tion and incorporation. While new prosthetic materials continue to be developed, no single biologic warrants routine use. These materials will continue to evolve, and they remain an important tool for challenging cases when used judiciously.Fixation Technique. Independent of prosthesis material, the method of its fixation remains disputed. Suturing, stapling, and tacking prostheses entail tissue perforation, which may cause inflammation, neurovascular injury, and chronic pain devel-opment. Conversely, improper prosthesis fixation may result in mesh migration, repair failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk


Surgery_Schwartz

Surgery_Schwartz. failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk for entrapment neuropathy. For hernias repaired via a strictly preperitoneal approach, prosthesis fixation may not be necessary at all.Fibrin glue fixation is a successful alternative to tack fixation in hernia repair with a synthetic prosthesis. Recent studies comparing fibrin glue fixation and suture fixation in open hernia repair show superior rates of chronic pain with both Lichtenstein and Plug and Patch techniques.62,63 Meta-analyses of endoscopic hernia repair determined the incidence of chronic postoperative pain after tacker fixation was significantly higher than after fibrin glue fixation, with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising


Surgery_Schwartz

Surgery_Schwartz. with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising technical refinement, and several studies have shown long-term benefit; however, its questionable efficacy in larger hernias and cost remain considerations.In TEP repairs, fixation of mesh may not be compulsory. A prospective randomized trial comparing fixation and no fixation in TEP repairs found a significant increase in new pain and equiv-alent recurrence rates in the fixation group several months after repair.64 A 2012 meta-analysis comparing laparoscopic tacker mesh fixation to no mesh fixation found no statistically signifi-cant differences in operative duration, pain, mesh-related compli-cations, recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar


Surgery_Schwartz

Surgery_Schwartz. recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar results.66 In the preperitoneal approach, the reapproxi-mation of surrounding tissues and physiologic intra-abdominal pressure hypothetically prevent mesh migration. Due to higher theoretical risk of mesh migration, repair without fixation is not recommended for anterior or transperitoneal approaches.COMPLICATIONSAs with other clean operations, the most common complications of inguinal hernia repair include bleeding, infection, seroma, urinary retention, ileus, and injury to adjacent structures (Table 37-6). Complications specific to herniorrhaphy include hernia recurrence, chronic inguinal and pubic pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain,


Surgery_Schwartz

Surgery_Schwartz. pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence should be considered. Com-mon medical issues associated with recurrence include malnu-trition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue Brunicardi_Ch37_p1599-p1624.indd 161829/01/19 2:04 PM 1619INGUINAL HERNIASCHAPTER 37Table 37-6Complications of groin hernia repairsRecurrenceChronic groin pain Nociceptive Somatic Visceral Neuropathic Iliohypogastric Ilioinguinal Genitofemoral Lateral cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound


Surgery_Schwartz

Surgery_Schwartz. cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound infectionSeromaHematoma Wound Scrotal RetroperitonealOsteitis pubisProsthetic complications Contraction Erosion Infection Rejection FractureLaparoscopic Vascular injury Intra-abdominal Retroperitoneal Abdominal wall Gas embolism Visceral injury Bowel perforation Bladder perforation Trocar site complications Hematoma Hernia Wound infection Keloid Bowel obstruction Trocar or peritoneal closure site hernia Adhesions Miscellaneous Diaphragmatic dysfunction HypercapniaGeneral Urinary Paralytic ileus Nausea and vomiting Aspiration pneumonia Cardiovascular and respiratory insufficiencyischemia, infection, and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is


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Surgery_Schwartz. and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood ves-sels, and nerves. After an initial anterior approach, the posterior endoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair.PainPain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain


Surgery_Schwartz

Surgery_Schwartz. (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction. Treat-ment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of direct nerve dam-age or entrapment. It may present early or late, and it mani-fests as a localized, sharp, burning, or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anes-thetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69


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Surgery_Schwartz. as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69 Despite the significant anatomic variation in the three inguinal nerves, literature reviews suggest identification of all three nerves is possible in 70% to 90% of cases.70 Meticulous nerve identification may prevent injury that results in debilitating chronic postoperative pain syndromes. Notwithstanding, moderate-to-severe pain adversely affects physical activity, social interactions, health care utilization, employment, and productivity in 6% to 8% of patients.67,68,71-74 Pain in this subset of patients comprises a tremendous individ-ual and societal burden.Postherniorrhaphy inguinodynia is a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh


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Surgery_Schwartz. a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh and fixation material, and revision of the repair are the three most common options for treatment. Nevertheless, anatomic variation and cross-innervation of the inguinal nerves in the retroperitoneum and inguinal canal make selective neurectomy less reliable.75-78 When inguinodynia is refractory to pharmacologic and interven-tional measures, triple neurectomy with removal of meshoma is routinely performed with acceptable outcomes in the majority of patients.74,76,77,79-84 Refractory inguinodynia with concurrent orchialgia also requires resection of the paravasal nerves.84A relatively newly described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric


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Surgery_Schwartz. described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric nerves and additional division of the genitofemoral nerve in the lumbar plexus.84,85 Several studies with moderate numbers of patients treated showed dura-ble reduction in pain scores.Other chronic pain syndromes include local nerve entrapment, meralgia paresthesia, and osteitis pubis. At greatest Brunicardi_Ch37_p1599-p1624.indd 161929/01/19 2:04 PM 1620SPECIFIC CONSIDERATIONSPART IIrisk of entrapment are the ilioinguinal and iliohypogastric nerves in anterior repairs and the genitofemoral and lateral femoral cutaneous nerves in endoscopic repairs. Clinical manifestations of nerve entrapment mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent


Surgery_Schwartz

Surgery_Schwartz. mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent paresthesia of the lateral thigh. Initial treatment of nerve entrapment consists of rest, ice, NSAIDs, physical therapy, and possible local corticosteroid and anesthetic injection. This can be followed by a trial of gabapentin86 or its analogues. Osteitis pubis is characterized by inflammation of the pubic symphysis and usually presents as medial groin or symphyseal pain that is reproduced by thigh adduction. Avoiding the pubic periosteum when placing sutures and tacks reduces the risk of developing osteitis pubis. CT scan or MRI excludes hernia recurrence, and bone scan is confirmatory for the diagnosis. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage.


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Surgery_Schwartz. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. Irrespective of treatment, the condition often takes six months to resolve.87Cord and Testes InjuryInjury to spermatic cord structures may result in ischemic orchitis or testicular atrophy. Ischemic orchitis is most com-monly caused by injury to the pampiniform plexus and not to the testicular artery. It usually manifests within 1 week of ingui-nal hernia repair as an enlarged, indurated, and painful testis, and it is almost certainly self-limited. It occurs in <1% of pri-mary hernia repairs; however, this figure is larger for recurrent inguinal hernia repairs.88 US will demonstrate testicular blood flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is


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Surgery_Schwartz. flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is manifest over a protracted period but does not always lead to testicular necrosis. This is because despite compromise of the artery, there is collateral flow from the inferior epigastric, vesi-cal, prostatic, and scrotal arteries that supply the testes, and in the case of insufficiency, there is atrophy. Treatment for isch-emic orchitis most frequently consists of reassurance, NSAIDs, and comfort measures. Intraoperatively, proximal ligation of large hernia sacs to avoid cord manipulation minimizes the risk of injury.Injury to the vas deferens within the cord may lead to infertility. In open inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a


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Surgery_Schwartz. inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a crush injury. Transections of the vas deferens should be addressed with a urologic consult and early anastomosis, if possible. Historically, surgeons and their patients speculated that synthetic material would increase the risks of mesh rejection, carcinogenesis, and inflammation; however, as mesh became used more frequently, these concerns did not manifest. Nevertheless, one study found prosthetic mesh may exert long-term deleterious effects upon the vas deferens, causing azoospermia.89 Similar studies report varied results, though. A recent prospective study from the Swedish Hernia Registry discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may


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Surgery_Schwartz. discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may lead to vas deferens obstruction, resulting in decreased fertility rates and a dysejaculation syndrome. Pain and burning during ejaculation are usually self-limited, and more common causes, such as sexually transmitted diseases, should be excluded.In females, the round ligament is the analog to the sper-matic cord, and it maintains uterine anteversion. Injury to the artery of the round ligament does not result in clinically signifi-cant morbidity.Laparoscopic ComplicationsIn general, the risks of the TEP technique mirror those of open anterior repairs, as the peritoneal space is not violated. Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and


Surgery_Schwartz

Surgery_Schwartz. Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and pneumothorax. The most common complications of endoscopic inguinal hernia repair are presented in this section.Urinary Retention. The most common cause of urinary reten-tion after hernia repair is general anesthesia, which is routine in endoscopic hernia repairs. Among 880 patients undergoing inguinal hernia repair with local anesthesia only, 0.2% devel-oped urinary retention, while the rate of urinary retention was 13% among 200 patients undergoing repair with general or spinal anesthesia.91 Overall, the risk of development of postop-erative urinary retention is 2% to 3%.92-95 Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with


Surgery_Schwartz

Surgery_Schwartz. factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with short-term catheterization. Patients will generally require an overnight admission and trial of normal voiding before discharge. Failure to void normally requires reinsertion of the catheter for up to a week. Chronic requirement of a urinary catheter is rare, though older patients may require prolonged catheterization. Risk of urinary retention can be minimized by ensuring voiding prior to surgery and minimization of perioperative fluid administration.96Ileus and Bowel Obstruction. The laparoscopic transab-dominal approach is associated with a higher incidence of ileus than other modes of repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be


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Surgery_Schwartz. repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be helpful to confirm the diagnosis and to exclude bowel obstruction. Prolonged absence of bowel function, in conjunction with a suspicious abdominal series, should raise concern for obstruction. In this case, CT of the abdomen is helpful to distinguish anatomic sites of obstruc-tion, inflammation, and ischemia. In TAPP repairs, obstruction occurs most commonly secondary to herniation of bowel loops through peritoneal defects or large trocar insertion sites; how-ever, the use of smaller trocars and the preponderance of TEP repairs have reduced the frequency of this complication. True obstruction warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may


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Surgery_Schwartz. warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may predispose to visceral injuries. Direct bowel injuries may also result from tro-car placement. In reoperative abdominal surgery, open Hasson technique and direct visualization of trocars are recommended to reduce the likelihood of visceral injury. Bowel injury may also occur secondary to electrocautery and instrument trauma outside of the camera field. Missed bowel injuries are associated with increased mortality. If injury to the bowel is suspected, its entire length should be examined, and conversion to open repair may be necessary.Brunicardi_Ch37_p1599-p1624.indd 162029/01/19 2:04 PM 1621INGUINAL HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions.


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Surgery_Schwartz. HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions. As with bladder injuries encountered in open surgery, cystotomies must be repaired in several layers with 1 to 2 weeks of Foley catheter decompression. A confirmatory cystogram may be performed before catheter removal to confirm healing of the injury.Vascular Injury. The most severe vascular injuries usually occur in iliac or femoral vessels, either by misplaced sutures in anterior repairs, endoscopic tacker use, or by trocar injury or direct dissection in laparoscopic repairs. In these cases, exsan-guination may be swift. Conversion to an open approach may be necessary, and bleeding should be temporarily controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac


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Surgery_Schwartz. controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac arter-ies. Although apparent upon initial approach, these vessels may be obscured during mesh positioning, and tacks or staples may injure them. Oftentimes, due to tamponade effect, injury to the inferior epigastric vessels is not apparent until the adjacent tro-car is removed. If injured, the inferior epigastrics may be ligated with a percutaneous suture passer or endoscopic vessel clips.If the tissue pressure exerted by pneumoperitoneum is greater than an injured vessel’s hydrostatic intraluminal pres-sure, bleeding will not manifest until pneumoperitoneum is released. The presentation of an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative


Surgery_Schwartz

Surgery_Schwartz. an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative consideration.Hematomas and SeromasHematomas may present as localized collections or as dif-fuse bruising over the operative site. Injury to spermatic cord vessels may result in a scrotal hematoma. Although they are self-limited, characteristic dark blue discoloration of the entire scrotum may alarm patients. Intermittent warm and cold com-pression aids in resolution. Hematomas may also develop in the incision, retroperitoneum, rectus sheath, and peritoneal cavity. The latter three sites are more frequently associated with lapa-roscopic repair. Bleeding within the peritoneum or preperitoneal space may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid


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Surgery_Schwartz. may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid collections that most commonly develop within one week of synthetic mesh repairs. Large hernia sac remnants may fill with physiologic fluid and mimic seromas. Patients often mistake seromas for early recurrence. Treatment consists of reassurance and warm compression to accelerate resolution. To avoid secondary infection, seromas should not be aspirated unless they cause discomfort or they restrict activ-ity for a prolonged time.OUTCOMESThe incidence of recurrence is the most-cited measure of post-operative outcome following inguinal hernia repair. In evaluat-ing the various available techniques, other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various


Surgery_Schwartz

Surgery_Schwartz. other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair.Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. A 2012 meta-analysis from the Cochrane database demonstrated significantly lower rates of hernia recurrence (OR 0.62, CI 0.45–0.85) in patients undergoing Shouldice operations when compared with other open tissue-based methods.97 In experienced hands, the overall recurrence rate for the Shouldice repair is about 1%.98 Although it is an elegant procedure, its meticulous nature requires significant technical expertise to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5%


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Surgery_Schwartz. to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5% after surgeons performed the repair six times.99 Compared with mesh repairs, the Shouldice technique resulted in significantly higher rates of recurrence (OR 3.65, CI 1.79–7.47); however, it is the most effective tissue-based repair when mesh is unavailable or contraindicated.97Hernia recurrence is drastically reduced as a result of the Lichtenstein tension-free repair.100 Compared with open elective tissue-based repairs, mesh repair is associated with fewer recur-rences (OR 0.37, CI 0.26–0.51) and with shorter hospital stay and faster return to usual activities.101,102 In a multi-institutional series, 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most


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Surgery_Schwartz. 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most commonly performed procedure worldwide. Meta-analysis demonstrates no significant differences in out-comes between the Lichtenstein and the Plug and Patch tech-niques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases.101,104,105 The Stoppa technique results in longer operative duration than the Lichtenstein technique. Nevertheless, postop-erative acute pain, chronic pain, and recurrence rates are similar between the two methods.106 Perhaps the most compelling advan-tage of the Lichtenstein technique is that nonexpert surgeons rapidly achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal


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Surgery_Schwartz. achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal hernias as the preferred open technique.102 Com-pared to open approaches, endoscopic primary inguinal hernia repair produces equivalent recurrence rates and improved recov-ery time, pain prevention, and return to normal activities.107 In a study of 168 patients randomized to either TEP or Lichtenstein repair, the 5-year recurrence rates were extremely low in both groups.108,109 Similarly, a study of 200 male patients randomized to either ambulatory TEP or Lichtenstein repair demonstrated no recurrences in either group after one year.110 Because endoscopic surgery requires specialized instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the


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Surgery_Schwartz. instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the long-term.Perhaps the most salient difference between open and endo-scopic techniques is the number of cases needed to develop techni-cal proficiency. In a randomized controlled trial performed by the VA Cooperative Study, two-year recurrence rates were 10.1% in patients undergoing endoscopic repair and 4.9% in those undergo-ing open repair, and the outcomes of endoscopic repairs improved after each surgeon performed at least 250 cases.111 More recently, Lal and colleagues found that surgeons sustained a decrease from 9% to 2.9% in postoperative recurrences after performing 100 TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC


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Surgery_Schwartz. TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC CONSIDERATIONSPART IIto 100 cases; however, this estimate has decreased precipitously since laparoscopic technique was first introduced.111,113,114Although controversy persists regarding the utility of TEP versus TAPP, reviews to date find no significant differences in operative duration, length of stay, time to recovery, or short-term recurrence rate between the two approaches. In TAPP repair, the risk of intra-abdominal injury is higher than in TEP repair. This finding prompted the IEHS to recommend TAPP should only be attempted by surgeons with sufficient experience.49 A Cochrane systematic review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however,


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Surgery_Schwartz. review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however, neither finding was sufficiently compelling to recommend one technique over the other.114The frequency with which the aforementioned ingui-nal hernia repair techniques are performed reinforces the importance of broad experience. The authors recommend that surgeons become proficient in several techniques to address dif-ferent manifestations of inguinal hernias. Surgeons should tailor this experience to optimize outcomes for each patient.REFERENCESEntries highlighted in bright blue are key references. 1. National Center for Health Statistics. National Hospital Discharge Survey and National Survey of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in


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Surgery_Schwartz. of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in western Jerusalem. J Epidemiol Community Health. 1978;32(1):59-67. 3. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am 1998;78(6):941-951, v-vi. 4. Johnson J, Roth JS, Hazey JW, et al. The history of open inguinal hernia repair. Curr Surg. 2004;61(1):49-52. 5. Gil J, Rodriguez JM, Hernandez Aguera Q, et al. The usefulness of international cooperation in the repair of inguinal hernias in Sub-Saharan Africa. World J Surg. 2015;39(11):2622-2629. 6. Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert surgeons using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc


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Surgery_Schwartz. using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg. 1991;1(5):269-277. 8. Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B, Gockel I. Transabdominal preperitoneal (TAPP) versus Lichtenstein operation for primary inguinal hernia repair—a systematic review and meta-analysis of randomized controlled trials. BMC Surg. 2017;17(1):55. 9. Fitzgibbons RJ, Jr, Salerno GM, Filipi CJ, Hunter WJ, Watson P. A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Ann Surg. 1994;219(2):144-156. 10. Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal


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Surgery_Schwartz. onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2(1):53-58. 12. Dulucq JL. Treatment of inguinal hernia by insertion of a subperitoneal patch under pre-peritoneoscopy (in French). Chirurgie. 1992;118(1-2):83-85. 13. Burcharth J, Pommergaard HC, Rosenberg J. The inheritance of groin hernia: a systematic review. Hernia. 2013;17(2):183-189. 14. Van Wessem KJ, Simons MP, Plaisier PW, Lange JF. The etiology of indirect inguinal hernias: congenital and/or acquired? Hernia. 2003;7(2):76-79. 15. Weaver KL, Poola AS, Gould JL, Sharp SW, St Peter SD, Holcomb GW 3rd. The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain


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Surgery_Schwartz. inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain risk factors. Eur J Epidemiol. 1992;8(2):277-282. 17. Lau H, Fang C, Yuen WK, Patil NG. Risk factors for inguinal hernia in adult males: a case-control study. Surgery. 2007;141(2):262-266. 18. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. 2007;165(10):1154-1161. 19. Klinge U, Binnebösel M, Mertens PR. Are collagens the culprits in the development of incisional and inguinal hernia disease? Hernia. 2006;10(6):472-477. 20. Franz MG. The biology of hernias and the abdominal wall. Hernia. 2006;10(6):462-471. 21. Ralphs DN, Brain AJ, Grundy DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect


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Surgery_Schwartz. DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg. 1994;81(2):250. 23. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11-18. 24. Jamadar DA, Jacobson JA, Morag Y, et al. Sonography of inguinal region hernias. AJR Am J Roentgenol. 2006;187(1): 185-190. 25. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 2011;31(2):E1-E12. 26. van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al.


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Surgery_Schwartz. of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. Watch-ful waiting vs repair of inguinal hernia in minimally symp-tomatic men: a randomized clinical trial. JAMA. 2006;295(3): 285-292. 28. Chen T, Zhang Y, Wang H, et al. Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital. BMC Anesthesiol. 2015;16:17. 29. van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgical repair of an asymptomatic groin hernia appropriate? A review. Hernia. 2011;15(3):251-259. 30. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. 2012;147(3):277-281. 31. Thompson JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1


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Surgery_Schwartz. JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014;18(2):151-163. 33. Law NW, Trapnell JE. Does a truss benefit a patient with inguinal hernia? BMJ. 1992;304(6834):1092. 34. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991;78(10): 1171-1173. 35. Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg. 2007;245(4):656-660.Brunicardi_Ch37_p1599-p1624.indd 162229/01/19 2:04 PM 1623INGUINAL HERNIASCHAPTER 37 36. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients


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Surgery_Schwartz. Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg. 2012;78(3):359-365. 38. Delikoukos S, Lavant L, Hlias G, Palogos K, Gikas D. The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: a prospective randomized study. Hernia. 2007;11(5):425-428. 39. Desarda MP. Inguinal herniorrhaphy with an undetached strip of external oblique aponeurosis: a new approach used in 400 patients. Eur J Surg. 2001;167(6):443-448. 40. Desarda MP. New method of inguinal hernia repair: a new solution. ANZ J Surg. 2001;71(4):241-244. 41. Desarda MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the


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Surgery_Schwartz. MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open “tension-free” hernioplasty. Am J Surg. 1993;165(3):369-371. 43. Gilbert AI. Sutureless repair of inguinal hernia. Am J Surg. 1992;163(3):331-335. 44. Millikan KW, Cummings B, Doolas A. The Millikan modified mesh-plug hernioplasty. Arch Surg. 2003;138(5):525-529; discussion 529-530. 45. Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg. 2002;184(1):6-10. 46. Antunes AA, Dall’oglio M, Crippa A, Srougi M. Inguinal hernia repair with polypropylene mesh during radical retropubic prostatectomy: an easy and practical approach. BJU Int. 2005;96(3):330-333. 47. Lee BC, Rodin DM, Shah KK, Dahl DM. Laparoscopic inguinal hernia repair during laparoscopic radical prostatectomy. BJU Int.


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Surgery_Schwartz. an easy and practical approach. BJU Int. 2005;96(3):330-333. 47. Lee BC, Rodin DM, Shah KK, Dahl DM. Laparoscopic inguinal hernia repair during laparoscopic radical prostatectomy. BJU Int. 2007;99(3):637-639. 48. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society [IEHS]). Surg Endosc. 2011;25(9):2773-2843. 49. Bittner R, Montgomery MA, Arregui E, et al. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc. 2015;29(2):289-321. 50. Waite KE, Herman MA, Doyle PJ. Comparison of robotic versus laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. J Robot Surg. 2016;10(3):239-244. 51. Higgins RM, Frelich MJ, Bosler ME, Gould JC. Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. 2017;31(1):185-192. 52. Kolachalam R, Dickens E, D’Amico L, et


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Surgery_Schwartz. RM, Frelich MJ, Bosler ME, Gould JC. Cost analysis of robotic versus laparoscopic general surgery procedures. Surg Endosc. 2017;31(1):185-192. 52. Kolachalam R, Dickens E, D’Amico L, et al. Early outcomes of robotic-assisted inguinal hernia repair in obese patients: a multi-institutional, retrospective study. Surg Endosc. 2018;32(1):229-235. 53. Iraniha A, Peloquin J. Long-term quality of life and outcomes following robotic assisted TAPP inguinal hernia repair. J Robot Surg. 2018;12(2):261-269. 54. Pickett LC. Prosthetic choice in open inguinal hernia repair. In: Jacob BP, Ramshaw B, eds. The SAGES Manual of Hernia Repair. New York: Springer; 2013:19-26. 55. Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavy-weight mesh in open inguinal hernia repair. Br J Surg. 2012;99(1):29-37. 56. Sorensen CG, Rosenberg J. The use of sterilized mosquito nets for hernioplasty: a systematic review. Hernia. 2012;16(6): 621-625. 57. Luboga


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Surgery_Schwartz. inguinal hernia repair. Br J Surg. 2012;99(1):29-37. 56. Sorensen CG, Rosenberg J. The use of sterilized mosquito nets for hernioplasty: a systematic review. Hernia. 2012;16(6): 621-625. 57. Luboga S, Macfarlane SB, von Schreeb J, et al. Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med. 2009;6(12):e1000200. 58. Jacobs DO. Improving surgical services in developing nations: getting to go. World J Surg. 2010;34(11):2509-2510. 59. Earle DB, Mark LA. Prosthetic material in inguinal hernia repair: how do I choose? Surg Clin North Am. 2008;88(1):179-201. 60. Beale EW, Hoxworth RE, Livingston EH, Trussler AP. The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature. Am J Surg. 2012;204(4):510-517. 61. Smart NJ, Bloor S. Durability of biologic implants for use in hernia repair: a review. Surg Innov.


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Surgery_Schwartz. reconstruction: a systematic review of the current literature. Am J Surg. 2012;204(4):510-517. 61. Smart NJ, Bloor S. Durability of biologic implants for use in hernia repair: a review. Surg Innov. 2012;19(3):221-229. 62. Campanelli G, Sfeclan C, Cavalli M, Biondi A. Reducing postoperative pain: the use of Tisseel for mesh fixation in inguinal hernia repair. Surg Technol Int. 2012;22:134-139. 63. Fortelny RH, Petter-Puchner AH, Glaser KS, Redl H. Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review. Surg Endosc. 2012;26(7):1803-1812. 64. Taylor C, Layani L, Liew V, Ghusn M, Crampton N, White S. Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial. Surg Endosc. 2008;22(3):757-762. 65. Sajid MS, Ladwa N, Kalra L, McFall M, Baig MK, Sains P. A meta-analysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. Am J Surg.


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Surgery_Schwartz. MS, Ladwa N, Kalra L, McFall M, Baig MK, Sains P. A meta-analysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. Am J Surg. 2013;206(1):103-111. 66. Morrison JE, Jr, Jacobs VR. Laparoscopic preperitoneal inguinal hernia repair using preformed polyester mesh without fixation: prospective study with 1-year follow-up results in a rural setting. Surg Laparosc Endosc Percutan Tech. 2008;18(1):33-39. 67. Aasvang E, Kehlet H. Surgical management of chronic pain after inguinal hernia repair. Br J Surg. 2005;92(7):795-801. 68. Kehlet H. Chronic pain after groin hernia repair. Br J Surg. 2008;95(2):135-136. 69. Reinpold WM, Nehls J, Eggert A. Nerve management and chronic pain after open inguinal hernia repair: a prospective two phase study. Ann Surg. 2011;254(1):163-168. 70. Alfieri S, Amid PK, Campanelli G, et al. International guide-lines for prevention and management of post-operative chronic pain following inguinal hernia surgery.


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Surgery_Schwartz. Ann Surg. 2011;254(1):163-168. 70. Alfieri S, Amid PK, Campanelli G, et al. International guide-lines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011; 15(3):239-249. 71. Callesen T, Beck K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg. 1999;86(12):1528-1531. 72. Bay-Nielsen M, Perkins FM, Kehlet H; Danish Hernia Database. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233(1):1-7. 73. Aasvang EK, Bay-Nielsen M, Kehlet H. Pain and functional impairment 6 years after inguinal herniorrhaphy. Hernia. 2006;10(4):316-321. 74. Aasvang EK, Kehlet H. The effect of mesh removal and selective neurectomy on persistent postherniotomy pain. Ann Surg. 2009;249(2):327-334. 75. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg.


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Surgery_Schwartz. Ann Surg. 2009;249(2):327-334. 75. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001; 108(6):1618-1623. 76. Loos MJ, Scheltinga MR, Roumen RM. Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia. Surgery. 2010;147(2):275-281. 77. Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioinguinal neurectomy for chronic pain. J Neurosurg. 2010;112(4):784-789. 78. Klaassen Z, Marshall E, Tubbs RS, Louis RG, Jr, Wartmann CT, Loukas M. Anatomy of the ilioinguinal and iliohypogastric Brunicardi_Ch37_p1599-p1624.indd 162329/01/19 2:04 PM 1624SPECIFIC CONSIDERATIONSPART IInerves with observations of their spinal nerve contributions. Clin Anat. 2011;24(4):454-461. 79. Starling JR, Harms BA, Schroeder ME, Eichman PL. Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia. Surgery.


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Surgery_Schwartz. nerve contributions. Clin Anat. 2011;24(4):454-461. 79. Starling JR, Harms BA, Schroeder ME, Eichman PL. Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia. Surgery. 1987;102(4):581-586. 80. Starling JR, Harms BA. Ilioinguinal, iliohypogastric, and genitofemoral neuralgia. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernia. Austin, TX: RG Landes Co; 1994: 351-356. 81. Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord. Arch Surg. 2002;137(1):100-104. 82. Kim DH, Murovic JA, Tiel RL, Kline DG. Surgical management of 33 ilioinguinal and iliohypogastric neuralgias at Louisiana State University Health Sciences Center. Neurosurgery. 2005;56(5):1013-1020; discussion 1013-1020. 83. Madura JA, Madura JA 2nd, Copper CM, Worth RM. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients. Am J Surg. 2005;189(3):283-287. 84. Amid


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Surgery_Schwartz. discussion 1013-1020. 83. Madura JA, Madura JA 2nd, Copper CM, Worth RM. Inguinal neurectomy for inguinal nerve entrapment: an experience with 100 patients. Am J Surg. 2005;189(3):283-287. 84. Amid PK, Chen DC. Surgical treatment of chronic groin and testicular pain after laparoscopic and open preperitoneal inguinal hernia repair. J Am Coll Surg. 2011;213(4):531-536. 85. Chen DC, Hiatt JR, Amid PK. Operative management of refractory neuropathic inguinodynia by a laparoscopic ret-roperitoneal approach. JAMA Surg. 2013;148(10):962-967. 86. Benito-Leon J, Picardo A, Garrido A, Cuberes R. Gabapentin therapy for genitofemoral and ilioinguinal neuralgia. J Neurol. 2001;248(10):907-908. 87. LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003;7(2):68-71. 88. Fong Y, Wantz GE. Prevention of ischemic orchitis during inguinal hernioplasty. Surg Gynecol Obstet. 1992;174(5):399-402. 89. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with polypropylene mesh causing inguinal vasal


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Surgery_Schwartz. ischemic orchitis during inguinal hernioplasty. Surg Gynecol Obstet. 1992;174(5):399-402. 89. Shin D, Lipshultz LI, Goldstein M, et al. Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia. Ann Surg. 2005;241(4):553-558. 90. Hallén M, Sandblom G, Nordin P, et al. Male infertility after mesh hernia repair: a prospective study. Surgery. 2011; 149(2):179-184. 91. Finley RK, Jr, Miller SF, Jones LM. Elimination of urinary retention following inguinal herniorrhaphy. Am Surg. 1991;57(8):486-488; discussion 488-489. 92. Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J. Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc. 1999;13(11):1115-1120. 93. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100


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Surgery_Schwartz. and Thoracoscopic Surgery (SALTC). Surg Endosc. 1999;13(11):1115-1120. 93. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc. 2009;23(3):482-486. 94. Kapiris S, Mavromatis T, Andrikopoulos S, Georgiades C, Floros D, Diamantopoulos G. Laparoscopic transabdominal preperitoneal hernia repair (TAPP): stapling the mesh is not mandatory. J Laparoendosc Adv Surg Tech A. 2009;19(3):419-422. 95. Swadia ND. Laparoscopic totally extra-peritoneal inguinal hernia repair: 9 year’s experience. Hernia. 2011;15(3):273-279. 96. Petros JG, Rimm EB, Robillard RJ, Argy O. Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg. 1991;161(4):431-433; discussion 434. 97. Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev.


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Surgery_Schwartz. Am J Surg. 1991;161(4):431-433; discussion 434. 97. Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2012;(4):CD001543. 98. Glassow F. The Shouldice Hospital technique. Int Surg. 1986;71(3):148-153. 99. Kingsnorth AN, Britton BJ, Morris PJ. Recurrent inguinal hernia after local anaesthetic repair. Br J Surg. 1991;68(4):273-275. 100. Lichtenstein IL, Shulman AG, Amid PK. Use of mesh to prevent recurrence of hernias. Postgrad Med. 1990;87(1):155-158, 160. 101. Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev. 2002;(4):CD002197. 102. Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal her-nia in adult patients. Hernia. 2009;13(4):343-403. 103. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for primary inguinal hernias:


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Surgery_Schwartz. guidelines on the treatment of inguinal her-nia in adult patients. Hernia. 2009;13(4):343-403. 103. Shulman AG, Amid PK, Lichtenstein IL. The safety of mesh repair for primary inguinal hernias: results of 3,019 operations from five diverse surgical sources. Am Surg. 1992;58(4):255-257. 104. Kingsnorth AN, Porter CS, Bennett DH, Walker AJ, Hyland ME, Sodergren S. Lichtenstein patch or Perfix plug-and-patch in inguinal hernia: a prospective double-blind randomized controlled trial of short-term outcome. Surgery. 2000;127(3):276-283. 105. Li J, Ji Z, Li Y. Comparison of mesh-plug and Lichtenstein for inguinal hernia repair: a meta-analysis of randomized controlled trials. Hernia. 2012;16(5):541-548. 106. Willaert W, De Bacquer D, Rogiers X, Troisi R, Berrevoet F. Open preperitoneal techniques versus lichtenstein repair for elective inguinal hernias. Cochrane Database Syst Rev. 2012;(7):CD008034. 107. McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration.


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Surgery_Schwartz. versus lichtenstein repair for elective inguinal hernias. Cochrane Database Syst Rev. 2012;(7):CD008034. 107. McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic tech-niques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003;(1):CD001785. 108. Andersson B, Hallén M, Leveau P, Bergenfelz A, Westerdahl J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: a prospective randomized controlled trial. Surgery. 2003;133(5):464-472. 109. Hallén M, Bergenfelz A, Westerdahl J. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair: long-term follow-up of a randomized controlled trial. Surgery. 2008;143(3):313-317. 110. Lau H, Patil NG, Yuen WK. Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial. Surg Endosc. 2006;20(1):76-81. 111. Neumayer L,


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Surgery_Schwartz. extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial. Surg Endosc. 2006;20(1):76-81. 111. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350(18):1819-1827. 112. Lal P, Kajla RK, Chander J, Ramteke VK. Laparoscopic total extraperitoneal (TEP) inguinal hernia repair: overcoming the learning curve. Surg Endosc. 2004;18(4):642-645. 113. Katkhouda N, Campos GM, Mavor E, Trussler A, Khalil M, Stoppa R. Laparoscopic extraperitoneal inguinal hernia repair. A safe approach based on the understanding of rectus sheath anatomy. Surg Endosc. 1999;13(12):1243-1246. 114. Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for ingui-nal hernia repair. Cochrane Database Syst Rev. 2005;(1): CD004703.Brunicardi_Ch37_p1599-p1624.indd


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Surgery_Schwartz. pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for ingui-nal hernia repair. Cochrane Database Syst Rev. 2005;(1): CD004703.Brunicardi_Ch37_p1599-p1624.indd 162429/01/19 2:04 PM


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Surgery_Schwartz. Thyroid, Parathyroid, and AdrenalGeeta Lal and Orlo H. Clark 38chapterTHYROIDHistorical BackgroundGoiters (from the Latin guttur, throat), defined as an enlarge-ment of the thyroid, have been recognized since 2700 b.c. even though the thyroid gland was not documented as such until the Renaissance period. In 1619, Hieronymus Fabricius ab Aqua-pendente recognized that goiters arose from the thyroid gland. The term thyroid gland (Greek thyreoeides, shield-shaped) is, however, attributed to Thomas Wharton in his Adenographia (1656). In 1776, the thyroid was classified as a ductless gland by Albrecht von Haller and was thought to have numerous func-tions ranging from lubrication of the larynx to acting as a res-ervoir for blood to provide continuous flow to the brain, and to beautifying women’s necks. Burnt seaweed was considered to be the most effective treatment for goiters.The first accounts of thyroid surgery for the treatment of goiters were given by Roger Frugardi in 1170. In


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Surgery_Schwartz. women’s necks. Burnt seaweed was considered to be the most effective treatment for goiters.The first accounts of thyroid surgery for the treatment of goiters were given by Roger Frugardi in 1170. In response to failure of medical treatment, two setons were inserted at right angles into the goiter and tightened twice daily until the goiter separated. The open wound was treated with caustic powder and left to heal. However, thyroid surgery continued to be hazardous with prohibitive mortality rates (>40%) until the latter half of the 19th century, when advances in general anesthesia, antisep-sis, and hemostasis enabled surgeons to perform thyroid sur-gery with significantly reduced mortality and morbidity rates. The most notable thyroid surgeons were Emil Theodor Kocher (1841–1917) and C.A. Theodor Billroth (1829–1894), who per-formed thousands of operations with increasingly successful results. However, as more patients survived thyroid operations, new problems and issues became


Surgery_Schwartz

Surgery_Schwartz. C.A. Theodor Billroth (1829–1894), who per-formed thousands of operations with increasingly successful results. However, as more patients survived thyroid operations, new problems and issues became apparent. After total thyroid-ectomy, patients (particularly children) became myxedematous with cretinous features. Myxedema was first effectively treated in 1891 by George Murray using a subcutaneous injection of an extract of sheep’s thyroid, and later, Edward Fox demonstrated that oral therapy was equally effective. In 1909, Kocher was awarded the Nobel Prize for medicine in recognition “for his works on the physiology, pathology, and surgery of the thyroid gland.”EmbryologyThe thyroid gland arises as an outpouching of the primitive foregut around the third week of gestation. It originates at the base of the tongue at the foramen cecum. Endoderm cells in the floor of the pharyngeal anlage thicken to form the medial thyroid anlage (Fig. 38-1) that descends in the neck anterior to


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Surgery_Schwartz. at the base of the tongue at the foramen cecum. Endoderm cells in the floor of the pharyngeal anlage thicken to form the medial thyroid anlage (Fig. 38-1) that descends in the neck anterior to structures that form the hyoid bone and larynx. During its descent, the anlage remains connected to the foramen cecum via an epithelial-lined tube known as the thyroglossal duct. The epithelial cells making up the anlage give rise to the thyroid fol-licular cells. The paired lateral anlages originate from the fourth branchial pouch and fuse with the median anlage at approxi-mately the fifth week of gestation. The lateral anlages are neu-roectodermal in origin (ultimobranchial bodies) and provide the calcitonin producing parafollicular or C cells, which thus come to lie in the superoposterior region of the gland. Thyroid fol-licles are initially apparent by 8 weeks, and colloid formation begins by the 11th week of gestation.Developmental AbnormalitiesThyroglossal Duct Cyst and Sinus. Thyroglossal


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Surgery_Schwartz. the gland. Thyroid fol-licles are initially apparent by 8 weeks, and colloid formation begins by the 11th week of gestation.Developmental AbnormalitiesThyroglossal Duct Cyst and Sinus. Thyroglossal duct cysts are the most commonly encountered congenital cervical anoma-lies. During the fifth week of gestation, the thyroglossal duct lumen starts to obliterate, and the duct disappears by the eighth week of gestation. Rarely, the thyroglossal duct may persist in whole or in part. Thyroglossal duct cysts may occur anywhere along the migratory path of the thyroid, although 80% are found in juxtaposition to the hyoid bone. They are usually asymptom-atic but occasionally become infected by oral bacteria, prompt-ing the patient to seek medical advice. Thyroglossal duct sinuses Thyroid 1625Historical Background / 1625Embryology / 1625Developmental Abnormalities / 1625Thyroid Anatomy / 1627Thyroid Histology / 1629Thyroid Physiology / 1629Evaluation of Patients With Thyroid Disease / 1633Benign


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Surgery_Schwartz. Background / 1625Embryology / 1625Developmental Abnormalities / 1625Thyroid Anatomy / 1627Thyroid Histology / 1629Thyroid Physiology / 1629Evaluation of Patients With Thyroid Disease / 1633Benign Thyroid Disorders / 1634Solitary Thyroid Nodule / 1641Malignant Thyroid Disease / 1645Parathyroid 1663Historical Background / 1663Embryology / 1663Anatomy and Histology / 1664Parathyroid Physiology and Calcium Homeostasis / 1664Hyperparathyroidism / 1665Hypoparathyroidism / 1681Adrenal 1681Historical Background / 1681Embryology / 1681Anatomy / 1682Adrenal Physiology / 1682Disorders of the Adrenal Cortex / 1685Disorders of the Adrenal Medulla / 1693The Adrenal Incidentaloma / 1695Adrenal Insufficiency / 1697Adrenal Surgery / 1698Brunicardi_Ch38_p1625-p1704.indd 162501/03/19 11:20 AM 1626result from infection of the cyst secondary to spontaneous or surgical drainage of the cyst and are accompanied by minor inflammation of the surrounding skin. Histologically, thyroglos-sal duct cysts are


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Surgery_Schwartz. from infection of the cyst secondary to spontaneous or surgical drainage of the cyst and are accompanied by minor inflammation of the surrounding skin. Histologically, thyroglos-sal duct cysts are lined by pseudostratified ciliated columnar epithelium and squamous epithelium, with heterotopic thyroid tissue present in 20% of cases.The diagnosis usually is established by observing a 1to 2-cm, smooth, well-defined midline neck mass that moves upward with protrusion of the tongue. Routine thyroid imaging is not necessary, although thyroid scintigraphy and ultrasound have been performed to document the presence of normal thy-roid tissue in the neck. Treatment involves the “Sistrunk opera-tion,” which consists of en bloc cystectomy and excision of the central hyoid bone to minimize recurrence. Approximately 1% of thyroglossal duct cysts are found to contain cancer, which is usually papillary (85%). The role of total thyroidectomy in this setting is debated, but it is advised in patients


Surgery_Schwartz

Surgery_Schwartz. Approximately 1% of thyroglossal duct cysts are found to contain cancer, which is usually papillary (85%). The role of total thyroidectomy in this setting is debated, but it is advised in patients with large tumors, particularly if there are additional thyroid nodules and evidence of cyst wall invasion or lymph node metastases.1 Squamous, Hürthle cell, and anaplastic cancers also have been reported but are rare. Medullary thyroid cancers (MTCs) are, however, not found in thyroglossal duct cysts.Lingual Thyroid. A lingual thyroid represents a failure of the median thyroid anlage to descend normally and may be the only thyroid tissue present. Intervention becomes necessary for obstructive symptoms such as choking, dysphagia, airway obstruction, or hemorrhage. Many of these patients develop hypothyroidism. Medical treatment options include administra-tion of exogenous thyroid hormone to suppress thyroid-stim-ulating hormone (TSH) and radioactive iodine (RAI) ablation followed by hormone


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Surgery_Schwartz. hypothyroidism. Medical treatment options include administra-tion of exogenous thyroid hormone to suppress thyroid-stim-ulating hormone (TSH) and radioactive iodine (RAI) ablation followed by hormone replacement. Surgical excision is rarely needed but, if required, should be preceded by an evaluation of normal thyroid tissue in the neck to avoid inadvertently render-ing the patient hypothyroid.Ectopic Thyroid. Normal thyroid tissue may be found any-where in the central neck compartment, including the esopha-gus, trachea, and anterior mediastinum. Thyroid tissue has been observed adjacent to the aortic arch, in the aortopulmonary win-dow, within the upper pericardium, or in the interventricular septum. Often, “tongues” of thyroid tissue are seen to extend off the inferior poles of the gland and are particularly appar-ent in large goiters. Thyroid tissue situated lateral to the carotid sheath and jugular vein, previously termed lateral aberrant thyroid, almost always represents


Surgery_Schwartz

Surgery_Schwartz. the gland and are particularly appar-ent in large goiters. Thyroid tissue situated lateral to the carotid sheath and jugular vein, previously termed lateral aberrant thyroid, almost always represents metastatic thyroid cancer in lymph nodes, and not remnants of the lateral anlage that had Buccalcavity1234EndodermMedian thyroiddiverticulumTracheo-esophageal tube1stpharyngealpouch2nd pouch 3rd pouch 4th pouch Figure 38-1. Thyroid embryology—early development of the median thyroid anlage as a pharyngeal pouch. (Reproduced with permission from Cady B, Rossi R: Surgery of the Thyroid and Para-thyroid Glands. Philadelphia, PA: WB Saunders; 1991.)Key Points1 There has been a paradigm shift in the surgical manage-ment of Graves’ disease with increased use of total or near-total thyroidectomy, rather than subtotal thyroidectomy.2 Familial nonmedullary thyroid cancer is increasingly being recognized as a separate entity. Surgeons must be aware of the potential for false-negative fine-needle


Surgery_Schwartz

Surgery_Schwartz. rather than subtotal thyroidectomy.2 Familial nonmedullary thyroid cancer is increasingly being recognized as a separate entity. Surgeons must be aware of the potential for false-negative fine-needle aspi-ration biopsy in this setting.3 Fine-needle aspiration biopsies are now classified into six groups based on the risk of malignancy associated with each group (Bethesda criteria).4 Encapsulated follicular variants of papillary thyroid can-cers are now designated noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).5 Lobectomy or total/near-total thyroidectomy are consid-ered appropriate treatments for low-risk thyroid cancers. Some small papillary thyroid cancers (<1 cm) can be fol-lowed with active surveillance.6 Focused mini-incision parathyroidectomy, after appropri-ate localization, has become the procedure of choice for the treatment of sporadic primary hyperparathyroidism.7 Parathyroidectomy has been shown to improve the clas-sic and the so-called