Pure tissue repairs: a timely and critical revival

Area of Science:

• Abdominal wall surgery
• Hernia repair techniques
• Surgical anatomy

Background:

• The Shouldice Hospital has specialized in abdominal wall hernia treatment since 1945, emphasizing anatomical knowledge and surgical volume for expertise.
• Historical context of hernia repair, noting numerous techniques since Bassini, with limited success attributed to a failure to appreciate the preperitoneal space.

Observation:

• Francis Usher (1960) suggested mesh prostheses for hernias where primary repair is challenging due to tension or poor fascial structures.
• Large direct inguinal hernias, incisional hernias with large defects, and most recurrent hernias are identified as candidates for mesh repair.
• The preperitoneal space is crucial for successful hernia repair, enabling identification of key muscle layers for reconstruction without tension.

Findings:

• The preperitoneal approach avoids plication of the posterior inguinal wall, which is often deficient in direct inguinal hernias.
• This approach facilitates the identification and utilization of rectus, transversus, and internal oblique muscles for tension-free reconstruction of the posterior inguinal wall.
• The Shouldice and McVay procedures, which emphasize entering the preperitoneal space, have demonstrated continued success.

Implications:

• Understanding and accessing the preperitoneal space is critical for improving hernia repair outcomes.
• Mesh prostheses should be judiciously used for specific complex hernia cases, not as a routine solution.
• Continued emphasis on anatomical understanding and surgical experience is vital for advancing hernia repair surgery.