Treatment of Hernias  

 

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Anatomy

Indirect Hernia

Direct Hernia

Femoral Hernia

Ventral Hernia

Other Hernias

Treatment

 

Treatment

General

Inguinal Hernia Truss

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 abdominal wall.

Surgical Repair

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.

Bassini Repair

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.

Bassini repairBassini repairBassini repairBassini 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.

McVay repair

Shouldice Repair

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.

Shouldice repairShouldice repairShouldice repair

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. 

Open repair with mesh

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.

Open repair with 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.

Laparoscopic Repairs

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 disability.

Laparoscopy for hernia repair uses one incision for the camera and two for the instruments (usually all down the midline)

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.

Laparoscopic view of right inguinal area with mesh in place

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 balloon).

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.

Others

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.

Laparoscopic view of mesh being sutured under a ventral hernia

Complications

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 collateralization.

In addition, injury to nerves in the area (particularly the ilioinguinal nerve) can cause pain in the L1 dermatome (see Anatomy section on previous page).

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.