Inguinal hernia: an old condition with new solutions

To review the recent surgical advances in the treatment of inguinal hernias.

Traditional tissue-based techniques (eg, Bassini, McVay, Shouldice) characterized the armamentarium of the inguinal hernia surgeon during the 1970s and early 1980s. With the need to reduce the rate of hernia recurrence, as well as postoperative pain and convalescence, the treatment of inguinal hernias underwent a dramatic evolution over the past 15 years. The major advances included the introduction of the concept of tension-free hernia surgery, the use of prosthetic materials, and the development of laparoscopic techniques.

The recognition that excessive suture-line tension was primarily responsible for high recurrence rates and significant postoperative pain following tissue-based repairs led to the introduction of the concept of tension-free hernia surgery. The development of prosthetic materials ushered in the current era of hernia surgery, allowing a tension-free repair to be performed even for the largest defects and the most difficult procedures. Tension-free mesh-based repairs (eg, Lichtenstein, plug and patch) began to increase in number in the late 1980s. More recently, with the advent of laparoscopy for general surgery, various laparoscopic techniques have been developed for inguinal hernia repair, including the transabdominal preperitoneal repair, the intraperitoneal onlay mesh repair, and the totally extraperitoneal repair.

Today, open and laparoscopic mesh-based techniques dominate the inguinal hernia repair marketplace. The Lichtenstein tension-free mesh onlay repair is the most frequently performed inguinal hernia operation, with a recurrence rate of less than 1%. Although the use of laparoscopic techniques for bilateral or recurrent hernias is now accepted, the application of laparoscopy to unilateral primary inguinal hernias remains controversial. Ongoing studies will address the questions of long-term recurrence and cost-effectiveness of laparoscopic hernia repair.