Exploring Groin Hernias: A Visual 3D Guide to Diagnosis and Treatment

Inguinal hernia repair is one of the most commonly performed procedures, with roughly 11 more than 20 million procedures performed annually worldwide. [1]. This amount is easy to 12 understand when considering the high lifetime risk of inguinal hernia development, which is 13 3% and 27% in women and men respectively [1]. Femoral hernias on the other hand are 4 14 times more common in female patients [1]. Several different methods for repair exist: open 15 versus minimally invasive and mesh versus non-mesh. While originally described as an open 16 pure tissue repair, the use of prostheses and their improved long-term outcomes in 17 preventing hernia recurrences have led many surgeons to move away from traditional tissue-18 based repairs, as illustrated by the Danish Hernia Database, showing almost a 100% mesh 19 usage for inguinal hernia repair [1][2][3][4]. Mesh can be placed in 2 different planes, the anterior 20 and posterior plane. While the anterior plane can only be accessed through an open 21 approach, first coined by Lichtenstein in 1989 [5], the posterior plane can be accessed 22through both an open and laparo-endoscopic approach. 23As recurrence declined, the focus shifted towards avoiding chronic post-operative pain, 24 which affects about 10-12% of patients at three months follow-up, with a 0.5-6% risk of pain 25affecting everyday life at one year [6]. 26Current guidelines recommend a mesh-based repair technique for the majority of patients 27 undergoing inguinal hernia repair. First choice is a posterior laparo-endoscopic approach 28 provided that a surgeon with specific expertise and sufficient resources is available [1]. 29However, there are patient and hernia characteristics that warrant Lichtenstein as first choice 30 [1]. Large surveys, as well as registry-data are in line with this and show a predominant use of 31 a laparoscopic TEP or TAPP-approach or an open anterior Lichtenstein approach [3,4,[7][8][9]. 32Although the evidence for a tissue-based repair is (very) low, the Shouldice technique can be 33 suggested after careful patient selection in a minority of patients and if expertise is available 34 [1]. 35 Shared decision-making between surgeon and patient will take into account patient related 36 factors, patient opinion, hernia characteristics, surgeon's preference and local access to 37 resources. For patients to be well informed in the preoperative setting, it is useful to learn 38 about the difference between an inguinal and femoral hernia, anterior vs. posterior mesh 39 placement, and the course of the inguinal nerves. It will allow them to better understand 40 both the surgical procedure and the risks of recurrence and chronic pain. However, 41 illustrating the surgical anatomy of the groin in a simplified yet correct and attractive way 42 remains problematic. Therefore, we developed a video which will hopefully serve as an easy-43 to-understand guide of the groin and explains the normal anatomy, the pathophysiology of 44 an inguinal hernia and the concept of open Lichtenstein and posterior (laparoscopic) repair. 45We believe this video will also be very useful for teaching of students and surgeons in