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Our contribution to the evolution of ideas concerning groin hernia surgery.

Updated: Nov 15, 2022

History of the main currents, our contribution to minimally invasive surgery, called Minimal Open Preperitoneal (MOPP).

After nearly two centuries of evolution, hernia surgery is still the subject of passionate battles at most of our congresses. Theodore Billroth in 1857 stated that the ideal treatment for groin hernias would be achieved when fascias and tendons could be artificially reproduced. G. Amato from Palermo explained that in the context of hernial pathology we also find degenerative anomalies, particularly in the nerves, veins, arteries, muscles, with the presence of an inflammatory infiltration, and that the solution had to take support this pathophysiology dynamically and not statically. Unfortunately these pious wishes, will not have, until this day, an exploitable translation. A more pragmatic solution, which could represent a certain ideal, could be the reinforcement of the entire visceral sac with a giant prosthesis as described by R Stoppa in 1967. (1-2-3-4).

This approach was developed after the work of Jean Rives (5-6) who was one of the first French surgeons to use prosthetic materials very widely, especially at that time: polyester (Mersuture, Dacron).

The parietal reinforcement prosthesis was then used by many supporters, advocating here, the anterior approach, and there, the posterior approach. My purpose is to show that we can escape this face to face between: On the one hand the so-called open surgery, which is in fact, for most authors synonymous with the Liechtenstein technique, and derivatives. And on the other hand laparoscopic surgery, synonymous with posterior surgery. There is thus a third way which is open (but it is a very short inguinal incision), but also posterior, according to the principles of the pioneers of this way. It is this 3rd way that we are currently developing and distributing that I want to present to you.

Les pionniers: anatomistes, et chirurgiens adeptes de l’abord antérieur

It is impossible to talk about anatomy without mentioning A.P. Cooper (7) famous for having described, among other things, the fascia transversalis. After the progress of asepsis, and under the impulse of Lister (8), it is possible to approach the abdominal wall, without condemning the patient to problems of often fatal secondary infection. Thus Lucas Championnière (9) will be the first surgeon to incise the aponeurosis of the external oblique muscle, even before Bassini (10). Bassini will describe in 1938 the famous technique which will be the first technique by an anterior approach dedicated to the repair of the transversalis fascia. This technique is still widespread in certain developing countries, where the prosthetic materials are too expensive, and where the more recent techniques have not yet been widely established. C.B.Mc Vay (11) will describe the technique for treating femoral hernias. The most successful technique performing a complex plasty on the musculofascial plan will be developed by E. Earle Shouldice (12) (1890-1965), it will be the gold standard during the years preceding the reign of prosthetic surgery. Followers of the anterior approach, such as Lichtenstein (12-14), and his students, will then use this prosthesis reinforcing from the front, "the inguinal level of the musculoperineal orifice" These techniques will be preferred by surgeons until nowadays.

The pioneers: anatomists, and surgeons adept at the posterior approach.

Cloquet (15), in 1817, was the first anatomist to describe the posterior face of the inguinal region. In 1876, Annandale (16) described for the first time the concept of the posterior preperitoneal approach, for a patient who presented with external oblique, direct and femoral hernias. Lawson Tait (17) of Birmingham reported in 1883 and in 1891 the subumbilical midline incision approach to treat hernias of the groin, he stated in 1891 that he felt that radical cure of hernias other than umbilical hernias could be achieved by midline laparotomy. In 1920, Sir Lenthal Cheatle (18) of London sutured inguinal and femoral hernias using a median preperitoneal approach. But the surgeon who really popularized this posterior approach was Llyod Nyhus (19-20), from Chicago, and this, from the beginning of the 1960s. The French surgeon and anatomist Henri R. Fruchaud (21), has been ignored for too long, for his anatomical treatises have only very recently been translated into English by R Bendavid. In his anatomy laboratory worked Jean Rives and René Stoppa. H Fruchaud said “the surgical treatment of inguinal and femoral hernias should not be the closure of the inguinal canal or the femoral orifice, but the deep reconstruction of the abdominal wall in the entire groin region”. He thus recommended covering the whole of the musculo-pectineal orifice that he had described, and which is quite rightly associated with his name. In 1965, Jean Rives, interested in this new prosthetic material presented by manufacturers and probably also known, following the contacts and conversations he had been able to have during two trips he had organized to the United States, began to place a large prosthesis by a median pre-peritoneal route for the treatment of unilateral hernias. Following this work by Jean Rives, René Stoppa therefore has proposed his famous giant prosthesis in 1967. Georges Wantz (22), who was very close to René Stoppa, had adapted the giant prosthesis technique for unilateral hernias. The avowed goal of Georges Wantz was to be able to treat the largest, most complex hernias by a transrectal transverse incision, preferably under local anesthesia, during outpatient surgery. Unfortunately, in practice, given the technical difficulties, and by his own admission, this intervention was ultimately usually performed under general anesthesia during conventional hospitalization. The pioneers of laparoscopic hernia surgery used the same principles to place large pre-peritoneal prostheses via the Trans Abdomino Pre-Peritoneal approach (L Leroy, G. Fromont) (23) or via the Totally Extra-Peritoneal approach (G Begin, J.L. Dulucq) (24).

The first step towards the third way called Minimal Open Pre Peritoneal: MOPP.

In 1981 Jean Henri Alexandre (25) published, among other things, in a monograph of the G.R.E.P.A. (the parent company of our learned societies specializing in the field of parietal surgery), an inguinal technique with placement of a large prosthesis in the preperitoneal space, after section of the inferior epigastric vessels and parietalization of the spermatic cord. This technique is the first important step before the development of new minimal invasive techniques. The true pioneer of Minimal Open Pre-Peritoneal surgery is Doctor Franz Ugahary (26). In 1995 he described the technique ; called "Grid Iron", achievable under AL during a hospital stay of a few hours. This technique makes it possible to treat practically any type of groin hernia by a very short inguinal incision (3-4 cm), and if necessary under local anesthesia, which is particularly interesting for very old, very fragile patient who can also immediately return to their homes. I introduced this technique in France in 2001, and I developed (27) different variants, in particular by using new prostheses with shape memory to facilitate its realization. Indeed the main difficulty is to unroll the large prosthesis, sometimes very flexible, through the very short incision. It was also sometimes difficult to control the correct position of the prosthesis without disturbing it.. In 2005, Doctor Edouard Pélissier (28-29-30-31-32-33) developed a shape-memory prosthesis, equipped with a rigid peripheral ring, greatly facilitating this type of intervention. Thanks to this new prosthesis, and under the impetus of Belgian surgeons, in particular doctors F. Berrevoet, S. De Gendt (34), and French surgeons (J.F. Gillion, J.M. Chollet), the Trans Inguinal Pre Peritoneal (TIPP) technique was able to develop. This is a technique that can easily be compared to the technique of Franz Ugahary but whose incision is lower, next to the deep inguinal orifice, which is then the point of penetration into the preperitoneal spaceI have been using the TIPP technique since 2011 after visiting our friends S. De Gendt, then J.F. Gillion and J.M. Chollet, and I have combined the principles of the TIPP path with certain specificities of the technique of F Ugahary, in one hand using, after having modified it, the instrumentation of F. Ugahary, (composed of retractors and dissecting valves), which facilitates the dissection of the vast cleavable planes allowing the positioning of these prostheses which must measure approximately 15 cm in the major axis and 10 cm in the minor axisin order to respond to the principles of wide coverage of the musculo-pectineal orifice, and on the other hand by creating our prosthesis, specifically adapted to this approach.

Why this technical development, given the multiple interventions already at our disposal?

This evolution of techniques is no longer intended to reduce the rate of recurrence, which seems to be almost identical regardless of the technique used in the hands of a specialized parietalist, but rather to improve the comfort of postoperative life, by reducing the rate of chronic pain induced by the intervention and also minimizing early postoperative pain. The Carolinas Medical Center (35) has invested a lot in this area, it has published a comfort scale which analyzes the patient's postoperative comfort as precisely as possible. He even studied the preoperative factors predicting chronic postoperative pain. The study of chronic postoperative pain is at the origin of numerous publications which often conclude that pain is more frequent after open surgery than after laparoscopic surgery. Indeed, it is generally accepted that the Lichtenstein technique is the cause of a certain number of cases of severe chronic pain, which can handicap the patient for years. While these problems are less after posterior approach techniques such as laparoscopic surgery (36-37-38-39-40) But these studies do not yet take into account the Pre-Peritoneal Open Minimal approac, a too technique. However two studies show the superiority of the TIPP technique over the Lichtenstein technique:

The study by Koning GG, Keus and co, 2012, which shows less chronic pain after one year (41) The study by Koning GG and De Vries, which shows better comfort of life (questionnaire SF36), in relation with less chronic pain at one year (42).

We have named our variant of the TIPP technique : the MOPP route, it is much closer to the laparoscopic technique than the classic anterior route, so it should give similar results in terms of post-operative and chronic pain, with plus the benefit of less aggression (adapted local or general anesthesia (without endotracheal intubation, without curarization), with a small and single skin incision)). The advent of the hernia club ( bringing together specialized parietalists, allows the realization of prospective studies comparing the experience of these experts using the techniques by anterior route, by laparoscopic route and by the third MOPP route, and thus to compare our data, the preliminary results confirm the good results of the MOPP route, they will be published as soon as possible.

The minimal open pre-peritoneal techniques allow the treatment of most groin hernias, primary or recurrent. They use the pre and retroperitoneal cleavable spaces, they respect Pascal's law, the prosthesis being pressed against the posterior abdominal wall, under the effect of intra-abdominal pressure. In the presence of a particular clinical form, it does not require conversion but a simple transition from the technique to a technique of the Wantz type for example. The technique does not require dissection of the nerves, the prosthesis is not in contact with them. It is usually not necessary to fix the prosthesis. In comparison with the previous classic techniques (Liechtenstein) the technique is minimally open, with an incision of three to four centimeters allowing the treatment of large hernias, and of course the material is pre-peritoneal! Compared to laparoscopic surgery, the technique is minimally invasive, as it can be performed under local anesthesia with analgesia, on outpatient, or under general anesthesia without intubation or curarization. this being particularly interesting for the oldest patients, or more fragile, for whom hernia surgery is still too often rejected for fear of postoperative complications. Our ongoing prospective studies will be published as soon as possible will demonstrate the merits of this minimally invasive surgery approach for elderly and fragile patients.

References :

(1) Stoppa R., Petit J., and Henry X : Plasties des hernies de l'aine par voie médiane sous-périto-néale : Actualités chirurgicales, Paris : Masson, 1 9 7 2. (2) Stoppa R., Petit J. and Abourachid H. : Procédé original de plastie des hernies de l'aine. L'interposition sans fixation d'une prothèse en tulle de dacron par voie médiane sous-périto-néale. Chirurgie, 1 9 7 3; 9 9: 1 1 9. (3) Stoppa R. Rives J., Warlaumont.C. et al. - The use of dacron in the repair of hernias of the groin. Surg Clinic North Am, 1 9 8 4; 6 4: 2 6 9 (4) Stoppa R, Warlaumont Ch, Verhaeghe P, Henry X. Tulle de Dacron et cure chirurgicale des hernies de l’aine. Chirurgie 1983;109:847-54. (5) Rives J, Lardennois B, Flament JB, Couvert G. La pièce en tulle de dacron, traitement de choix des hernies de l’aine de l’adulte. A propos de 183 cas. Chirurgie 1973;99:564-75. (6) Rives J, Stoppa R, Fortesa L, Nicaise H. Les pièces en dacron et leur place dans la chirurgie des hernies de l’aine. A propos de 65 cas recueillis sur une statistique intégrale de 274 interventions pour hernie. Ann Chir 1968; 22:159-71. (7) Cooper A.P. - The anatomy and surgical treatment of Abdominal Hernia (2 vols). London: Longman, 1804, 1807. (8) Lister (sir) J. On the antiseptic principle in the practice of surgery, Lancet, sept.21, 1867; 363 (9) Lucas-Championnière j cure radicale des hernies. Paris: Delahaye, 1887 (10) Bassini E. - Sulla cura radicale dell’ ernia inguinale. Arch Soc Ital Chir, 1887; 4 : 30. (11) Mac Vay C.B., ChAPP J.D Inguinal and femoral hernioplasty. Evaluation of a basic concept. Ann Surg, 1958; 148: 499 (12) Shouldice E.E. - Surgical treatment of hernia. Ontario Med Rev, 1945; 12: 43 (13) Lichtenstein.I.L Hernia repair without disability. St Louis: C.V. Mosby (14) Lichtenstein.I.L, Shulman A. G. et Al, The tension free hernioplastie, Am J Surg, 1989; 157:188 (15) J Cloquet, Paris: Mequigon-Marvis, 1817 (16) Annandale T. Case in which a reducible oblique and direct inguinal and femoral hernia existed on the same side and were successfully treated by operation. Edinburgh Med J, 1876 ; 21 : 1087. (17) Tait L. A discussion on treatment of hernia by median abdominal section. Br Med J, 1891; 2:285 (18) Cheatle G.L; An operation for the radical cure of inguinal and femoral hernia. Br Med J, 1920 ; 2: 6 8. (19) Nyhus L.M., Stevenson L.M., Listerud M.B., Harkins H.N. Preperitoneal hernioraphy. A preliminary report on fifty patients. West J Surg, 1959; 67: (20) Nyhus LM, Condon RE, Harkins HN. Clinical experience with preperitoneal hernia repair for all types of hernia of the groin. Am j surg. 1960; 100:234-450. (21) Fruchaud H. Anatomie chirurgicale des hernies de l’aine. Doin Ed, Paris, 1957. (22) Wantz G.E.: Giant prosthetic reinforcement of the visceral sac. Surgery Gynecol & Obstet, 1 9 8 9; 1 6 9 : 4 0 8. (23) Leroy J, Fromont : G. Hernies de l’aine de l’adulte : prothèse souspéritonéale sous contrôle coelioscopique (à propos de 110 cas). J Coelio Chir 1992;1:22-5. (24) Begin G. Cure coelioscopique des hernies de l’aine par voie propéritonéale. J Coelio Chir 1993;7:23-9. (25) Alexandre JH, Dupin P, levard H, Billebaud T. Cure des hernies de l’aine par prothèse non fendue de mersuture. Interêt de la pariétalisation du cordon et de la ligature des vaisseaux épigastriques. Presse Med 1984, 13(3)161-163 (26) Ugahary F. and R. Simmermacher: Groin hernia repair via a grid-iron incision: an alternative technique for preperitoneal mesh incision. Hernia 2(3): 1232-125(1998) (27) Soler M e-mémoires de l'Académie Nationale de Chirurgie, 2004, 3 (3) : 28-33 (28) Pélissier EP, Monek O, Blum D, Ngo P. The Polysoft patch: prospective evaluation of feasibility, postoperative pain and recovery. Hernia. 2007 Jun;11(3):229-34 (29) Pélissier E, Ngo Ph. Hernies de l’aine. Prothèse sous péritonéale par voie antérieure. Description de la technique. E-Mem Acad Natl Chir 2006; 5: 71-5. ( (30) Pélissier EP. Inguinal hernia: preperitoneal placement of a memory-ring patch by anterior approach. Preliminary experience. Hernia 2006;10:248-52. (31) Pelissier EP, Ngo P. Hernioplastie inguinale sous-péritonéale par voie antérieure, à l’aide d’une prothèse à mémoire de forme. Résultats préliminaires. Ann Chir 2006; 131:590-4. (32) Pelissier EP, Monek, O, Blum D, Ngo P. The Polysoft patch: prospective evaluation of feasibility, postoperative pain and recovery. Hernia 2007; 11:229-34.

(33) Pelissier EP, Blum D, Ngo P, Monek O. Transinguinal preperitoneal repair with the polysoft patch: prospective evaluation of recurrence and chronic pain. Hernia 2008; 12: 51-6. (34) Berrevoet F, Sommeling C, Berrevoet F, Breusegem C, de Hemptinne B. The preperitoneal memory-ring patch for inguinal hernia: a prospective multicentric feasibility study. Hernia 2009 Jun; 13(3):243-9. (35) Algorithmic Prediction of Chronic Pain after an Inguinal Hernia Repair Igor Belyansky, MD, Victor B. Tsirline, MD, Amanda L. Walters, MS, Paul D. Colavita, MD, Amy E. Lincourt, PhD, B. Todd Heniford, MD, FACS Carolinas Healthcare System (36) Nienhuijs et al Am J Surg 2007; 194: 394-400 (37) E. Aasvang, E. and B. Gmahle, J. Schwarz, R. Bittner, H. Kehlet, Anesthesiology 2010; 112: 1-13 (38) Bay-Nielsen M, Nilsson E, Nordin P, Kehlet H. Chronic pain after open mesh and sutured repair of indirect inguinal hernia in youngmales. Br J Surg 2004; 91:1372-76. (39) Aasvang E, Kehlet H. Surgical management of chronic pain after inguinal hernia repair. Br J Surg 2005; 92:795-801. (40) Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 2005; 19:189-99. (41) Koning GG, Keus and co, 2012, Randomized clinical trial of chronic pain after tansinguinal preperitoeal technique compared with lichtenstein's method for inguinal hernia repair. Br J Surg 99:1365-1373 (42) Koning GG, De Vries and co. Health status one year after TransInguinal PrePeritoneal inguinal hernia repair and Lichtenstein's method: an analysis alongside a randomized clinical study. Hernia 2013 jun;17(3):299-305

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