key: cord-0990676-6lbgoekh
authors: Hori, Tomohide; Yasukawa, Daiki
title: Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty
date: 2021-07-20
journal: World J Methodol
DOI: 10.5662/wjm.v11.i4.160
sha: 3c32cbb3749f93b65fb5bffde0542751434f2002
doc_id: 990676
cord_uid: 6lbgoekh

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

The etymology of the term "hernia" originates from the Latin word for "prolapse," and the earliest evidence of an inguinal hernia was recorded in approximately 1552 BC in ancient Egypt [1, 2] . In the early 1950s, the term "groin hernia" was first used by Henri Fruchaud [3] . Hernias in the groin include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias [4] . Herniorrhaphy has been performed to treat inguinal and femoral hernias since the 18th century. Edoardo Bassini (1844-1924) established a modern herniorrhaphy technique [5] ; thereafter, groin herniorrhaphy became the most common technique performed in the field of general surgery [4] . Recent studies have shown that approximately 750000 patients undergo this procedure yearly in the United States [4, 6] ; the direct annual cost is 2.5 billion dollars [4] .

In 1804, Astley Cooper (1768-1841) stated, "No disease of the human body, belonging to the province of the surgeon, requires in its treatment a greater combination of accurate anatomical knowledge with surgical skill than hernia in all its varieties." [7] Notably, herniorrhaphy treatment of pediatric patients is useful for accurate evaluation of the skills of general surgeons and residents [8] . Sir William Heneage Ogilvie (1887-1971) once stated, "I know more than a hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal." [9] Notably, both technical skill and anatomical recognition are crucial for safe and reliable surgery. Irving L. Lichtenstein established the concept of tension-free repair (TFR) in 1986 [10, 11] . Various meshes, including biological mesh, are currently available for groin surgery [12] . Surgical repair with mesh is categorized as hernioplasty, while classic repairs without mesh are termed herniorrhaphy. Many physicians focus on the preperitoneal (posterior) space (PPS)[3,7,13-21], topographic nerves[22-31], and regional vessels [4, [32] [33] [34] .

This review discusses existing knowledge regarding groin hernia. It summarizes historical turning points in the anatomy and surgery of groin hernias, described the current status of anatomical recognition and surgical repair, examines points of contention, and considers future perspectives. Despite the current global pandemic due to Chinese Wuhan pneumonia (so-called COVID 2019), general surgeons including residents thrive. We hope that this review including milestones of history, anatomy, and surgery will be informative for surgeons involved in the treatment of groin hernias.

Inguinal hernias constitute 75% of abdominal wall hernias and have the lifetime risks of inguinal hernias are 27% in men and boys and 3% in women and girls [35] . Indirect (external or lateral) inguinal hernias (IIHs) outnumber direct (internal or inner) inguinal hernias (DIHs) by a ratio of approximately 2:1 [35] . Suspected congenital causes for persistent patency of processus vaginalis include cryptorchidism, lack of carbachol response, absence of cholinergic receptors, absence of myofibroblasts, absence of apoptotic nuclei, failed apoptosis of smooth muscle, catecholaminergic HISTORY Groin hernias have an interesting anatomical and surgical history[1,11,63-65] (Table 1) , in accordance with the concept of the preperitoneal (posterior) approach[81]. The anterior rectus sheath was divided, and the abdominal rectus muscle was retracted medially; the TF was then exposed and the PPS was accessed. The IIH sac was ligated, and the defect was closed by approximating the conjoint tendon to the IPT and IL. Thereafter, based on the concept of the preperitoneal approach, prosthetic reinforcement in the PPS was first described by Jean Rives warned that polypropylene mesh did not cover the entire myopectineal orifice (MO) and that Lichtenstein's repair was therefore inadequate to prevent a femoral hernia [94] . Notably, he also stated that incomplete coverage of the MO by the mesh could predispose patients to subsequent DIH[94]. The IC is a passage in the anterior abdominal wall that conveys the SC in men and boys, whereas it conveys the RL in women and girls. The IL is bordered by the aponeurosis of the external abdominal oblique muscle anteriorly, the IAOM and transverse abdominal muscle superiorly, the IL and lacunar ligaments inferiorly, and the TF posteriorly.

In the early 1950s, Henri Fruchaud reported that all hernias at the groin result from a defect of the TF and pass through the myopectineal orifice (MO) (all three triangles of the groin) . Although an "on-lay patch," (placed on the anterior side of the TF) was historically used, the importance of an "under-lay (in-lay) patch" placed between the TF and peritoneum is now widely accepted. Hence, general surgeons commonly recognize the concept of optimal repair at the PPS. The PPS is observed between the TF and peritoneum; adequate creation of an extended PPS is important for optimal surgery [ 

Beginning in the latter half of the 20th century, prosthetic mesh was routinely used in accordance with the TFR concept; many surgeons recognized the importance of the PPS. Laparoscopy and endoscopy have therapeutic potential for hernia surgeries. Laparoscopic transabdominal preperitoneal (TAPP) repair is based on the same principle (i.e., therapeutic feasibility of the transperitoneal approach for groin hernia) as the technique published by Lawson Tait Surgeons can now choose from among several approaches (e.g., open vs laparoscopic/endoscopic and anterior vs preperitoneal), planes in which the mesh is placed ( e.g., layer in front of the TF vs the PPS), fixation devices (e.g., suture, sutureless, tack, or glue), and prostheses (e.g., soft vs hard meshes and sheeted vs three-dimensional meshes)[137].

Many meshes are currently available [12] . Hernia repair with mesh is regarded as hernioplasty, while traditional repairs without mesh are regarded as herniorrhaphy. . Monofilament polypropylene meshes (e.g., Prolene; Ethicon, Inc., Cincinnati, OH USA) are available from many manufacturers in the current era. One of the first synthetic meshes used was Marlex, which comprised crystalline polypropylene and high-density polyethylene. Irving L. Lichtenstein first introduced a mesh plug that consisted of polypropylene mesh in 1986[10,11]. Polypropylene, polyester, and expanded polytetrafluoroethylene were initially used; thereafter, polyglactin 910, cellulose, polyvinylidene fluoride, poliglecaprone 25, omega 3, titanium, and collagen were employed as additional materials.

Current meshes are chemically and physically inert; they are also nontoxic, stable, and nonimmunogenic [12] . However, none are biologically inert, due to the mesh physiology [12] . The introduction of a foreign material into the body triggers a healing response characterized by one of three reactions: destruction, tolerance, or rejection [12] . All meshes have their own characteristics with respect to elasticity (tensile strength), pore size, weight (density), constitution, and material absorption [12] .

Double-sided polypropylene mesh is designed as a bilayer polypropylene mesh with a connector between the layers; this mesh is fixated with fewer sutures than a monolayer polypropylene mesh. This system enables coverage of the MO and can repair IIHs, DIHs, and femoral hernias from an anterior approach. The on-lay patch covers the entire floor of the IC, while the under-lay patch is placed into the PPS. Robert Kugel placed a sutureless mesh in the PPS in 1999, and this mesh is known as the "Kugel hernia patch" [142] . This patch was later modified to a so-called "direct Kugel patch" for placement of the mesh by means of a minimal incision in the IL. Double-sided polypropylene mesh (e.g., Prolene Hernia System; Ethicon, Inc.) and the direct Kugel patch have become widespread on a commercial basis. Furthermore, polypropylene mesh itself is currently employed in surgeries for other diseases [143] .

Inguinal hernia repair is associated with a low incidence of complications that can be influenced by the type of mesh [144] . In terms of postoperative complication, lightweight and heavyweight meshes showed no differences regarding seromas, infections, erosion, and testicular atrophy [145] [146] [147] . Lightweight mesh may contribute to recurrence in patient with inguinal hernias [146] , but has advantages in terms of chronic pain and foreign body sensations [145] [146] [147] . Moreover, partially absorbable synthetic mesh improves postoperative chronic pain, functional outcomes, and quality of life [148, 149] .

Surface modification methods and nanofiber-based technology are actively under exploration to retain material strength and biocompatibility [12] . Biological mesh has superior biocompatibility to the above-described meshes and does not trigger an inflammatory response from the body, although higher cost has hampered its widespread acceptance [12] . In patients who experience complications, biological meshes can be placed for temporary or permanent closure of defects after mesh removal due to chronic pain or infection [150, 151] .

Hence, mesh materials are currently well-developed, but each mesh should be used in the correct manner12 Many types of meshes are available, and surgeons should follow the manufacturers' instructions to avoid malfunctions [12] . Surgeons must also ensure that their knowledge is regularly updated regarding mesh applications[12].

Postoperative recurrence is a critical issue [47, 152] . The reasons for inguinal hernia recurrence are most likely multifactorial and include both technical and nontechnical patient-related risk factors [47] . In one study, the overall reoperation rate was reportedly 3.8%[47], while the reoperation rates for IIH and DIH were 2.7% and 5.2%, respectively [47] . Notably, the right side has a higher recurrence rate than the left side [4,47,152].

Iatrogenic recurrence caused by lack of anatomical knowledge and inappropriate techniques should be avoided [47] . All surgeons, including trainees and residents, should ensure professional technique in clinical practice to reduce the risk of recurrence. Nontechnical patient-related factors that influence the risk of recurrence after surgery have not been studied in detail [47] . Female sex, DIH at the time of initial surgery, surgical treatment of a recurrent inguinal hernia, and smoking are considered risk factors for postoperative recurrence [47] . A significant relationship between the type of hernia at the time of initial surgery and reoperation has been identified with respect to hernia recurrence [47] .

Surgical repair is generally indicated[58,59], and a laparoscopic approach is strongly recommended for surgical repair of recurrent hernia[59].

Obturator hernias are internal herniations through the obturator foramen, bordered by the obturator vessels and nerve. This type of hernia was first described by Pierre Roland Arnaud de Ronsil in 1724 [153] , although a patient had been described by Le Maire in 1718 [153] . Notably, the Howship-Romberg sign [named after John Howship (1781-1841) and Moritz Heinrich Romberg (1795-1873)] is associated with obturator hernia [154] ; however, this rare hernia generally exhibits nonspecific signs and symptoms [155] . Hence, the usefulness of computed tomography for diagnosis was suggested in 1983[156]. Actual image findings are shown in Figure 5A .

Obturator hernia should be considered a bilateral disease [157] ; thus, unilateral repair may be inadequate [158, 159] . The normal diameter of the obturator foramen is approximately 1.0 cm [160] . Hence, the bilateral obturator foramina should be routinely checked during surgery [157] [158] [159] ; bilateral repair is required if even only a subtle dilation of the contralateral obturator foramen is observed during surgery [157] [158] [159] .

Lorenz Heister was the first to successfully repair a strangulated hernia.67 Thereafter, August Gottlieb Richter (1742-1812) produced a two-volume treatise regarding hernias from 1777 to 1779, which included the first description of a strangulated hernia involving only part of the intestine.

Incarcerations of the ovary and appendix are often observed. Although ovarian resection is not required for ovary incarceration, incarceration of the appendix (known as "Amyand's hernia", which is an inguinal hernia that traps the appendix) sometimes requires appendectomy. In 1735, Claudius Amyand (1660-1749) performed the first successful appendectomy [161] , which concerned an incarcerated hernia involving a swollen and perforated appendix. The reported incidence of Amyand Pathophysiological hypotheses for prolapse of the uterus and its appendages have been proposed for both girls and women [165, 166] . However, groin hernias involving the uterus and/or its appendages have not been described. The appendix has characteristic features and is completely distinct from the ileum, colon, and rectum [167] . In patients who exhibit a giant hernia involving incarceration of the ileocecal portion of the intestinal tract, only the appendix does not recover from ischemic changes, despite resolution of the strangulation (Figure 6) . Thus, incarceration of the appendix has several reasons for a distinctive name (i.e., Amyand's hernia).

In women and girls, the RL is attached to the uterus, near the origin of the fallopian tubes, and the extension of the parietal peritoneum follows the RL as it passes to the IC through the IIR [168] . A hydrocele of the canal of Nuck is a differential diagnosis for groin hernia [51, 168, 169] 

Recurrence of groin hernias is extremely challenging for general surgeons, and neuropathy may be intractable [161, 170, 171] . Injury of the SC or VD results in refractory pain with burning [172] . Potential complications include testicular ischemia [173] , testicular atrophy [174] , bowel obstruction and/or necrosis due to mesh adhesion [175, 176] , vascular injury [177] , visceral injury [176, 177] , wound infections [173] , and hematomas [173] . Rarely, patients with groin hernias have experienced fatal outcomes [178, 179] . material can influence the integrity of the SC and testicular function [180] [181] [182] . Contact with the mesh material may cause sterility in male patients [183] . Meshes inherently cause varying degrees of postoperative atrophy; therefore, biomechanical stability is extremely important [184] . Soft and hard meshes may result in unidirectional or matrix-like atrophy[12, 185, 186] . Soft mesh reduces chronic pain, but increases atrophic changes [12] . Biological mesh is predicted to become a powerful tool in the near future, although its cost remains high [12, 187, 188] . Testicular necrosis induces the formation of autoimmune antibodies to the body's own sperm [173] , subsequently causing male sterility[50].

Thorough knowledge of peritoneal innervation is important because neurarchy has clinical implications. Some authors have extensively described the anatomy of the nerves located in the groin[22-31] (Figures 7 and 8) . The peritoneum has both somatic and autonomic innervations, which are involved in various abdominal pathologies (Figures 7 and 8) . These six nerves of interest are the iliohypogastric, ilioinguinal, femoral (including the anterior cutaneous branch), genitofemoral (GFN) (femoral and genital branches), lateral femoral cutaneous (LFCN), and obturator nerves (Figure 8) . The reported incidence of postoperative pain and/or discomfort ranges from 14.7% to 17.3%, but the intensity of persistent chronic pain or discomfort after surgery is not sufficiently severe to disturb daily activities in most patients [34, 189] . However, a lack of anatomical knowledge and the use of an inadequate surgical technique may result in poor outcomes with refractory neuropathy and intractable chronic pain[4,22-31,34]. Notably, intractable and refractory pain may be an indication for removal of mesh and/or resection of entrapped nerves [190] .

The femoral nerve is generally well protected by the psoas tendon. Therefore, injury to this nerve during surgery is extremely rare [34] . Additionally, intraoperative injury to the obturator nerve is only anecdotal because this nerve is well hidden [34] .

Although branches of the GFNs course to the lower limbs, more common nerve injuries are observed in GFN branches in the trunk, as well as the LFCN[4,34] (Figure 8 ). The estimated risks of intraoperative injuries are 58.2% in the LFCN, 31.2% in the femoral branch of the GFN (Fb-GFN), and 4.7% in the Gb-GFN [34] . Although the courses of the obturator and femoral motor nerves are largely predictable and consistent, the courses of the sensory nerves (i.e., GFN and LFCN) demonstrate great variability and are involved in refractory symptoms (e.g., chronic and continuous pain) [34] . Wide variation in the number and course of sensory nerves that traverse the PPS creates considerable potential for overlap with the Gb -GFN, Fb-GFN, and LFCN[4,34] . Notably, the ilioinguinal nerve has a wide area in which injury can occur [4, 34] . Respecting these proper dissection planes and ensuring knowledge of relevant neuroanatomy will minimize contact and corresponding risk of injury [4, 34] .

Injury to the iliohypogastric nerve results in postoperative neuralgia and muscular atrophy [191] (Figure 8) . Additionally, injury to the ilioinguinal nerve may cause refractory pain[4,34] (Figure 8) .

Nerve preservation during surgery requires a carefully considered approach [4, 34, 192] . Subtle factors during surgery (e.g., skeletonization, direct detection, countertraction, and mesh contact) may cause postoperative neuropathy and chronic pain [34, 190, 192, 193] . Unnecessary procedures for nerve identification should be avoided if possible; anatomical recognition of the route of each nerve (without direct exposure or complete skeletonization) is generally sufficient during surgery [4, 34, 192] . July 20, 2021

Volume 11 Issue 4 

The initial laparoscopic view of the groin reveals five plicae (perineal folds) that serve as guiding landmarks [4, 34] . The median umbilical plica, observed at the midline, contains the obliterated urachus and is less clinically relevant to surgical repair[4,34]. The medial umbilical plica (MUP) is the most prominent landmark present on the July 20, 2021 Volume 11 Issue 4 initial view [4, 34] . This plica is easily recognized and contains remnant umbilical vessels [4, 34] . The MUP should not be routinely cut because the umbilical vessels may still be patent and cause bleeding [4, 34] . Although the lateral umbilical plica may be difficult to identify depending on the body habitus and fat distribution, recognition of this plica is important [4, 34] . This plica contains the inferior epigastric vessels, which divide the groin into a medial compartment (i.e., space of Retzius) and a lateral compartment (i.e., space of Bogros) [4, 34] . External palpation of the surface anatomy allows precise localization of the anterior superior iliac spine and pubic tubercle, thereby delineating the IPT that divides the groin into an upper and a (critical) lower part [4, 34] . The space of Bogros extends laterally from the space of Retzius toward the anterior superior iliac spine [4] . These spaces must be developed to allow adequate room for hernia repair and mesh placement[4]. These plicae create three flat fossae recognizable on each side, corresponding to possible hernia defects [4, 34] . The hernia presentation can be more easily evaluated by a laparoscopic view than by endoscopic or anterior view[4,34] (Figure 9 ). The lateral fossa, located in the triangle between the lateral umbilical plica and IPT, corresponds to the point of the IIR from which an IIH originates [4, 34] . The medial fossa is located between the lateral umbilical plica and MUP; this fossa is inferiorly limited by the IPT [4, 34] . A DIH is located in this region, passing through Hesselbach's triangle [4, 34] . The supravesical fossa is located medial to the MUP and cranial to the IPT, pubic bone, and urinary bladder [4, 34] . This weak point may rarely become the origin of a supravesical hernia [4, 34] . A femoral hernia develops within the region of the femoral canal (i.e., the triangle below the IPT, medial to the femoral vein, and superior to the pubic bone and Cooper's ligament) [4, 34] .

The pubic symphysis, a cartilaginous joint between the superior pubic rami, symphysis denotes the midline[4]. Cooper's ligament, a lateral extension of the lacunar ligament, forms the periosteum of the superior pubic rami[4].

Although the IIH enters the IIR lateral to the inferior epigastric vessels, a DIH protrudes through Hesselbach's triangle medial to the inferior epigastric vessels [4] . Important nerves are located on the lateral side of the IIR and travel from the pelvic interior to the thigh, coursing under the IPT [4, 34] . In contrast, most important vessels course on the internal side of the IIR[4,34]. The VD travels downward, crossing the iliac vessels medially [4, 34] . Hence, the VD comprises the "preperitoneal loop" in the DVL. Thereafter, the VD changes its direction at a 90-degree angle and dives down to the urogenital space to join the prostate gland [4, 34] .

The basic anatomical principles of the laparoscopic view were first described by Albert T. Spaw and Lynn P. Spaw in 1991, based on human cadaveric dissections [194] . They coined the term the "triangle of doom," which delineates the region between the VD and spermatic vessels. However, the neuroanatomy in the PPS was not considered [194] . Thereafter, James Rosser first described the inguinal neuroanatomy in 1994 and roughly delineated the anatomical course of the inguinal nerves [22] . Arnold S. Seid and Edwin Amos provided a more precise description of the nerves[23]; they postulated that the "triangle of doom" should be extended further laterally to the anterior superior iliac spine. Currently, the "triangle of doom" is regarded as an inverted V- 

Although TAPP and totally extraperitoneal repairs have a higher cost than conventional repair [4, 195] , the cost-effectiveness of TAPP repair has been documented in other medically advanced countries (e.g., nations in Europe, as well as the United States and Japan) [196, 197] . The direct cost and contribution margin are nearly equivalent between robotic and laparoscopic surgery [198] , although robotic surgery results in a higher cost for unilateral groin hernia [199] . Robotic surgery is employed in the field of hernia repair [200] [201] [202] ; the articulate robotic arms are advantageous for approaches without any visual disturbance by the medial umbilical ligament and bowels. Moreover, a singleport robotic surgery system (da Vinci SP system; Intuitive Surgical, Inc., Sunnyvale, CA, United States) is currently available. General surgeons thus have a very promising frontier in this field.

Although the cost of biological mesh is still high[12, 187, 188] , this mesh may resolve critical problems (e.g., female agenesis, male sterility, neuropathy, and chronic pain) associated with synthetic mesh [203, 204] . Currently, surgeons await less expensive, ethically responsible biological mesh to arrive on the world market. The advantages of biological mesh, compared with synthetic mesh, require long-term assessment in a large, multicenter, well-designed, and randomized controlled trial [205, 206] .

Some organizations (e.g., the European Hernia Society and the Society of American Gastrointestinal and Endoscopic Surgeons) currently provide comprehensive inguinal hernia guidelines, and well-known surgeons have discussed herniology in detail [207] [208] [209] [210] [211] [212] [213] [214] . However, many physicians may feel that no definitive criteria are available for the selection of surgical procedures. Indeed, the physician's choice, commercial basis, or cost-effective reasoning may be unchallenged in most instances. The surgical procedure should be carefully chosen based on sex (male or female) and age (pediatric, reproductive adult, or older adult). From the perspective of female fertility and male virility, female agenesis and male sterility should be avoided. Mesh material inherently causes varying degrees of postoperative atrophy[12,101,184-186]; moreover, mesh contact is associated with female agenesis, male sterility, neuropathy, and chronic pain[101,139, [180] [181] [182] [183] . Direct contact with mesh may also cause obstruction of the VD and SC [101] . Retroflexion of the uterus may cause female agenesis ( Figure 5B ). Only biological mesh can resolve these critical problems [203, 204] . Although the TFR concept is important[11,64,90], careless use of synthetic mesh should be avoided in younger patients of reproductive age [180] [181] [182] [183] . Potts' repair (accompanied by Koop's fixation in female patients) may be the optimal first choice for younger patients of reproductive age, as well as adolescents and children.

Based on its TFR concept and technical simplicity, so-called "mesh-plug hernioplasty" has spread worldwide [91] [92] [93] . However, the mesh should entirely reinforce the MO. Incomplete coverage of the MO results in long-term hernia recurrence after hernioplasty [94] . A DIH or femoral hernia may become a recurrent hernia, especially in female patients, who intrinsically have a wide pelvic space [94] . Female patients should undergo surgical repair at the PPS that fully covers the entire MO, as well as the obturator foramen[94], although "mesh-plug hernioplasty" is effective in men of advanced age [92] .

Notably, from the perspective of technical skills, pediatric herniorrhaphy actually reflects the individual ability of each surgeon[8]. Antibiotics are not routinely administered after surgery [215] . Although antibiotics are not indicated for elective surgery using synthetic material [185] , antibiotics may be appropriate if a trainee or resident performed surgery with a prolonged operative time and using synthetic material [216] . Administration of antibiotic prophylaxis in open mesh repair in highrisk patients in a low-risk environment is suggested [60, 61] .

Thorough knowledge of the inguinal anatomy is mandatory for successful herniorrhaphy and hernioplasty, and high-quality repair is required in the treatment of groin hernias. Surgical repair performed solely to prevent prolapse is inadequate and places patients with groin hernia at high risk. Important nerves and vessels should be carefully preserved. Hernia repair without careful consideration (i.e., hernia repair that involves reinforcement of the abdominal wall alone) causes intractable symptoms, such as neuropathy and agenesis. Complacency may lead surgeons to presume that the learning curves for herniorrhaphy and hernioplasty are very short. High-quality repair is of utmost importance for groin hernias. Additionally, a combination of anatomical knowledge and high surgical skill level is crucial and indispensable for successful treatment of groin hernias. The frontier is large for general surgeons including residents.

Both anatomical recognition and a skillful technique are essential for successful herniorrhaphy and hernioplasty for groin hernias. In particular, in-depth anatomical knowledge of the nerves and vessels at the PPS and MO is a critical consideration. Surgeons must also avoid female agenesis, male sterility, neuropathy, and chronic

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