When I completed my five years of surgical training in 1970 and became an “obligated volunteer” in the U.S.Army as Chief of General Surgery at the multinational NATO hospital, most surgeons in the world repaired hernias through an incision using a technique originating in Europe almost 100 years earlier. We dissected many layers; sutured together the tissues at the edge of the defect (or gap), sometimes with a healthy tug causing tension. A few minimally significant advances had occurred since 1888 when the German surgeon Bassini described that favored method. In 1962, a newly introduced plastic mesh proved to be problematic. Many hernias remained untreated and were allowed by primary care physicians and patients to reach impressive sizes. A classmate in medical school returned from Africa with a photo of a patient navigating his hernia containing most of his bowel in a wheel barrel. In the U.S. we treated patients with hernias the size of cantaloupes on a regular basis. Sometimes so much bowel was out of the abdomen that there wasn’t enough room to put it back. When I served in the Army in 1970, I saw one foreign serviceman whose hernia originated in a flaming plane crash in WW II and was on hold for decades. General or spinal anesthesia was routinely used because few American surgeons were skilled with local anesthesia. Hospitalization and recovery was lengthy. Prolonged pain and disability were expected. Recurrences were common. Prosthetic materials were not available.
Now, three decades later, multiple new materials, techniques and technologies have evolved. New and safer anesthetic agents and short acting sedatives have become routine allowing for minimal risk with inhalation anesthetics. Many surgeons have mastered local anesthesia. Safe and dependable prosthetic materials are available. Techniques adhering to the principle of Tension Free Repair minimize pain and maximize speedy recovery. Results of laparoscopic “minimally invasive “ techniques are competitive with classic anterior incision techniques in properly selected patients. Normal activity can be resumed shortly after surgery. Loss of work time is minimized. Low recurrence rates are predictable with minimal disability and postoperative pain.
Multiple techniques can successfully repair the same hernia. The appropriateness of many overlap, but each technique has its own advantages and disadvantages within the context of specific needs of each patients. One technique does not fit the needs of all patients who have hernias although many surgeons habitually use one technique and apply it to everyone. If the reader knows the risks, benefits, options, relative advantages and disadvantages among the multitude of options of technique and anesthesia described in this book, he is more likely to partake in the choice resulting in the best decision for him. Results from laparoscopic techniques are not equivalent in the hands of all surgeons.
A. Douglas Heymann,
Over 50 years of experience.
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