Hernias and Hernia Surgery

Description and causes of a Hernia

A hernia occurs when a portion of the abdomen's contents – while still held within the abdominal cavity's lining or peritoneum – pushes through a split in the muscle wall. This is similar to the way an inner tube pushes through a defect in a tyre casing.

In most cases, the patient will notice a swelling in the groin area: this is called an inguinal hernia. It is more noticeable when upright, as the abdominal contents fall more readily into the hernia sac when encouraged by gravity. The contents of the hernia are usually either intestine or fatty tissue called the omentum, but some of the swelling can be the layer of fatty tissue that exists between the peritoneum, which makes up the hernia sac, and the split layer of muscle.

The swelling usually vanishes when the patient lies down and the hernia's contents fall completely into the abdominal cavity. An irreducible hernia occurs when, on occasion, the contents either stick to, or become stuck in, the sac.Most patients report some level of discomfort or aching, often spreading down to the testicle, which is worsened by straining, lifting, or standing for extended periods. If the hernia is more painful, it may be because the contents are being squeezed within the sac's small opening, which could lead to loss of blood supply (strangulation).

Although popular opinion holds otherwise, only 10-15% of hernias are clearly linked to an event, such as a strain, causing swelling and pain. Usually people discover a hernia by chance, either through general discomfort in the groin, or by noticing a swelling while showering. The latter often prompts fears of cancer – but if the swelling vanishes upon lying down, it is usually not cancer.

When a hernia occurs in an infant, often fairly soon after birth, it points to a small flaw in development. This can also influence the likelihood of developing a hernia in later life. Adults are more susceptible to hernias if they lead more active lives, but people of all ages and lifestyles can still develop a hernia. Males make up around 97% of all cases, because the point at which the spermatic cord passes through the abdominal wall's muscle layers to the scrotum is particularly vulnerable to being breached.

Other types of Hernias

These hernias are named either for the areas of the body they push through, or for the person who first noted them.

Common Hernias

• Incisional Hernia
• Paraumbilical Hernia
• Umbilical Hernia
• Epigastric Hernia
• Femoral Hernia

Rarer Hernias

• Spigelian Hernia
• Obturator Hernia
• Littre Hernia
• Lumbar Hernia

Incisional Hernia

Scars from past surgery create weaker areas through which incisional hernias can push. A wound may been weak as a result of poor surgical technique, become infected following the original operation, or subjected to excess pressure before it was properly healed. The breached area can range in size from tiny to very large. The bulge in the abdomen may cause no symptoms at all, but it often uncomfortable and can occasionally cause strangulation (which is very dangerous if not treated). Fixing larger defects is often an involved process, with a high possibility of recurrent herniation.

To help combat this, non-absorbable polypropelene mesh is often fixed deep to the abdominal wall closure, offering additional security and markedly reducing the chance of a recurring herniation. This is usually carried out through open (non-laparoscopic) surgery, but it is possible to repair the hernia laparoscopically too. With the laparoscopic approach, the mesh is placed deep to the defect. The fascial defect is not closed as part of the operation and the bulge may persist after the operation. Therefore this process is better suited to smaller defects, where the edges to be bridged are fairly close together. Laparoscopic repairs usually involve specific types of mesh, as they sit in direct contact with the intestine. If the hernia is suitable for laparoscopy, the patient will likely benefit from smaller wounds, less post-operative pain, and a speedier recovery. Unless the hernia is very small, surgery for an incisional hernia usually entails a hospital stay of one to two nights.

Umbilical/ Paraumbilical Hernias

These occur in both infants and adults. The former are managed by paediatric surgeons. In adults, it is common for the patient to be unaware he/she has a hernia. These hernias often do not need repairing unless the hernia protrudes noticeably and is visible through clothing. Discomfort or pain can be a feature. It is highly unlikely the contents of a hernia will strangulate.

An umbilical hernia is usually treated as a day case, with the patient under a general anaesthetic. Commonly, surgeons use an open (non-laparoscopic) method to fix umbilical hernias, making a transverse cut at the edge of the umbilicus, closing the defect with a strong, permanent suture. If needed, a synthetic mesh material such as polypropylene is placed over or deep to the closure. Pain is usually controlled with paracetamol and anti-inflammatories post-operatively. It is advisable to take some time off work, according to the type of work undertaken, and avoid heavy lifting for around 4 weeks.

Epigastric Hernia

The procedures and recovery times for epigastric hernias are akin to those used for umbilical hernias (see above). Mesh is not always used to strengthen the repairs, although it may be advisable, particularly if there are several defects.

Avoiding surgery

It is a perfectly valid option to leave the hernia alone if there are no problems or symptoms. If surgery needs to be delayed, or avoided altogether in the case of an elderly or frail patient, a hernia truss can be used. This is a belt-like piece of equipment with a pad that sits over the point where the hernia protrudes. It is fitted when the patient is lying down and the hernia is reduced, so that the pad holds in the hernia.

Hernias tend to enlarge with time. Lifestyle influences may have some bearing on a decision about surgery. Surgery may become more risky as the patient ages, health insurance cover may change and increase the cost of the operation, or an imminent trip may take the patient away from reliable medical facilities.

What are the surgical options for Inguinal Hernia repair?

There are two options for treating these hernias surgically. The open method involves a larger incision. The laparoscopic approach employs slender instruments and a laparoscope, with video camera attached, which are used to perform “keyhole” surgery through smaller abdominal incisions. For more information on each method, see the relevant sections.

Open Inguinal Hernia Surgery

The traditional open method has been used for decades, although methods have been refined in recent years to improve results and lessen post-operative pain. The Bassini technique used a suture to bind the inguinal canal, until the Shouldice technique became the standard in the 1980s. Now the Lichenstein technique is usually used, involving tension-free repair with a synthetic mesh. This has the advantage of greater comfort for the patient and a lower chance of a recurring hernia (around 2%, compared to 10%, with follow-up of more than 5 years).

Laparoscopic Repair

Laparoscopy has been used to fix hernias for more than 15 years. This technique avoids muscle cutting. Small incisions are made through skin, between the muscles, reducing even further the patient’s level of post-operative discomfort, allowing a faster return to work. Mesh is used to cover the defect, but it is attached to the inner aspect of the muscle layer, also in a "tension-free" fashion. The recurrence rate is close to zero when this method is performed correctly.

A small (10-15mm) incision is made at the umbilicus and access gained to the extraperitoneal space between the peritoneum and muscle layers. (Referring back to the analogy of an inner tube pushing through a tyre casing, the peritoneum is the inner tube and the muscle is the tyre casing.) The laparoscope – a narrow telescope connected to a TV monitor – is used to gain a close-up image of the defect. Long surgical instruments pass through two smaller (5mm) incisions, and are used to repair the hernia by covering the split with prolene mesh, attaching it with titanium screws, mainly to the pubic bone. In other words, the patch is attached to the tyre casing, between the inner tube and the split tyre casing. Surgical glue can also be used to secure the mesh, but it has the disadvantage of providing temporary fixation only.

The laparoscopic method is more difficult to learn than the open approach, but once a surgeon is proficient at it, it is extremely safe and reliable. Surgery may be more difficult if a patient is either overweight or has a very large hernia, but this does not mean the laparoscopic option is not possible.

What can be expected after a laparoscopic hernia operation?

A general anaesthetic is required i.e. the patient is put to sleep. The operation is usually done as a day case and full normal activities are encouraged soon after. The nature of the surgical technique means the repair will withstand heavy physical abuse from the outset. Although discomfort is present at first, a rapid recovery is helped by early physical activity. I encourage my patients to get out and have a good walk the next day, stretching and loosening the affected area. Painkillers such as paracetamol and anti-inflammatories are recommended, although not all need them. I encourage my patients to set activity records following laparoscopic hernia repair. Here are some examples of what has been achieved:

• Day 0 - Cycling
• Day 0 - Ballroom dancing
• Day 1 - Mowing lawns
• Day 1 - Rowing single scull
• Day 1 - Full round of golf
• Day 2 - Chopping down tree with axe
• Day 2 - Pig hunting
• Day 2 - Tramping
• Day 2 - Deep sea fishing (landed 117kg marlin)
• Day 2 - Fence post hole digging
• Day 2 - Basketball (social game)
• Day 3 - Pall bearing
• Day 5 - Surfing on Auckland's West Coast
• Day 3 - 10km run
• Day 1 - Basketball
• Day 1 - Indoor Cricket
• Day 1 - Volleyball
• NB. In all three team events the hernia team won
  

When ACC is involved (New Zealand only)

If, as in a minority of cases, a sudden slip or specific injury causes a hernia, and other criteria are also met, the Accident Compensation Corporation (ACC) may cover the treatment costs. Payment ranges from full (if in a private hospital under a contract arrangement) to part (the alternative co-payment system).

Waiting times are longer if a patient goes through the contract system, as the hospital that has an arrangement with ACC must apportion their allocated funds over the whole contract period. Other specialists working on trauma-related operations must also receive some of these funds.

Co-payment is usually a faster system, as a date for surgery can be set upon ACC approval (usually about one month). The patient funds around 45% of the total cost – either from their private health insurer, or from their own pocket.

Do all surgeons perform laparoscopic inguinal hernia repairs?

All general surgeons have been taught how to repair hernias, although some learned before laparoscopic technology became common. Today, all surgeons are trained to develop videolaparoscopic skills, although they utilise a different set of skills to open surgery and do not suit every surgical temperament or ability. A surgeon performs laparoscopy by watching pictures of the affected area on a video monitor, resulting in a two-dimensional view and a need for specific eye-hand coordination skills.

Most surgeons manage this technique, but of course some will be more adept than others. The indication to "bail out" and revert to open surgery can be influenced by temperament. When removing gallstones through laparoscopy, the procedure is the same but is carried out using different tools. In contrast, with laparoscopic hernia repair, the surgeon needs to learn new anatomy, as the surgery is performed from an internal approach rather than an external one and new technology is being employed. Once these variables are mastered, the operation is straightforward.

Initially, using laparoscopy to treat inguinal hernias was not well received, but patient satisfaction and glowing statistics have meant the procedure is now commonly used – in fact, 80% of private-sector inguinal hernia operations are done laparoscopically in Auckland and more than 50% nation-wide.

Andrew Bowker and laparoscopic inguinal hernia repair

I have been involved with this technology since it first became available for general surgeons to use. I performed my first laparoscopic inguinal hernia repair in 1991. As well as continuing to operate today, I teach other surgeons this technique, both in New Zealand and abroad.

Surgical statistics

Initially Transabdominal Preperitoneal (TAPP) approach, with smaller (10x6cm) mesh:

• No. of repairs - 236
• No. of recurrences - 6 (2.5%)

Subsequently switched to Extraperitoneal (EP) approach, with larger (15x10cm) mesh:

• No. of repairs - 4650 (May 2009)
• No. of recurrences - 7 (0.15%)

(In this series, 10% of the repairs were for recurrences following previous open hernia repair.)