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Hernia
Repair

A hernia is a protrusion of usually a loop of bowel or a tissue through an opening in the wall of the abdominal cavity in which the bowel lies. Hernias are one of the most common conditions requiring surgery. A hernia is a protrusion of usually a loop of bowel or a tissue through an opening in the wall of the abdominal cavity in which the bowel lies. Hernias can occur in men and women of all ages and in children (see Pediatric Hernia Repair). Hernias can develop around the navel, in the groin, or any place where you may have had a surgical incision. Some hernias are present at birth. Others develop slowly over a period of months or years. Hernias may also come on quite suddenly.

Anatomy

  • The abdominal wall in the groin area is made up of different structures going from deep to superficial layers (Figure 1 and 2):
    1. Peritoneum - the lining of the abdominal cavity (becomes the hernia sac)
    2. Subperitoneal fat - fat beneath the peritoneum
    3. Transversalis fascia - sheet of fibrous tissue that envelops the peritoneum
    4. Transversus abdominis muscle
    5. Internal oblique muscle
    6. External oblique muscle
    7. Subcutaneous fat
    8. Skin
Figure 1 - Layers of the abdominal wall, inguinal canal and their relations to the spermatic cord and testies. © C. SaliciFigure 2 - Anatomy of the inguinal canal and relationship to the pelvic bone. © C. Salici
  • The spermatic cord (in males) contains the blood vessels and nerves that pass from the abdominal cavity into the scrotum. The scrotum is the sac of skin that holds the testicles
  • During development the testis (testicle) normally descends from a higher location (near the lower pole of the kidney) pulling a covering of peritoneum (the processus vaginalis) with it to become fixed in the scrotum
  • The testicle and spermatic cord penetrate the abdominal wall through an opening called the internal inguinal ring. The cord then runs obliquely through the inguinal canal to exit the abdominal wall through the external inguinal ring near the scrotal sac. A similarly placed cord, the round ligament, is found in females
  • The processus vaginalis is a finger like protrusion of the peritoneal lining of the abdominal cavity. It accompanies the testicle and spermatic cord structures lying against the cord in the inguinal canal. Imagine a ball pushed into an inflated balloon. The ball or testicle is now covered with two layers of peritoneum. The processus vaginalis normally becomes fused from it's origin to the level of the 'balloon' around the testicle
  • The internal inguinal ring is lateral (away from the midline) to the inferior epigastric artery and is the site where the cord penetrates the internal oblique muscle to lie in the inguinal canal (Figure 1)
  • The external inguinal ring is the opening in the external oblique muscle and fascia where the cord moves from the inguinal canal to the subcutaneous tissue to enter the scrotum
  • The inguinal ligament is the inferior tough fascia portion of the external oblique muscle that inserts on the anterior superior iliac spine of the pelvic bone and has a free border going medially (towards the midline) until it attaches to the pubic tubercle
  • In the female, the round ligament of the uterus accompanies the processus vaginalis in the inguinal canal. The round ligament exits the inguinal canal at the external ring and inserts into the pubic tubercle

Pathology

  • Hernias commonly develop in an area of weakness. These areas include natural spaces and thin tissue, such as the internal inguinal ring and the floor of the inguinal canal. Hernias may develop at these sites or other areas due to aging, injury, an old incision, or a weakness present at birth
  • Another important factor in the development of hernias is an increase in the intra-abdominal pressure. This could be secondary to chronic constipation and prolonged straining, chronic persistent coughing, or lifting heavy objects.
  • Types of Hernia
    1. Inguinal hernias are in the groin area. They are most common in men, primarily because of the unsupported space left in the groin after the testicles descend into the scrotum. Inguinal hernias can be indirect, the hernia sac exits through the internal inguinal ring and takes an oblique path; or direct, the hernia sac exits through the external inguinal ring directly (Figures 3 and 4)
    2. Femoral hernia occurs at the top of the thigh in the space through which the femoral artery, vein, and nerve pass into the thigh. These hernias occur most often in women and commonly result from pregnancy and childbirth
    3. Umbilical hernias occur in the umbilicus (belly button) and occur most often in infants
    4. Incisional hernias occur at the site of previous abdominal surgery
Figure 3 - Schematic diagram of an indirect inguinal hernia. © C. SaliciFigure 4 - Schematic diagram of a direct inguinal hernia. © C. Salici

History and Examination

  • Some patients with hernias are unaware of their presence until the hernias are pointed out to them
  • The patient may notice a bulge under the skin without any associated symptoms
  • Typically, a hernia sac with its contents enlarges and transmits a palpable impulse when strain or cough
  • Symptomatic hernias produce a wide variety of nonspecific symptoms
  • Discomfort related to the contents of the hernia sac and pressure of the sac on the surrounding tissue
  • Pain when lifting a heavy object, coughing, or straining during urination or bowel movement. In some cases the pain is a dull ache that gets worse towards the end of the day after standing for long periods of time and is relieved at night when you lie down and the hernia reduces (goes back in)
  • Most hernias are reducible
    1. The contents of the hernia sac can be squeezed back into the abdominal cavity without difficulty
    2. If the hernia remains bulging for a long time or the contents of the hernia are crowded, then it may be difficult to reduce the hernia. This is an incarcerated hernia
    3. If the hernia continues to be incarcerated (trapped) for some time then the contents of the hernia, which is most commonly bowel, will become swollen and there will be compromise of the blood supply to the bowel. This is called a strangulated hernia and is a surgical emergency
    4. A hernia that strangulates produces intense pain in the hernia followed by marked tenderness. Because of intestinal obstruction, there is abdominal pain and vomiting

Tests

  • Hernias are usually easy to diagnose on physical examination.
  • It is unusual to do herniography (dye injected into abdominal cavity with X-ray to see if a hernia sac is present)
  • Plain X-rays may show gas or mass effect in the groin area
  • CT (computerized tomography) scan or MRI (magnetic resonance imaging) studies are rarely indicated
  • Ultrasound may be helpful in diagnosing a mass or fluid in the groin

Indications for Surgery

  • There are two reasons for hernia surgery:
    1. Correct or prevent a dangerous strangulated hernia
    2. Eliminate the pain that may be interfering with normal activity
  • In general, all hernias should be repaired unless there are other conditions in the patient that preclude a safe outcome
  • Trusses and surgical belts are helpful in the management of small hernias when surgery is contraindicated

Surgical Repair

  • A hernia repair is usually done on an outpatient basis. Typically, the procedure takes less than an hour to complete. Most patients are fully ambulatory and able to go home after about two to four hours.
  • Inguinal hernia
    1. An inguinal hernia is repaired by first making an incision just above the crease where the abdomen meets the thigh. (Figure 5)
    2. The inguinal canal is opened, the hernia sac separated from the spermatic cord, lifted and opened. (Figure 6) Intestine or other tissue is then placed back into the abdominal cavity. The excess sac is tied off and removed. (Figure 7) The opening at the internal ring may be tightened and the abdominal wall reinforced using sutures to bring together the neighboring tissues without tension (Figure 8)
    3. A synthetic mesh and/or plug may be used to repair the hernia. The tapered shape of the plug eases insertion into the defect and fills the 'hole' much like a cork in a bottle. (Figures 9 and 10) A second piece of flat mesh may be placed over the plug to help prevent future hernias at the same site
    4. The wound is closed with sutures (Figure 11)
    5. Another way of repairing the hernia is through the laparoscope. The laparoscope is introduced through a small incision at the naval. Two or three small incisions are made and the hernia is repaired from the inside of the abdominal cavity. A flat mesh is placed over the internal inguinal ring to prevent tissues or organs from protruding through the opening
    6. Postoperatively the patient may experience local wound pain, scrotal swelling, retention of urine, or bruising. These are temporary problems and will resolve eventually
Figure 5 - The line of incision for an inguinal hernia. © C. SaliciFigure 6 - The wound is opened and the hernia sac exposed. © C. Salici
Figure 7 - Excess sac is tied off. © C. SaliciFigure 8 - The muscle (with its fascia) is sutured to the inguinal ligament. © C. Salici
Figure 9 - Mesh may be used to reinforce the wound closure. © C. SaliciFigure 10 - A mesh plug may also be used to reinforce the repair. © C. Salici
 
Figure 11 - The muscle layers and skin are closed.
  • Femoral hernia:
    1. The skin incision for a femoral hernia is similar to that for an inguinal hernia. The hernia sac is lifted and opened. Intestine or other tissue is then placed back into the abdominal cavity. The excess sac is tied off and removed
    2. The femoral canal (a space near the femoral vein that carries blood from the leg) is closed with sutures or reinforced with synthetic mesh. The skin incision may be sutured or stapled
  • Incisional hernia
    1. The incision from the earlier surgery is reopened at the site of the hernia. The hernia sac is carefully dissected and opened. The intestine or other tissue in the hernia sac is placed back into the abdominal cavity
    2. The defect is repaired or reinforced either with synthetic mesh or by pulling together and suturing the abdominal muscle tissue. The skin incision may be stapled or sutured
  • Umbilical hernia
    1. A semicircular incision is made near the navel. After the navel is raised, the intestine or tissue in the hernia sac is placed back into the abdominal cavity
    2. The umbilical weakness is tightened with sutures or reinforced with synthetic mesh and the navel is returned to its normal position
    3. The skin incision is closed with staples or sutures

Complications

  • Chronic pain may result from surgical handling of the sensory nerve in the groin area during surgery, or after surgery from constricting scar tissue
  • Infection
  • Hemorrhage
  • Ischemic orchitis due to thrombosis of the spermatic cord and venous congestion produces pain and swelling
  • Recurrence of the hernia due to excessive tension during repair, inadequate tissue, inadequate repair, and overlooked hernias. Recurrence rates are 1-4%

Post-operative and After Care

  • Following surgery you may be given medication to relieve pain in the area of your incision. It is normal to see some swelling and discoloration around your incision. This will disappear with time
  • After surgery, if you must lift something, lift only light objects that you can manage easily. Keep your back straight, and allow your legs to do most of the work
  • Driving may strain your incision. Ask your physician when you can drive. Do not drive while taking your pain medication.
  • To avoid constipation that could cause you to strain against your incision, eat a high-fiber diet and drink lots of fluid. If necessary ask your doctor about using a stool softener
  • Your doctor will let you know when it is okay to work again. If you have a desk job, you may be able to go back to work within a week or two. If your job requires more physical activity, you may have to wait longer
  • Your doctor may schedule a follow-up visit in about a week. During the visit, your doctor will remove stitches or staples, if necessary, and check the progress of healing