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about Hernias

Proudly Serving Clients throughout Oxford, Banbury, Oxfordshire

Advances in Hernia Repair Technique

From primary autogenous tissue repair to tension-free (mesh) repair. New meshes include composite, prolene, and biological.

Identifying Patients Who Will benefit from Hernia Surgery

A Lavender statement regarding inguinal hernia surgery in 2006 stated: “The elective treatment of asymptomatic or mildly symptomatic inguinal hernias in adults is a low priority treatment and patients will not be normally be offered surgery”.

Exceptions

  • History of Incarceration of, or Real Difficultly in, Reducing the Hernia
  • An Inguino-Scrotal Hernia 
  • Increase in Size Month-to-Month
  • Pain or Discomfort Significantly Interfering with Activities of Daily Living
  • Work-Related Issues: Light Duties, Off Work, Missed Work, Unable to Work

Watchful Wait Vs Surgical Repair

Studies suggest watchful wait is as safe and effective as surgical repair in terms of groin pain and complications. The risk of strangulation remains low and a third of the total number on watchful wait came to surgery after a follow-up of 5 years. It is difficult to identify the group at higher risk of complications and strangulation.

Which Hernias to Refer

  • All Patients with a Diagnosed Hernia Should Be Referred for Surgical Evaluation
  • Patients with Simple Asymptomatic Hernias May only Require Monitoring
  • Surgery is Usually Indicated if the Hernia Causes Pain or Is at Risk of Strangulation
  • All Ventral and Incisional Hernias Should Be Referred
  • Femoral Hernias

Presentation

  • Asymptomatic and Present as a Painless Bulge
  • Minor Pain or Discomfort 
  • Symptoms of Bowel Obstruction, Pain Distension, and Vomiting 
  • Skin Changes, Such as Erythema 
  • Strangulated Hernias are a Surgical Emergency and Require Immediate Intervention; Timely Diagnosis is Important

Patients with Groin Pain

  • Groin Pain without Obvious Bulge or Cough Impulse are a Difficult Group
  • Hernia is Still Possible 
  • Difficult Examination in Obese
  • Gilmour’s Groin and Sportsman’s Groin
  • Imaging is Useful in Diagnosing a Hernia in This Group

Warning Signs: Immediate Referral Required

  • Irreducible Painful Hernias
  • Tenderness in an Incarcerated Hernia
  • Abdominal Pain, Nausea, Vomiting, or Underlying Skin Changes
  • Sudden Onset of Symptoms and Pain: Impending Strangulation
  • Strangulated Hernias Still Cause the Death of More Than 200 Patients in North America

Goals of Hernia Repair

  • Optimum Repair
  • Minimise Postoperative Pain and Discomfort
  • Excellent Cosmetic Result
  • Increased Mobility
  • Quick Recovery and Early Return to Work
  • Low Recurrence Rates
  • Day Case Surgery

Inguinal Hernias

Open methods of repair, currently in use:

  • Lichtenstein Method
  • Plug and Patch Repair
  • Gilbert (1998) – Bilayer Polypropylene Patch with an Overlay and a Sublay Piece Connected by a Cylinder of Mesh

Lichenstein Method

This technique has been modified several times since it was first used. Recommended: 3-4 continuous passes along the inguinal ligament (a. Amid PK. Videosurgery and Other Miniinvasive Techniques 2009-4 25-31).

Laparoscopic Repair

  • Same Recurrence in Expert Hands
  • Less Chronic Pain Than Open Repair in Expert Hands

Advantages

  • With High-Intensity Light Source and Magnification, all of the Hernia Spaces of the Myopectineal Orifice Can Be Covered
  • Less Cutting
  • Less Pain
  • Earlier Return to Work and General Activity
  • Less Stay in the Hospital
  • Better Cosmetic Result
  • Bilateral Hernias Can Be Repaired with the Same 3 Ports

Types of Laparoscopic Repairs

  • IPOM (Intraperitoneal Onlay Mesh)
  • TAPP (Transabdominal Pre-Peritoneal) 
  • TEP (Totally Extraperitoneal) 
  • Intraperitoneal Onlay Mesh
  • Transabdominal Pre-Peritoneal
  • Totally Extraperitoneal

Advantages of TEP Over TAPP

  • Keeps it Extraperitoneal 
  • No Risk of Bowl or Intra-Abdominal Viscus Injury
  • Low Risk of Peritoneal Adhesions 
  • No Need to Close the Peritoneal Leaf

Open Vs Laparoscopic Repairs

Lap Vs Open: Meta-Analysis Conclusion

  • Laparoscopic Repair:
    - Similar Recurrence Rates as Open
    - Less Post-Operative Pain
    - Faster Return to Work
    - Longer Operating Time

Lap V Open: RTC

  • Diversity of Results in Different Studies 
  • Recurrence Rates
  • Postoperative Pain
  • Return to Work
  • Complications

NICE Guidelines

First time primary hernias should be repaired using the open approach. Laparoscopic repair of groin hernias should be offered to patients with bilateral hernias and recurrent hernias, and should be performed in specialist units.

Current Position

Laparoscopic repair of inguinal hernias is currently restricted to:

  • Bilateral Hernias
  • Recurrent Hernias after Open Surgery

Inguinal Recurrence

  • Long-Term Follow up is Needed 
  • Most Studies with Lightweight and Heavyweight Mesh Are Equal
  • Repair Laparoscopic Recurrence with an Open Approach
  • Studies Show the Laparoscopic Method is the Best Repair for Open Recurrence

Chronic Pain

  • Correlates with Mesh Use
  • Inguinal Region is at High Risk
  • Only 30% of Patients Have ‘Typical Nerve Anatomy’ 
  • Symmetric in Only 40% of Patients

Incisional Hernias

  • Develop in 4-11% of Patients after Abdominal Surgery
  • Recurrence Rates of up to 33% after First Repair, and 44% After Second Repair

Contributing Factors

  • Old Age
  • Suture Type and Technique
  • Male Sex
  • Chest Infection
  • Obesity
  • Abdominal Distension
  • Bowel Surgery
  • Wound Infection

Open Rives-Stoppa Mesh Repair

  • Recurrence Rates of 0-8% 
  • Technically Difficult and Not for Everyone
  • Takes a Long Time (between 3-4 Hours)
  • Involves Retro-Muscular Placement of Mesh in Front of Posterior Sheath and Primary Closure of Anterior Fascia and Muscles
  • Average LOS 5-7 Days

Components Separation

  • For Large Midline Ventral Hernias with Big Defects 
  • Involves Separation of External and Internal Oblique Muscles Lateral to the Rectus Muscles on Both Sides
  • Provides Extra 8-10cms to Close the Rectus Sheath over the Mesh without Undue Tension
  • Originally Described by Ramirez 1990