Giampiero Campanelli

Several types of 3-dimensional (3D) biological matrices are employed for clinical and surgical applications, but few indications are available to guide surgeons in the choice among these materials. Here we compare the in vitro growth of human primary fibroblasts on different biological matrices commonly used for clinical and surgical applications and the activation of specific molecular pathways over 30 days of growth. Morphological analyses by Scanning Electron Microscopy and proliferation curves showed that fibroblasts have different ability to attach and proliferate on the different biological matrices. They activated similar gene expression programs, reducing the expression of collagen genes and myofibroblast differentiation markers compared to fibroblasts grown in 2D. However, differences among 3D matrices were observed in the expression of specific metalloproteinases and interleukin-6. Indeed, cell proliferation and expression of matrix degrading enzymes occur in the initial steps of interaction between fibroblast and the investigated meshes, whereas collagen and interleukin-6 expression appear to start later. The data reported here highlight features of fibroblasts grown on different 3D biological matrices and warrant further studies to understand how these findings may be used to help the clinicians choose the correct material for specific applications.

Since 1989, the authors have been using the Trabucco tension-free and sutureless technique for the repair of primary groin hernia with a pre-shaped mesh in more than 8,000 surgical procedures for complex and "simple" abdominal and inguinal hernias; over 4,000 cases have been considered in this study. The great majority of these procedures were performed under local anaesthesia and with a complete and careful nerve sparing. Compared to the Lichtenstein's technique, which is currently the golden standard treatment worldwide, there are no significant differences in the observed recurrence rate (below 2%). For the Law of Pascal, the pre-shaped prosthesis developed by Trabucco remains stretched uniformly in the inguinal canal, without the need to be secured with sutures and without forming dead space, which is a cause of infections, pain, and recurrence. The main advantage of a tension-free and sutureless repair is given by the relevant reduction in postoperative chronic neuralgia, which is not an uncommon complication and, depending on its intensity, can also potentially jeopardize a patient's work and social activities. The identification and the sparing of the three nerves of the inguinal region is of crucial importance to reduce the rate of neuralgia in the short and long term. Furthermore, the use of a local anaesthesia imposes the surgeon to properly recognize those nerves and to respect them during the repair. It goes without saying that the complete exposition of the right anatomy of inguinal canal is mandatory. The intentional section of one or more nerves, when it is not technically possible to achieve a satisfactory nerve sparing, or special tricks to create proper fenestrations (small window) on the edge of the prosthesis to prevent the scar tissue to involve the spared nerves, ensures a further reduction of the rate of neuralgia and excellent patient outcomes.

Giant inguinoscrotal hernia are a real challenge for every kind of surgeon. The technique that we adopt is suggested as a good option to deal with this cases. We report our experience in five cases of giant inguinoscrotal hernia with loss of domain from 2005 to 2012. Five patients with hernia that descended below the knees in the standing position, with an anteroposterior diameter not inferior to 30 cm and a laterolateral diameter of about 50 cm. Penis was not visible. We did the same procedure for all the five patients: single pararectus incision extended to groin region until proximal half of scrotum, isolation of the entire large sac out of the scrotal cavity, paying attention to not opening it, progressive reduction of the viscera without opening the sac with the hug technique, as shown in the video, placement of a heavyweight polypropylene meshes in the preperitoneal space, scrotal skin reductive plastic. In three of our five cases we obtained restoration of herniated viscera without resection of them. Orchiectomy was performed in all cases. No general neither wound complications were recorded. Long term follow up ranges from 8 years to 18 months: we did not record recurrence or chronic groin pain and scrotal size is normal in each patient. The technique proposed permits to treat with success giant inguinaoscrotal hernia, avoiding the use of further specific procedure such as the preoperative progressive pneumoperitoneum. All our patients were satisfied with the surgeries and their quality of daily life had definitely improved.

The "sportsman's hernia" commonly presents as a painful groin in those sports that involve kicking and twisting movements while running, particularly in rugby, football, soccer, and ice hockey players. Moreover, sportsman's hernia can be encountered even in normally physically active people. The pain experienced is recognized at the common point of origin of the rectus abdominis muscle and the adductor longus tendon on the pubic bone and the insertion of the inguinal ligament on the pubic bone. It is accepted that this chronic pain caused by abdominal wall weakness or injury occurs without a palpable hernia. We proposed the new name "pubic inguinal pain syndrome." In the period between January 2006 and November 2013 all patients afferent in our ambulatory clinic for chronic groin pain without a clinically evident hernia were assessed with medical history, physical examination, dynamic ultrasound, and pelvic and lumbar MRI. All patients were proposed for a conservative treatment and then, if it was not effective, for a surgical treatment. Our etiopathogenetic theory is based on three factors: (1) the compression of the three nerves of the inguinal region, (2) the imbalance in strength of adductor and abdominal wall muscles caused by the hypertrophy and stiffness of the insertion of rectus muscle and adductor longus muscle, and (3) the partial weakness of the posterior wall. Our surgical procedure includes the release of all three nerves of the region, the correction of the imbalance in strength with the partial tenotomy of the rectus and adductor longus muscles, and the repair of the partial weakness of the posterior wall with a lightweight mesh. This treatment reported excellent results with complete relief of symptoms after resumption of physical activity in all cases.

The new objective in primary hernia surgery should be the reduction of disabling chronic pain. This article will discuss the safety, efficacy, and reduction of pain of a sutureless glue mesh procedure for primary uncomplicated inguinal hernia repair. We began performing sutureless glue mesh repairs in 2004 for primary uncomplicated inguinal hernias with good results. After reduction of the hernia sac, polypropylene medium-weight preshaped flat mesh is fixed to the posterior inguinal wall with 0.5 mL of fibrin glue on the pubic tubercle; another 1.5 mL is sprayed on the entire mesh surface. The cord is positioned in subcutaneous space. The TI.ME.LI (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia repair) trial was planned and conducted based on this experience. In two years, we treated more than 600 primary inguinal hernias with fibrin glue mesh fixation repair. At follow-up (2 to 96 months after surgery), no patients presented with severe pain, 2.7% of patients complained of moderate pain. Fibrin sealant for mesh fixation in open repair is well tolerated and it should be considered as a first-line option for mesh fixation in open inguinal hernia repair.

The use of nonabsorbable prosthetic materials such as polypropylene, polyester, and ePTFE, have expanded and are now widely used in reparative surgery for abdominal wall hernias.

A review of the history of inguinal hernia repair from the far surgical approach performed by Celso, trought the physiological reconstruction of inguinal canal by Bassini and the introduction of the concept of tensionfree repair, to the newest find in this specialist surgery. Nowadays in addition to the choice of approach (open vs laparoscopic, anterior vs preperitoneal), the plane where placing the mesh (in front of the trasversalis fascia vs preperitoneal space), and the fixation device (suture vs sutureless vs glue), surgeons can select among a wide range of prosthesis. Choosing the proper biomaterial can determine the success of an operation and prevent biomaterial-related complications. Indepth knowledge and understanding of the physical properties of the prosthesis, porosity, and pore size in particular are required. Modern advances in hernia repair are credited with reduced recurrence rate, so surgeons' attention is shifted from preventing recurrence to the new topic of chronic pain after surgery.