Inguinal hernia surgery is an operation to correct a weakness in the abdominal wall that abnormally allows the intestines to enter into a narrow tube called the inguinal canal in the groin area.
Surgery remains the primary treatment for any type of hernia because they will not heal by themselves, but not all require immediate repair. Elective surgery is offered to most patients by considering the level of pain, discomfort, level of disturbance in normal activity, as well as their overall health level. Emergency surgery is usually reserved for patients with life-threatening complications of inguinal hernias such as arrest and strangulation. Detention occurs when the intra-abdominal fat or small intestine is caught in the duct and can not be shifted back into the abdominal cavity either by itself or by manual maneuvers. If left untreated, detention may develop into intestinal strangulation as a result of limited blood supply to the trapped gut segment causing the passage to die. Successful improvement results are usually measured through recurrence rates of hernia, pain and subsequent quality of life.
Surgical repair of inguinal hernia is one of the most frequently performed surgeries worldwide and the most frequently performed surgery in the United States. The combined 20 million cases of inguinal and femoral hernia repairs are conducted annually worldwide with 800,000 cases in the US in 2003. The UK reports about 70,000 cases done annually. The basal hernia account of nearly 75% of all abdominal wall hernias with lifetime risk of inguinal hernia in men and women is 27% and 3% respectively. Men account for almost 90% of all improvements made and have a bimodal incidence of inguinal hernia that peaks at the age of 1 year and again in those over 40 years of age. Although women are responsible for about 70% of femoral hernia repairs, indirect inguinal hernia is still the most common subtype of the groin hernia in males and females.
Video Inguinal hernia surgery
Indications for operations
Community guidelines recommend that indications for surgery take into account the severity of the symptoms, the type of hernia, previous surgery, the size of the hernia, bowel detention (intestinal can no longer return to the stomach) and overall general health of the person.
Non-urgent fixes
Elective surgery is planned to help relieve symptoms, respect people's preferences, and prevent future complications that may require emergency surgery.
Surgery is offered to the majority of people who:
- have symptoms that interfere with their normal level of activity.
- has a hernia that is becoming increasingly difficult to reduce.
- are women because it is often difficult to classify hernia subtypes based on the exam alone.
Symptomatic hernias tend to cause pain or discomfort in the groin area which can increase with exertion and improve with rest. A swollen scrotum in males may coincide with persistent heavy feelings or general underlying abdominal discomfort. Thigh pressure sensation tends to be most prominent at the end of the day as well as after strenuous activity. Changes in sensation can be experienced along the scrotum and inner thighs.
Urgent repairs
A hernia where the small intestine has become incarcerated or strangulated is a surgical emergency. Symptoms include: 1 fever 2 nausea and vomiting 3 extreme pain in the hernia 4 hot hernia bulge with redness surrounding skin 5 can no longer remove gas or stool Surgical repair within 6 hours of the above symptoms may be able to salvage intestinal strangulata portion.
Maps Inguinal hernia surgery
Contraindication operations
People with a hernia should be given the opportunity to participate in decision-making with their physician because almost all procedures carry significant risks. The benefits of inguinal hernia repair can become overshadowed by risks such as elective repair is no longer in the best interest of a person. These cases include:
- Persons with unstable medical conditions
- Repairs using mesh are retained if someone has an active infection in the groin or in the bloodstream
- Elective repair is delayed in pregnant women up to 4 weeks after delivery
In addition, certain medical conditions may prevent people from candidates for a laparoscopic approach to repair. Examples include:
- Persons who can not undergo general anesthesia
- Previous big abdominal surgery
- People who have ascites
- Previous radiation therapy to the pelvis
- A complicated hernia
Operating approach
Techniques to improve the inguinal hernia are divided into two broad categories called "open" and "laparoscopic". Surgeons adjust their approach by considering factors such as their own experiences with techniques, features of the hernia itself, and the needs of anesthesia.
The costs associated with one approach vary in different regions. For example, the British NHS spent Ã, Â £ 56 million per year to repair 96% improved inguinal hernia through the open mesh approach while only 4% were done laparoscopically. The latest guidelines published by the International Endo- ria Society doubt the feasibility of cost comparison studies because of the complexity inherent in inter-institutional cost calculations. The IES emphasizes that hospital and social costs are in fact lower for laparoscopic repair than open approaches. They recommend routine use of reusable instruments as well as improving the ability of surgeons to help reduce further costs and time spent in OR.
Open hernia repair
All techniques involve a 10 cm incision in the groin. Once exposed, the hernia sacs are returned to the abdominal cavity or cut and the abdominal wall is very often reinforced with mesh. There are many techniques that do not utilize mesh and have their own situation where they are better.
Open repair is classified by whether the prosthetic mesh is used or whether the patient's own tissue is used to correct weaknesses. Prosthetic repair allows the surgeon to repair a hernia without causing undue tension in the surrounding tissue while strengthening the abdominal wall. Improvements with undue tension have been shown to increase the likelihood that the hernia will recur. Improvements not using prosthetic mesh are a better option in patients with an above-average infection risk such as cases where the bowel has become choked (blood supply is lost due to constriction).
One of the great benefits of this approach lies in its ability to adapt anesthesia to the needs of a person. People can be given local anesthesia, spinal block, and general anesthesia. Local anesthesia has been shown to cause less pain after surgery, shorten surgery time, shorten recovery time and reduce the need to return to the hospital. However, people undergoing general anesthesia tend to go home faster and experience fewer complications. The European Hernia Society recommends the use of local anesthesia especially for people with ongoing medical conditions.
Open mesh repair
Mesh improvement is usually the first recommendation for most patients including those undergoing laparoscopic repair. Procedures that use mesh are most commonly performed because they have been able to show greater results compared to non-mesh improvements. The mesh-utilizing approach has been able to show faster return to regular activity, lower persistent pain levels, shorter hospital stay, and lower likelihood that the hernia will recur.
Options for mesh include synthetic or biological. Synthetic nets provide an option to use "heavy" and "light" variations according to the diameter and number of mesh fibers. The mild mesh has been shown to have fewer complications associated with the mesh itself than its weight class counterpart. It also correlates with a lower rate of chronic pain while sharing the same recurrence rate of the hernia compared to the heavyweight option. This has led to mild mesh adoption to minimize the possibility of chronic pain after surgery. Biological nets are indicated in cases where the risk of infection is of primary concern such as cases where the intestines become choked. They tend to have lower tensile strength than their synthetic counterparts lend them to a higher level of broken net.
Biomesh is growing in popularity since it was first used in 1999 and the next introduction on the market in 2003. Some mesh have prices that are comparable to high end synthetic mesh, the cheapest ($ 500) is Surgisis-Biodesign, produced by Cook Group, made from a matrix extra cellular pig submucosa small intestine. Currently, there is a fully absorbable synthetic mesh, Tigr Matrix, produced by Novus Scientific, in the US market (510 (k) of the Food and Drug Administration license) since 2010 and in the EU market since 2011. It has only one year 3 years of pre-clinical evidence of sheep.
Nets made of cloth netting, in polyethylene and polypropylene copolymers have been used for low-income patients in rural India and Ghana. Each deduction costs $ 0.01, 3700 times cheaper than equivalent commercial net. They provide identical results with commercial traps in terms of infection and recurrence rates at 5 years.
Lichtenstein Technique
The Lichtenstein free-voltage repair has survived 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 is used as the preferred method. Recent studies have shown that netting attachment with the use of adhesive glue is faster and less likely to cause postoperative pain compared with attachment through stitching materials.
Plug and patch techniques
Tension-free plug and patch techniques have failed due to higher mesh shift rates along with their tendency to irritate surrounding tissue. This has led the European Hernia Society to recommend that this technique is not used in many cases.
Other open mesh repair techniques
Various other free tension techniques have been developed and include:
- Prolene mesh system (PHS)
- Kugel (preperitoneal repair)
- Stoppa
- Trabucco (Hertra mesh)
- Wantz
- Rutkow/Robbins
Go to non-mesh fixes
Techniques in which mesh is not used are called tissue repair techniques, stitching techniques, and voltage techniques. All involve putting together the network with stitches and is a viable alternative when mesh placement is contraindicated. Such situations are most often due to contamination concerns in cases where there is infection in the groin, bowel strangulation or perforation.
Shouldice Technique
Shouldice technique is the most effective non-mesh repair making it one of the most commonly used methods. A number of studies have been able to validate the conclusion that patients have lower recurrence rates of hernias with Shouldice techniques compared to other non-mesh repair techniques. However, this method often has longer time and longer hospitalization. Despite superior non-mesh techniques, the Shouldice method results in a higher rate of hernia recurrence in patients when compared with mesh improvement.
Bassini Technique
The first efficient improvement of inguinal hernia was explained by Edoardo Bassini in the 1880s. In the Bassini technique, the conjoin tendon (formed by the distal end of the transversus abdominis and the internal oblique muscle) is estimated to be inguinal and closed ligament.
Other non-mesh open techniques
Shouldice technique itself is an evolution of previous techniques that have been very advanced in the field of operating inguinal hernia. Classic open non-mesh improvements include:
- McVay Technique
- Halsted
- Maloney whispers
- Whitelisting
- Desarda Technique A 1-2 cm piece of external oblique aponeurosis is sewn below to the inguinal ligament and above to the muscle arch without disturbing its continuity at both ends. [2] It provides immediate protection so that no activity restrictions are required. It is a very simple stress-free and tension-free repair based on physiological principles with very low recurrences and complications.
Laparoscopic repair
There are two main methods of laparoscopic repair: transabdominal preperitoneal and are really extra-peritoneal repair. When performed by an experienced surgeon in hernia repair, laparoscopic repair leads to fewer complications than Lichtenstein, especially chronic less pain. However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not recommended as it causes more risk of recurrence than Lichtenstein while also posing a risk of serious complications, as an organ injury. Indeed, the TAPP approach must go through the stomach. All that was said, many surgeons moved into the laparoscopic methodology because they caused smaller incisions, resulting in less bleeding, less infections, faster recovery, reduced hospitalization, and reduced chronic pain.
The rate of recurrence is identical when laparoscopy is performed by an experienced surgeon. When performed by an inexperienced surgeon in inguinal hernia lap repair, the recurrence is greater than after Lichtenstein.
Non-surgical management
Studies have shown that men whose hernias cause little or no symptoms can safely continue to delay surgery until the most convenient time for patients and their health teams. Research shows that the risk of complications of inguinal hernia remains below 1% in the population. Vigilant waiting requires the patient to maintain a strict follow-up schedule with the provider to monitor the course of their hernia for any symptoms change and can be safely offered for up to 2 years.
Patients who choose to wait with vigilance end up experiencing improvements in five years because 25% will develop symptoms such as worsening of pain. Discussion of elective improvement should be reviewed if patients begin to avoid aspects of their normal routine because of their hernia. After 1 year it is estimated that 16% of patients who initially chose to wait with alert will eventually undergo surgery. Furthermore, 54% and 72% will undergo improvements on the 5 year and 7.5 year marks respectively.
Use of truss is an additional non-surgical option for men. It resembles an athlete rope that utilizes a pad to put pressure on the hernia site to prevent a hernia sack trip. It has little evidence to support routine and unproven use to prevent complications such as arrest (bowel can no longer slide back to the stomach) or intestinal strangulation (narrowing causes loss of blood supply). However some patients report symptoms that are soothing during use.
Complications and prognosis
Complications of inguinal hernia repair are unusual, and the overall procedure proves to be relatively safe for the majority of patients. The risks inherent in almost all surgical procedures include:
- bleeding
- infection
- liquids collection
- damage to surrounding structures such as blood vessels, nerves, or bladders
- Urine retention requires a catheter
Specific risks for the improvement of the inguinal hernia include such things as:
- hernia recurrence
- sexual activity disorders, such as genital pain or ejaculation
- in males, injury to tubes that carry sperm from the testes to the penis
- in men, bruises and swelling of the scrotum
- chronic regional pain (also known as post-herniorrhaphy inguinodynia, or chronic post-surgical inguinal pain)
Post-herniorraphy pain syndrome
Inguinodynia post-herniorrhaphy is a condition in which 10-12% of patients experience severe pain after inguinal hernia repair, due to the complex combination of various forms of pain signals. This may occur with inguinal hernia repair techniques, and if not responsive to pain medication, further surgical intervention is often necessary. Removal of embedded mesh, in combination with regional nerve divisions, is usually done to treat such cases. There is still ongoing discussion among surgeons regarding the usefulness of the regional neural resection plans in an effort to prevent the occurrence.
Mortality rate
The mortality rate for non-urgent elective procedures is shown as 0.1%, and about 3% for the procedure performed immediately. In addition to urgent improvements, risk factors also associated with increased mortality include women, requiring improvement in femoral hernia, and older age.
Followup
Upon waking of anesthesia, patients are monitored for their ability to drink fluids, produce urine, and their ability to walk after surgery. Most patients can then return home after the condition is met. Not infrequently patients experience residual pain for several days after surgery. Patients are encouraged to make a strong effort to get up and running around the day after surgery. Most patients can continue their daily daily routine of the week such as driving, bathing, light lifting, and sexual activity. The long absence of work is rarely needed and the length of the sick day is likely to be determined by the respective employment policy.
In general, it is not advisable to administer antibiotics as prophylaxis after improvement of elective inguinal hernias. However, the rate of wound infection determines the proper use of antibiotics.
Post-op development of the following should ensure timely reporting by phone:
- fever greater than 39C/101F
- the progressive swelling of the surgical site
- severe pain
- repeated nausea or vomiting
- worsening of redness around the incision
- drainage of pus from an incision
- difficulty or lack of producing urine
- new onset breath
Prevention and filtering
Most indirect inguinal hernia in the abdominal wall can not be prevented. A direct inguinal hernia may be prevented by maintaining a healthy body weight, avoiding smoking, preventing strain during bowel movements, and maintaining proper lifting techniques when lifting weights. There is no evidence to suggest that physicians should routinely screen for asymptomatic inguinal hernia during patient visits.
References
Source of the article : Wikipedia
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