Maximo Deysine

Recurrence is the most common complication of inguinal herniorrhaphy and its mending carries an unacceptably high recurrence rate. During the development of a hernia clinic we initially repaired recurrent inguinal hernias using the Shouldice technique which requires complicated dissection followed by tissue approximation under tension. The necessary tissue exposure may injure anatomical elements incorporated into the scarred tissues. We progressively developed a modality that approaches the hernia sac directly, dissecting it centripetally up to the hernia’s neck which was then occluded with a pre-formed polypropylene plug (233 patients). This technique, used for defects measuring up to 3 cm in diameter minimizes the dissection of tissues not involved in the repair reducing the chances of injury to nerves, vas deferent ducts, and veins. For defects larger than 3 cm, the posterior inguinal wall was mesh-reinforced utilizing the Rives or Kugel approaches (19 patients). The centripetal technique, used in the repair of 233 recurrent inguinal hernias produced three recurrences in a ten-year follow up. Incidences of infection, testicular ischemia, or disabling neuropathy were not observed. In our hands the selective use of the centripetal technique produced good and reproducible results.

Since 1981, 4,029 consecutive inguinal herniorrhaphies (IH) were performed under protocol utilizing several emerging techniques progressively incorporated to lower complication rates. Patients were operated with identical protocols from 1981 to 1988 at a teaching institution (Group A patients) and from 1988 till the present at two community hospitals (Group B patients). Emergent techniques were sequentially incorporated, progressing from a modified Shouldice approach to the Rives technique, Lichtenstein rolled plugs, and finally to the Rutkow–Robbins mesh plug. Several technical as well as aseptic and antiseptic measures were incorporated in the protocol to prevent episodes of wound infection, testicular atrophy, and inguinodynia. A total of 4,029 IH were performed: Group A (1,199 primary and 113 recurrent IH), Group B (2,466 primary and 251 recurrent IH). There were 1,834 IH performed with the Shouldice technique [recurrence rate (RR) 1%], 224 utilizing the Rives technique (RR 0%), the Lichtenstein rolled plug in 47 (RR 0%), and plug mesh in 1,910 (RR 0.23%). One hundred and six recurrent hernias were operated by the Shouldice technique (RR 0%), nine by the Lichtenstein rolled plug (RR 0%), and 233 by the plug-mesh method (RR 0%). Five subfascial wound infections were encountered (0.12%). Testicular ischemia was observed in five (0.12%), all prior to 1983; 32 inconsequential distal hydroceles were seen, all after dividing inguinoscrotal sacs and leaving the distal portion undisturbed. Superficial, self-reabsorbing wound hematoma occurred in 29 patients, and 14 patients suffered from temporary urinary retention. No instances of postoperative neuralgia were observed. Personal and institutional follow-up in both groups evolved from 95.5% for 1 year to 70% after 6 years. There was no mortality. Utilizing evolving techniques, including strict operating room aseptic and antiseptic measures, plus the use of systemic and local antibiotics, inguinal herniorrhaphy can be performed with minimal complications. The plug-mesh technique is presently our technical choice for most primary and recurrent hernias.

The present infection rate of 3 to 4% for inguinal herniorrhaphy should be considered unacceptable. Modern understanding of bacterial film formation, dynamics, and molecular composition should allow the performance of virtually infection-free inguinal and ventral herniorrhaphy. In our service, the reinstitution of accepted and time-tested aseptic regimens combined with antiseptic measures consisting of 1 gram of intravenous cefazolin administered 1 hour before surgery plus frequent wound irrigations with a solution of 80 mg of gentamycin sulphate dissolved in 250 ml of normal saline solution have yielded an infection rate of 0.11% in over 4,000 clean inguinal and 350 clean ventral herniorrhaphies. Our last wound infection occurred in 1983. These results supporting the experience of orthopedic joint replacement suggest that very low postherniorrhaphy infection rates are achievable goals.

Post Mesh Herniorrhaphy Infection [PMHI] occurs between 3 to 4% of inguinal and 8 to 14% of ventral herniorrhaphies producing an unacceptably high morbidity. Before opening a Hernia Clinic, our infection rate was around 5% for “clean” inguinals and 8% for “clean” ventral herniorrhaphies. Starting in 1982 we implemented a stricter operative aseptic protocol plus the per-operative administration of 1 g of intravenous Cefazolin. In addition, wounds were irrigated with a solution containing 80 mgs of Gentamycin Sulphate dissolved in 250 ml of Normal Saline Solution. During a period of 25 years these measures were used in 4300 consecutive “clean “Inguinal and 320 “clean” Ventral herniorrhaphies. Since the implementation of the above-mentioned aseptic and antiseptic steps no further wound infections were encountered. In our hands, the combination of rigorous aseptic operating room routine plus intravenous and topical antibiotics have, up to now, effectively eliminated wound infections in “clean” herniorrhaphy cases.