Acta Chirurgica Mediterranea, 2009, 25: 29 '- G - F - Carbone Editore

Acta Chirurgica Mediterranea, 2009, 25: 29
TRABUCCO’S TECHNIQUE IN THE TREATMENT OF INGUINAL HERNIA: TEN-YEAR EXPERIENCE
GIUSEPPE VADALA’- GIUSEPPINA SANGANI - FILIPPO MUGAVERO - FLAVIA GENTILE - SALVATORE VADALA’
University of Catania - II Chair of Emergency Surgery and P. S. (Head: Prof. G. Vadalà)
SUMMARY
Treatment of inguinal hernia is actually based on the use
of synthetic prothesis. The “tension free technique” of
Lichtenstein and Trabucco represents a gold standard in this
pathology.
The present study demonstrates how the “tension free
technique”, idealized by Lichtenstein, and then modified by
Trabucco is a good treatment than the laparoscopic one.
The A.A. review their experience, from January 2000 to
July 2008; during this period, at the II Chair of Emergency
Surgery University of Catania, they have treated for inguinal
hernia 122 patients. They have performed the hernioplasty with
a “tension free technique” ideated by Lichtestein, and then
modified by Trabucco.
Morbility was only 1%, no mortality.
The Authors think so that the technique adopted is
safety, not expensive and when it is possible, actuated in day
surgery by the use of local anesthesia.
Key words: Inguinal hernia, hernioplasty, tension free technique
Introduction
[Il trattamento dell’ernia inguinale secondo la tecnica di Trabucco: nostra esperienza decennale]
Hernia disease represent about 70% of the
pathology of the abdominal wall.
In Italy the incidence is approximately 15
cases for 1,000 inhabitants, equal to 1, 5%. There is
a clear predominance of males in the presentation
than females (5 to 10:1).
The intervention of hernioplasty is, in fact, the
most frequently performed in the departments of
general surgery (15% of total).
RIASSUNTO
Il trattamento dell’ernia inguinale verte attualmente sull’utilizzo
delle protesi. Le metodiche “tension free” di Lichtenstein
prima e di Trabucco poi, con le loro varianti, rappresentano
oggigiorno un punto fermo per la chirurgia erniaria (1) .
Abbiamo analizzato retrospettivamente la nostra esperienza
comprendente il periodo gennaio 2000- luglio 2008,
durante il quale, presso la II Cattedra di Chirurgia D’Urgenza
e Pronto Soccorso, sono stati sottoposti ad intervento chirurgico
per ernia inguinale 122 pazienti. In tutti i pazienti abbiamo
utilizzato l’intervento di alloplastica secondo le metodiche “tension
free”, ideato da Lichtenstein e poi modificato da
Trabucco (2) . La percentuale di recidive pervenute alla nostra
osservazione fino al luglio 2008 è stata dell'1% (1 solo caso). In
6 casi (4,9%) si sono rilevate complicanze minori.
Ambedue le metodiche sembrano pertanto rispondere in
maniera ottimale a criteri di sicurezza, efficacia e limitato costo
socio-economico, nonché la possibilità di conduzione in anestesia
locale dell’intervento
Risulta pertanto molto discutibile il tentativo, secondo la
nostra esperienza, di allargare anche all’ernia le indicazioni
della “chirurgia laparoscopica” o mini-invasiva. In questa tipologia
di intervento infatti la tecnica è certamente più complessa,
costosa e sicuramente molto più aggressiva rispetto alla chirurgia
aperta.
Parole chiave: Ernia inguinale, ernioplastica, tecnica tension
free
Material and methods
In the period between January 1998 and July
2008, at the II Chair of Emergency Surgery and
First Aid of Catania University, 122 patients were
treated for inguinal hernia disease.
The average age was 52 years (range 10-84
years); in all patients it was used the intervention
of halloplastic according to "tension free technique”,
performed by Lichtenstein and then modified
by Trabucco (2) (fig.1, 2).

30 G. Vadalà - G. Sangani et Al
Trabucco Hernia Institute
29-22 30th AVE. New York, NY
Ermanno E. Trabucco M.D.
Fig. II: Plano of positioning
mesh.
Fig. I: Text about
Trabucco’s technique.
In most cases it is used the local anesthesia or
under specific conditions, if required by the patient,
spinal or general anesthesia.
The intervention was carried out always following
the technique described by Trabucco. The average
duration was 55 minutes. The main points are:
• a singular administration of a cephalosporin
immediately before the intervention (short term
therapy);
• Infiltration for anatomical plans, step by
step, of structures with an average use of 40 cc of
anesthetic solution of Carbocaina, this method facilitates
the preparation of anatomical, exploiting the
effect of “hydrodissection” due to the anesthetic
mixture;
• Transverse para-inguinal skin incision, of
about 10 cm;
• Opening of the external oblique muscle aponeurosis,
after sub fascial infiltration of about 3 ml.
of carbocaina in order to anesthetize and isolate ileo
inguinal and ileo ipogastric nerves;
• Opening of the external inguinal ring and
dissection of the elements contained in the channel
(deferential duct and sperm vessels);
• Isolation of the hernia, that can be closed,
opened or resected; positioning, in the internal
inguinal ring, of a “plug” conformed to cigarette
and folded “V” this is possible to be fixed, to prevent
migration, between internal oblique-transverse
muscle and inguinal ligament;
• Use of a polypropylene mesh cut for the passage
of the spermatic funicle and its components;
• It is possible to fix the mesh to the pubic
tubercle, to the Poopart’s ligament and to the external
oblique muscle fascia after closing the tails
behind the passage of the funicular;
• Closure of the fascia of the external oblique
muscle with two semi continuous suture of non
absorbable material (prolene 3 / 0);
• Closure of the skin with intradermic suture
or with metal clips.
Of the 122 patients with inguinal hernia operated
by the “tension free” technique according to
Trabucco, only 1 patient presented a relapse in the
subsequent two years: the relapse at the tubercle of
the pubis was caused by a too small mesh and by a
not concomitant treatment of direct hernia.
No major intra-and post-operative complication
occurred.
In 6 cases (4.9%) minor complications were
detected as follows: 4 patients had a sieroma, 2 an
hematoma. In each case, the resolution is achieved
by drainage, without removing the mesh.
Postoperative pain was easily controlled with
Ketorolac 30 mg fl/im.
The functional recovery was very rapid (24
hours average) for all patients. The average postoperative
hospital stay was between 1 and 5 days. The
follow-up was performed from 6 months to 5 years
without signs of note, and no hernia recurrence.
The percentage of recurrences was 1% of
cases. This result appears contrary to that described
in the literature for the method of Bassini which
give 15-20% of recurrences, even if they were reduced
with the changes made by Postemsky and Mac
Vay.
Discussion
The first codified treatment for hernia disease
was described by Bassini, in 1884 (3,4) .
Until some years ago, this technique has been
used from many surgeons (5, 6) .
In 1983 Madden published a masterly on the
hernia surgery, reaffirming the validity of Bassini’s
method.

Trabucco’s technique in the treatment of Inguinal Hernia: ten-year experience 31
The complications secondary to this method
(high incidence of recurrence) were due to the
increase in tissue’s tension with consequent instability
of the sutures, had brought, in the last years, to
search alternative technique “tension free” as
McVay, Postemsky, Shouldice (4, 7) .
The real revolution came in 1974 with the studies
of Lichtenstein (9,10, 1) about synthetic materials
(mersylene, polypropylene, etc..) and their routine use
as prosthetic material. These materials with which
meshes were made given at first time many reactions
(rejection even after years), that limited their use.
Some French Authors had realize the importance
of the “biologically inert” materials so “steel
meshes”, but their use had many limitations related
to the low ductility of the material and the considerable
inconvenience caused by his visible presence.
Lichtenstein performed a correction of the hernia
defect, under local anesthesia, through the use of
a polypropylene mesh, that allowed a “tension free”
reconstruction of the integrity of the posterior wall
of the inguinal canal (12) . The results were excellent in
terms of compliance, of effectiveness and of morbility
near and far (1-2% of recurrence) and of socioeconomic
aspects. These results are been accepted
by entire scientific world (13,14,15,16) .
Other studies have proposed some variations,
especially relate to the kind of the mesh , to the seat
of his positioning, the type of approach (front or
rear), and the type of anesthesia (17) .
The real innovations were introduced by
Trabucco in 1993, who codified a “tension free” and
“sutureless” hernioplastic (18) which included the use
of a “plug” to fill the defect of the posterior wall of
inguinal canal (2:15). Others A.A. (Stoppa, Rives
etc..) proposed the correction with posterior approach,
were little used because of not satisfying the
needs of minor surgical possible “pollution”.
The surgeon has a choice of treatment options
based on the concept of repair with biomaterials, the
choice between each of them must be guided and
influenced only by the personal experience, since
the effectiveness of each is substantially similar to
the others.
The incidence rate of recurrence with “plug
and mesh method is around 0.5-1% of cases, as in
our experience (2,15) . The ideal surgical procedure is
the technique that combines simplicity with maximum
efficiency.
The use of local anesthesia and the “day surgery”
recovery have an additional element of pleasure
for the patient.
The routine use of prosthetic material has brought
to the total delate of Bassini Postemsky Mac
Vay technique. Methods, first described by
Lichtenstein and then by Trabucco, seem to respond
optimally to the criterions of safety, effectiveness
and limited socio-economical cost.
The only case of a recurrence complained, in
our experience, was due to the failure of the methodology
adopted by us. The mesh used was, in fact,
too small, and didn’t overlap the pubic tubercle.
Trabucco with his concept of “tension free”
plastic, using routinely the plug, have helped to
alleviate recurrences secondary to wall’s collapse.
We use simplex or standard mesh because sometimes
we want to adapt the prothesis to the patient
and not viceversa. Plug’s shape, formed a “V”,
reflects the need to bridge inguinal orifice in an elastic
way without leaving empty spaces. The medial
section of the mesh is useful to the passage of the
funicle without creating areas of weakness and eliminating
the possibility of “guillotine” effect exercised
by the thermal-induced retraction in time.
Considering that among the most feared complications,
prosthesis’s infection is the more
worrying, because it is cause of relapse and septic
issues both local and generalized, some AA, in order
to prevent infection, use a powder of clindamycin or
chemicetina over the mesh, in order to avoiding
responding bacterial prosthetic infection.
“Staphylococcus epidermidis” is in particular (16,
17) , the principle agent of prosthetic sepsis, but, in
general, all the Coag-negative germs generate a glicocalix
(18) , that is a mucosal extracellular substance
extracellular essentially composed of 70% by N-
Acetyl-Glucosamine, and that cements the bacteria
to the prosthesis, creating a barrier to antibiotic penetration.
It thus prevents bacterial colonization, the
first step in the chronic infection of the prosthesis.
Anesthetic infiltration for plans allows a slow
release of anesthetic (20 cc of mepivacaina, 10 cc of
bupivacaina, 20cc of saline and 5 cc of sodium
bicarbonate), and an hydro dissection of the anatomical
structures with good and rapid intervention
conduction. Some A.A. use a gel (Emla), which
when applied well in advance on the skin, provides
excellent pre-and postoperative analgesia.
About External oblique hernias, the technical
changes concern both the plug, both the mesh (19 ).
The plug of polypropylene folded “V”, positioned in
the internal inguinal ring, is fixed with two points:
in this way it retains its function as a stopper, however,
ensuring flexibility and ductility to the structure.

32 G. Vadalà - G. Sangani et Al
The mesh, which is also made of polypropylene,
is modeled to cover the pubis and below the
large muscles medially and superiorly, with side
access to the funicle. We prefer a single sheet rather
than a double because it may cause mechanical prosthetic
infection or give pain. When possible, it must
reconstruct the Cremaster fascia that provides additional
protection to the internal inguinal ring.
In direct hernias, the positioning of the mesh
and the opening is preceded by the anchoring of the
trasversalis fascia that allows optimal distension of
the prothesis.
The opening of trasversalis muscle fascia and
of transverse abdominal muscle aponeurosis, around
the herniary protrusion, promotes fibroblast proliferation.
Conclusions
The modern treatment of herniary disease was
born with the advent of biocompatible prothesis.
“Tension free” methods by Lichtenstein at first,
and then Trabucco, with their variations, are now
accepted for the treatment of herniary surgery (1) .
Both respond optimally to the criteria of safety,
effectiveness and not expensive.
The possibility to conduct operation under
local anesthesia has contributed to the spread of
“day surgery” treatment.
We can conclude, in accord with the results
from our experience, comforted by the international
literature, that the “tension-free” technique by
Trabucco can be considered the gold standard for
the treatment of inguinal hernia.
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_________
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Prof. GIUSEPPE VADALÀ
Via Aloisio 20
95124 Catania
(Italy)