Inguinal (Groin) Hernia Repair

Inguinal hernias or groin hernias are the most common type of hernia in adults. Inguinal hernias are much more common in men although they can also occur in women. With an inguinal hernia, abdominal contents , most commonly the small intestine, can protrude through a weakness in the abdominal wall creating a visible bulge. The weakness in the abdominal wall is caused by a disruption in the fascia of the abdominal wall.

Fascia is a strong sheet of connective tissue that extends from the top of you abdomen (where it meets your chest) down past your groin. The fascia is your strength layer for your abdominal wall. It is responsible for keeping your abdominal contents in your abdomen. A hernia is a hole in your fascia.

Inguinal hernias can occur on one side or both sides (bilateral) of the body. Most often hernias present as a painless bulge in the groin. The bulge may become more pronounced with exercise, coughing, or standing. The bulge may disappear when lying down. A hernia may also cause pain or discomfort. More serious complications may result if the hernia becomes incarcerated or strangulated.

Groin hernias may increase in size and, thus, cause more discomfort and pain.

Hernia repair is the most frequently performed surgery by general surgeons throughout the entire world. More than 1 million hernia repairs are performed annually in the United States. Worldwide more than 20 million hernia repairs are performed each year.

Inguinal Hernia Treatment Options

Do I need to fix my hernia?

Most hernias should be repaired but some hernias do not require surgery. Many hernias are found on routine physical exams by your medical doctor. Generally, if your hernia is small and not causing any symptoms, then you may elect not to have surgery. Dr. Lublin will evaluate each patient and determine individually if you require hernia surgery.

There are few options available for a patient who has a hernia

Do nothing
Use of a truss or hernia belt is rarely prescribed as it is usually ineffective.
Surgery through an open or laparoscopic approach

Do nothing. If you hernia is small, produces no symptoms, and you do not wish to have a surgical repair, you may be able to just “live with your hernia”. If it does begin to produce symptoms, then surgery may be necessary

Truss or hernia belt. If you hernia is causing symptoms and you still wish to avoid surgery, a truss or hernia belt may be helpful. The belt is positioned in such a way as to not allow the hernia to protrude and, thus, not cause symptoms. This treatment is usually ineffective.

Surgical correction is almost always necessary to repair a hernia. Hernias do not heal on their own or “just go away” and cannot be fixed with some sort of diet or exercise. The safest, most effective way to repair a hernia is with mesh in a tension-free method. This repair can either be performed laparoscopically (through small incisions) or through an open method.

How is Hernia Surgery Performed?

An open approach to a hernia is done from the outside through a three to four inch incision in the skin in the groin or the area of the hernia. The incision will extend through the skin, and divide the subcutaneous fat and muscle in order to get to the level of the hernia or hole. The hernia contents will be reduced back through the hole and place a piece of surgical mesh is placed to repair the defect or hole. This technique is usually done with a local anesthetic and sedation but may be performed using a spinal or general anesthetic.

A laparoscopic hernia repair. In this approach, the hernia is repaired through three tiny incisions in your abdominal wall. Through one incision, a small video camera is inserted and the surgery is performed on a video screen. The surgeon operates through the other two incisions with small instruments. The hernia is repaired from behind the abdominal wall. There is no dividing or cutting of any muscle or structures. This leads to less trauma and thus a quicker and less painful recovery. A piece of surgical mesh is placed over the hernia defect and held in place with small surgical staples. This operation is usually performed with general anesthesia or occasionally using regional or spinal anesthesia.

In either method, a mesh is placed through an incision to cover the hernia. This creates a tension-free repair and leads to few recurrences. Prior to using this technique, the hernia was closed by sewing the edges of the hole (the hernia) together, This created a great deal of tension and led to many recurrences.

By using mesh to reinforce and support the surrounding tissue, the surgery can effectively repair primary and recurrent inguinal hernias as well as most other abdominal wall hernias. The mesh incorporates itself safely and easily into the abdominal wall. Extending beyond the edges of the original weakness or tear, the mesh also supports the weak, thin tissue surrounding the hernia where it is most effective and will not lift or separate later with strenuous physical activity or excessive abdominal strain. The mesh is quite thin and is unable to be felt under the incision.

Dr. Lublin performs a laparoscopic tension-free repair that bridges the hole or weakness with a piece of plastic-like mesh or screen material. The mesh is a permanent material that spans the margins of the defect and allows the body’s normal healing process to incorporate it into the local structures. This has proven to be a much more effective means of repair.

Why a Laparoscopic Hernia Repair?

A laparosopic hernia repair is a less invasive approach than conventional or open hernia repair. There is no cutting of tissue and no suturing (stitching) of tissue. It is a blunt surgery – meaning no structures are cut or divided. The mesh is not held in by stitches but is anchored by three small dissolvable tacks.

What are the advantages of Laparoscopic Hernia Repair?

Laparoscopic Hernia Repair is a technique to fix tears in the abdominal wall (muscle) using small incisions, video cameras and a patch (mesh). The recovery is faster and associated with less pain when compare to open hernia repair. Approximately 14% of patients undergoing open hernia repair can experience long term groin pain. This is almost non-existent following laparoscopic hernia repair.

Laparoscopic hernia surgery offers a quicker return to work and normal activities and decreased pain, both short and long term when compared to open or conventional hernia surgery.

All Benefits:

Less early post-operative pain
Less late post-peratiev pain
Quicker return to normal activity
Quicker return to work
Quicker return to exercise
More cosmesis
Ability to correct bilateral (hernias on both sides) through the same three small incisions

A Clinical Study comparing Laparoscopic versus Open Hernia Repair

Contemporary Surgery – Literature Review

Open Versus Laparoscopic Inguinal Hernia Repair

CHARLES H. COOK, MD, FACS

Assistant Professor of Surgery Department of Surgery The Ohio State University

The debate over the superiority of laparoscopic versus open repair of inguinal hernia continues.

A Prospective Comparison

A prospective study from Sweden suggests that laparoscopic inguinal hernia repair may result in shorter time to full recovery and earlier return to work [Johansen B, Hallerback B, Glise H, Anesten B, Smedberg S, Roman J. Laparoscopic mesh versus open preperitoneal versus conventional technique for inguinal hernia repair. Ann Surg. 1999;230:225-231].

Commentary

This randomized prospective study confirms the findings of several other studies in the literature showing a faster return to normal activity as well as faster return to work in patients undergoing laparoscopic inguinal hernia repairs.

Laparoscopic Hernia Repair Video

The above video demonstrates the technique of laparosocpic repair of an inguinal (groin) hernia. To perform the surgery, two trocars (small tubes where surgical instruments are passed through) are first inserted. These are seen being placed in the beginning of the video. Next the hernia is found and gently peeled of the spermatic cord, vessels which supply blood to the testicle. Once the hernia is reduced or fully brought out of the groin, a piece of mesh is then placed to cover the hole, where the hernia was. The mesh is held in posiiton by two metallic clips, which hold the mesh to tissue. These are seen being placed in the video. At this point, the mesh is held in position and residual gas is removed. The mesh is checked to make sure it stays in the correct position.

When can I go back to work?

Depending upon the work that you do, you may be able to return to work in as little as 2-3 days. The less strenuous your job is and less activity your job requires, the sooner you will be able to return to work.

When can I exercise?

Generally, at one week after surgery, you can resume cardiac exercise such as walking, jogging, running, biking, or stairmaster. Core exercises such as yoga, sit ups, or heavy exercise can be begun at 2 weeks. Always use your good judgement when beginning any exercise. If you experience pain, when exercising, you should stop that particular exercise.

Are you a Candidate for Laparoscopic Hernia Repair?

Most patients are eligible for a laparoscopic repair. Only after a thorough examination can it be decided whether laparoscopic hernia repair is right for you.

If you had a hernia repair via an open procedure and now you have a recurrence, you still can (and should) have a laparoscopic repair to fix the recurrence

The procedure may not be best for some patients who have had previous abdominal surgery or underlying medical conditions.

I had hernia surgery awhile ago and now my hernia has returned. Can I now have a laparoscopic repair?

Yes. In fact, a laparoscopic repair is the preferred method if the original hernia surgery was performed in the open or conventional fashion. There is less scar tissue encountered and a better chance of performing a permanent repair.

I have hernias on both sides? Can both hernias be fixed laparoscopically?

Yes, in fact both sides can be fixed at the same time laparoscopically through the same three small holes.

What Preparation is required?

Most hernia operations are performed on an outpatient basis, meaning that you go home on the same day that the operation is performed.
The surgery generally lasts approximately 1 hour.
Usually the entire process from checking in to leaving lasts approximately 4 hours

What should I expect after Surgery?

Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
Once you are awake and able to walk, you will be sent home.
With any hernia operation, you can expect some soreness mostly during the first 24 to 48 hours.
You are encouraged to be up and about the day after surgery.
With laparoscopic hernia repair, you will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.

What complications can occur?

Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.
There is a slight risk of injury to the urinary bladder or intestines.
Difficulty urinating after surgery is not unusual and may require a temporary tube inserted into the bladder which would be removed in a few days.
Any time a hernia is repaired it can come back. This is called a recurrence.

What happens if the operation cannot be performed or completed by the Laparoscopic method?

In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made either before or during the actual operation. When it is necessary to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

Who cannot have a Laparoscopic Repair?

If you have had lower abdominal surgery through a scar in the middle of your abdomen below your belly-button, a laparoscopic hernia repair may not be appropriate. If you have had surgery through a bikini or Pfannensteil incision, you generally can still have a laparoscopic repair. For patients who take blood thinners, an open surgery may be a better option.

Open tension-free Hernia Repair

Dr.Lublin does perform the open tension-free repair on some patients (SEE ABOVE).

The tension-free repair is done as follows:

An incision (cut) is made over the area of the hernia and down into the underlying layers of tissue

The normal tissue is separated from the herniated tissue, defining the margins of the hole or weakness.
The weakness is closed with a plastic-like mesh.
The overlying tissues and skin are closed with absorbable sutures.

The recovery from a traditional repair is longer than a laparoscopic repair. People, still, do quite well following this type of repair.