The Art of Hernia Surgery: A Step-by-Step Guide

Description

Foreword Preface Contents Part I: General Aspects 1: History and Evolution of Hernia Surgery References 2: Teaching Hernia Surgery: The Experience of the Italian School 2.1 Introduction 2.2 Italian School of Hernia and Abdominal Wall Surgery References 3: Alterations of the Extracellular Matrix of the Connective Tissue in Inguinal Herniogenesis 3.1 Introduction 3.2 Role of the Extracellular Matrix in Hernia Pathology 3.2.1 Collagen Fibers 3.2.2 Matrix Metalloproteinases (MMPs) 3.2.3 Growth Factors 3.2.4 Elastic Fibers 3.3 Discussion References 4: Classification of Inguinal and Abdominal Wall Hernia 4.1 Inguinal Hernia Classification 4.2 Primary and Incisional Abdominal Wall Hernia Classification 4.2.1 Classification of Primary Abdominal Wall Hernias 4.2.2 Classification of Incisional Abdominal Wall Hernias References 5: Diagnostic Tools in Hernia Disease 5.1 Introduction 5.2 History and Physical 5.3 Diagnostic Tools for Inguinal Hernia 5.3.1 Imaging in Inguinal Hernias 5.3.2 Ultrasound 5.3.3 CT Scan 5.3.4 MRI 5.3.5 Herniography 5.3.6 Diagnostic Laparoscopy 5.4 Summary and Recommendations for Diagnostic Tools in Inguinal Hernia 5.5 Diagnostic Tools for Ventral Hernia 5.6 Summary and Recommendations for Diagnostic Tools in Ventral/Incisional Hernia References 6: Materials, Devices and Gadgets for Hernia Surgery 6.1 Prosthetic Mesh Materials 6.1.1 Introduction 6.1.2 History of Prosthetics in Hernia Surgery 6.1.3 Pathophysiology of Prosthetic Mesh Incorporation 6.1.3.1 Wound Healing Process 6.1.3.2 The Foreign Body Reaction 6.1.4 The Ideal Prosthetic Mesh 6.2 Mesh Properties 6.2.1 Materials 6.2.1.1 Plastic (Synthetic) Meshes: Non-Absorbable Polypropylene Mesh (PPM) Polyester Mesh ePTFE cPTFE PVDF 6.2.1.2 Plastic (Synthetic) Meshes: Absorbable Polyglycolic Acid Polyglactin 910 6.2.1.3 Plastic (Synthetic) Meshes: Bioabsorbable Meshes 6.2.1.4 Composite/Hybrid Meshes 6.2.1.5 Biological Meshes 6.2.1.6 Cross-Linked Vs. Non-Cross-Linked 6.2.2 Mesh Construction 6.2.3 Mesh Weight and Pore Size 6.2.4 Tensile Strength and Elasticity 6.2.5 Classification of Meshes 6.2.6 Commercially Available Meshes 6.2.6.1 Low-Cost Mesh 6.3 Techniques of Mesh Fixation 6.3.1 Introduction 6.3.2 Fixation Methods 6.3.2.1 Suture Fixation Suture Material Suture Technique 6.3.2.2 Glue Fixation 6.3.2.3 Fibrin Sealant Fixation 6.3.2.4 Staple Fixation 6.3.2.5 Tacks and Anchor Fixation 6.3.2.6 No Fixation 6.3.2.7 Self-Fixing Mesh References 7: Guidelines: Options and Limit 7.1 Introduction 7.2 Clinical Practice Guidelines (CPGs) 7.2.1 Definition and Objective 7.2.2 Types of CPGs 7.2.3 Other Tools 7.2.4 When It Is Necessary to Develop a CPG? 7.2.5 Steps in the Development of a CPG 7.2.5.1 Selection of the Problem to Be Evaluated 7.2.5.2 Group Members 7.2.5.3 Development of the CPG 7.2.6 The GRADE Approach 7.3 Drafting, Reviewing, and Updating CPGs 7.4 Implementation of CPGs 7.5 Benefits of CPGs 7.6 Potential Limitations of CPGs References 8: Creation, Advantages, and Limits of Registries: The Herniamed Experience 8.1 Introduction 8.2 Creation of Herniamed 8.3 Advantages of Registries 8.3.1 Quality Improvement by Registries 8.4 Registry-Based Research 8.5 Registries in the Early Scientific Evaluation of Surgical Innovations 8.6 Cost of RCTs vs. Registries 8.6.1 Registries in the Postmarketing Surveillance of Surgical Products 8.7 Nationwide Change of Clinical Practice by Registry Data 8.8 Published Data from the Herniamed Registry 8.9 Limits of Registries References 9: Management of Database in Hernia Surgery 9.1 Introduction 9.2 What Is the Goal of Databanks? 9.3 How Much Data Makes a Successful Databank? 9.4 Which Algorithms and Mechanisms Are Needed to Maintain a Databank? 9.5 The Databank as a Diagnostic Tool for Improving Treatment References 10: Ventral Hernia Surgery in Europe: Trends and Actual Situation 10.1 Background 10.2 Trends 10.2.1 Prevalence of Ventral Hernia 10.2.2 Prevention of Ventral Hernia 10.2.3 Risk Factors for Ventral Hernia Recurrence 10.3 The Mesh Implant 10.4 Ventral Hernia Grading Scales 10.5 Reduction in Hospital Length of Stay 10.5.1 Day Surgery 10.5.2 Laparoscopic Ventral Hernia Surgery 10.6 Actual Situation 10.6.1 Innovative Surgical Techniques 10.6.2 Sub-Specialisation 10.6.3 Prevention of Surgical Site Infections 10.6.4 National and International Ventral Hernia Databases References 11: Hernia Repair in the United States: Current Situation and Trends 11.1 Hernia Epidemiology 11.1.1 Groin Hernia 11.1.2 Ventral Incisional Hernia 11.2 Pre-Habilitation 11.3 Operative Techniques 11.4 Mesh Type and Location 11.5 Robot-Assisted Hernia Repair 11.6 Outcomes Assessment and Mentorship References 12: Hernia Surgery in Asia 12.1 Introduction References 13: Hernia Surgery in Australasia 13.1 A Brief History for Australia and New Zealand (and Probably the World) 13.2 Early Days in New Zealand 13.3 The Current Situation for Australia and New Zealand 13.4 Survey of Surgeon Preferences for Hernia Repair 13.4.1 Inguinal Hernia Repair 13.4.2 Paraumbilical and Epigastric Hernia Repair 13.4.3 Incisional Hernia Repair 13.5 Laparoscopic Training 13.6 TAPP Versus TEP 13.7 Open Inguinal Hernia Repair 13.8 Mesh Controversy 13.9 The Wider Influence of Videolaparoscopy on Hernia Repair 13.10 The Pacific Island Nations 13.11 Laparoscopic Inguinal Hernia Repair: A Theory for Pain Prevention with Penetrative Fixation References 14: Hernia Surgery in Africa 14.1 Summary 15: Humanitarian Hernia Surgery: Lessons Learned 15.1 Introduction 15.2 Service Missions 15.2.1 Surgeon Selection 15.2.2 Staff Selection 15.3 Surgical Technique and Equipment Used 15.3.1 Procedures to Closely Monitor in the Austere Operating Room Environment 15.3.2 HRFU Hydrocele Protocol and Guidelines [11, 18, 19] 15.3.3 Adult Giant Scrotal Hernias and Large Inguinal Scrotal Hernias 15.3.4 Pediatric Hernia Repair and Undescended Testicle 15.3.5 Incisional Hernias 15.3.6 Anesthesia Care 15.3.7 Patient Follow-Up 15.4 Training Missions 15.4.1 Capacity Building 15.4.2 Training Method 15.4.3 Hernia Mesh in Developing Countries 15.4.4 Surgeon Trainee Selection 15.4.5 Additional Barriers to Education Assessment and Sustainability References 16: The Most Important Clinical Trial in the Last 10 Years in Inguinal and Incisional Hernia Surgery References Part II: Inguinal 17: Anatomy of the Inguinal Region 17.1 The Myopectineal Orifice of Fruchaud and the Inguinal Region: Three Muscular Layers Concurring to Weakness (Fig. 17.2) 17.2 The Inguinal Canal (Fig. 17.7) 17.3 Entrance to the Channel: the Deep Inguinal Ring 17.4 Exit to the Channel: the Superficial Inguinal Ring 17.5 Floor of the Channel: the Inguinal Ligament 17.6 Front Wall of the Inguinal Canal: External Oblique Aponeurosis 17.7 Back wall of the Inguinal Canal: Transversalis Fascia 17.8 Spermatic Cord and Vascular Issues 17.9 The Nerves of the Inguinal Region: Turning Enemies to Friends 17.10 Inguinal Canal: Some Notions of Embryology (Fig. 17.15) References 18: Ambulatory Hernia Surgery 18.1 Definition 18.2 History 18.3 Ambulatory Hernia Surgery Evidence 18.4 International Comparison 18.5 Practical Requirements and Current Data References 19: Obscure Groin Pain in Women 19.1 History of the Hidden Hernia 19.2 Anatomical Explanation for the Hidden Hernia 19.3 Symptoms in Women 19.4 Subtle Physical Examination Findings Suggested Readings 20: Individualization Treatment of Inguinal Hernia in Children 20.1 Etiology 20.2 Clinical Manifestation 20.3 Physical and Accessory Examination 20.4 Diagnosis and Differential Diagnosis 20.5 Treatment 20.5.1 Indications for Surgery 20.5.2 Modified Open Pediatric Inguinal Hernia Repair 20.5.3 Operative Steps for the Modified Open Pediatric Inguinal Hernias Repair 20.5.4 Laparoscopy High Hernia Sac Ligation Assisted with a Needle-Type Grasper 20.5.5 Preoperative Preparation 20.5.6 Patient and Team Position 20.5.7 Surgical Procedures 20.5.8 Lichtenstein Hernioplasty Using Biological Patch 20.5.9 Surgical Procedures References 21: Indications for Pure Tissue Repairs 21.1 Broad Aperçu of the Scientific Literature 21.2 Statistical Relevance 21.3 Pure Tissue Repairs 21.4 Indications for Pure Tissue Repair 21.5 Indications for Pure Tissue Repairs in Women 21.6 Indications for Pure Tissue Repairs as Assessed at Arm’s Length from Outside Shouldice Hospital: A Comparative Statistical Study—The Contribution of Herniamed 21.7 Chronic Post-Herniorrhaphy Pain Syndrome: The Newest Indication for Pure Tissue Repair 21.8 Understanding the Pathology of Mesh-Body Interactions and Its Importance in Understanding and Retaining Pure Tissue Repairs 21.8.1 Foreign Object 21.8.2 Mesh as a Porous (Compartmentalized) Structure 21.9 Material-Related Changes References 22: Local Anesthesia in Inguinal Hernia: Indications and Techniques 22.1 Introduction 22.2 Personal Experience 22.3 Indications 22.4 Surgical Technique References 23: Bassini Repair 23.1 Introduction 23.2 Position of the Patient 23.3 Skin Incision 23.4 Exposure of the Aponeurosis of the External Oblique Muscle 23.5 Incision of the Aponeurosis of the External Oblique Muscle: Opening of the Anterior Wall of the Inguinal Canal and of the External Inguinal Ring 23.6 Excision of the Cremasteric Muscle and Suture Ligature of the Stumps 23.7 Opening of the Internal Spermatic Fascia 23.8 Isolation of the Sac 23.9 Opening of the Transversalis Fascia 23.10 Opening of the Sac Ani 23.11 Reconstruction of the Posterior Wall of the Inguinal Canal and the Internal Inguinal Ring 23.12 The Filzetta Stitch 23.13 The First Stitch 23.14 The Second Stitch 23.15 The Third Stitch 23.16 The Last Stitch 23.17 Tying the Sutures 23.18 Reconstruction of the Anterior Wall of the Inguinal Canal and of the External Inguinal Ring 23.19 Closure of the Skin 24: The Shouldice Repair 24.1 Introduction 24.2 Local Anaesthesia 24.3 Surgical Technique in Male Patients 24.3.1 Dissection 24.3.2 Reconstruction 24.4 Shouldice Repair in Female Patients 24.4.1 Dissection 24.4.2 Reconstruction References 25: Primary Inguinal Hernia: Sutureless Open Anterior, Trabucco Repair 25.1 Introduction 25.2 Surgical Indications 25.3 Surgical Technique 25.4 Tips and Tricks 25.5 Outcomes References 26: Lichtenstein Onlay Mesh Hernioplasty: Original Technique and Personal Modifications 26.1 Indications 26.2 Patient Preparation 26.3 Original Technique 26.3.1 Anesthesia 26.3.2 Local Anesthesia 26.3.2.1 Mixture 26.3.3 Technique 26.4 Surgical Dissection 26.4.1 Hernia Sac Treatment 26.4.1.1 Medial Hernia Sac 26.4.1.2 Lateral Hernia Sac 26.4.2 The Mesh: Material 26.4.3 Mesh Fixation 26.4.4 Closure of the Surgical Wound 26.4.5 Patient Discharge and Aftercare References 27: Mesh Plug Repair 27.1 Introduction 27.2 Surgical Technique 27.3 Comments References 28: Self-Gripping Mesh Repair in Primary Inguinal Hernia 28.1 Introduction 28.2 Description of the Self-Gripping Mesh 28.3 Surgical Procedure 28.3.1 Anesthesia 28.3.2 Incision, Opening, and Exploration of the Inguinal Canal 28.3.3 Hernioplasty and Mesh Application 28.4 Tips and Tricks 28.4.1 Antibiotic Prophylaxis 28.4.2 Preoperative Landmarks 28.4.3 Anesthesia 28.4.4 Nerve Management 28.4.5 Hernial Sac Management 28.4.6 Mesh Application 28.4.7 In Females 28.5 Discussion and Conclusions References 29: Gilbert Technique: PHS Bilayer Repair 29.1 Anatomy: Principles of Repair 29.2 Background: Lessons from History 29.3 Suture Repairs 29.4 Anterior Mesh Repairs 29.5 Preperitoneal Retro-muscular Repairs 29.6 Bilayer Repair: The Prolene Hernia System® (PHS-UHS) 29.7 Preoperative Evaluation and Planning 29.8 Operative Venue, Preparation, and Anesthesia 29.9 Steps in Bilayer Repair 29.9.1 Incision and Exposure 29.9.2 Preparation of the Anterior Space 29.9.3 Management of Indirect Hernia Sac and Lipoma 29.9.4 Dissection of the Posterior Space 29.9.4.1 Medial (Direct) Hernias 29.9.4.2 Lateral (Indirect) Hernias 29.9.5 Deployment of Underlay 29.9.6 PHS Overlay Placement and Fixation 29.9.7 Post-op Care 29.10 Results 29.11 Quality of Life Issues 29.12 Selection of Technique: Tailored Repair 29.13 Discussion References 30: Open New Simplified Totally Extraperitoneal (ONSTEP) Technique for Inguinal Hernia Repair 30.1 Introduction 30.2 The ONSTEP Technique 30.2.1 Why a Technique Involves Two Different Planes 30.2.2 The Onflex Mesh 30.2.3 Pain from the Recoil Ring 30.2.4 Recurrence Repair After Previous ONSTEP 30.3 Clinical Data 30.4 Learning, Training, and Implementation 30.5 Health Economics 30.6 Perspectives References 31: Transinguinal Preperitoneal (TIPP) Inguinal Hernia Repair Using a Totally Extraperitoneal, Parietalized, Memory-Ring Patch 31.1 Introduction 31.2 Anesthesia 31.3 Operative Technique: Lateral Hernia 31.3.1 First Step: Skin Incision 31.3.2 Second Step: Nerve Preservation 31.3.3 Third Step: Treatment of the Hernia Sac 31.3.4 Fourth Step: Dissecting the Preperitoneal Space 31.3.5 Fifth Step: Parietalization of the Cord Elements 31.3.6 Sixth Step: Anterolateral Release of the Peritoneum 31.3.7 Seventh Step: Positioning the Mesh 31.4 Operative Technique: Medial Hernia 31.5 Operative Technique: Tips and Tricks 31.6 Results 31.7 Advantages of the TIPP References 32: Minimal Open Preperitoneal (MOPP) Technique 32.1 Introduction 32.2 Prosthesis and Instrumentation 32.3 Surgical Technique 32.3.1 The Minimal Open Route Between the Skin and the Deep Inguinal Ring 32.3.2 Cleavage of the Preperitoneal Space 32.3.3 Parietalization of the Spermatic Cord 32.3.4 Placing the Prosthesis 32.4 Indications 32.5 Special Cases 32.5.1 Female Hernias 32.5.2 Femoral Hernia 32.5.3 Scrotal Hernia 32.5.4 Strangulated Hernia 32.6 Contraindications 32.7 Personal Data References 33: Total Extraperitoneal (TEP) Approach in Inguinal Hernia Repair: The Old and the New 33.1 Introduction 33.2 Indications 33.3 Contraindications 33.4 Relative Contraindications 33.5 Preoperative Preparation 33.6 Operating Theatre Setup 33.6.1 Instruments 33.6.2 Patient and Surgical Team Positioning 33.7 Surgical Technique 33.7.1 Entering and Creating the Preperitoneal Space 33.7.2 Medial Dissection (Space of Retzius or Prevesical Space) 33.7.3 Lateral Dissection (Lateral Space of Bogros) 33.7.4 Hernia Sac Identification and Reduction 33.7.5 Hernia Reduction 33.7.5.1 Medial or Direct Hernia 33.7.5.2 Femoral Hernia 33.7.5.3 Obturator Hernia 33.7.5.4 Indirect Hernia 33.7.5.5 Mesh Repair 33.7.5.6 Reduced- and Single-Port Technique 33.8 Postoperative Care 33.9 Complications References 34: Primary Inguinal Hernia: TAPP 34.1 Introduction 34.2 Indication for TAPP Technique 34.3 The Standardized TAPP Technique 34.3.1 Pneumoperitoneum 34.3.2 Trocar Placement 34.3.3 Dissection 34.3.4 Mesh Placement 34.3.5 Fixation 34.3.6 Peritoneal Closure 34.3.7 Closure of the Trocar Incisions 34.3.8 Antibiotic and Thromboembolic Prophylaxes References 35: Biological Prosthesis in Inguinal Hernia Repair 35.1 Introduction 35.2 Biological Prosthesis 35.2.1 Features 35.2.2 Cross-Linked and Non-Cross-Linked 35.2.3 BP Physiopathological Process Compared to Synthetic Meshes 35.3 Which Kind of BP to Use? 35.4 Complications 35.5 Clean Fields 35.6 Contaminated Fields 35.7 Inguinal Sports Hernias 35.8 Hernia Repair in Emergency Surgery References 36: Inguinal Hernia Recurrence 36.1 Introduction 36.2 Risk Factors for Inguinal Hernia Recurrence 36.3 When to Repair Recurrent Inguinal Hernias 36.4 Surgical Approach to Recurrent Inguinal Hernias 36.5 Anterior Approach to Recurrent Inguinal Hernia Repair for Prior Failed Posterior Repairs 36.6 Laparoscopic Approach to Recurrent Inguinal Hernia Repair After Failed Anterior Repair 36.7 Approach to Inguinal Hernia Repair After Failed Anterior and Posterior Repairs 36.8 Special Attention to the Femoral Canal References 37: Giant Hernia: Hug and TOP Technique 37.1 Introduction 37.2 Clinical Presentation 37.3 Literature Review 37.4 Surgical Technique References 38: Pubic Inguinal Pain Syndrome (PIPS) 38.1 Introduction 38.2 Clinical Aspect 38.3 Diagnosis 38.4 Management 38.4.1 Conservative Treatment 38.4.2 Surgical Treatment References 39: Surgical Emergencies in Inguinal Hernia 39.1 Definition and Clinical Presentation 39.1.1 Incarcerated Hernia 39.1.2 Intestinal Occlusion 39.1.3 Strangulation 39.2 Diagnosis 39.2.1 Physical Examination 39.2.2 Ultrasound 39.2.3 Abdominal Radiographs 39.2.4 Computed Tomography 39.2.5 Nuclear Magnetic Resonance Imaging 39.2.6 Laparoscopy 39.2.7 Deep Inguinal Ring Laparoscopy 39.3 Surgical Options Bibliography 40: Results and Complications of Inguinal Hernia Repair 40.1 Watchful Waiting 40.2 Results and Complications 40.2.1 Open Inguinal Hernia Repair 40.2.1.1 Mesh-Based Repair 40.2.1.2 Mesh Types 40.2.1.3 Lichtenstein Repair 40.2.1.4 Non-Lichtenstein Mesh Repairs 40.2.1.5 Plug and Patch 40.2.1.6 Bilayered Mesh System 40.2.1.7 Self-Gripping Mesh 40.2.1.8 Glue Fixation 40.2.1.9 Preperitoneal Approaches 40.2.1.10 Suture-Based Open Repairs 40.2.2 Laparoscopic Inguinal Hernia Repair 40.2.3 Complications 40.2.3.1 Recurrence 40.2.3.2 Chronic Pain 40.2.3.3 Meshoma and Other Mesh-Related Complications 40.2.3.4 Infections 40.2.3.5 Urinary Retention 40.2.3.6 Sexual Dysfunction 40.2.3.7 Hematoma and Other Vascular Injuries 40.2.3.8 Seroma 40.2.3.9 Late and Serious Postoperative Complications References 41: Aetiology, Pathogenesis and Assessment of Chronic Pain After Inguinal Hernia Repair 41.1 Definition 41.2 Epidemiology 41.3 Aetiology and Pathogenesis 41.3.1 Neuropathic Pain Syndromes 41.3.1.1 Inguinal Nerve Involvement 41.3.1.2 Lower Intercostal Nerve 41.3.1.3 Neuroma Formation 41.3.1.4 Deafferentation and Centralization of Pain 41.3.2 Non-Neuropathic Pain Syndromes 41.3.2.1 Mesh-Related Pain Meshoma Formation 41.3.2.2 Adductor Tendinopathy 41.3.2.3 Periostitis Pubis 41.3.2.4 Iliopectineal Bursitis 41.3.3 Combined Groin Pain Syndromes 41.3.3.1 Dysejaculation 41.3.3.2 Orchialgia Versus Scrotal Pain 41.4 Assessment 41.4.1 Patient’s History 41.4.1.1 Diagnostic Clues for Neuropathic Pain 41.4.1.2 Diagnostic Clues for Non-­Neuropathic Pain 41.4.1.3 Diagnostic Questionnaires 41.4.2 Physical Examination 41.4.2.1 Tests for Diagnosing Sensory Disturbances 41.4.2.2 Localization of Pain 41.4.2.3 Musculoskeletal Examination 41.4.2.4 Spine Examination 41.4.3 Pitfalls 41.4.4 Imaging 41.4.4.1 Ultrasonography 41.4.4.2 Computed Tomography 41.4.4.3 Magnetic Resonance Imaging 41.4.5 Other Diagnostics 41.4.5.1 Diagnostic Injections Local Anaesthetic Agents Corticosteroids 41.4.5.2 Quantitative Sensory Testing 41.4.5.3 Other Imaging Techniques References 42: Postoperative Chronic Pain Assessment and THOPA Philosophy 42.1 Clinical Assessment 42.2 Treatment References 43: Laparoscopic Approaches to Chronic Postoperative Inguinal Pain 43.1 Surgical Techniques 43.1.1 Endoscopic Groin Exploration 43.1.2 Meshoma 43.1.3 Fixation 43.1.4 Recurrent Hernia and Retained Cord Lipoma 43.1.5 Orchialgia 43.1.6 Endoscopic Retroperitoneal Triple Neurectomy 43.1.6.1 Operative Technique 43.2 Results References Part III: Femoral 44: Anatomy of the Femoral Region References 45: Primary Femoral Hernia: Open Anterior Treatment 45.1 Introduction 45.2 Anatomic Characteristics of the Femoral Canal and the Femoral Fascia 45.3 Materials: Important Element for a Rational Use 45.4 Anaesthesia 45.5 Surgical Techniques 45.5.1 UHS: Ultrapro Hernia System 45.5.2 PHS: Prolene Hernia System 45.5.3 UPP: Ultrapro Plug 45.6 Emergency Femoral Hernias: The Surgical Technique 45.7 Personal Technique in Emergency 45.8 Personal Experience (1996–2015) 45.9 Consideration on Personal Case Studies from 1996 to 2015 45.9.1 Type of Prosthesis 45.9.2 Anaesthesia 45.9.3 Local Complications n. 41 (16.8%) 45.9.4 Abdominal Complications 45.10 Tactical Considerations: Tips and Tricks 45.10.1 The Choice of Materials and Shape: UHS Mesh and UPP Plug 45.10.2 Advantages of the Infrainguinal Approach 45.10.3 What Does a More Minimally Invasive Approach Mean? 45.10.4 Infrainguinal Open Approach in Emergencies 45.11 Conclusion: Low Approach Double Disc Prosthesis 45.12 Femoral Hernias: General Key Points References 46: Open Posterior Approaches for Femoral Hernia Repair 46.1 Introduction 46.1.1 Indications and Contraindications 46.1.2 Anesthesia 46.1.3 Surgical Techniques 46.1.3.1 The Kugel Approach 46.1.3.2 The Transinguinal Preperitoneal Technique (TIPP) 46.1.3.3 The Transrectus Sheath Preperitoneal Mesh Technique (TREPP) 46.1.3.4 Postoperative Recommendations 46.1.4 Literature and General Considerations References 47: Laparoscopic Femoral Hernia Repair 47.1 Introduction to the Clinical Problem 47.2 Differential Diagnosis and Diagnostic Work-Up 47.3 Contraindications to Laparoscopic Femoral Hernia Repair 47.4 Anatomic Landmarks and Areas of Concern 47.5 Operative Technique 47.5.1 Total Extraperitoneal Repair (TEP) 47.5.2 Transabdominal Preperitoneal (TAPP) Repair 47.5.3 Intraperitoneal Onlay Mesh Repair 47.5.4 Robotic Femoral Hernia Repair 47.6 Postoperative Complications and Considerations References 48: Results and Complications of Femoral Hernia Repair 48.1 Risk Factors 48.2 Emergency Vs. Elective Surgery 48.3 Surgical Technique Repair 48.4 Surgical Site Infection 48.5 Persisting Chronic Pain 48.6 Recurrence and Reoperation 48.7 Risk of Malignancy References Part IV: Ventral (Midline and Lateral) 49: Anatomy of the Ventral Region 49.1 Rectus, External Oblique, Internal Oblique, and Transverse Muscles: The Entwined Quartet 49.1.1 Rectus Muscle 49.2 Points of Weakness of the Ventral Region References 50: Umbilical Hernia Repair 50.1 Introduction 50.2 Open Repair 50.2.1 Tissue Repair 50.2.2 Mesh Repair 50.3 Minimally Invasive Repair 50.3.1 Laparoscopic Repair 50.3.2 Robotic Repair References 51: Endoscopically Assisted Mini or Less Open Sublay (MILOS) Mesh Repair of Abdominal Wall Hernias 51.1 Introduction 51.2 The MILOS Technique 51.3 MILOS Operation of Diastasis Recti 51.4 Results 51.5 Discussion References 52: The Spigelian Hernia 52.1 Introduction 52.2 Epidemiology 52.2.1 Symptoms 52.3 Imaging 52.4 Treatment 52.4.1 Conventional, Open Approach 52.4.2 Laparoscopic Approaches 52.4.3 Robotic Repair References 53: Flank Hernia 53.1 Introduction 53.2 Patient Selection and Evaluation 53.3 Surgical Technique References 54: Diastasis Recti and the Floppy Abdomen 54.1 Introduction 54.2 Anatomy 54.3 Etiology 54.4 Diagnosis 54.5 Classification 54.6 Indications for Surgery 54.7 Treatment 54.8 Exercise and Support Garments 54.9 Abdominoplasty 54.9.1 Step by Step 54.10 Plication of the Linea Alba and Linea Semilunares 54.10.1 Step by Step 54.11 Fascial Plication and Onlay Mesh 54.11.1 Step by Step 54.12 Retro-Rectus Repair with Sublay Mesh 54.12.1 Step by Step 54.13 Endoscopic/Laparoscopic 54.13.1 Step by Step 54.14 Outcomes 54.15 Complications References 55: Results and Complications of Laparoscopic Ventral and Incisional Hernia Repair 55.1 Early Postoperative Outcomes 55.1.1 Iatrogenic Enterotomy (IE) 55.1.2 Early Postoperative Pain 55.1.3 Seroma 55.2 Late Postoperative Outcomes 55.2.1 Recurrence 55.2.2 Chronic Pain 55.2.2.1 Chronic Postoperative Pain 55.2.3 Mesh Infection 55.2.4 Small Bowel Obstruction 55.2.5 Trocar Site Hernia 55.2.6 Quality of Life (QOL) References Part V: Incisional 56: The Prevention of Incisional Hernia 56.1 Introduction 56.2 Suturing Technique 56.3 Suture Materials 56.4 Surgical Site Infections 56.5 Prophylactic Mesh Augmentation 56.6 Patient Optimization References 57: Laparoscopic Ventral Hernia Repair: Where Is the Border? 57.1 What Does the Literature Say? 57.2 Background 57.3 Our Experience: An Evolution of Ideas 57.4 Personal Observations About the Laparoscopical Approach to Ventral Hernias 57.5 Costs 57.6 End Point of the Treatment 57.7 Beyond Literature 57.8 What Can We Learn from These Experiences? 57.8.1 What Is the border? References 58: IPOM and IPOM Plus 58.1 Preface 58.2 Introduction 58.3 IPOM 58.3.1 Limits and Limitations 58.3.1.1 Contraindications 58.3.1.2 Hernia Type 58.3.1.3 Hernia Location 58.3.1.4 Hernia Size 58.3.1.5 Hernia History 58.3.1.6 Patient’s Risk Factors 58.3.2 Technique 58.3.2.1 Patient’s Position 58.3.2.2 Preoperative Measures 58.3.2.3 Safe Pneumoperitoneum 58.3.2.4 First Trocar Insertion 58.3.2.5 Working Ports 58.3.2.6 Adhesiolysis 58.3.2.7 Defect Size Assessment 58.3.2.8 Mesh Choice 58.3.2.9 Mesh Size 58.3.2.10 Mesh Fixation 58.3.2.11 Trocar Incisions Closure 58.3.2.12 Postoperative Measures 58.3.3 Temporary Conclusion 58.4 IPOM Plus 58.4.1 Discussion References 59: Incisional Hernia: The Open Approach, Introducing MILA Technique (Minimally Invasive Laparotomy Approach) 59.1 Introduction 59.2 Surgical Indications 59.3 Surgical Technique 59.4 Tips and Tricks 59.5 Outcomes References 60: Component Separation: Options and Techniques 60.1 Introduction 60.2 Anterior Component Separation Technique 60.2.1 Key Steps to the Procedure 60.2.2 Advantages and Disadvantages of This Procedure 60.3 Periumbilical Perforator-Sparing Anterior Component Separation Technique 60.3.1 Key Steps to the Procedure 60.3.2 Advantages and Disadvantages of This Procedure 60.4 Laparoscopic/Endoscopic Component Separation Technique 60.4.1 Key Steps to the Procedure 60.4.2 Advantages and Disadvantages of This Procedure 60.5 Posterior Component Separation Technique 60.5.1 Key Steps to the Procedure 60.5.2 Advantages and Disadvantages of This Procedure References 61: The Transversus Abdominis Muscle Release (TAR) Procedure 61.1 Introduction 61.2 Anatomical Basis for TAR 61.3 Indications 61.4 Preoperative Considerations 61.5 Technical Aspects 61.6 Physiologic Basis of TAR 61.7 Postoperative Care 61.8 Outcomes References 62: Parietal Disaster 62.1 Strangulated Incisional Hernia 62.2 Iatrogenic Enterotomy (IE) 62.2.1 Key Points for Iatrogenic Enterotomy (IE) 62.3 Recurrence 62.4 Mesh Infection 62.5 Recommendations 62.6 Loss of Domain 62.7 Wisdom of Strategic Surgical Retreat References 63: Open Abdomen 63.1 Historical Aspects 63.2 Pathophysiological Aspects 63.3 Clinical Strategy 63.4 Clinical Scenario and Classification of Open Abdomen 63.5 Temporary Abdominal Closure (TAC) 63.6 Definitive Abdominal Closure References 64: Results and Complications of Incisional Hernia Surgery 64.1 Introduction 64.2 Material 64.3 Results 64.4 Conclusions 64.5 Discussion Herniamed Study Group Scientific Board Members References 65: Incisional Hernia: The Robotic Approach 65.1 Introduction 65.2 Preoperative Considerations 65.3 Double-Dock Robotic TAR Technique 65.3.1 Patient Positioning and Theater Setup 65.3.2 Incision and Access 65.3.3 Operative Steps 65.3.4 Closure 65.4 Single-Dock Rives-Stoppa Retromuscular Technique for Epigastric and Suprapubic Hernias 65.4.1 Patient Positioning and Theater Setup 65.4.2 Initial Access and Port Placement 65.4.3 Operative Steps 65.4.4 Postoperative Management References 66: Parastomal Hernia Prevention and Treatment 66.1 Introduction 66.1.1 Definition and Incidence 66.1.2 Predisposing Factors and Pathogenesis 66.1.3 Prevention 66.2 EHS Classification 66.3 Prophylactic Mesh Placement During Stoma Construction 66.4 Indications to Parastomal Hernia Repair 66.5 Techniques of Parastomal Hernia Repair 66.5.1 General Considerations 66.5.1.1 Patient Preparation 66.5.2 EHS Types I–III: Modified Laparoscopic Sugarbaker Technique 66.5.2.1 Positioning of the Patient 66.5.2.2 Induction of Pneumoperitoneum and Trocar Disposition 66.5.2.3 Dissection 66.5.2.4 The Mesh 66.5.2.5 Fixation 66.5.2.6 End of Procedure 66.5.3 EHS Types II–IV: Modified Retromuscular Mesh Repair 66.5.3.1 Patient Position 66.5.3.2 Dissection 66.5.3.3 Reconstruction 66.5.3.4 The Mesh 66.5.3.5 End of Procedure 66.6 Postoperative Care References 67: Scarless Surgery for Ventral and Incisional Hernias 67.1 Introduction 67.2 Suggested Instrumentation for Successful Adoption of Single-Incision Laparoscopic (SIL) Ventral and Incisional Herniorrhaphy 67.3 Infraumbilical Incision and Closure 67.4 Upper Outer Quadrant Incision 67.5 Suprapubic Incision 67.6 Insertion of the Single-Port Device 67.6.1 Triport 67.6.2 SILS Port 67.6.3 GelPOINT Mini Port 67.7 Overcoming the Relative Lack of Triangulation During SILS 67.8 Hernias in the Suprapubic Space 67.9 Spigelian and Lateral/Lumbar Hernias 67.10 Lateral and Lumbar Hernias 67.11 Traumatic Lumbar Hernia from Seatbelt Injury 67.12 SIL Ventral and Incisional Hernia Repair 67.13 SIL Ventral Hernia with Suprapubic Incision 67.14 Discussion References