Textbook of surgery

A hernia is an abnormal protrusion of a viscus (or part of a viscus) through a defect either in the con-
taining wall of that viscus or within the cavity in which the viscus is normally situated. The ‘wall’ refers to
the muscle layers of the abdomen or the diaphragm, or the walls of the pelvis. Hernias are either
external or internal.

A hernia occurs because of (i) weakness or defect in the abdominal wall and (ii) positive intra‐abdominal
pressure (IAP), which is often raised, forces the viscus into the defect.

Inguinal hernia is the commonest hernia and is approximately 10 times more common in males than
females (see Tables 43.1 and 43.2). Two types of inguinal hernia are recognised (Figure  43.4), indirect
inguinal hernia (IIH) and direct inguinal hernia (DIH), but they can occur together.

recurrence is related to surgical technique, expertise and experience of the operator,

Textbook of hernia

It is esti-mated that more than 20 million groin hernia repairs are per-formed every year worldwide. Of
these, nearly 800,000 are inguinal hernia repairs performed in the USA.

Emergency procedures account for 5–10 % of all inguinal hernia repairs,

The incidences of inguinal hernia repair increase almost exponentially for men during their third decade
and onward,

After inguinal hernia repair 3–8 % of patients develop recur-rence of the hernia

Engbang et al (2021)

An inguinal hernia is defined as the passage under the skin of a portion of the peritoneum possibly
containing abdominal viscera through the inguinal canal or directly through the abdominal muscles [1].
Almost 95% of groin hernias are inguinal hernias. The remaining 5% concern crural hernias. They mainly
affect the male subject between 20 and 60 years. Ten percent of digestive surgery procedures are cures
for inguinal hernias [2]. A distinction is made between direct inguinal hernia, external oblique hernia,
pantal hernia and inguinoscrotal hernia. Worldwide, there are more than 20 million inguinal hernia
cures per year [3]. In the United States of America (USA), 800,000 cures for inguinal hernias are
performed each year [3].

Baylon (2017)

Hernias can be uncomfortable and are sometimes accompanied by severe pain, which worsens during
bowel movements, urination, heavy lifting, or straining [3]. Occasionally, a hernia can become
strangulated, which occurs when the protruding tissue swells and becomes incarcerated. Strangulation
will interrupt blood supply and can lead to infection, necrosis, and potentially life-threatening conditions
[4]

Surgical meshes could be made from an absorbable or non-absorbable material. Non-absorbable

meshes can withstand the mechanical requirements, are easy to shape intraoperative and have long-
term stability. However, complications such as mesh stiffness over time, hernia recurrence, mesh
erosion, and adhesions have been documented. On the other hand, absorbable meshes were developed
to reduce these long-term complications. These meshes favor postoperative fibroblast activity.
Nevertheless, after prosthesis absorption, the resulting scar tissue is not as strong as it was, and alone is
insufficient to provide the needed strength and could result in hernia recurrence.

Given the difficulty to find a single surgical mesh that fulfills all of the “ideal” characteristics, there are
more than 70 meshes for hernia repair available in the market. These are classified according to the
composition or type of material as: (1) first generation (synthetic non-absorbable prosthesis), (2) second
generation (mixed or composite prosthesis), and (3) third generation (biological prosthesis).

There is general tendency to use light meshes with macropores which reduce the post-operative risk of
chronic pain and mesh infection.

Mulita (2020)

Almost one third of males are diagnosed with an ingui- nal hernia during their lifetime. The highest
incidence in adults is after 50 years of age (2)

Inguinal anatomy is complicated and of essential knowledge for the general surgeon and numerous
times hernia surgery represents a major challenge even for the most experienced surgeons (5).

One of the major patient concerns undergoing ingui- nal hernia repair is postoperative pain and the
need to return to work and daily activity as soon as possible.

Darmojo et al

Data yang dikemukakan oleh Simarmata pada tahun 2003, bahwa insidensi hernia inguinalis di Indonesia
diperkirakan mencapai 15% populasi dewasa, 5-8% pada rentang usia 25-40 tahun, dan 45% pada usia
75 tahun.6

Takahashi et al

Hernia repair feasibility contributes to hernia recurrence.

Saha, Tanushree
In 1958, Usher first introduced mesh prosthesis as a hernia repair tool that addressed the recurrence
problem to a great extent [2]

Hernia mesh is a flexible, thin flat piece of woven or knitted material with a porous structure. It has been
reported that more than 80% of hernia surgery uses mesh materials [2]. At present, approximately 20
million hernia repairs per year are conducted worldwide [7], and about one million meshes are
consumed every year during hernia surgery. Mesh materials are applied at the defect site to cover and
reinforce the weak surrounding tissues of the abdominal wall after sending back the protruded intestine
to the abdomen cavity

Carmine wang see

There are around 70-80 types of commercially available meshes for hernia repair [38] . Current hernia
treatment uses one of the two main types of meshes, synthetic and biological. Biological mesh usually
consist of human porcine orfetal bovine dermis that is decellularized. Decellularization leaves the
complex collagen structure of the dermis. Porcine small intestine submucosa and bovine pericardium is
also commonly used. The mesh is designed for the host tissue to recolonize with cells and promote
tissue growth, leading up to reabsorbtion [65] . Compared to synthetic meshes, biological meshes are
more biocompatible and trigger less inflammatory response from the body, but they are associated with
more hernia recurrences because of their lower mechanical strength compared to synthetic meshes.

First generation synthetic meshes were based on PP systems with three different categories:
macroporous meshes, microporous meshes and macroporous meshes with multifilament or
microporous components [20] (

Macroporous meshes have a pore size larger than 75μm. Microporous meshes have smaller pore sizes
around 10μm. Multifilament macroporous meshes with microporous components have plaited
multifilamentary threads in their composition. The threads are less than 10μm apart and the mesh pore
size is larger than 75μm.

The mechanical strength of synthetic meshes are much greater than Biological mesh.

Watson 2020

Chronic pain or inguinodynia lasting longer than 3 months after inguinal hernia sur- gery is an important
problem for many patients.12 The fixation technique and mesh type may influence pain postoperatively.