Inguinal Hernia Surgery
What is an inguinal hernia?
An inguinal hernia is protrusion of an organ or a tissue through a weak spot in a muscle in the groin region. As the inguinal hernia enlarges, it forms a sac and internal organs such as the intestines can fall into this sac creating a bulge. The bulge is most often visible when a person is standing and may temporarily disappear in lying down position.A hernia occurs when a section of intestine protrudes through a weakness in the abdominal muscles. A soft bulge is seen underneath the skin where the hernia has occurred. A hernia that occurs in the groin area is called an inguinal hernia.A hernia is a condition in which part of the intestine bulges through a weak area in muscles in the abdomen.
Inguinal hernia: Protrusion of the intestines out of the groin area.s
Symptoms of Inguinal hernia
Inguinal hernia includes the 3 symptoms listed below:
a full, round abdomen
pain or fussiness
redness or discoloration
What causes an inguinal hernia?
A hernia can develop in the first few months after the baby is born because of a weakness in the muscles of the abdomen.
As a male fetus grows and matures during pregnancy, the testicles develop in the abdomen and then move down into the scrotum through an area called the inguinal canal. Shortly after the baby is born, the inguinal canal closes, preventing the testicles from moving back into the abdomen. If this area does not close off completely, a loop of intestine can move into the inguinal canal through the weakened area of the lower abdominal wall and cause a hernia.
Although girls do not have testicles, they do have an inguinal canal, so they can develop hernias in this area as well.
Who is at risk for developing a hernia?
Hernias occur more often in children who have one or more of the following risk factors:
A parent or sibling who had a hernia as an infant
Developmental dysplasia of the hip
Abnormalities of the urethra
How are inguinal hernias repaired?
By and large, there are two types of operations for repairing an inguinal hernia.
The traditional open repair: This type of repair may be performed under local, spinal or general anaesthesia. A 10 - 15 cm incision is made in the groin; it cuts through layers of skin, fatty tissue and muscle to reveal the hernial sac. Contents of the hernial sac are then pushed back. Then the weak area is reinforced with a special nylon net or a mesh. Subsequently, the muscles and ligaments in the groin are stitched together in an effort to strengthen the area. The mesh stays in the body permanently and strengthens the area. Generally, it does not cause any side effects. With a mesh repair the rate of recurrence of hernia is as low as 1% - 2%. However, as a large cut is made, the patient may have some pain / discomfort in the area of surgery for a week or more. Also the patient may not be able to permitted carry out all activities for upto six weeks. Moreover, if a patient has hernias on both the sides, as is often the case, the repair requires two separate incisions ? one in each groin.
Laparoscopic hernia repair: This technique of hernia repair is performed under general anaesthesia. The surgeon makes a small (1cm) cut near the navel and introduces a cannula (a tube-like instrument) inside the abdomen or between the muscles of the abdomen. A laparoscope (a telescope) attached to a miniature video camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a video monitor. The surgeon operates by watching the image on the screen. Two additional cannulas are inserted through 5mm cuts to accommodate special long instruments. The surgeon then pulls the hernial sac back into the abdominal cavity and exposes the weak area in the abdominal wall from inside. This area is covered with a mesh that is fixed to the abdominal wall. Following the repair, the small incisions are closed with stitches.
The advantages of laparoscopic hernia repair are that it requires only 3 tiny cuts instead of the traditional 10 - 15 cm incision. As a result, patients experience much less pain after the operation, are able to perform their activities much sooner, and are able to return to work sooner than after the open operation. If a patient has hernias on both sides, they can be repaired through the same small cuts. In some patients after a previous open operation for hernia the hernia comes back (recurrent hernia). In such cases a laparoscopic operation is far better than another operation. The cost of the laparoscopic operation is marginally higher than the open procedure because of the specialized equipment used. However, this is more than compensated by the benefits the patients gets after a laparoscopic operation.
What happens after the operation?
How soon a patient starts drinking liquids and eating food after the hernia operation depends on the type of anaesthetic used. If an open operation has been performed using local anaesthesia, the patient may be allowed to eat and drink shortly after the operation. After an operation under spinal or general anaesthesia the patient is usually kept fasting for about four to six hours. Some patients may require a saline drip for a few hours. In the first few hours after recovery some patients may experience some nausea or headache (after a spinal anaesthetic).
How soon can one resume work?
This depends very much on the nature of the job a patient does and the type of operation he has had. With the open repair patients may be advised take it easy for upto six weeks and they may not be allowed to lift heavy objects for upto three months. When a laparoscopic repair is performed, almost all activity is permissible within about 8 - 10 days after surgery and the patient return to work within 10 ? 15 days after surgery.
It can be said that the modern laparoscopic repair of inguinal hernia has revolutionized the way this common ailment is treated. If one were to require surgery for hernia laparoscopic repair forms the procedure of choice for most patients.
The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. Patients should also report a fever, and men should report any pain or swelling of the testicles. The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. The postoperative activities of patients undergoing repeat procedures may be even more restricted.
Prevention of indirect hernias, which are congenital, is not possible. However, preventing direct hernias and reducing the risk of recurrence of direct and indirect hernias can be accomplished by:
Maintaining body weight suitable for age and height
Strengthening abdominal muscles through regular exercise
Reducing abdominal pressure by avoiding constipation and the build-up of excess body fluids, achieved by adopting a high-fiber, low-salt diet
Lifting heavy objects in a safe, low-stress way, using arm and leg muscles
Hernia surgery is considered to be a relatively safe procedure, although complication rates range from 1–26%, most in the 7–12% range. This means that about 10% of the 700,000 inguinal hernia repairs each year will have complications. Certain specialized clinics report markedly fewer complications, often related to whether open or laparoscopic technique is used. One of the greatest risks of inquinal hernia repair is that the hernia will recur. Unfortunately, 10–15% of hernias may develop again at the same site in adults, representing about 100,000 recurrences annually. The risk of recurrence in children is only about 1%. Recurrent hernias can present a serious problem because incarceration and strangulation are more likely and because additional surgical repair is more difficult than the first surgery. When the first hernia repair breaks down, the surgeon must work around scar tissue as well as the recurrent hernia. Incisional hernias, which are hernias that occur at the site of a prior surgery, present the same circumstance of combined scar tissue and hernia and even greater risk of recurrence. Each time a repair is performed, the surgery is less likely to be successful. Recurrence and infection rates for mesh repairs have been shown in some studies to be lower than with conventional surgeries.
Complications that can occur during surgery include injury to the spermatic cord structure; injuries to veins or arteries, causing hemorrhage; severing or entrapping nerves, which can cause paralysis; injuries to the bladder or bowel; reactions to anesthesia; and systemic complications such as cardiac arrythmias, cardiac arrest, or death. Postoperative complications include infection of the surgical incision (less in laparoscopy); the formation of blood clots at the site that can travel to other parts of the body; pulmonary (lung) problems; and urinary retention or urinary tract infection.
Inguinal hernia repair is usually effective, depending on the size of the hernia, how much time has gone by between its first appearance and the corrective surgery, and the underlying condition of the patient. Most first-time hernia repair procedures will be one-day surgeries, in which the patient will go home the same day or in 24 hours. Only the most challenging cases will require an overnight stay. Recovery times will vary, depending on the type of surgery performed. Patients undergoing open surgery will experience little discomfort and will resume normal activities within one to two weeks. Laparoscopy patients will be able to enjoy normal activities within one or two days, returning to a normal work routine and lifestyle within four to seven days, with the exception of heavy lifting and contact sports.
Morbidity and mortality rates
Mortality related to inguinal hernia repair or postoperative complications is unlikely, but with advanced age or severe underlying conditions, deaths do occur. Recurrence is a notable complication and is associated with increased morbidity, with recurrence rates for indirect hernias from less than 1–7% and 4–10% for direct.
If a hernia is not surgically repaired, an incarcerated or strangulated hernia can result, sometimes involving life-threatening bowel obstruction or ischemia.