Surgical Techniques for Inguinal Hernia Repair: Open Techniques—Tissue Repairs
The pathophysiology of inguinal hernia is based primarily on a defect in the myopectineal orifice of Fruchaud (Fig. 8.1), which may be repaired by approximation of tissues together to close the defect (tissue repair) or bridging the defect with a mesh to create a tension-free repair (mesh repair). The rapid development in technology has revolutionized the treatment of hernia repair with the development of the mesh and endoscopic instrumentations which made the posterior approach to the inguinal area accessible, and highly effective in treating the hernia defect. Despite these advances, tissue repair still remains to be an acceptable procedure for some inguinal hernias, particularly in cases where the local condition in the inguinal area is contaminated or potentially contaminated, which contraindicates the use of a foreign material, like the mesh. Besides, some tissue repairs, like the Shouldice repair, have been shown by studies to have a recurrence rate of 1%  and that could be comparable to the tension-free or mesh repair, whether done with the anterior or posterior approach. Based on the guidelines of the European Hernia Society, Shouldice repair is the best non-mesh repair for inguinal hernias . 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 . In a study of McGuillicuddy et al., Shouldice repair can compare with Lichtenstein technique in terms of effectivity. However, in the long-term basis Lichtenstein technique has a shorter learning curve, easier to learn, and could be done also under local anesthesia, with lesser recurrences .
I would like to thank and acknowledge my artist illustrator Dr. Frank Joseph Viray for providing the illustrations in my discussion of the various open techniques of tissue repairs for inguinal hernias.
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