[Inguinal hernia. What techniques are available for the surgeon? Theoretical and practical advantages and...

There are many hernia repair techniques. Among the most popular, the Shouldice Hospital method was the most widely used in the 1980s. Since then, methods employing prosthetic mesh have taken over, mainly because they are tension-free and therefore seem to lead to less recurrence and cause less postoperative pain. There are several ways of placing the prosthesis, which differ according to the approach used and the superficial or deep situation of the prosthesis. The Lichtenstein technique consists of placing and fixing the prosthesis on the posterior wall of the inguinal canal through an inguinal incision: it is currently the most widely used procedure because of its simplicity. The concept of placing the prosthesis in the subperitoneal space was developed by the French school (Rives, Stoppa). Initially the operation was performed through an inguinal (Rives) or midline (Stoppa) incision. These techniques are no longer adapted to the minimally invasive concept of surgery that prevails today and therefore are less used. The laparoscopic approach places the prosthesis through the trocars instead of through a large incision. The transabdominal approach opens the preperitoneal space through the abdominal cavity, breaching the peritoneum. The extraperitoneal approach consists of direct penetration of the preperitoneal space without violating the peritoneum, as in the Stoppa technique. This is undoubtedly the most elegant laparoscopic technique, but more difficult to perform. Other, simpler methods can also reinforce the posterior wall with a preperitoneal prosthesis. The Polysoft prosthesis, placed through an inguinal incision and inguinal ring, is a modern substitute for the Rives technique, but can be performed under local or locoregional anesthesia. Other types of prostheses, consisting of two, both superficial and deep, components are available: the Prolene Hernia System, for instance, is composed of two circular plates, linked together by a central stalk; there are also several types of plugs. As for anesthesia, there are several evidence-based arguments that indicate that local anesthesia is best.