Inguinal herniorrhaphy: 25-year results of technical improvements leading to reduced morbidity in 4,029 patients.
Since 1981, 4,029 consecutive inguinal herniorrhaphies (IH) were performed under protocol utilizing several emerging techniques progressively incorporated to lower complication rates. Patients were operated with identical protocols from 1981 to 1988 at a teaching institution (Group A patients) and from 1988 till the present at two community hospitals (Group B patients). Emergent techniques were sequentially incorporated, progressing from a modified Shouldice approach to the Rives technique, Lichtenstein rolled plugs, and finally to the Rutkow-Robbins mesh plug. Several technical as well as aseptic and antiseptic measures were incorporated in the protocol to prevent episodes of wound infection, testicular atrophy, and inguinodynia. A total of 4,029 IH were performed: Group A (1,199 primary and 113 recurrent IH), Group B (2,466 primary and 251 recurrent IH). There were 1,834 IH performed with the Shouldice technique [recurrence rate (RR) 1%], 224 utilizing the Rives technique (RR 0%), the Lichtenstein rolled plug in 47 (RR 0%), and plug mesh in 1,910 (RR 0.23%). One hundred and six recurrent hernias were operated by the Shouldice technique (RR 0%), nine by the Lichtenstein rolled plug (RR 0%), and 233 by the plug-mesh method (RR 0%). Five subfascial wound infections were encountered (0.12%). Testicular ischemia was observed in five (0.12%), all prior to 1983; 32 inconsequential distal hydroceles were seen, all after dividing inguinoscrotal sacs and leaving the distal portion undisturbed. Superficial, self-reabsorbing wound hematoma occurred in 29 patients, and 14 patients suffered from temporary urinary retention. No instances of postoperative neuralgia were observed. Personal and institutional follow-up in both groups evolved from 95.5% for 1 year to 70% after 6 years. There was no mortality. Utilizing evolving techniques, including strict operating room aseptic and antiseptic measures, plus the use of systemic and local antibiotics, inguinal herniorrhaphy can be performed with minimal complications. The plug-mesh technique is presently our technical choice for most primary and recurrent hernias.