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El Libro De La Hernia Inguinal EL LIBRO DE LA HERNIA INGUINAL

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El Libro De La Hernia Inguinal EL LIBRO DE LA HERNIA INGUINAL RONALD DE LA CUADRA- OWEN KORN (EDITORES) El libro de la Hernia Inguinal EL LIBRO DE LA HERNIA INGUINAL Para Verónica mi mujer, mis hijas Viviana y Alejandra, por su infinita comprensión y abnegada paciencia ante los tantos momentos de ausencia y, que hicieron posible mi entrega y devoción a tan ilustre y cautivante especialidad. Prof. Dr. R. de la Cuadra. Editor A los que nos precedieron a los herniotomistas trashumantes, por la castración y el cauterio, el braguero y el punto de oro, al dolor indescriptible, por la anatomía, la cura radical, la tensión y la prótesis, al genio y al ingenio humano, aun nos falta camino…pero menos. Prof. Dr. O Korn. Editor 1 AUTORES Dr. Alberto Acevedo Fagalde. M.S.C.Ch. Profesor Asociado de Cirugía. Departa- mento y Servicio de Cirugía, Hospital Salvador, Santiago Prof. Dr. José Amat Vidal. M.S.C.Ch. F.A.C.S. Profesor Emerito y Titular de Ci- rugía Universidad de Chile Prof. Dr. Parviz Amid MD, FACS, FRCS. Clinical Professor of Surgery David Geffen School of Medicine at UCLA, Director Lichtenstein, Amid Hernia Clinic at UCLA. Los Angeles, California. Dr. Manuel Barroso Vásquez. M.S.C.Ch. Facultad de Medicina U. de La Frontera, Temuco Dr. Marcelo Beltrán Saavedra. M.S.C.Ch. Servicio de Cirugía Hospital Regional de La Serena; La Serena Dr. Jorge Bezama Murray. M.S.C.Ch. Profesor Asistente de Cirugía. Hospital Hangaroa, Isla de Pascua. Dr. Pablo Borquez Morales. M.S.C.Ch. Servicio de Cirugía Hospital Base de Osorno, Osorno Dr. Juan Eduardo Contreras Parraguez. M.S.C.Ch. F.A.C.S. Profesor Asistente de Cirugía. Departamento de Cirugía Hospital Salvador. Departamento de Cirugía, Clínica Santa María, Santiago Prof. Dr. Claudio Cortes Arriagada. Profesor Titular de Radiología. Director De- partamento de imagenologia, Hospital Clinico Universidad de Chile, Santiago Prof. Dr. Ronald de la Cuadra Espinosa. M.S.C.Ch. Profesor Titular de Cirugía Universidad de Chile Dr. Hernan Guzmán Cespedes. M.S.C.Ch. Servicio de Cirugía Hospital Dipreca, Santiago Dr. Arturo Jirón Silva. M.S.C.Ch. Departamento y Servicio de Cirugía de Cirugía Hospital San Juan de Dios, Santiago. 2 Dr. Carlos Lizana Siri. M.S.C.Ch. F.A.C.S. Servicio de Cirugía Clínica Las Con- des, Santiago Dr. Marcos Rocha Guerrero. M.S.C.Ch. Profesor Asistente de Cirugía. Departa- mento de Cirugía Clínica Dávila, Santiago Dr. Marcelo Ross Zelada. M.S.C.Ch. Servicio de Cirugía Hospital Naval “Ciru- jano Guzmán” Punta Arenas Dr. Eduardo Schiefelbein Grossi. M.S.C.Ch. Servicio de Cirugía y Urgencia Hos- pital Naval Almirante Nef, Valparaiso Dr. Gerardo Thonet Rodas. M.S.C.Ch. Servicio de Cirugía Hospital San José, San- tiago Dr. Mario Venegas Concha. F.A.C.S. Departamento de Cirugía, Clínica Santa María. Santiago Dr. Claudio Wainstein Gewolb. M.S.C.Ch. Cirugía Clinica Las Condes, Santiago Ilustraciones Prof. Dr. Owen Korn Bruzzone. M.S.C.Ch. F.A.C.S. Profesor Titular de Cirugía, Departamento de Cirugía Hospital Clínico Universidad de Chile, Santiago. Dr. Alberto Acevedo Fagalde. M.S.C.Ch. Profesor Asociado de Cirugía. Departa- mento y Servicio de Cirugía Hospital Salvador, Santiago 3 PRÓLOGO Prof. Dr. Parviz Amid For more than a century the field of hernia surgery was dominated by Bassini inguinal hernia repair and its more than 75 variants, all of which had in common tension along the suture line that led to a painful postoperative course, a long recovery period, and a high recurrence rate. The rapid increase in health care costs, with its consequent increase in the cost of hernia repair, has added more weight to the existing burdens of pain, recovery, and recurrence associated with inguinal hernia. As far back as 1800, Cooper suspected that weakening of abdominal wall tissue was one of the causes of inguinal hernia, and thus Billroth recognized the need for prosthetic reinforcement of weakened abdominal wall tissue; he mused, 4 “If only proper material could be created to artificially produce tissue of the density and toughness of fascia and tendon, the secret of the radical cure for hernia would be discovered. However, the early generation of prostheses resulted in disastrous complications from rejection and infection. The issue of rejection was resolved by the introduction of polypropylene mesh, and the issue of infection was resolved by the production of the microporouse and monofilament meshes. Meanwhile, treatment strategies that would have been considered heretical in the past changed surgeons’ attitude toward the treatment of “hernia,” a condition that, historically, has presented difficulties in its surgical management from the distant past into the present. This change of attitude was the result of four fundamental concepts that have affected the way surgeons practice the art of hernia repair based on scientific evidence: (1) the widespread acceptance of the tension- free principles pioneered by the Lichtenstein group, (2) widespread acceptance of inguinal hernia repair under local anesthesia, (3) the idea of using the preperitoneal space for hernia repair, and (4) laparoscopic hernia repair. The laparoscopic approach to hernia repair has been a more orderly affair than open hernia repair. Excitement for the new technology resulted in quick assessment and randomized controlled studies of the different techniques of laparoscopic repair, leading the European Hernia Society to reach evidence-based conclusions: “For adults’ primary unilateral and bilateral inguinal hernias, Lichtenstein or endoscopic repairs are both recommended. Endoscopic repair, only if expertise is available”. But issues of cost and a steep learning curve of laparoscopic inguinal hernia repair, when compared with the simple open tension-free approach under local anesthesia, remain a concern. Certainly, in the modern era, most techniques have recurrence rates of less than 2% when they are performed at dedicated centers or by surgeons with a special interest in hernia surgery. But how this translates for the work of less dedicated general surgeons, particularly in the context of the less exciting open operations, remains unanswered. Perhaps following in the footsteps of experts in both open and laparoscopic hernia repair with less subjective emotionalism and more objective pragmatism is the answer. The subject of hernia surgery has always fascinated surgeons worldwide. In this masterful book, Professor Ronald De la Cuadra has elaborately bridged from antiq- 5 uity to the modern era current technology, leaving controversial issues to the reader’s judgment. Durante más de un siglo, el campo de la cirugía de la hernia fue dominado por la reparación de Bassini y sus más de 75 variantes, todas las cuales tenían en común la tensión a lo largo de la línea de sutura, que llevaba a un curso postoperatorio doloroso, un período de recuperación largo y una alta tasa de recurrencia. El rápido aumento en los costos de atención de la salud, con el consiguiente au- mento del costo de la reparación herniaria, ha añadido más peso a las dudas exis- tentes en relación al dolor, recuperación y recurrencia asociados al tratamiento de una hernia inguinal. Hacia el 1800, Cooper sospechó que el debilitamiento del tejido de la pared abdominal era una de las causas de la hernia inguinal y posteri- ormente siguiendo la misma línea de pensamiento, Billroth se convenció de la ne- cesidad de un reforzamiento protésico al tejido debilitado de la pared abdominal; y pronosticó: “Si sólo pudiera crearse un material apropiado para producir artifi- cialmente un tejido de la densidad y dureza de la fascia y el tendón, el secreto de la cura radical de la hernia sería descubierto”. Sin embargo, la primera genera- ción de prótesis resultó en complicaciones desastrosas en lo referente a rechazo e infección; el rechazo se resolvió mediante la introducción de una malla de poli- propileno y el problema de la infección con el desarrollo y producción de las prótesis de monofilamento y microporosas. En el intertanto, la estrategia de trata- miento muchas veces considerada herética en el pasado, cambiaron la actitud de los cirujanos hacia el tratamiento de la “hernia”, condición que históricamente, ha presentado dificultades en su quehacer quirúrgico en un pasado lejano y el pre- sente actual. Este cambio de actitud se debió a cuatro conceptos fundamentales que han afectado la forma en que los cirujanos practican el arte de reparar una hernia basado en la evidencia científica: 1) la aceptación generalizada del prin- cipio “libre de tensión” preconizado por el grupo Lichtenstein, (2) la aceptación generalizada del tratamiento de la hernia inguinal con anestesia local, (3) la idea de utilizar el espacio preperitoneal para la reparación de la hernia, y (4) la repar- ación laparoscópica de la hernia. El enfoque laparoscópico de la hernia inguinal, ha sido muchísimo más ordenado que lo ocurrido con la reparación abierta. 6 El entusiasmo por la nueva tecnología, dio lugar a una rápida evaluación con el desarrollo de estudios aleatorios controlados de las diferentes técnicas de repara- ción laparoscópica, lo que llevó a la Sociedad Europea de Hernia, llegar a conclu- siones basadas en la evidencia: “Para una hernia inguinal unilateral y bilateral primaria en el adulto, tanto la técnica de reparación de Lichtenstein como la re- paración endoscópica y/o ambas son recomendables. Esta última, sólo si la expe- riencia está convenientemente evaluada”. Pero los problemas de costo y una empinada curva de aprendizaje de la reparación de la hernia inguinal por vía laparoscópica, en comparación con el enfoque simple abierto sin tensión bajo an- estesia local, siguen siendo una preocupación”. Ciertamente en la era moderna, la mayoría de las técnicas tienen tasas de recurrencia de menos del 2% cuando se llevan a cabo en los centros dedicados o por cirujanos con un interés especial en la cirugía de la hernia.
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