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240
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24.2 Local Anaesthesia
The use of local anaesthesia is central to the
encouragement of a gentle and atraumatic surgical approach as well as avoiding excessive traction on tissues. Local anaesthesia also allows to
test a repair in a cooperating patient.
The anaesthesiologist can associate sedation to
maintain the patient in a completely relaxed state.
The technique used is called ‘sandwich anaesthesia’: 10mL ropivacaine solution for injection
10 mg/mL subcutaneously before entering the
operating room, followed by 1% lidocaine up to
60 mL during the dissection, and then again
100mg in 10mL of ropivacaine injected subcutaneously to conclude the surgery.
24.3 Surgical Technique inMale
Patients
It is thanks to Dr. Robert Bendavid that the
Shouldice repair technique spread in Europe in
the 1980s. I have, myself, learnt the technique,
visiting him in Canada in those years. The following description derives from Bendavid’s work [6].
24.3.1 Dissection
The skin incision runs anterior to the inguinal
ligament rather than 2–3cm superior to it. This
incision, from experience, provides a better
access to the working area of the groin. The incision will be 6–10 cm in length. The external
oblique aponeurosis readily appears under the
subcutaneous tissue.
One proceeds then with a subaponeurotic
inltration of lidocaine when the external oblique
aponeurosis is still intact to block the ilioinguinal
and iliohypogastric nerves as well as the genital
branch of the genitofemoral nerve.
As soon as the cribriform fascia, in the region
of Scarpa’s triangle, is opened, the inguinal ligament becomes more mobile. If present, a femoral
hernia can now be identied.
Proceed with the incision of the external
oblique aponeurosis up to the external inguinal
ring, and prolong it 2–3cm lateral to the internal
ring. This incision has to be as medial as possible
to preserve a larger lateral ap of the external
oblique aponeurosis.
The incision shows the internal oblique muscle, the spermatic cord and the sulcus of the
inguinal ligament.
Gently separate the external oblique aponeurosis from these elements with a peanut gauze. It
is now that the ilioinguinal nerve can be identied along the cremaster and the iliohypogastric
nerve on the internal oblique muscle.
After inltrating the cremasteric bres with
lidocaine, it is incised longitudinally to obtain
two aps: a medial ap and a lateral one with the
spermatic cord lying on top of the longitudinal
mid-portion of the splayed cremasteric fascia
(muscle). The cord can now be lifted with a
Penrose drain. An indirect hernia sac, if present,
becomes easily identiable.
The medial ap is resected with adequate haemostasis. The lateral ap is sectioned between
two clamps. The ilioinguinal nerve is preferably
sectioned and ligated separately, if need be. Two
stumps remain: a proximal (lateral) and a distal
(medial) one.
The two cremaster muscle stumps are doubly
ligated: it is between these two ligatures that the
needle will pass throughout at the end of the rst
suture line.
The external spermatic vessels and the genital
branch of genitofemoral nerve can be ligated separately or together with the cremasteric lateral
ap, depending on their anatomic conguration.
It is now necessary to search for an internal
oblique hernia sac. If a sac is present, it has to be
separated from the spermatic cord, isolating it as
much as possible inside the internal inguinal ring
in the preperitoneal space. Resection and ligature
of the sac are not necessary; furthermore, they
could lead to early postoperative pain.
Once the indirect hernia sac disappears deep
to the internal inguinal ring, the cord has to be
retracted laterally.
Now the posterior wall of the inguinal canal,
represented by the triple layer, is in full view.
This area is vaguely shaped like a triangle
(Hesselbach’s triangle): the base in the latero-
24 The Shouldice Repair
241
cranial position, the triangle’s apex at the pubic
tubercle, the two sides represented medially by
the internal oblique muscle and laterally by the
inguinal ligament. The inferior epigastric vessels
run just a little underneath the transversalis fascia
at the base of this triangle.
Whether or not a direct hernia is present, the
transversalis fascia must be incised from the internal ring to the pubic tubercle. The transversalis
fascia should be incised closer to the oblique muscle rather than to the inguinal ligament for two
main reasons: rstly, in case of accidental lesion
of the epigastric vessels, the ligature will be easier
if more distal from the iliac vessels, and, secondly,
in order to leave a larger portion of the fascia
towards the inguinal ligament (iliopubic tract).
The fascia’s portion closer to the inguinal ligament is the iliopubic ligament (iliopubic tract,
Thomson’s ligament), and it is generally quite
resistant.
In case of a direct hernia, the transversalis fascia
is quite thinned out. Any excessive, thin or redundant portion of the posterior wall should be excised.
Once the transversalis fascia is incised, the
preperitoneal fat can be seen as a glistening yellow layer.
With the help of a gauze, the fat is separated in
order to medially highlight the posterior aspect of
the transverse and rectus muscles and laterally
the posterior aspect of the iliopubic tract.
Often, a small vein, called by Bendavid ‘the
iliopubic vein’, runs adherent and parallel to the
deep portion of the iliopubic tract. This marginal
vein can cause disturbing bleedings and must be
avoided.
through the so-called triple layer and the lateral
edge of the rectus.
The suture continues towards the internal ring.
It must include, laterally, the iliopubic tract and,
medially, the posterior aspect of rectus muscle
for the rst two or three sutures, and then, again,
the iliopubic tract and the posterior aspect of the
transverse and internal oblique muscles, up to the
internal inguinal ring (Fig.24.2).
Fig. 24.1 Beginning the rst line of suture
24.3.2 Reconstruction
The reconstruction of the posterior inguinal wall
is done with four continuous lines using two nonabsorbable sutures. The rst suture is used for the
rst two lines and the second suture for the third
and fourth lines.
The rst line of continuous suture starts at the
level of the pubic tubercle (Fig.24.1).
Firstly, the needle passes through the more
medial corner of the iliopubic tract and then
Fig. 24.2 Continuing the rst line of suture
242
This rst suture line is correctly done if the
border—composed by the transversalis fascia,
the transverse muscle, and the internal oblique
muscle—is not included in the suture and remains
medially free by forming an edge or a ap.
The last bite of the rst suture line will incorporate the proximal stump of the cremaster muscle before crossing over to start the second line of
suture at the free edge or border just described,
just medial to the internal ring (Fig.24.3).
The continuous suture (second line) goes back
(Fig. 24.4) towards the pubic tubercle and
includes medially the triple layer left free earlier
(the border formed by the transversalis fascia, the
transverse muscle and the internal oblique muscle) and the area of the inguinal ligament up to
the initial tie. It is then knotted to the tail clamped
earlier (Fig.24.5).
The posterior inguinal wall is now
reconstructed.
The third line of suture starts at the level of the
internal inguinal ring where it will be knotted,
clamping again the tail of the suture. This suture
line continues towards the pubic tubercle remaining slightly more supercial than the previous
one. The internal oblique muscle is sutured again
to the area of the inguinal ligament, but more
supercially than the previous inguinal suture
line (Fig.24.6).
P. Bo cc hi
Fig. 24.4 Beginning the second line of suture
Fig. 24.3 End of the rst line with the doubly ligated lat-
eral cremasteric stump
Fig. 24.5 Continuing the second line returning to the
pubic tubercle
The division of the cremaster may cause a
drooping of the ipsilateral testicle. To avoid this
event and support the testicle, the most distal
stitch of the third suture line can include the distal cremasteric stump previously doubly ligated.
24 The Shouldice Repair
243
Fig. 24.6 The third line of suture
Fig. 24.7 The last stitch of the third line of suture
At the level of the pubic tubercle, the suture
returns towards the internal ring (fourth line)
remaining even more supercial than the third
suture line (Fig.24.7).
Arriving at the internal ring, the fourth line
has to be knotted to the suture tail knotted at the
beginning of the third line (Fig.24.8).
The posterior wall is now extremely resistant.
Fig. 24.8 Fourth (and last) line of suture
The cord is repositioned in its original site.
Now the external oblique muscle aponeurosis can
be re-approximated.
To better balance the external ring, it is appropriate to start the suture of the external oblique
muscle aponeurosis from the new external inguinal ring and proceed laterally.
The repair ends with another subcutaneous
injection of 100mg of ropivacaine to prolong the
effects of local anaesthesia.
At the end of surgery, the patient can get up
from the operating table with some assistance.
Generally, antibiotic and antithrombotic
prophylaxis are not necessary.
24.4 Shouldice Repair inFemale
Patients
It is a well-known fact that inguinal hernia occurs
in females with a 10 times lower incidence than
in males [7]. The posterior wall of the female
inguinal canal is generally more resistant than the
male ones, resulting in much lower direct hernia
occurrence [8].
In females the Shouldice repair is performed
mainly following the same steps used in males,
although, the different anatomy demands some
distinctions in the surgical approach.
244
P. Bo cc hi
24.4.1 Dissection
The incision of the external oblique aponeurosis
shows the round ligament of the uterus surrounded by bres and small vessels. Its size varies greatly among patients: it could be just
residual or sized almost as a spermatic cord.
If the round ligament is only residual, it can be
clamped and accurately ligated. If it is of noticeable size, it should be treated as a spermatic cord
and preserved accordingly.
Search for an indirect hernia sac and dissect it
from the round ligament up to the internalringas
high as possible as done in male patients.
Open the transversalis fascia using the same
criteria applied in male patients.
In the majority of cases, the Hesselbach
triangle is narrower than in males because of the
female pelvic conformation. The Henle’s ligament
(that is a reinforcement of the transversalis fascia)
is more evident, thus making unnecessary—counterproductive, actually—the complete opening of
the posterior wall up to the pubic tubercle.
Preserving the genital branch of the genitofemoral nerve is particularly important in females. In
fact, its dissection may impact on the sensitiveness
of the labium majus [9].
24.4.2 Reconstruction
The reconstruction is done with a similar technique and accuracy (four lines of suture) as in
male patients.
References
1. Shouldice EE.The treatment of hernia. Ont Med Rev.
1945;12:43–69.
2. Bocchi P. L’operation de Shouldice: peut-on avoir
dans un service de chirurgie générale les mêmes résultats que dans un service super—spécialisé? Journal de
Chirurgie (Paris). 1993;130(6–7):275–7.
3. Bocchi P. The Shouldice operation: can be done by
the average surgeon in an average surgical service?
An analysis of the recurrence. Probl Gen Surg.
1995;12(1):101–4.
4. Bassini E. Sulla cura radicale dell’ernia inguinale.
Archivi Società Italiana di Chirurgia. 1887;4:380.
5. Wantz GE.Atlas of hernia surgery. NewYork: Raven
Press; 1991.
6. Bendavid R.L’operation de Shouldice. Encyclopedie
Medico-Chirurgicales, Paris, Techniques
Chirurgicales. Appareil Digestif. 1986;40112:5.
7. Rutkow IM. Epidemiologic, economic and sociologic aspects of hernia surgery in United States in the
1990’s. Surg Clin North Am. 1998;78(6):941–51.
8. Weber A, etal. Epidemology of hernias in the female
in abdominal wall hernias. Berlin: Springer; 2001.
p.613–9.
9. Bendavid R. Complications of groin hernia surgery.
Surg Clin North Am. 1998;78(6):1089–103.
Primary Inguinal Hernia:
25
Sutureless Open Anterior,
Trabucco Repair
GiampieroCampanelli, PieroGiovanniBruni,
AndreaMorlacchi, FrancescaLombardo,
andMartaCavalli
25.1 Introduction
In 1974, Lichtenstein adopted a new “tensionfree” approach using a polypropylene prosthesis
to improve results [1, 2].
Ermanno Ennio Trabucco (August 15, 1926–
March 9, 2015; Fig.25.1) improved on the tension-free concept by introducing his complete
“sutureless” technique for all primary groin hernia repair which is based on the utilization of a
universal pre-shaped mesh that will virtually
always t into subaponeurotic inguinal space of
every individual [3, 4]. In effect, it had been
observed that the size and shape of this anatomical space has minimal variations from one individual to another.
A medium-weight pre-shaped mesh with controlled memory [5], like a monolament polypropylene prosthesis (middle weight), does not need
to be sutured once placed into a closed space. Based on Pascal’s principle, the intra-abdominal
G. Campanelli (*) · P. G. Bruni · F. Lombardo
M. Cavalli
University of Insubria, Varese, Italy
General and Day Surgery Unit, Center of Research
and High Specialization for the Pathologies of
Abdominal Wall and Surgical Treatment and Repair
of Abdominal Hernia, Milano Hernia Center, Istituto
Clinico Sant’Ambrogio, Milan, Italy
e-mail: Giampiero.Campanelli@grupposandonato.it
A. Morlacchi
Surgical Department, Ospedale di Circolo di Varese e
Fondazione Macchi, University of Insubria,
Varese, Italy
Fig. 25.1 Ermanno Ennio Trabucco (August 15, 1926 to
March 9, 2015)
pressure is evenly distributed over a large surface
area of mesh: the prosthesis will remain stretched
uniformly in the inguinal box, without a tendency
to wrinkle or curl, without the need to be secured
with sutures. In other words, such a mesh, thanks
to its optimum rigidity and memory shape, is
positioned without sutures and will always lie at
and will not move or form dead space [3, 5, 6]
avoiding complications such as seroma, hematoma, or even relapse, remaining at and adhering to the underlying tissue during the broblastic
inltration into its pores, a process that seals the
mesh into place [6].
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_25
245
246
Fig. 25.2 Universal pre-shaped polypropylene mesh
developed by Trabucco
Ideated and developed by Trabucco in the
1988, the Hertra Herniamesh® pre-shaped prosthesis (n.1–6: from most rigid meshes to the softest ones, which are ideal for athletes and for
young patients; Fig.25.2) is time-saving and easy
to implant, was never found to curl or to shrink
after implantation [7], and for our experience is
one of the possible good choices for all simple,
not complicated, primary inguinal hernias [8, 9].
We clearly believe that the main advantage of
a tension-free and sutureless repair is given by
the relevant reduction in postoperative pain and
neuralgia [10, 11]. The chronic postoperative
inguinodynia occurs in about 10% of patients
undergoing inguinal hernioplasty with prosthesis
and sutures [10, 12]; it is not an uncommon complication and, depending on its intensity, can also
potentially jeopardize patient’s work and social
activities.
The Trabucco repair, which requires a perfect
knowledge of the inguinal anatomy, maximizes
the preservation of physiology of the abdominal
wall, through the correct recognition and respect
of the noble structures and the sparing of the
three nerves of the groin region (iliohypogastric,
ilioinguinal, and genitofemoral; Figs. 25.3 and
25.4), minimizing postoperative pain in order to
ensure the best patient comfort with a more rapid
and efcient recovery of his usual daily
activities.
G. Campanelli et al.
Fig. 25.3 Local anesthesia during Trabucco’s primary
hernia repair: sub-fascial inltration of iliohypogastric
and ilioinguinal nerves
Fig. 25.4 Local anesthesia during Trabucco’s primary
hernia repair: inltration of genital branch of genitofemoral nerve on the attened oor of the inguinal box
The intentional section of one or more nerves,
when it is not possible to achieve a satisfactory
nerve sparing, or special tricks to create tailored
fenestrations in the prosthesis to prevent the scar
tissue to involve the spared nerves during broblastic processes, ensures a further reduction of
the rate of neuralgia [10].
Moreover, the Trabucco repair can be easily
and routinely performed under local anesthesia
[8, 9], permitting some useful tricks during the
surgery, like the hydro-dissection of inltrated
tissues, for a less traumatic and more safe isolation of the hernial sac (Fig.25.5), the spermatic
25 Primary Inguinal Hernia: Sutureless Open Anterior, Trabucco Repair
Fig. 25.5 Isolation by hydro-dissection of an indirect
external oblique hernial sac
Fig. 25.6 Exposure of the external oblique aponeurosis
chord components, and the nerves from the adjacent structures within the inguinal region.
The mastery of this technique under local
anesthesia gives also a further advantage, helping
the surgeon to discover any hidden and unknown
hernial defect (Spigelian included) simply by
asking the patient to give a cough during the
intraoperative exploration of both the inguinal
box and the femoral canal (that always should be
explored). It allows also the patients to return
home just a few hours after the intervention (by
keeping down hospitalization costs), going back
to a sedentary work the day after and to their full
activities rapidly [8, 9, 13, 14].
level. Normally, in normal BMI patients, the incision length is 3–5cm.
After the ligature of subcutaneous vessels and
after the incision of the external oblique
aponeurosis (Fig.25.6), a blunt dissection of the
subaponeurotic space is made by nger to accommodate the sutureless prosthesis; it goes without
saying that the complete exposition of the right
anatomy of inguinal canal is mandatory.
The conjoint tendon and rectus sheath, pubic
tubercle with the horizontal portion of pubic
bone, inguinal ligament till anterior inferior iliac
spine, and internal ring, all these “normal” structures must be not only recognized but carefully
prepared in order to have the “bed” where to lie
25.2 Surgical Indications
the mesh: with the same attention, all the external
oblique aponeurosis subspace has to be fully pre-
An open anterior sutureless and tension-free
repair is indicated for all simple, not complicated
primary inguinal hernia.
pared from above to below in order to cover the
prosthesis completely and uniformly, from pubic
tubercle to its upper opening. Only if this closure,
putting the chord in the subcutaneous space, is
perfectly realized, from the point 1.5cm on the
pubic bone to the upper part, the mesh can be
25.3 Surgical Technique
completely stable without stitches or sutures.
The iliohypogastric, ilioinguinal, and genito-
Every repair should start with a horizontal left/
right sovrapubic incision, at the aim to respect the
cutaneous sensory nerves of the inguinal region
that would be more traumatized by a classical
transverse incision because of their line of metameric distribution through the skin at that precise
femoral nerves must be always detected, carefully
isolated, and when possible well preserved, paying particular attention to never leave them in
direct contact with the prosthesis, by practicing in
some specic cases some small tailored cutouts
on the edge of the pre-shaped mesh itself (small
247
248
window), at the aim to protect each single nerve
from possible entrapment in the later broblastic
processes. In a few cases, an intentional section of
nerves could be needed showing an abnormal
position within the inguinal box, but only when,
after careful thoughts of the operator on the surgical anatomy of that particular individual, no other
solutions for their sparing are seen.
Small indirect hernias should be repaired by
careful isolation and reduction of the sac into the
deep ring, which is then narrowed with absorbable sutures. A sutureless Hertra Herniamesh® is
then implanted on the posterior wall and the
external oblique aponeurosis always closed over
the mesh and under the spermatic chord.
Medium and large indirect hernias should be
repaired by dissection and reduction of the sac. In
the beginning of the experience, these kinds of
hernia were followed by implantation of a T4 at
plug positioned around the spermatic chord in the
preperitoneal space (Fig.25.7). Recently, depend-
ing on the real size of the defect that is found case
by case, through a very careful and tailored
choice, is adopted or a direct narrowing of the
internal ring with absorbable suture or the use of
T4 at plug. A pre-shaped Hertra Herniamesh® is
always then implanted on the attened posterior
wall of the inguinal canal.
G. Campanelli et al.
Fig. 25.8 Final view of a polypropylene pre-shaped
mesh implanted in the inguinal box
Direct hernias with partial or total wall
involvement should be repaired by reduction of
the sac with a continuous absorbable running
suture, which attened the oor of the inguinal
canal, thus allowing for a better apposition with a
pre-shaped Hertra Herniamesh®. Distal tip of the
mesh must be placed upon the pubic tubercle
with enough overlap, laterally to the hollow of
the inguinal ligament and medially at the sheath
of abdominal rectus muscle. With an absorbable
stitch, the two tails of the mesh are approached;
in this way the surgeon recreates a new internal
inguinal ring, and no stitches are positioned on
the surrounding tissues (Fig.25.8).
Fig. 25.7 T4 at plug into a large internal inguinal ring,
anchored to the pre-shaped onlay mesh—original drawings supplied by E.E. Trabucco [6]
25.4 Tips andTricks
– For the Law of Pascal, the pre-shaped prosthe-
sis developed by Trabucco remains stretched
uniformly in the inguinal canal, without the
need to be secured with sutures at conditions
that all the mesh is completely covered from
external oblique aponeurosis, without forming
dead space which is the cause of infections,
pain, and recurrences.
– The identication and the sparing of the three
nerves of the inguinal region is of crucial
importance to reduce the rate of neuralgia in
the short and long term, and the use of a local
anesthesia imposes the surgeon to properly
25 Primary Inguinal Hernia: Sutureless Open Anterior, Trabucco Repair
249
recognize those nerves and to respect them
during the repair.
– The intentional section of one or more nerves,
when it is not technically possible to achieve a
satisfactory nerve sparing, or special tricks to
create proper fenestrations (small window) on
the edge of the prosthesis to prevent the scar
tissue to involve the spared nerves, ensures a
further reduction of the rate of neuralgia and
excellent patient outcomes.
25.5 Outcomes
The main advantage of a tension-free and sutureless repair is given by the relevant reduction in
postoperative chronic neuralgia, which is not an
uncommon complication and, depending on its
intensity, can also potentially jeopardize patient’s
work and social activities.
With the complete sutureless repair ideated by
Trabucco (eventually performed with some little
modications regarding the choice of an absorbable plug for indirect large defects), the postoperative discomfort is minimal, the nerve injury is
rare, and the recurrence rate is very low. The
identication and the respect of the three nerves
of the inguinal region is of crucial importance to
signicantly reduce the rate of neuralgia in the
short and long term.
The use of local anesthesia imposes the surgeon to properly recognize those nerves and to
respect them during the repair, providing precious advantages, but certainly requires more
attention and care by the surgeon, in order to
avoid useless discomfort to the patient. The
Trabucco’s technique can be routinely performed
in a day surgery regimen, under local anesthesia,
obtaining the maximization of comfort for the
patients and offering excellent results for the
repair of any type of primary inguinal hernia.
Compared to the Lichtenstein’s technique and
TAPP, which are at now the golden standard treatment for primary inguinal hernias worldwide [12],
there are no signicant differences in the observed
recurrences and chronic pain rate [12, 15, 16].
With our experience of over 4.000 open hernia
repairs using this safe technique, the results (pro-
spective database) have been extremely satisfactory, as compared to Lichtenstein’s tension-free
technique, translating into an overall risk for the
patients of developing chronic groin pain well
below 1%.
Then even if our personal convinced approach
to all hernia diseases is a real “tailored” approach,
using open and laparoscopic, anterior and posterior and combined, synthetic and biologic, with
local and spinal and general anesthesia, with
sutures, sutureless and/or glue, ambulatory or
hospitalized, so in other words to choose the better option for each single patient, we think that
Trabucco technique for primary inguinal hernia
should be in the armamentarium of each hernia
and general surgeon.
References
1. Lichtenstein IL, Shulman AG, Amid PK, Montlor
MM. The tension-free hernioplasty. Am J Surg.
1989;157(2):188–93.
2. Lichtenstein IL, Shulman AG, Amid PK, Montlor
MM.Cause and prevention of postherniorrhaphy neuralgia: a proposed protocol for treatment. Am J Surg.
1988;155(6):786–90.
3. Trabucco EE, Trabucco AF. Flat plug and mesh her-
nioplasty in the “inguinal box”: description of the surgical technique. Hernia. 1998;2:133–8.
4. Trabucco EE, Trabucco AF, Rollino R, et al.
Ernioplastlca inguinale tension-free con rete presagomata senza suture secondoTrabucco, vol 2. Torino:
Chirurgia Minerva Medica; 1998.
5. Trabucco EE, Campanelli G, etal. Nuove protesi erni-
arie in polypropylene. Min Chir. 1998;53:337–41.
6. Trabucco EE. The ofce hernioplasty and the
Trabucco repair. Ann Ital Chir. 1993;44:127–49.
7. Petruzelli L, et al. Utilization of a rigid pre-shaped
mesh according to the Trabucco technique: an
experimental study. In National Congress of
SICADS.Ambulatory Surgery in Italy, April 15–18,
1999, Rome: Atti of Congress; 1999. p.47.
8. Campanelli G, Cavagnoli R, Gabrielli F, Pietri
P.Trabucco’s procedure and local anaesthesia in surgical treatment of inguinal and femoral hernia. Int
Surg. 1995;80(1):29–34.
9. Campanelli G, Ciof U, Cavagnoli R, Bastazza M,
Bruni PG, Senni Buratti M. Open sutureless tension-free repair for primary inguinal hernia. Hernia.
1999;3(3):121–4.
10. Aleri S, Amid PK, Campanelli G, Izard G,
Kehlet H, Wijsmuller AR, Di Miceli D, Doglietto
GB. International guidelines for prevention and