Inguinal hernia surgery is an operation to repair a weakness in the abdominal wall that abnormally allows abdominal contents to slip into a narrow tube called the
inguinal canal
The inguinal canals are the two passages in the anterior abdominal wall of humans and animals which in males convey the spermatic cords and in females the round ligament of the uterus. The inguinal canals are larger and more prominent in males. T ...
in the groin region.
There are two different clusters of hernia: groin and ventral (abdominal) wall. Groin hernia includes femoral, obturator, and inguinal.
Inguinal hernia is the most common type of hernia and consist of about 75% of all hernia surgery cases in the US. Inguinal hernia, which results from lower abdominal wall weakness or defect, is more common among men with about 90% of total cases.
In the inguinal hernia, fatty tissue or a part of the small intestine gets inserted into the inguinal canal.
Other structures that are uncommon but may get stuck in inguinal hernia can be the appendix, caecum, and transverse colon. Hernias can be asymptomatic, incarcerated, or strangled.
Incarcerated hernia leads to impairment of intestinal flow, and strangled hernia obstructs blood flow in addition to intestinal flow.
Inguinal hernia can make a small lump in the groin region which can be detected during a physical exam and verified by imaging techniques such as computed tomography (CT) . This lump can disappear by lying down and reappear through physical activities, laughing, crying, or forceful bowel movement. Other symptoms can include pain around the groin, an increase in the size of bulge over the time, pain while lifting, and a dull aching sensation.
In occult (hidden) hernia, the bulge cannot be detected by physical examination and magnetic resonance imaging (MRI) can be more helpful in this situation. Males who have asymptomatic inguinal hernia and pregnant women with uncomplicated inguinal hernia can be observed, but the definitive treatment is mostly surgery.
Surgery remains the ultimate treatment for all types of
hernia
A hernia is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. Various types of hernias can occur, most commonly involving the abdomen, and specifically the gr ...
s as they will not get better on their own, however not all require immediate repair.
Elective surgery
Elective surgery or elective procedure (from the la, eligere, meaning to choose) is surgery that is scheduled in advance because it does not involve a medical emergency. Semi-elective surgery is a surgery that must be done to preserve the patien ...
is offered to most patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health.
Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when
intra-abdominal fat or small intestine becomes stuck within the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation as a result of restricted blood supply to the trapped segment of small intestine causing that portion to die.
Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life.
Surgical repair of inguinal hernias is one of the most commonly performed operations worldwide and the most commonly performed surgery within the United States. A combined 20 million cases of both inguinal and
femoral hernia
Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness in the abdominal wall called the femoral canal. Femoral hernias are a relatively uncommon type, accounting for only 3% of ...
repair are performed every year around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year.
Groin hernias account for almost 75% of all abdominal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men account for nearly 90% of all repairs performed and have a
bimodal incidence of inguinal hernias peaking at 1 year of age and again in those over the age of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most common subtype of groin hernia in both males and females.
Inguinal hernia surgery is also one of the most common surgical procedures, with an estimated incidence of 0.8-2% and increasing up to 20% in preterm children.
Indications for surgery
Society guidelines recommend that indications for surgery take into account the severity of symptoms, the type of hernia, previous surgeries, hernia size, bowel incarceration (bowel can no longer return to the abdomen) and the overall general health of the person.
Non-urgent repair
Elective surgery
Elective surgery or elective procedure (from the la, eligere, meaning to choose) is surgery that is scheduled in advance because it does not involve a medical emergency. Semi-elective surgery is a surgery that must be done to preserve the patien ...
is planned in order to help relieve symptoms, respect the person's preference, and prevent future complications that may require emergency surgery.
[DynaMed Plus nternet Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 113880, Groin hernia in adults and adolescents; pdated 2017 Nov 27, cited Nov 27, 2017 bout 28 screens Available from http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=113880. Registration and login required.]
Surgery is offered to the majority of people who:
* have symptoms that interfere with their normal level of activity.
* have hernias that become increasingly difficult to reduce.
* are female as it is often difficult to classify the subtype of hernia based on an exam alone.
Symptomatic hernias tend to cause pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to be most prominent at the end of the day as well as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh.
Urgent repair
A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include:
* Fever
* Nausea and vomiting
* Extreme pain in the area of the hernia
* Warm hernia bulge with surrounding skin redness
* Can no longer pass gas or stool
Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of the intestine.
Although pediatric inguinal hernias sometimes present asymptomatically, surgical repair is still the standard of care to prevent hernia incarceration, which for children who are born with hernias has a risk of 12% in full-term children and 39% in preterm children. In preterm neonates, the timing for intervention appears to be of utter importance as surgical hernia repair after neonatal intensive care unit (NICU) discharge might decrease recurrence and anesthesia-induced respiratory difficulties compared to surgery before NICU discharge.
Contraindications to surgery
The person with the hernia should be given an opportunity to participate in the
shared decision-making
Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to pa ...
with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such that elective repair is no longer in a person's best interest. Such cases include:
* People
with unstable medical conditions
* Repair using
mesh
A mesh is a barrier made of connected strands of metal, fiber, or other flexible or ductile materials. A mesh is similar to a web or a net in that it has many attached or woven strands.
Types
* A plastic mesh may be extruded, oriented, ex ...
is withheld if a person has an active infection within the groin or
within the blood stream
* Elective repair is delayed in pregnant women until 4 weeks after delivery
Additionally, certain medical conditions can prevent people from being candidates for laparoscopic approaches to repair. Examples of such include:
* People who are unable to undergo general anesthesia
* Prior major open abdominal surgery
* People who have
ascites
Ascites is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdominal size, increased weight, ab ...
* Previous radiation therapy to the pelvis
* A complex hernia
Surgical approaches
Techniques to repair inguinal hernias fall into two broad categories termed "open" and "
laparoscopic
Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
". Surgeons tailor their approach by taking into account factors such as their own experience with either techniques, the features of the hernia itself, and the person's anesthetic needs.
The cost associated with either approach varies widely across regions, but updated guidelines published by the International Endohernia Society (IES) cast doubt on the comprehensiveness of cost comparison studies due in part to the complexity inherent in calculating costs across institutions. The IES asserts that hospital and societal costs are lower for laparoscopic repairs as compared to open approaches. They recommend the routine use of reusable instruments as well as improving the proficiency of surgeons to help further decrease costs as well as time spent in the OR. However, as an example, the
UK's
National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
spends £56 million a year in repairing inguinal hernias, 96% of which were repaired via the open mesh approach while only 4% were done laparoscopically.
Open hernia repair
All techniques involve an approximate 10-cm incision in the groin. Once exposed, the hernia sac is returned to the abdominal cavity or excised and the abdominal wall is very often reinforced with
mesh
A mesh is a barrier made of connected strands of metal, fiber, or other flexible or ductile materials. A mesh is similar to a web or a net in that it has many attached or woven strands.
Types
* A plastic mesh may be extruded, oriented, ex ...
.
There are many techniques that do not utilize mesh and have their own situations where they are preferable.
Open repairs are classified via whether prosthetic mesh is utilized or whether the patient's own tissue is used to repair the weakness. Prosthetic repairs enable surgeons to repair a hernia without causing undue tension in the surrounding tissues while reinforcing the abdominal wall. Repairs with undue tension have been shown to increase the likelihood that the hernia will recur. Repairs not using prosthetic mesh are preferable options in patients with an above-average risk of infection such as cases where the bowel has become strangulated (blood supply lost due to constriction).
One large benefit of this approach lies in its ability to tailor anesthesia to a person's needs. People can be administered
local anesthesia
Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...
, a
spinal block
Spine or spinal may refer to:
Science Biology
* Vertebral column, also known as the backbone
* Dendritic spine, a small membranous protrusion from a neuron's dendrite
* Thorns, spines, and prickles, needle-like structures in plants
* Spine (zoolo ...
, as well as
general anesthesia
General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...
.
Local anesthesia has been shown to cause less pain after surgery, shorten operating times, shorten recovery times as well as decrease the need to return to the hospital. However, people who undergo general anesthesia tend to be able to go home faster and experience fewer complications.
The European Hernia Society recommends the use of local anesthesia particularly for people with ongoing medical conditions.
Open mesh repairs
![Inguinal Hernia Patch](https://upload.wikimedia.org/wikipedia/commons/c/cc/Inguinal_Hernia_Patch.png)
Repairs that utilize mesh are usually the first recommendation for the vast majority of patients including those that undergo laparoscopic repair.
Procedures that employ mesh are the most commonly performed as they have been able to demonstrate better results compared to non-mesh repairs.
Approaches utilizing mesh have been able to demonstrate faster return to usual activity, lower rates of persistent pain, shorter hospital stays, and a lower likelihood that the hernia will recur.
Options for mesh include either
synthetic or
biologic. Synthetic mesh provides the option of using "heavyweight" as well as "lightweight" variations according to the diameter and number of mesh fibers. Lightweight mesh has been shown to have fewer complications related to the mesh itself than its heavyweight counterparts. It was additionally correlated with lower rates of chronic pain while sharing the same rates of hernia recurrence as compared to heavyweight options. This has led to the adoption of lightweight mesh for minimizing the chance of chronic pain after surgery.
Biologic mesh is indicated in cases where the risk of infection is a major concern such as cases in which the bowel has become strangulated. They tend to have lower
tensile strength
Ultimate tensile strength (UTS), often shortened to tensile strength (TS), ultimate strength, or F_\text within equations, is the maximum stress that a material can withstand while being stretched or pulled before breaking. In brittle materials t ...
than their synthetic counterparts lending them to higher rates of mesh rupture.
Biomeshes are increasingly popular since their first use in 1999 and their subsequent introduction to the market in 2003. Some have a similar price to high end synthetic meshes. They can be produced from absorbable, animal-sourced
extra cellular matrix
In biology, the extracellular matrix (ECM), also called intercellular matrix, is a three-dimensional network consisting of extracellular macromolecules and minerals, such as collagen, enzymes, glycoproteins and hydroxyapatite that provide structu ...
, or by other means. Synthetic absorbable meshes are also available.
Meshes made of
mosquito net
A mosquito net is a type of meshed curtain that is circumferentially draped over a bed or a sleeping area, to offer the sleeper barrier protection against bites and stings from mosquitos, flies, and other pest insects, and thus against the di ...
cloth, in
copolymer
In polymer chemistry, a copolymer is a polymer derived from more than one species of monomer. The polymerization of monomers into copolymers is called copolymerization. Copolymers obtained from the copolymerization of two monomer species are some ...
of
polyethylene
Polyethylene or polythene (abbreviated PE; IUPAC name polyethene or poly(methylene)) is the most commonly produced plastic. It is a polymer, primarily used for packaging ( plastic bags, plastic films, geomembranes and containers including bo ...
and
polypropylene
Polypropylene (PP), also known as polypropene, is a thermoplastic polymer used in a wide variety of applications. It is produced via chain-growth polymerization from the monomer propylene.
Polypropylene
belongs to the group of polyolefins and ...
have been used for low-income patients in rural
India
India, officially the Republic of India (Hindi: ), is a country in South Asia. It is the seventh-largest country by area, the second-most populous country, and the most populous democracy in the world. Bounded by the Indian Ocean on the so ...
and
Ghana
Ghana (; tw, Gaana, ee, Gana), officially the Republic of Ghana, is a country in West Africa. It abuts the Gulf of Guinea and the Atlantic Ocean to the south, sharing borders with Ivory Coast in the west, Burkina Faso in the north, and To ...
. Each piece costs $0.01, 3700 times cheaper than an equivalent commercial mesh.
They give results identical to commercial meshes in terms of infection and recurrence rate at 5 years.
= Lichtenstein technique
=
The Lichtenstein tension-free repair has persisted as one of the most commonly performed procedures in the world. The European Hernia Society recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method.
Recent studies have indicated that mesh attachment with the use of
adhesive glue is faster and less likely to cause post-op pain as compared to attachment via suture material.
= Plug and patch technique
=
The plug and patch tension-free technique has fallen out of favor due to higher rates of mesh shift along with its tendency to irritate surrounding tissue. This has led to the European Hernia Society recommending that the technique not be used in most cases.
= Other open mesh repair techniques
=
A variety of other tension-free techniques have been developed and include:
* Prolene mesh system (PHS)
* Kugel (preperitoneal repair)
* Stoppa
* Trabucco (Hertra mesh)
* Wantz
* Rutkow/Robbins
* Modified APP
Open non-mesh repairs
Techniques in which mesh is not used are referred to as tissue repair technique, suture technique, and tension technique. All involve bringing together the tissue with sutures and are a viable alternative when mesh placement is contraindicated.
Such situations are most commonly due to concerns of contamination in cases where there are infections of the groin, strangulation or perforation of the bowel.
= Shouldice technique
=
The Shouldice technique is the most effective non-mesh repair thus making it one of the most commonly utilized methods.
Numerous studies have been able to validate the conclusion that patients have lower rates of hernia recurrence with the Shouldice technique as compared to other non-mesh repair techniques.
However this method frequently experiences longer procedure times and length of hospital stay. Despite being the superior non-mesh technique, the Shouldice method results much higher rates of hernia recurrence in patients when compared to repairs that utilize mesh.
= Bassini technique
=
The Bassini technique, described by
Edoardo Bassini
Edoardo Bassini (April 14, 1844 – July 19, 1924) was an Italian surgeon born in Pavia.
In 1866 he received his medical degree from the University of Pavia, and afterwards joined the Italian Unification movement as an infantry soldier und ...
in the 1880s, was the first efficient inguinal hernia repair.
[Bassini E, ''Nuovo metodo operativo per la cura dell'ernia inguinale''. Padua, 1889.] In this technique, the
conjoint tendon
The conjoint tendon (previously known as the inguinal aponeurotic falx) is a sheath of connective tissue formed from the lower part of the common aponeurosis of the abdominal internal oblique muscle and the transversus abdominis muscle, joining th ...
(formed by the distal ends of the
transversus abdominis
The transverse abdominal muscle (TVA), also known as the transverse abdominis, transversalis muscle and transversus abdominis muscle, is a muscle layer of the anterior and lateral (front and side) abdominal wall which is deep to (layered below) th ...
and
internal oblique
The abdominal internal oblique muscle, also internal oblique muscle or interior oblique, is an abdominal muscle in the abdominal wall that lies below the external oblique muscle and just above the transverse abdominal muscle.
Structure
Its fibers ...
muscles) is approximated to the
inguinal ligament
The inguinal ligament (), also known as Poupart's ligament or groin ligament, is a band running from the pubic tubercle to the anterior superior iliac spine. It forms the base of the inguinal canal through which an indirect inguinal hernia may dev ...
and closed.
= Other open non-mesh techniques
=
The Shouldice technique was itself an evolution of prior techniques that had greatly advanced the field of inguinal hernia surgery. Such classic open non-mesh repairs include:
* McVay technique
* Halsted
* Maloney darn
* Plication darn
Desarda techniqueA 1–2 cm strip of the external oblique aponeurosis is stitched below to the inguinal ligament and above to the muscle arch without disturbing its continuity at either end. This gives immediate protection, so no restrictions on activities are required. The procedures results in very low recurrence and complication rates.
Laparoscopic repair
![Ramus genitalis n genitofemoralis in inguinal canal](https://upload.wikimedia.org/wikipedia/commons/0/09/Ramus_genitalis_n_genitofemoralis_in_inguinal_canal.jpg)
There are two main methods of laparoscopic repair: ''transabdominal preperitoneal'' (''TAPP'') and ''totally extra-peritoneal'' (''TEP'') repair. When performed by a surgeon experienced in hernia repair,
laparoscopic
Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
repair causes fewer complications than Lichtenstein, particularly less
chronic pain
Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between Acute (medicine), acute and Chronic condition, chronic pain is sometimes determined by the amount of time since onset. Two commonly ...
. However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. All that said, many surgeons are shifting to using laparoscopic techniques as they require smaller incisions, and result in less bleeding, lower infection rates, faster recovery, shorter hospitalization periods, and reduced chronic pain.
Recurrence rates are identical when laparoscopy is performed by an experienced surgeon.
When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein.
Robotic surgery
Robot assisted repair of inguinal hernias has demonstrated safety and efficacy in surgeries repairing inguinal hernias that present on both sides of the pubic bone (bilateral) as well as inguinal hernias that present on one side (unilateral). In comparing robot assisted repair of inguinal hernias to traditional laparoscopic techniques, robot assisted surgeries repairing inguinal hernias have longer operating times and can be more costly. However, measures of safety, complication rates, and readmission rates did not significantly differ between robot assisted repair and traditional laparoscopic repair.
Non-surgical management
Studies have demonstrated that men whose hernias cause little to no symptoms can safely continue to delay surgery until a time that is most convenient for patients and their healthcare team. Research shows that the risk of inguinal hernia complications remains under 1% within the population.
Watchful waiting requires that patients maintain a close follow-up schedule with providers to monitor the course of their hernia for any changes in symptoms and can be safely offered for up to 2 years.
Patients who do elect watchful waiting eventually undergo repair within five years as 25% will experience a progression of symptoms such as worsening of pain. Elective repair discussions should be revisited if patients begin to avoid aspects of their normal routine due to their hernia.
After 1 year it is estimated that 16% of patients who initially opted for watchful waiting will eventually undergo surgery. Furthermore, 54% and 72% will undergo repair at 5-year and 7.5-year marks respectively.
The use of a
truss
A truss is an assembly of ''members'' such as beams, connected by ''nodes'', that creates a rigid structure.
In engineering, a truss is a structure that "consists of two-force members only, where the members are organized so that the assembl ...
is an additional non-surgical option for men. It resembles a jock-strap that utilizes a pad to exert pressure at the site of the hernia in order prevent excursion of the hernia sack. It has little evidence to support its routine use and has not been shown to prevent complications such as incarceration (bowel can no longer slide back into abdomen) or strangulation of bowel (constriction causing loss of blood supply). However some patients do report a soothing of symptoms when utilized.
Complications and prognosis
Inguinal hernia repair complications are unusual, and the procedure as a whole proves to be relatively safe for the majority of patients. Risks inherent in almost all surgical procedures include:
* bleeding
* infection
*
fluid collections
* damage to surrounding structures such as blood vessels, nerves, or the bladder
* urinary retention requiring a
catheter
In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...
Risks that are specific to inguinal hernia repairs include such things as:
* recurrence of the hernia
* impairment of sexual activity, such as genital or ejaculatory pain
* in males, injury to the
tube that conveys sperm from the testicle to the penis
* in males, bruising and swelling of the scrotum
* chronic regional pain (also known as post-herniorrhaphy inguinodynia, or chronic postoperative inguinal pain)
Post-herniorraphy pain syndrome
Post-herniorrhaphy inguinodynia is a condition where 10-12% of patients experience severe pain after inguinal hernia repair, due to a complex combination of different
forms of pain signals.
It can occur with any inguinal hernia repair technique, and if unresponsive to pain medications, further surgical intervention is often required. Removal of the implanted mesh, in combination with
bisection of regional nerves, is commonly performed to address such cases.
There remains ongoing discussion amongst surgeons regarding the utility of planned resections of regional nerves as an attempt to prevent its occurrence.
Mortality rates
Mortality rates for non-urgent, elective procedures was demonstrated as 0.1%, and around 3% for procedures performed urgently.
Other than urgent repair, risk factors that were also associated with increased mortality included being female, requiring a femoral hernia repair, and older age.
Follow-up
Upon awakening from anesthesia, patients are monitored for their ability to drink fluids, produce urine, as well as their ability to walk after surgery. Most patients are then able to return home once those conditions are met.
It is not uncommon for patients to experience residual soreness for a couple of days after surgery.
Patients are encouraged to make strong efforts in getting up and walking around the day after surgery.
Most patients can resume their normal routine of daily living within the week such as driving, showering, light lifting, as well as sexual activity.
Long work absences are rarely necessary and length of sick days tend to be dictated by respective employment policies.
In general, it is not recommended to administer antibiotics as prophylaxis after elective inguinal hernia repair. However, the rate of wound infection determines the appropriate use of the antibiotics.
Post-op development of any of the following should warrant timely reporting via phone:
* fever greater than 39C/101F
* progressive swelling of the surgical site
* severe pain
* recurring nausea or vomiting
* worsening redness around incisions
* drainage of pus from incisions
* difficulty or lack of producing urine
* new-onset shortness of breath
Prevention and screening
Most indirect inguinal hernias in the abdominal wall are not preventable. Direct inguinal hernias may be prevented by maintaining a healthy weight, refraining from smoking, preventing straining during bowel movements, and maintaining proper lifting techniques when heavy lifting.
There is no evidence that indicates physicians should routinely
screen
Screen or Screens may refer to:
Arts
* Screen printing (also called ''silkscreening''), a method of printing
* Big screen, a nickname associated with the motion picture industry
* Split screen (filmmaking), a film composition paradigm in which mul ...
for asymptomatic inguinal hernias during patient visits.
[DynaMed Plus nternet Ipswich (MA): EBSCO Information Services. 1995 - . Record No. 113880, Groin hernia in adults and adolescents; pdated 2017 Nov 27, cited Nov 27, 2017 bout 28 screens Available from http://www.dynamed.com/login.aspx?direct=true&site=DynaMed&id=113880. Registration and login required.]
References
{{DEFAULTSORT:Inguinal Hernia Repair
Inguinal hernias
Abdominal surgical procedures
Digestive system surgery
it:Chirurgia dell'ernia inguinale