Inguinal hernia repair
Encyclopedia
Inguinal hernia repair refers to a surgical operation
for the correction of an inguinal hernia
.
is described as a herniotomy. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous
(patient's own tissue) or heterogeneous
material such as prolene
mesh, it is termed hernioplasty as opposed to herniorrhaphy, in which no autogenous or heterogeneous material is used for reinforcement.
Almost 700,000 herniorrhaphies are performed each year in the United States.
Herniorrhaphy techniques can be divided into four groups:
(formed by the distal ends of the transversus abdominis
and internal oblique
muscles) is approximated to the inguinal ligament
and closed.
Due to the high rate of hernia recurrence, long recovery period and postoperative pain, tension repairs are less commonly used today than in previous years. However, a few tension repairs are still in use today; these include the Shouldice
and the Cooper's ligament
/McVay repair.
The Shouldice technique is a complicated four layer reconstruction; however, it has relatively low reported recurrence rates.
, Gore-Tex
, polypropylene
or polyester
, although some companies market Teflon
meshes and partially absorbable meshes. Patients typically go home within a few hours of surgery, often requiring no medication beyond aspirin
or acetaminophen
. Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation. Recurrence rates are 1% or less, compared with over 10% for a tension repair. Rates of complications
are generally low but they can be quite serious, and can include chronic pain
, ischemic orchitis
, and testicular atrophy
.
repair of inguinal hernia has emerged as an option. Laparoscopic repairs (sometimes referred to as minimally invasive surgery or "keyhole surgery") are also tension-free, although the mesh is placed within the pre-peritoneal space behind the defect as opposed to in or over it. Advantages of lap over the open method include a faster recovery time and a lower post-operative pain score.
Like the open method, laparoscopic surgery may involve local or general anesthesia, depending on the size and related factors of the hernia. Lap is usually more expensive as it requires more Operating Room time than open repair, but a shorter hospitalization period.
There is no definitive consensus as to the comparative risk of complications, or comparative rate of recurrence compared to the open tension-free repairs. However, most non-emergent abdominal surgeries are moving to laproscopic methodologies, as the smaller incisions used result in less bleeding, less infection, faster recovery, reduced hospitalization and reduced pain.
One specific method of laparoscopic repair is totally extraperitoneal (TEP) repair. TEp repair has been associated with fewer complications and a significantly shorter duration of post-operative analgesia than Lichtenstein repair for recurrent inguinal hernia.
In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. They concluded that recurrence rates are identical, but newer studies have questioned this. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that laparoscopic repair has less risk of wound infection, less bleeding, and less swelling after surgery. They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results, however, are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.
Mesh repairs have shown reduced recurrences or early recovery compared to tension repairs. Mesh repair complications include infection
, mesh migration, adhesion
formation, erosion into intraperitoneal
organs, and chronic pain - due probably to entrapment of nerves, vessels
, or the vas deferens
. Such complications usually become apparent weeks to years after the initial repair, presenting as abscess
, fistula
, or bowel obstruction
. More recently, concerns have been raised about the possibility of obstruction of the vas deferens as a result of the fibroblast
ic reaction to the mesh.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
for the correction of an inguinal hernia
Inguinal hernia
An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. They are very common , and their repair is one of the most frequently performed surgical operations....
.
Techniques
An operation in which the hernia sac is removed without any repair of the inguinal canalInguinal canal
The inguinal canal is a passage in the anterior abdominal wall which in men conveys the spermatic cord and in women the round ligament. The inguinal canal is larger and more prominent in men.-Site:...
is described as a herniotomy. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous
Autotransplantation
Autotransplantation is the transplantation of organs, tissues or even proteins from one part of the body to another in the same individual. Tissue transplanted by such "autologous" procedure is referred to as an autograft or autotransplant. It is contrasted with xenotransplantation and...
(patient's own tissue) or heterogeneous
Homogeneity and heterogeneity
Homogeneity and heterogeneity are concepts relating to the uniformity or lack thereof in a substance. A material that is homogeneous is uniform in composition or character; one that is heterogeneous lacks uniformity in one of these qualities....
material such as prolene
Prolene
Prolene is a synthetic, monofilament, nonabsorbable polypropylene suture. It is indicated for skin closure and general soft tissue approximation and ligation. Its advantages include minimal tissue reactivity and durability...
mesh, it is termed hernioplasty as opposed to herniorrhaphy, in which no autogenous or heterogeneous material is used for reinforcement.
Almost 700,000 herniorrhaphies are performed each year in the United States.
Herniorrhaphy techniques can be divided into four groups:
- Group 1: open "tension" repair
- Group 2: open "tension" repair
- Group 3: open "tension-free" repair
- Group 4: laparoscopic repair
Groups 1 and 2: open "tension" repair
A commonly performed herniorrhaphy technique was first described by Bassini in the 1880s. The Bassini technique is a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendonConjoint tendon
The conjoint tendon is a structure formed from the lower part transversus abdominis muscle as it inserts into the crest of the pubis and pectineal line immediately behind the superficial inguinal ring. It is usually conjoint with the tendon of the abdominal internal oblique muscle, but they may be...
(formed by the distal ends of the transversus abdominis
Transversus abdominis muscle
The transversus abdominis muscle, also known as the transverse abdominus, transversalis muscle and transverse abdominal muscle, is a muscle layer of the anterior and lateral abdominal wall which is deep to the internal oblique muscle...
and internal oblique
Abdominal internal oblique muscle
The internal oblique muscle is the intermediate muscle of the abdomen, lying just underneath the external oblique and just above the transverse abdominal muscle.-Structure:...
muscles) is approximated to the inguinal ligament
Inguinal ligament
The inguinal ligament is a band running from the pubic tubercle to the anterior superior iliac spine. Its anatomy is very important for operating on hernia patients.-Anatomy:...
and closed.
Due to the high rate of hernia recurrence, long recovery period and postoperative pain, tension repairs are less commonly used today than in previous years. However, a few tension repairs are still in use today; these include the Shouldice
Shouldice Hernia Centre
Shouldice Hernia Centre is a hospital in Thornhill, Ontario, Canada, that is known for its specialization in external abdominal hernia operations. Shouldice uses a natural tissue, tension free, technique developed during World War II by Dr. Edward Earle Shouldice. Their ten full-time surgeons...
and the Cooper's ligament
Pectineal ligament
The pectineal ligament is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone....
/McVay repair.
The Shouldice technique is a complicated four layer reconstruction; however, it has relatively low reported recurrence rates.
Group 3: open "tension-free" repair
Most inguinal herniorrhaphies today are "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a hernioplasty. The meshes used are typically made from MarlexMarlex
Marlex is a trademarked name for crystalline polypropylene and high-density polyethylene . These plastics were invented by J. Paul Hogan and Robert Banks, two research chemists at the Phillips Petroleum company....
, Gore-Tex
Gore-Tex
Gore-Tex is a waterproof/breathable fabric, and a registered trademark of W. L. Gore and Associates. It was co-invented by Wilbert L. Gore, Rowena Taylor, and Gore's son, Robert W. Gore. Robert Gore was granted on April 27, 1976, for a porous form of polytetrafluoroethylene with a...
, polypropylene
Polypropylene
Polypropylene , also known as polypropene, is a thermoplastic polymer used in a wide variety of applications including packaging, textiles , stationery, plastic parts and reusable containers of various types, laboratory equipment, loudspeakers, automotive components, and polymer banknotes...
or polyester
Polyester
Polyester is a category of polymers which contain the ester functional group in their main chain. Although there are many polyesters, the term "polyester" as a specific material most commonly refers to polyethylene terephthalate...
, although some companies market Teflon
Polytetrafluoroethylene
Polytetrafluoroethylene is a synthetic fluoropolymer of tetrafluoroethylene that finds numerous applications. PTFE is most well known by the DuPont brand name Teflon....
meshes and partially absorbable meshes. Patients typically go home within a few hours of surgery, often requiring no medication beyond aspirin
Aspirin
Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
or acetaminophen
Paracetamol
Paracetamol INN , or acetaminophen USAN , is a widely used over-the-counter analgesic and antipyretic . It is commonly used for the relief of headaches and other minor aches and pains and is a major ingredient in numerous cold and flu remedies...
. Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation. Recurrence rates are 1% or less, compared with over 10% for a tension repair. Rates of complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
are generally low but they can be quite serious, and can include chronic pain
Chronic pain
Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and...
, ischemic orchitis
Orchitis
Orchitis or orchiditis is a condition of the testes involving inflammation. It can also involve swelling and frequent infection.-Symptoms:Symptoms of orchitis are similar to those of testicular torsion...
, and testicular atrophy
Testicular atrophy
Testicular atrophy is a medical condition in which the male reproductive organs diminish in size and may be accompanied by loss of function. This does not refer to temporary changes, such as those brought on by cold.Some medications can cause testicular atrophy...
.
Group 4: laparoscopic repair
In recent years, as in other areas of surgery, laparoscopicLaparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
repair of inguinal hernia has emerged as an option. Laparoscopic repairs (sometimes referred to as minimally invasive surgery or "keyhole surgery") are also tension-free, although the mesh is placed within the pre-peritoneal space behind the defect as opposed to in or over it. Advantages of lap over the open method include a faster recovery time and a lower post-operative pain score.
Like the open method, laparoscopic surgery may involve local or general anesthesia, depending on the size and related factors of the hernia. Lap is usually more expensive as it requires more Operating Room time than open repair, but a shorter hospitalization period.
There is no definitive consensus as to the comparative risk of complications, or comparative rate of recurrence compared to the open tension-free repairs. However, most non-emergent abdominal surgeries are moving to laproscopic methodologies, as the smaller incisions used result in less bleeding, less infection, faster recovery, reduced hospitalization and reduced pain.
One specific method of laparoscopic repair is totally extraperitoneal (TEP) repair. TEp repair has been associated with fewer complications and a significantly shorter duration of post-operative analgesia than Lichtenstein repair for recurrent inguinal hernia.
Comparisons
| Advantages | Disadvantages |
|---|---|
|
|
In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. They concluded that recurrence rates are identical, but newer studies have questioned this. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that laparoscopic repair has less risk of wound infection, less bleeding, and less swelling after surgery. They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results, however, are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.
Mesh repairs have shown reduced recurrences or early recovery compared to tension repairs. Mesh repair complications include infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, mesh migration, adhesion
Adhesion (medicine)
Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connect tissues not normally connected.-Pathophysiology:...
formation, erosion into intraperitoneal
Peritoneum
The peritoneum is the serous membrane that forms the lining of the abdominal cavity or the coelom — it covers most of the intra-abdominal organs — in amniotes and some invertebrates...
organs, and chronic pain - due probably to entrapment of nerves, vessels
Blood vessel
The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and...
, or the vas deferens
Vas deferens
The vas deferens , also called ductus deferens, , is part of the male anatomy of many vertebrates; they transport sperm from the epididymis in anticipation of ejaculation....
. Such complications usually become apparent weeks to years after the initial repair, presenting as abscess
Abscess
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...
, fistula
Fistula
In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
, or bowel obstruction
Bowel obstruction
Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
. More recently, concerns have been raised about the possibility of obstruction of the vas deferens as a result of the fibroblast
Fibroblast
A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...
ic reaction to the mesh.