Unfortunately, hernias are not typically amenable to medical
therapy. Occasionally, for an uncomplicated hernia (not incarcerated or
strangulated), palliation can be maintained with the use of a truss (a
fist-sized ball of leather, rubber, or fabric) that is fastened in place over
the hernia bulge. However, since hernia defects never close spontaneously,
the use of a truss only prolongs the problem, leading to a greater chance of
possible incarceration later. Thus, early diagnosis and surgical repair of
hernias is the mainstay of treatment.
The repair of a hernia is conceptually simple. Regardless
of the type (inguinal, femoral, ventral, etc.), the goal is to return the
herniated contents to their anatomic position and restore the continuity of the
The surgical repair of hernia is known as herniorrhaphy.
It involves making a small incision over the hernia, pushing the bulging
tissue back into place and removing the hernia sac. The muscles or similar
tissues are then sewn together firmly over the hernial orifice. As
described below, there are a number of open repairs that have been created,
some which are still used today.
Typical recovery time to return to normal activities is four
to six weeks for hernias resulting from stress or strain. The chance that
the hernia will reappear can be as much as 10-15 percent. The surgery is
usually performed on an outpatient basis, but rarely the physician will
recommend a one or two day stay.
Until recently, the Bassini repair was the most widely used
surgical repair of inguinal hernias. In this superficial repair, the
external oblique aponeurosis is opened over the inguinal canal and the spermatic
cord is visualized. Any indirect hernia sac is ligated under direct vision at
the level of the internal ring. Originally a triple layer repair was performed
where the transversalis fascia was opened and included with the internal oblique
muscle and transverse abdominus aponeurosis and fascia and sewn to the iliopubic
tract and inguinal ligament. Most surgeons do not incise the transversalis
fascia and include it in this repair and subsequently use a variation of the
original procedure. Suture line tension probably accounts for most recurrences
after the Bassini repair.
McVay (Cooper's Ligament) Repair
The McVay Repair requires that the medial portion of the
iliopubic tract be excised to expose the medial edge of the femoral sheath and iliopectineal (Cooper's) ligament for the placement of sutures. This repair
always requires a relaxing incision at the point of fusion of the external
oblique aponeurosis and the anterior rectus sheath to reduce tension. The repair
begins at the pubic tubercle by anchoring the transverse abdominus aponeurosis
and the transversalis fascia to Cooper's ligament. This line of sutures is
carried to the femoral sheath. The repair is then continued laterally
using the iliopubic tract to anchor the transversalis fascia and transverse
abdominus aponeurosis. The suture line is continued until the internal ring
reapproximation admits only a fingertip alongside the spermatic cord. The cord
structures are replaced in the normal anatomical position within the inguinal
canal and the external oblique aponeurosis is closed over the cord.
The Shouldice repair can be thought of as a combination of a
Bassini and McVay repair. First, the transversalis fascia is divided from
the internal inguinal ring to the pubic tubercle. The posterior wall repair is
accomplished by imbricating the lateral and medial leaves of the divided
transverse aponeurotic fascial fibers with a continuous suture. The superomedial
flap is brought over the inferolateral flap. The first suture line begins at the
pubic tubercle and is sewn in a continuous fashion up to the internal ring,
suturing the free edge of the inferolateral flap to the underside of the
superomedial flap. At the internal inguinal ring, the cranial portion of the
cremaster may be included in the suture line. This gives additional strength to
the internal inguinal ring. The suture line is then doubled back bringing the
leading edge of the superomedial flap to the edge of the inguinal ligament. The
lacunar ligament is included in this suture line to obliterate the dead space
medial to the femoral vessels. A second suture, beginning at the internal ring,
brings the internal oblique and transversus muscles down to the deep surface of
the inguinal ligament. At the level of the pubic bone, this suture doubles back,
attaching the same structures in a more superficial plane and the suture is tied
to itself at the internal ring.
Tension Free (Mesh) Repairs
The use of synthetic sheets of meshed material (mainly
polypropylene (Marlex) and polytetrafluoroethylene (Gore-Tex)) was made popular
by Lichtenstein around 1976. He began using mesh in all primary hernia
repairs mainly as prophylaxis against recurrent direct herniation following
repair for indirect herniation. Because of their space filling properties,
these materials not only provide strength to the repair, but also release tissue
tension on anatomic structures.
Available as patches, plugs, or customized patterns, these materials do not
alter the anatomic features of the repair and do not require the use of tension
on adjacent structures. An onlay patch is placed on the anterior surface
of the posterior wall of the inguinal canal from the pubic tubercle to above the
internal ring. A slit made in the mesh permits egress of the spermatic cord and
the tails of the mesh are overlapped. Some surgeons also place a mesh plug
(similar to a badminton shuttlecock) into the internal ring as reinforcement.
Over time the muscles and tendons send out fibrous tissue
which grows around and through the mesh.
Although the infection rate using mesh does not appear to be increased over
older methods, an infection which does involve these materials can be severe,
and warrant mesh removal.
This surgery is also an outpatient procedure, and usually
takes less than an hour. After about 45 minutes it is quite common for the
patient to be able to get up, go up and down stairs, go for a walk, and even
ride an exercise bicycle. Returning to normal activity depends upon a
number of factors. Typically the patient can return to "office" routines in
about three days and "physical" occupations within two weeks.
The latest addition to the general surgeons armamentarium for
hernia repair has been the introduction of laparoscopy. Like tensionless
repairs, laparoscopic methods have been developed in an effort to reduce the
long term recurrence rate of an anterior repair while improving the short term
Today, most laparoscopic herniorrhaphies are performed using
either the transabdominal preperitoneal (TAPP) approach or the total
extraperitoneal (TEP) approach. The TAPP approach involves placing laparoscopic
trocars in the abdominal cavity and approaching the inguinal region from the
inside. This allows the mesh to be placed and then covered with peritoneum.
While the TAPP approach is a straightforward laparoscopic procedure, it requires
entrance into the peritoneal cavity for dissection. Consequently, the bowel or
vascular structures may be injured during the procedure.
In the TEP procedure, an inflatable balloon is insufflated in
the preperitoneal (aka extraperitoneal) space of the inguinal region, so as to
push the peritoneum posteriorly, creating a working space for the laparoscope.
The repair is similar to the TAPP approach, except that the peritoneum is never
entered, eliminating risk of injury to the bowel.
In both the TAPP and TEP approaches, the hernia sac is reduced,
and a large piece of mesh is placed over the area in order to cover any
indirect, direct, or femoral hernia found. The mesh can be held in place
using staples, or by the pressure of the peritoneum alone (after removing the
The laparoscopic approach has several advantages over previous
repairs. They include smaller incisions, less pain and disability, a
quicker return to work, and less recurrence.
Other hernia repairs (ventral, umbilical, femoral, etc.) are
done in similar fashion to inguinal repairs. They can be done open (via
laparotomy) or laparoscopically. Similarly, they can be closed primarily
with sutures or via tension-free techniques with mesh. A photo of a
laparoscopic, ventral repair using mesh is shown below.
Complications following hernia repair differ among various the different
operative procedures. In general, they include hemorrhage, injury to the vas,
nerve injury, bladder injury, wound infection and recurrence.
Hemorrhage during herniorrhaphy commonly may occur from the pubic branch of
the obturator artery, the inferior deep epigastric vessels, the deep circumflex
iliac vessels, the cremasteric artery, and the external iliac vessels. Injury to
all but the external iliac vessels can be ligated because of extensive arterial
In addition, injury to nerves in the area (particularly the ilioinguinal
nerve) can cause pain in the L1 dermatome (see Anatomy section on previous
Recurrence is probably the most common postoperative complication following
repair of inguinal hernia. Representative recurrence rate after three to
six years are 1-5% for indirect inguinal hernias, 2-8% for direct inguinal
hernias, and 2-20% for recurrent inguinal hernias. Factors that determine
recurrence rate include missed hernias, technical errors, suture line tension,
and biologic factors such as collagen turnover and deposition.