A hernia occurs when there is a weakening in the abdominal wall. This weakening of the natural support allows abdominal contents (bowel) to slide into the hole (referred to as the “Defect”). If part of the bowel slides through and gets caught (incarcerated), it can be painful and dangerous since the blood supply can be jeopardized. You may feel or see a pouching out (lump or swelling) of the belly or groin area, or you may feel and see nothing at all. Hernias are more noticeable when standing, coughing and straining, and may disappear when lying down. They sometimes can be pushed in with the finger, but all should be examined by a physician.
Sites of Hernia
The groin area is the most common site of a hernia (80%), hernias in this area are called inguinal hernias. But hernias can occur below the groin area (femoral), at the belly button (umbilical), in the abdominal area and at sites of prior surgery (incisional).
Causes of Hernia
Men, women, and children of any age can get hernias. They can occur because you were born with a natural weakness in the abdominal wall, or from a weakness acquired with age. Contributing factors include previous surgery in the abdominal area, excessive weight gain, pregnancy, constipation, infection, malignancy, or trauma. Strenuous physical activity including heavy lifting may also be a contributing factor.
Treatment of Hernia
Hernias don’t go away. All defects, even ones that show no symptoms (“Asymptomatic”), should be surgically corrected since the risks of surgery are much less than the risks to you of not fixing the hernia. Once you develop symptoms, surgical repair is mandatory. Small asymptomatic hernias can sometimes be pushed back into place by your doctor, but surgery is the only way to really fix a hernia.
Surgical Repair
There are two main ways to surgically fix a hernia: open repair and minimally invasive laparoscopic repair.
Open Surgical Repair of Hernia
This type of repair involves making a cut (incision) over the hernia, carefully dissecting through the body tissues and closing the area of weakness. Usually a mesh (composed of gortex, teflon or other material) is sewn into place over or under the weakened area to make it stronger and to prevent recurrence. After the repair, the incision is closed and covered with bandages and tape.
Local anesthesia (lidocaine, mepivacaine) is commonly used to prevent you from feeling pain during the procedure. In addition, the anesthesiologist gives a mixture of short–acting sedating medications to provide comfort. Occasionally spinal or general anesthesia may be required for larger hernias or more complicated cases. Postoperative pain may be managed with a combination of intravenous, intramuscular and oral painkillers. You may have some trouble urinating for the first 12–24 hours following the procedure.
The main disadvantage of the open technique is that it can cause considerable pain. You may not be able to return to work for a week or longer and full activity may not be possible for up to six weeks. Swelling and black and blue discoloration of the wound site is common. Repairs of repeat inguinal hernias, and two sided repairs, are much more painful and have a much longer recovery period.
Laparoscopic Hernia Repair
A small incision at the area of the belly button (umbilicus) is made through which a telescopic device called the Laparoscope, is inserted. Your surgeon looks through the laparoscope and at a magnified image projected onto a video monitor. A balloon device is used to carefully open up the area to be repaired, and the area is inflated with carbon dioxide so that the surgery can be safely performed. Your surgeon passes instruments through small incisions (one–fourth to one–half inch) to dissect body tissues and to repair the hernia. A mesh to strengthen the weakness is fixed into place with titanium staples to strengthen the area and prevent recurrence of the hernia. After the repair, local anesthesia is given at the incision sites to minimize pain and all of the small incisions are closed and covered with steri–strips or Band–Aids.
There are 2 choices today for the repair of an inguinal hernia. Namely Laparoscopic or Open Laparoscopic Repair.
With the minimally invasive approach the surgery is performed through 3 small incisions. A balloon is placed beneath the abdominal muscles and the hernia is reduced into the space created. A mesh patch is then placed over the defect and tacked to the surrounding ligaments and muscles with titanium tacks. Pro’s include limited postoperative pain and early return to work in as few as 3–4 days. Early return to full activities by 2 weeks. 5 year results reveal recurrence rate around 2% must be performed using a general anesthetic.
Laparoscopic Hernia Repair
Hernia repair can now be performed with the aid of a small camera called a Laparoscope. This allows the surgeon to use small incisions to place the instruments and mesh needed to repair a hernia. The first incision is made below the belly button.
A balloon is then placed beneath he abdominal muscles and inflated to create a working space. Two additional 1/2 inch incisions are made below the belly button. After the hernia sac is returned below the muscles a mesh patch is placed over the hernia defect and tacked to the surrounding ligaments and muscle with titanium tacks. The incisions are then closed with a single dissolvable suture.
Post Surgery Care
The advantage of laparoscopic repair is the quicker recovery. Most patients return to work between 1–2 weeks depending on the amount of lifting required. No heavy lifting greater than 20 pounds is advised for the first 2 weeks. You may resume normal activities the same day, including walking up stairs, and may shower the following day. Driving should wait until there is minimal discomfort, usually 4–5 days.
Indication of Laparoscopic Surgery
Anyone with an inguinal or groin type hernia can be repaired with the laparoscopic technique unless there has been previous surgery in the middle of the lower abdomen, the patient is unable to tolerate a general anesthetic due to medical illness, or the hernia is too large (such as those that remain in the scrotum). A patient with a previous hernia repair, or a hernia on both sides is an excellent candidates for this procedure.
Anesthetia
A general anesthetic is used to allow complete relaxation of the abdominal muscles. This results in nausea for some patients as the main side effect. The anesthesiologist will discuss other risks with you at the time of the procedure.
Potential Complications
As with any surgery we always worry about the risk of bleeding or infection where the surgery was performed (less than 1%). Additionally, with hernia surgery there is a risk of injury to the spermatic cord which carries the blood supply and sperm tube, which could result in sterility if injured on both sides or can cause changes in the testicles such as pain, swelling or shrinkage (less than 1%). The patch which is placed is artificial and can become infected requiring treatment with antibiotics or even removal. There is an approximately 1% recurrence rate in the immediate postoperative period with the 5 year results about 2%.
Open Repair
With the open or traditional approach an incision is made in the groin over the site of the bulge. The muscle layers are divided to reach the neck of the hernia which is then reduced into the abdomen. The muscle layers are then reap–proximated and a patch material is placed over the repair to help prevent a recurrence.
Pro’s include known long term results with a recurrence rate approximately 2–5% may be performed with a local, spinal or general anesthetic. Con’s include increased discomfort in immediate postoperative period. Time–off of work approximately 2–4 weeks.
