Inguinal hernia: intervention
Inguinal hernia surgery in the history of surgery
The goal of all inguinal hernia surgical techniques historically proposed has always been to achieve an effective and lasting repair.
Although the hernia seems at first glance a superficial and apparently trivial pathology, the inguinal canal is a very complex and dynamic anatomical region, it is transited by important structures, such as the spermatic funiculus in the male (or the round ligament in the female) and as the three sensory nerves ileo-hypogastric, ileo-inguinal and genito-femoral. Also extremely close to the inguinal region are the femoral artery and vein.
Because of this complex anatomy, the reconstructive techniques of ancient times, and partly those of a relatively recent past, were burdened by a certain rate of complications. Nevertheless, surgery has always been a necessity and even in the past centuries it was proposed despite the risks of that time, because an eventual strangulation would have meant the worst.
Already in the second half of 1800 the Italian Edorado Bassini, in the absence of prosthetic materials suitable for reconstruction, proposed a repair technique that became one of the most performed in the world until the last century, when the appearance of synthetic material mesh allowed a great step forward in this type of surgery.
With the advent of synthetic mesh, it was finally possible to implant a supporting tissue to repair hernial defects. Therefore, more versatile and durable techniques were born and are still performed today, such as the technique of Irving Lichtenstein (1920-2000).
Despite considerable progress and countless patients now satisfactorily treated with these traditional techniques, critical points remain. In fact, all hernial repairs by traditional means require incision and surgical opening of the inguinal canal with mobilization of the spermatic funiculus.
Even if performed with expertise and in "day surgery" these maneuvers expose to a certain traumatism the flat tendons and the spermatic funiculus, requiring a long time to heal.
Healing leaves visible external and internal scarring between tissues. In addition, the mesh or its means of fixation, within the inguinal canal, is in close contact with the spermatic cord and may result in its long-term suffering or may compress the nerves causing chronic pain.
With laparoscopic surgery has begun to circulate more and more the concept of access to the groin by posterior way and without surgical incisions at the inguinal level. This concept, theoretically very valid, finds an obstacle mainly in the very limited mobility of laparoscopic instruments.
It is therefore necessary to adopt compromise solutions especially in the creation of the work plan, in the choice of the type of nets and in their positioning with fixing means (often traumatic).
Inguinal hernia surgery in robotic surgery
Thanks to the latest generation of robotic surgery systems, the manuality of the working instruments (only apparently similar to the laparoscopic ones from which they derive) has been completely redefined thanks to the conferral of articulability.
Robotic surgery systems miniaturize the surgeon's movement, allowing him to work in much smaller spaces than ever before. With even greater articulability than the human wrist and under the guidance of a stereoscopic (truly three-dimensional) viewer, complex reconstructions can be handled without compromise.
We in robotic surgery preferentially adopt reconstructive techniques with access R-TAPP which stands for Robotic-Trans-Abdominal-Pre-Peritoneal.
Through three small holes of a few millimeters, a pre-peritoneal working space is reached and without the need to open the inguinal canal, the hernia is reduced by repairing the defect.
Nets are placed, which we prefer to have a light weave, semi-absorbable and self-fixing (therefore atraumatic) that, thanks to the excellent dexterity of the robotic instrumentation, are made to adhere very well. In the post-operative period the net is colonized by the cells of the organism and becomes one with the tissues, moreover the partial reabsorption of its fibers will lighten even more the reconstruction enhancing its dynamism.
The particular positioning region of the mesh (posterior to the muscle-tendon barrier) gives extreme strength. In fact, as the abdominal pressure increases, during physical efforts, the reconstruction impacts on the solid tissue drawing support and stability. Furthermore, since the mesh is placed in the pre-peritoneal space, it is totally isolated from the inside of the abdominal cavity and there is no contact between the reconstruction and the viscera.
Thanks to these structural characteristics, the post-operative course is easy for the patient, allowing him/her to safely return to normal everyday activities and sports in a short time.
Bilateral inguinal hernia surgery
Inguinal hernia frequently occurs bilaterally. The logical sequence of repair in traditional surgery has always been to perform two distinct operations, initially repairing the more severe side and then moving on to the less compromised side in the following months.
It was usual to divide the repair in two separate sessions to limit the traumatic impact of surgical incisions. With robotics, on the other hand, it is advisable to repair both sides in the same operating session because the surgical trauma is reduced to a minimum and it is possible to access both groins easily through the same three millimetric access routes that are used.
Inguinal hernia surgery and anesthesia
In inguinal hernia, anesthesia may vary from local anesthesia to general anesthesia.
Interventions performed with traditional techniques are mainly performed under local anesthesia.
The patient during the procedure is either awake or lightly sedated with associated positive and negative aspects. In fact, if on the one hand some patients would have primarily the desire to be awake during the intervention, in reality the experience may unexpectedly cause stress in some of them, then not always the analgesic coverage is complete and there is a risk that during the intervention may episodically be felt pain.
Considering these aspects, general anesthesia proves to be much more homogeneous and standardized, the patient sleeps during the entire duration of the procedure, is constantly monitored by the anesthesiologist and at the end of the procedure does not retain negative memories of the experience.
With regard to all the most modern methods,general anesthesia is indicated, as they are techniques based on a different surgical approach.
The indication for local anesthesia rather than general anesthesia does not correlate at all with the level of invasiveness of the procedure.
This concept is very well represented in inguinal hernia surgery where the most dated and invasive procedures are performed mainly under local anesthesia while the most modern and minimally invasive procedures are performed under general anesthesia.
Robotic surgery does not require any anesthesia differences from all other laparoscopic techniques.
Inguinal hernia and post-operative recovery
The speed of post-operative recovery depends on various factors including the stage of the pathology at the time of surgery, the technique used by the surgeon and the general clinical aspects of the patient. We prefer low-invasive techniques performed in robotics mainly because of their optimal reconstructive architecture but also because of their fast recovery.
Normally after bilateral R-TAPP inguinal reconstruction for hernias of medium severity our patients resume their normal activities within a few days after surgery.
We usually schedule a night's admission to the clinic for the benefit of patient comfort and to allow for the return trip the next day in full autonomy.
Normally, a follow-up visit is scheduled within 15 days of surgery to remove the three accessway patches and give the green light to resumelight physical activity.
Due to the low traumatic nature of the procedure, only mild pain medication is generally prescribed for the three days following the procedure.
