Open techniques of inguinal hernia repair

Inguinal hernia repair is one of the oldest and one of the most common procedure performed in general surgery. Inguinal hernia repair amounts to significant costs to health care and society because of the high incidence of the problem. Repair techniques for inguinal hernia has been evolving for the past 130 years and the pace of evolution has accelerated in the last decade. The advent of the tension-free repair and the laparoscopic repair with introduction of the specialized hernia clinics has revolutionized the hernia repair. The traditional suturing techniques include Bassini's, Darning, McVay and Shouldice repairs. Other rarely performed tissue-tissue suture techniques include Lytle repair and Marcy repair technique. The main drawback of the "non-mesh" suture repair procedures is the high incidence of recurrence. Introduction of Marlex mesh in hernia repair in 1959 by Usher et al., did not gain widespread acceptance until 80's till tension-free repair approach by Lichtenstein et al., was introduced. Today prosthetic repairs are accepted to be superior to ?non-mesh? suture repairs. Various prosthetic anterior repair techniques in addition to Lichtenstein repair and its modifications include plug repairs, patch and plug repairs, and double layer devices. Lichtenstein repair technique is considered as "gold standard" by American College of Surgeons. Tension free repair with non-resorbable mesh (polypropylene) has been used in a higher number of cases during the past few years. The original first generation of meshes described for the treatment of hernias were of the heavy type (Prolene®) with a smaller pore size, greater weight/area, lesser elasticity and higher burst pressure. The latter generation of meshes included the light weight meshes (VyproII®) with larger pore size resulting in smaller interface between the mesh and surrounding tissues, low weight per area, greater elasticity and a lower burst pressure. Different techniques are involved in holding the mesh at place. Various methods involved are use of tacks, fibrin glue, and self-gripping (Covidien: ProGrip™) mesh. ProGrip™ meshes offer patients greater comfort following surgery, and allow physicians the ability to position and secure the mesh in less than 60 seconds, thus reducing the operation time. The conventional methods of repair using mesh do not provide sufficient internal ring reinforcement. Internal ring reinforcement is a key step in the repair of indirect inguinal hernias. Recently variation of mesh preperitoneal repair of inguinal hernias has been described. The procedure involves internal ring occlusion and floor support (IROFS) technique of hernia repair. The pioneers of this technique used Marlex mesh, and involves the placement of a piece of rolled mesh in the floor to plug the internal ring in addition to directly stabilizing and counteracting the outward force vectors. The chapter reviews the newer advancements in open inguinal hernia repair techniques and evolution of meshes and other options available for the surgeons in the current era.