The changing path of inguinal hernia surgery
Abstract: Inguinal hernia repair is the most common operation in general surgery and the main challenge has been to lower the recurrence rate. With the introduction of endoscopic repair in the beginning of the 1990´s, the demand for randomised controlled studies has increased resulting in a growing interest in this surgical field. Standardised techniques with a growing use of tension free mesh repairs, teaching programs and registers are in a continuous developing process. After introduction of these changes at the County Hospital of Karlskrona a tenfold decrease in recurrence rate was accomplished at five years follow up (28% to 3%). The SMIL-group (Swedish Multicenter trial of Inguinal hernia repair by Laparoscopy) was formed in 1993 to conduct large randomised multicenter studies comparing laparoscopic and standardised open repairs. The SMIL-1 study comparing laparoscopic (TAPP) and Shouldice operation showed no difference in complication rate but patients in the TAPP group had less postoperative pain, better postoperative functional status and shorter sick leave at the price of a longer operation time. The recurrence rate at five years follow up was 6.6% in the TAPP group and 6.7% in the Shouldice group (ns). There was a correlation between poor surgical performance and recurrence rate. Inguinal hernia patients show bilateral disease at admission in 15%-20%. In the past, two consecutive operations have been performed. Simultaneous endoscopic operation in 168 patients (336 hernias) was safe with few major complications, a three years recurrence rate of 2.7% and only one patient with severe late discomfort. It is known that mesh causes a foreign body reaction and the last decade new meshes has been introduced to minimise this effect. Theoretically, foreign body reaction could be a threat to the spermatic cord structures but this effect is poorly documented. In a rat model, comparing suture repair, standard polypropylene mesh and low weight composite polyglactin/polypropylene mesh, there was patency in all vas deferens. An impaired s-testosterone production and a reduced cross sectional area of the vas deferens was found in the composite mesh group. There was no difference in inflammation or fibrosis between the two mesh groups. This thesis has contributed in changing the path of inguinal hernia surgery by focusing on the introduction of standardised open and laparoscopic techniques and dealing further with potential problems associated with mesh implantation.
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