A hernia is caused by a weakening or tear (essentially a hole in the strong tissues) of the abdominal wall. The inner lining of the abdomen, fat or internal organs can push through this weakened area and cause a sack to form. At this point you may not be able to see the bulge but may feel burning or tingling. As the intestines begin pushing into the sack, a bulge may be noticeable. If the bulge flattens out when you lie down or push against it, the hernia is reducible. If the hernia, caused by pressure from internal organs becomes trapped, the bulge may not be flattened out and can produce a non-reducible hernia which can disrupt digestion and require prompt surgery. If surgery is not performed to correct this weakness, the intestines may become trapped or strangulated and lose their blood supply. This will then require emergency surgery. When a hernia is diagnosed, prompt surgical repair is usually recommended because it will not go away by itself and can develop serious complications.
Hernias can occur in any weak or torn part of the abdominal wall. An incisional hernia usually protrudes through the scars of previous surgical incisions and can develop years after the initial surgery. An umbilical hernia looks like an inflated navel and is caused by a weakness at birth or is acquired over time. The most common hernias occur in the groin area. An indirect hernia is the result of a natural weakness at the internal ring and can extend all the way into the scrotum. A direct inguinal hernia occurs less frequently and is usually caused by an acquired weakness in the groin area near the internal ring. The femoral hernia is more common in women and is the result of an acquired weakness in the lower groin area.
The traditional repair of an inguinal or femoral hernia is a relatively simple procedure. The operation usually takes about an hour using local, general, or spinal anesthesia and does not require hospital admission. A small incision is made just above the line where your abdomen and thigh meet. The intestines and tissue in the sack are placed back into the abdominal cavity, and the excess sack that has been stretched may be tied off or removed. Once the bulge has been eliminated, the abdominal wall is repaired with suture or reinforced and patched with a piece of synthetic (plastic) mesh. The skin incision is then closed with either stitch, staple, or tape strip. While this type of hernia repair usually does not require admission to the hospital, there is mild postoperative pain. Normal activities of daily living can be resumed immediately postoperatively, but strenuous activity should be avoided for two weeks.
Laparoscopic hernia repair may also be performed. A small one-half inch skin incision is made near the navel and the abdominal wall is elevated by inflating the abdomen with CO2 after creating space with a balloon. A small metal tube is placed through this incision into the abdomen. This allows the laparoscope to be introduced to view the abdomen and identify the hernia. Two more hollow sheaths or cannulas are then introduced, and the surgeon uses them to introduce the patch, the stapler and various instruments to perform the surgery.
Once the defect has been identified, an appropriate piece of mesh is introduced and stapled into place. The abdomen is desufflated, the internal strong layer called the fascia is closed with a suture and the skin incisions are closed with dissolving sutures. All three incisions are then covered with small tapes called steri-strips. The patient is usually discharged the same day or the next morning with activities limited for two weeks.
Minor postoperative discomfort, due to the abdominal distension with CO2 or to the three abdominal puncture wounds, should be anticipated. These will be treated with injectable and/or oral pain medications. Minimal pain is anticipated to occur at the site of the hernia repair, since no tissue has been sutured together under tension. The primary disadvantages of this approach are the requirement of general anesthesia, the entry into the abdominal cavity and the unknown long-term results of laparoscopic hernia repair.
Laparoscopy, the term used to describe the insufflation of the abdomen with gas and placement of the telescope, is not experimental and is used routinely in general surgery. It has a slight risk of damage to organs or blood vessels in the abdomen. The clip applier and patch used to repair the hernia are also used in various surgical procedures. There are, however, some possible risks associated with laparoscopic hernia repair. These include possible adhesions developing between the organs in the abdomen and the plastic patch, infection of the patch and damage to the intestines, the spermatic cord in men or nerves and blood vessels which feed the leg.
The plastic patch used to repair the defect in the abdominal wall is a "foreign body." It is possible for this to become infected. This would require removal of the patch and concurrent treatment. The patch is placed in close proximity to the nerves and blood vessels which supply the leg and to the spermatic cord in men. It is conceivable that one of these structures could be damaged.
Our experience has indicated that the traditional open repair is usually the operation of choice for inguinal hernias not previously repaired. The laparoscopic approach is most often used for those patients who have recurrent hernias or hernias on both sides. The appropriate method will be determined after your examination and consultation with the surgeon.
