What is a hernia?
A hernia is a weakness or hole in the abdominal muscle wall through which abdominal contents protrude causing a bulge. The protruding contents push out a pouch of the abdominal lining or peritoneum through the weakness forming the “sac of the hernia”.
Why do they occur?
There are sites of potential weakness in the abdominal wall. The areas in which hernias most commonly develop are the umbilicus, the groin and where there has been an abdominal incision.
There is frequently an opening in the muscle layer at the umbilicus that may have been present since birth. It may enlarge due to anything that causes raised abdominal pressure, such as muscular strain or pregnancy. A hernia may then appear.
In male patients, blood vessels running through the groin muscles to the testicle create a weak area where an indirect inguinal hernia may develop. Strain or muscle deterioration can enlarge this weak spot and force through it, abdominal contents resulting in the development of a hernia. Inguinal hernias may occur in women, although less commonly, and follow the round ligament of the uterus.
Other causes include incisions from old operations which may weaken the abdominal wall, if they do not heal properly after surgery or are weakened by infection. Muscle wall deterioration with age, inactivity or strain which may allow the muscle wall to tear or bulge, resulting in the development of various forms of hernias.
Why should it be repaired?
There are a number of reasons for advising repair.
In decreasing order of importance they are:
- The possibility of intestines being caught in the hernial sac causing bowel obstruction. Without urgent surgical intervention this may lead onto strangulation, cutting off the blood supply to the bowel, with resultant death of the loop of bowel. This in turn causes peritonitis. This is a life threatening situation.
- Pain or discomfort in the hernia especially on standing for long periods or walking long distances. The discomfort, in the case of inguinal hernias in male patients, may radiate to the testicle.
- Difficulty lifting as strain forces abdominal contents into the hernia causing discomfort and a feeling of weakness.
- Progressive enlargement of the size of the hernia with increasing likelihood of the above complications and increasing difficulty with repair.
- The presence of a bulge of which the patient is aware and which may be visible causing embarrassment.
What types of hernia are there?
The most common type is the groin or inguinal hernia. Herniae may also occur through the umbilicus (umbilical hernia), through old abdominal scars (incisional hernia), through the muscles in the upper abdomen (ventral hernia) or alongside blood vessels running into the thigh (femoral hernia). Laparoscopic repair is mainly used for inguinal or femoral hernia repairs, although increasingly ventral hernias are being repaired by laparoscopic techniques.
How are hernias repaired?
Various forms of repairs have been utilised over the years. The defect or hole in the muscle layer may be repaired by stitching the muscles on each side of the defect together and allowing them to heal together, thus closing the opening. This is the traditional method of repair. Hernias may also be repaired by placing a synthetic mesh to cover the opening in the muscle layer. The body’s tissue will then grow through the mesh creating a strong new layer, thus repairing the hernia. Laparoscopic repair employs a mesh to repair the defect.
Why choose laparoscopic repair?
I believe that laparoscopic repair is less painful than conventional repair, both in the short and long term. It allows for shorter hospitalisation and the patients are able to resume normal activities at an earlier stage, than with traditional repairs. Dr Ritchie has only seen one recurrence in an inguinal laparoscopic repair in over 3500 cases, whereas traditional methods carry a 5% recurrence rate. The only disadvantages are that the procedure requires a general anaesthetic and that there are more equipment expenses namely; the laparoscopic ports, the mesh and the hernia tacker, that is used to fix the mesh in place. As mentioned however, hospital stays and convalescent times tend to be shorter than with open repairs.
How is it performed?
This description refers to extra-peritoneal laparoscopic repair for an inguinal or femoral hernia. Under a general anaesthetic, three small incisions are made in the abdominal wall. The largest of these is a vertical incision about 2cm just below the umbilicus. A small transverse incision in the superficial sheath of the rectus abdominis muscle, the only cutting of muscle in this procedure, is made and a balloon dilating device is passed downwards to the pubic bone between the abdominal muscles and the lining of the abdomen, the peritoneum. The balloon is blown up separating the peritoneum from the muscle layer. This separates easily with little bleeding. The balloon is withdrawn after deflation and replaced by a tube-like structure called a laparoscopic port. The space is inflated with CO2 and a telescope inserted into the space. The abdominal cavity is not entered during this procedure, therefore greatly reducing the likelihood of damage to the abdominal organs or production of adhesions. Two further 0.5 cm incisions are made between umbilicus and pubic bone on the opposite side of the abdominal wall to the hernia to puncture into the space two fine 0.5 cm diameter ports to accommodate operating instruments. The peritoneum is then gently pushed away from the muscle layer until a sizeable space is created and the muscle defect is revealed. The sac of the hernia is pulled back into this space. Other structures that are revealed include the back of the pubic bone and the blood vessels running to the leg and, in a male patient, those running to the testicle and the abdominal wall. Once the muscle layer is cleared a piece of flexible polypropylene mesh measuring 12 X 15cm approximately, is then slid down the large port and manoeuvred so as to cover the hole in the muscle and also all other potential areas where hernias can occur in this area. The mesh is held in place with approximately 8-10 tiny absorbable tacking devices. The space is filled with local anaesthetic and the ports withdrawn.
The positive pressure in the abdominal cavity pushes the peritoneum onto the mesh trapping it like the meat in a sandwich. Any increase in the abdominal pressure, as in straining, simply pushes the mesh firmly against the abdominal wall. Straining therefore, does not have the effect of pulling apart the repair as it does in sutured repairs. This contributes enormously to the strength and durability of the repair. As the repair is tension free, it is less painful than sutured techniques. Skin wounds are closed with dissolving sutures.
What are the complications?
In my experience of over 3500 extra-peritoneal laparoscopic repairs, over a 9 year period, there have been no serious complications.
Potential complications include:-
- Anaesthetic problems such as anaphylactic shock, cardiac irregularities or cardiac arrest, causing death. Incidence in my experience is 0%.
- Damage to blood vessels . Incidence of two cases which had to be converted to an open procedure to control bleeding. The patients made an uneventful recovery.
- Recurrence of the hernia. Only 2 recurrences that I know of. It is believed that if the repair is going to fail, it would do so in the first few months before the mesh is fixed in place by fibrous tissue. With most conventional repairs, up to 5% recurrence is expected.
- Infection of the mesh. This could require removal of the mesh and is the reason antibiotics are given at the time of surgery. Incidence 2 cases.
- Nerve injury. Some of the nerves supplying the skin of the upper thigh lie near the site of the repair. 10 patients have experienced temporary pain radiating down the outer part of the thigh. I believe the incidence of numbness and pain in the groin is far higher with conventional repair.
- Pain in the repair. All types of hernia repair have an incidence of long term discomfort such as sharp twinges or minor burning pain. The incidence of pain long term in my series is low, approx 3%. Testicular pain can also be experienced in 7%. This usually resolves over 12 months. It is due to bruising of the testicular cord when the hernial sac is stripped away from cord structures.
- Two patients have developed haematomas in the pelvis that have been large enough to require laparoscopic drainage. Scrotal haematomas can occur with very large hernias extending into the scrotum especially when these are long standing. These can require drainage.
- Bowel obstruction. I have had 2 cases where the small bowel became trapped in an accidental tear in the deep muscle under the uppermost incision or in a peritoneal tear These were readily rectified.
- Pneumonia and other lung complications. No serious complications of this type to date partly due to fact that patients are able to walk and mobilise on the day of surgery.
- Thrombosis and lung embolism. Three patients have developed small pulmonary emboli and we now administer anticoagulant injections and use calf compressors during surgery.
- Bowel Trauma- one case in which the bowel was trapped in the sac of a hernia that was previously repaired 3 times by open surgery. This required an open abdominal procedure with resection of damaged bowel.
This is by no means a complete list all of the complications that can occur in this, and indeed in any other operation. It is merely an attempt to cover the most serious, specific complications that could potentially occur in this procedure. Again I would like to emphasise that the incidence of complications to date, is very low and I have no hesitation in recommending this type of repair in appropriate cases.
Laparoscopic Repair Of Incisional Hernias
This is a newer technique and has become available largely because of special meshes that have been developed. These have two sides, one that adheres to the muscle layer and the other that is exposed to the intestines is smooth and non-adhesive so that the bowel will not stick to it. I am not enthusiastic about this type of repair as I feel it is inherently weak as there is still a muscular opening which is not repaired and the mesh can bulge through it.
Briefly, the procedure is performed by inflating the abdomen with CO2 gas and placing 3-4 laparoscopic ports out to one side of the abdominal wall. The hernia contents then have to be reduced back into the abdominal cavity. They are often stuck and have to be dissected away from the sac of the hernia. This step does carry a risk of perforating the bowel. If this can be safely achieved, then the defect or hole in the abdominal wall can be exposed. If not, then the procedure may have to be converted to an open conventional repair. Once the defect is fully exposed, a piece of mesh, such as Gortex Dual Mesh, is placed in the abdomen. This is rolled up initially and has a number of pre-tied sutures placed around its edges. It is unrolled in the abdomen and the pre-tied sutures picked up one-by-one through small incisions and the mesh tied up to the abdominal wall. This fixes the mesh up against the abdominal wall and covers the hernial defect. The mesh is then further fixed around its edges with hernia tacks to hold it firmly in place. The laparoscopic ports are withdrawn and the wounds closed with dissolving sutures. The mesh should then heal into place over the next six weeks, thus repairing the hernia.
This technique is still relatively new and long term results are not yet available. At present I do not repair incisional hernia laparoscopic ally as I do not believe is not a strong durable repair. I prefer to open the scar, return the bowel to the abdominal cavity, place a mesh beneath the muscle layer and close the muscles together over the mesh. The hole in the muscle layer is then repaired and this gives strength to the repair and prevents bulging.
How long am I in hospital?
Day surgery is possible although I usually advise an overnight stay.
How long is the convalescence?
Sedentary workers may resume duties in a few days. Manual labourers can resume duties in 3-4 weeks. I advise no strenuous exercise such as tennis or golf for 4 weeks.
What are the side effects?
Local discomfort and stiffness diminishes over 2-3 weeks. Twinges of pain can occur on exertion for up to six months after the procedure. These are usually not severe and diminish steadily. In 2-3% persistent discomfort can be a problem. This can be a problem in manual workers. All varieties of hernia repairs have an incidence of ongoing discomfort and pain. The incidence in laparoscopic repair is low compared to other techniques. Bruising usually appears in the genital area. This is not painful and disappears over 1-2 weeks.
Swelling in the groin, at the site of the hernia, may occur due to serum collecting in the cavity left by reducing the hernial sac. This can alarm patients who think that the hernia is still present but it rapidly absorbs or may be aspirated if it is large. In men, there can be some swelling and tenderness in the scrotum and involving the testes. This also resolves over a few weeks.
Are all inguinal herniae suitable for laparoscopic repairs?
The vast majority of inguinal herniae, including recurrent herniae, are suitable for this procedure. Pelvic or lower abdominal surgery, such as radical prostatectomy or aorto-femoral grafts, would prevent the peritoneum separating from the muscle and are therefore unsuitable for this technique. We prefer to repair these herniae with an open mesh repair.