20Wojciech Szczęsny et al.fluids <strong>and</strong> tissues.– must be chemically inactive, must not induce foreignbody response or ,inflammatory reaction.– must not be carcinogenic <strong>and</strong> hypoallergenic.– must show mechanical strength, be sterilizable <strong>and</strong>infection resistant.A material meeting all of the above criteria has notyet been synthesized, however many materials approachthis ideal (polyester, polypropylene, Teflon-PTFE).In 1944, French surgeons Aquaviva <strong>and</strong> Bounet reportedtheir experiences with nylon meshes shapedsimilarly to present-day implants. Over time, nylon hasproved to be less than perfect: it loses its properties dueto hydrolysis, denaturations <strong>and</strong> frequent infections[19].Teflon, or polytetrafluoroethylene (PTFE) was accidentallysynthesized in 1938 at the Du Pont chemicalplant. It has been perfected in 1963 in Japan, <strong>and</strong> madeready to use in medicine. Its mechanical properties <strong>and</strong>ideal smoothness have made it indispensable in manyfields of surgery.Usher is universally considered the pioneer of syntheticmesh use. In 1955 he took an interest in a newproduct – polypropylene, trade-named „Marlex”. Itdisplayed many of the characteristics of an ideal prosthesis.After a series of experiments, in 1958 he usedMarlex for hernia repair. He published over 20 reports,presenting many technical innovations. Above all, hedesisted from covering the defect with the implant,using the mesh as a „bridge” over the defect with anappropriate margin around it [20].Around that time, Dacron (ethylene polytereftalane)was introduced to hernia surgery. However, itsproperties were inferior to those of Marlex <strong>and</strong> Goretex(PTFE).PRESENT DAYMany of the methods described above remain inuse today. Even though synthetic materials were in useearlier, the greatest role in the popularization of „tension-free”techniques was played by Irving Lichtenstein.In 1989 he reported a series of 1000 patientsoperated by his technique under local anesthesia in a„day-case” setting. Although the procedure was technicallysimple, Lichtenstein did not recommend thathernioplasty should be performed by any surgeon inany center. Parviz Amid, a student <strong>and</strong> follower ofLichtenstein, recollects two distinct periods in theevolution of his technique: the years 1984-1988 <strong>and</strong>the period after 1988, when the shape <strong>and</strong> size of theimplant were changed. The size was increased to helpprevent recurrence due to mesh shrinkage. Lichtenstein’srepair became the „gold st<strong>and</strong>ard” againstwhich all new hernioplasty techniques are compared[21].Modern „open” surgery of inguinal hernia gravitatestoward outpatient procedures. Local anesthesia isconsidered safe <strong>and</strong> sufficient for the majority of hernias.The concept of local anesthesia dates back to late1800’s, hen it was introduced by Cushing <strong>and</strong> popularizedby Halsted. According to Amid, anesthesia is oneof the key elements of successful hernioplasty.Other concepts of hernia repair developed simultaneously.The “plugging” concept is quite old. In the1830’s Pierze Nicholas Gerdy used an inverted flap ofscrotal skin to fill the inguinal canal, suturing it closed<strong>and</strong> inducing inflammation. Wutzer proposed placingforeign bodies, such as wooden plugs, in the inguinalcanal to close it through induced inflammation. [2, 3].In modern times, Irving Lichtenstein pioneered theplug technique, introducing a cigarette-shaped Marleximplant in 1968 to treat femoral <strong>and</strong> recurrent herniaswith favorable results. In 1987 Bendavid used an “umbrella-shaped”mesh; a shape which was also used byGilbert who ab<strong>and</strong>oned his experiments with a cigarshapedimplant after unfavorable results [2, 3, 4].Many of the implants manufactured presently comein ready-to-use sets, provided in several sizes. One ofthem is the „Perfix” system, formed according to Rutkow’srecommendations, consisting of an „umbrella”<strong>and</strong> a patch similar to Lichtenstein’s. The „PHS/UHS”(Prolene Hernia System) – two flat mesh implantsconnected by a plug (in a fashion similar to a cufflink)has also been gaining popularity due to favorable outcomes.Synthetic materials have been criticized for the increasedlikelihood of infection, mesh migration <strong>and</strong>even carcinogenesis. This last allegation is probablyfalse, <strong>and</strong> implant migrations are rare [22 ]. Infectionscan be prevented by maintaining a proper aseptic regime<strong>and</strong> using antibiotic prophylaxis. “Light meshes”have been in use for a few years, consisting of an absorbable(Vicryl) <strong>and</strong> non-absorbable part (polypropylene).After healing <strong>and</strong> remodeling of the inguinalregion, the absorbable part undergoes biodegradationwhile the polypropylene provides a sufficient scaffoldingto reinforce tissues. The patient does not feela foreign body, which is especially important in large
The history <strong>and</strong> the present of herniology 21postoperative hernia repair. [23]The problem of recurrent <strong>and</strong> bilateral hernia repairhas remained unsolved for many years. Repeated operationsusing the same approach did not work underaltered anatomical conditions among weakened tissues.Lichtenstein’s <strong>and</strong> Rutkow’s repairs are two representativesof „tension-free” inguinal hernia repair (flat<strong>and</strong> 3D implant, respectively). A third tension-freemethod has been described by Rene Stoppa, a Frenchsurgeon. In 1975 he reported a series of cases of recurrenthernias repaired with the use of Dacron mesh. Theimportant difference lay in a completely differentchoice of approach to the hernial defect. The preperitonealspace was accessed via an inferior midline incision,The contents of the hernial sac were reduced intothe abdominal cavity, giving excellent view of thedefect, which was then covered by a relatively largeimplant, covering both musculopectineal orifices. Thechevron-shaped mesh secured the area of the surgicalincision as well. It was fixed in place in 2-3 places onlyto prevent folding, the main force fixating the mesh inplace being the abdominal pump, acting according toPascal’s law. The preperitoneal space proved to be theideal location for the implant. Mesh placement in aspace unaccessed during previous repair attempts wasan excellent solution especially for patients with numerousrecurrencies [24 ].Even though preperitoneal repairs evoke the nameof Stoppa, the history of this approach is longer. It wasprobably first used by Thomas Ann<strong>and</strong>ale of Edinburghin 1876. Two reports exist of operations utilizingthis approach as early as 1743 [2]. The idea was revisitedin early 1900’s in the USA. Cheatle performedoperations using the midline incision in the Trendelenburgposition in 1920. After separating the rectus muscles,he dissected the peritoneum off the anterior pelvicwall <strong>and</strong> bladder, reduced the contents of the hernia tothe abdominal cavity, leaving a part of the transectedsac in the inguinal canal, <strong>and</strong> partially closed the deepring. He used this approach on inguinal <strong>and</strong> femoralhernias. Cheatle also utilized the Pfannenstiel incision.His ideas were popularized by A. Henry. The preperitonealapproach gained popularity in the 1950’s in theUSA. Mc Evedy utilized an oblique incision within therectus sheath, gaining excellent view of the preperitonealspace. Read <strong>and</strong> McVay also operated in thisfashion, but it was Nyhus who performed thoroughanatomical <strong>and</strong> clinical research on the subject. In 1959he was the first to use a synthetic implant via apreperitoneal approach. His idea was further developedby Rignault <strong>and</strong> Stoppa [25 ].In spite of the successful introduction of syntheticmaterials into hernia surgery in the latter half of theXX th century, „pure tissue repair” techniques were notab<strong>and</strong>oned. The most well-known of these, besidesBassini’s repair which remained to be used <strong>and</strong> modified,was Shouldice’s method, known as “Canadianrepair”. Developed in the early 1950’s, this techniquewas perfected in Shouldice’s clinic, where the recurrentrates did not exceed 2%. In other centers the resultswere less spectacular, <strong>and</strong> the technique is considereddifficult to perform. In many other centers –including Polish ones – tension methods such as Bassini’s,Halsted’s <strong>and</strong> others are still used [ 26].A remarkable method has been proposed by theabove-mentioned M. Desarda. He used a deep externaloblique aponeurosis as a natural “mesh”. The resultsgiven by the author <strong>and</strong> confirmed by our Departmentseem favorable [13].The wonderful development of videosurgery didnot omit hernia surgery. The concept of intraperitonealapproach to inguinal hernia has been conceived in thelate 1970’s at the Albert Einstein College of Medicinein the USA. The idea was based on the reduction ofhernial defect size by clips in order to prevent the migrationof the viscera into the inguinal canal. Initialresults, performed during laparotomy for unrelateddiseases, appeared inviting. At that time, the laparoscopictechniques were insufficiently developed toallow hernia repair. A series of procedures performedin 1982 was less successful. Bogojavlenski initiatedlaparoscopic hernia treatment in 1989, using a syntheticmesh. The development of this technique wasagain halted by the lack of proper equipment. In 1990,Schultz introduced a technique of plug insertion intothe deep ring after a peritoneal incision. The implantwas not fixed in place <strong>and</strong> the recurrence rates after 2years reached 25%. Therefore, the technique evolvedtoward larger implants fixated by clips. Early experienceswith the onlay technique were equally poor (intestinaladhesions <strong>and</strong> recurrences) <strong>and</strong> it is infrequentlyused today. Contemporarily, two techniques oflaparoscopic herniotomy are used: TAPP (transabdominalpreperitoneal) in which the mesh is placedunder the peritoneum <strong>and</strong> TEPA (total extraperitonealapproach) – in which the preperitoneal space is dissectedby a special balloon device <strong>and</strong>a mesh placed there. The laparoscopic approach, particularlythe TEPA technique, is a development of theclassical Stoppa technique [2].
- Page 8: 8Wojciech J. Baranowskirating) move
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- Page 26: 26Anna Budzyńska et al.Gram-dodatn
- Page 32 and 33: 32Piotr Kamiński et al.Streszczeni
- Page 34 and 35: 34Piotr Kamiński et al.both in Pom
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