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2 Tension-free, Sutureless Primary Inguinal Hernia Repair: the Trabucco Technique
References
description of the surgical technique. Hernia 2:133–138
primary inguinal hernia. Hernia 3:121–124
4. Trabucco EE, Trabucco AF, Rollino R et al (1998) Ernioplastica inguinale tension-free con
Italy, Rome
6. Trabucco EE, Campanelli G, Cavagnoli R (1998) Nuove protesi erniarie in polipropilene.
Minerva Chir 53:337–342
15:239–249
9. Campanelli G, Cavagnoli R, Gabrielli F et al (1995) Trabucco’s procedure and local
anaesthesia in surgical treatment of inguinal and femoral hernia. Int Surg 80:29–34
31
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_3, © Springer-Verlag Italia 2017
A.I. Gilbert ()
Miller-Miami Medical School, Hernia Institute of Florida
Miami, Florida, USA
e-mail: Bigart32@aol.com
3
Gilbert Technique of Inguinal Hernia Repair
Arthur I. Gilbert, Jerrold Young, and Rafael Azuaje
3.1 Introduction
The Gilbert technique of groin hernia repair has undergone generations of im-
provement since its inception in 1985 yet certain basic principles have been con-
stant.
currently presenting hernias and to prevent future hernias from forming in
patients that create intraabdominal pressures during natural bodily functions
spermatic fascia covering the spermatic cord is opened the primary indirect
peritoneal sac can be dissected free and invaginated into the preperitoneal
space (space of Bogros).
ideal space for placement of any barrier device (mesh or biologic) to protect
d. Tension on any repair produces unnecessary postoperative pain that can
be long in duration and disabling. Tension in any repair, sutured or mesh,
promotes the likelihood of recurrence.
32
A.I. Gilbert et al.
3.2 History
changed to the Shouldice technique using polypropylene suture to do that three-
a rolled polypropylene plug repair sutured in the internal ring to repair all but very
large indirect inguinal hernias. By 1986 I changed the rolled plug into a patch-
iteration, in 1997, is a hybrid of groin hernia repairs that I did prior to 1984, and
indirect hernia. The underlay patch mimics the posterior mesh repairs described
inguinal hernias.
3.3 Gilbert Technique of Hernia Repair
is incised and the subcutaneous layer is opened. Fifteen milliliters of additional
undisturbed. The cremasteric fascia is opened and the spermatic cord is elevated.
of the genitofemoral nerve is preserved. The mesentery of the cord is opened to
later accommodate the onlay patch. The transparent internal spermatic fascia that
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3 Gilbert Technique of Inguinal Hernia Repair
dissected up to its true neck. If the sac’s head is attached or scarred to the internal
spermatic vessels, its mid-portion is divided leaving its distal portion in place.
dissected, it is invaginated through the deep ring (or, if preferred, the sac is ligated
and divided). For direct hernias, the defective transversalis fascia is opened
Fig. 3.1
Fischer’s Mastery of
Surgery, 4th edn. © Lippincott Williams & Wilkins, 2011)
34
A.I. Gilbert et al.
Fig. 3.2
Fischer’s Mastery of Surgery, 4th edn.
© Lippincott Williams & Wilkins, 2011)
Fig. 3.3 The bilayer connected mesh device is placed in preparation to suture onlay patch
Fischer’s Mastery of Surgery, 4th edn.
© Lippincott Williams & Wilkins, 2011)
35
3 Gilbert Technique of Inguinal Hernia Repair
underlay patch is deployed from its connector. The connector and onlay patch are
deployment of the circular underlay patch is facilitated. The technical goal of
deployment is to spread the edge of the underlay patch circumferentially to be
patient’s intraabdominal pressure. Typically, the internal ring is not tightened
The connector remains in the internal ring or in the direct defect. The medial
medial leaf is loosely sutured 2 cm over the pubic tubercle. Effectiveness of the
underlay patch alone can be evaluated by having the patent cough and perform
a Valsalva maneuver before any sutures are placed in the onlay patch. In all
into the periostium) over the pubic bone medial to the tubercle, at the middle of
the transversus arch and at the middle of the inguinal ligament. To accommodate
the spermatic cord through the onlay patch, a central slit is made close to the
connector. The third suture is placed in the mid-portion of the inguinal ligament
after the spermatic cord is accommodated. For the repair of an indirect hernia it
through the slit. The patient again tests the repair by coughing and straining. Any
a 3-0 Vicryl Rapide suture is done. Dermabond is applied to the skin, making
dressing is unnecessary.
sitting up on the operating table and moving from there to the gurney, the patient
is retuned to the recovery room. After a light meal and being able to urinate, the
patient leaves the ambulatory center about an hour after the operation. An ice bag,
36
A.I. Gilbert et al.
applied in the recovery area, is used for the remainder of the operative day. The
number and encourage them to stay in contact regarding their progress. They are
Suggested Readings
inguinal hernia. Am J Surg 157:331–333
Gilbert AI (1997) Symposium on the management of inguinal hernias. Sutureless technique:
second version. Can J Surg 40:209–212
37
G. Campanelli (Ed), Inguinal Hernia Surgery,
Updates in Surgery
DOI: 10.1007/978-88-470-3947-6_4, © Springer-Verlag Italia 2017
J.W. Murphy ()
William Beaumont Hospital-Troy
4
Inguinal Hernia Repair Now and in the Future
John W. Murphy
4.1 Introduction
Inguinal hernia repair is one of the most common surgical procedures performed
understanding of the underlying anatomical and physiological processes of hernia
To understand the foundation of this rapid and remarkable improvement
to consider three basic tenets in modern day hernia repair. These principles
4.2 Past Advances
disease process, rather than heavy lifting, coughing or a patent process vaginalis.
population of Veterans Administration patients. He attributed this to a protease-
postulated that this imbalance caused similar changes in the connective tissue of
38
J.W. Murphy
elastase in smokers [2].
inguinal hernias [5].
repair in the last 25 years. Today, there are over 50 different mesh hernia devices
for individual patients resulting in better outcomes [8].
4.3 Present Practice
The improvement in surgical outcomes since adoption of these three tenets has
39
4 Inguinal Hernia Repair Now and in the Future
the continued popularity of tension (tissue) hernia repair. Based on our current
physiological understanding of the tissue abnormality underlying hernia
surgeons continue performing these repairs and advocating for their application,
current literature.
maintain competency.
today is chronic groin pain [9]. Various studies have placed the incidence of
850,000 hernia repairs performed in the U.S. annually, one can derive an absolute
of this outcome, as neither the primary care physician nor the pain management
letter to the surgeon.
In June 2011, the European Hernia Society published the International