Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting
herniaA hernia is protrusion of an organ or the muscular wall of an organ through the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards into the mediastinum through the esophageal opening in the diaphragm.-Pathophysiology:...
. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the
abdomenIn vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
,
groinIn human anatomy, the groin areas are the two creases at the junction of the torso with the legs, on either side of the pubic area. A pulled groin muscle usually refers to a painful injury sustained by straining the hip adduction muscle....
, and at the site of a previous surgery.
An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy'.
When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous (patient's own tissue) or heterogeneous (like steel or prolene mesh) material it is termed Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement.
Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery," procedure in the USA.
Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting
herniaA hernia is protrusion of an organ or the muscular wall of an organ through the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards into the mediastinum through the esophageal opening in the diaphragm.-Pathophysiology:...
. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the
abdomenIn vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
,
groinIn human anatomy, the groin areas are the two creases at the junction of the torso with the legs, on either side of the pubic area. A pulled groin muscle usually refers to a painful injury sustained by straining the hip adduction muscle....
, and at the site of a previous surgery.
An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy'.
When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous (patient's own tissue) or heterogeneous (like steel or prolene mesh) material it is termed Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement.
Techniques
Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery," procedure in the USA. In other countries, however, it is more common to be admitted for a 2-3 day hospital stay. Almost 700,000 are performed each year in the United States.
These techniques can be divided into four groups.
Groups 1 and 2: open "tension" repair
A workable technique of repairing hernia was first described by Bassini in the 1880s; the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the
conjoint tendonThe conjoint tendon is a structure formed from the transversus abdominis insertion into the pecten pubis.-Anatomy:It is mainly formed by the lower part of the tendon of the transversus abdominis and the internal oblique muscle, and is inserted into the crest of the pubis and pectineal line...
(formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the
inguinal canalThe inguinal canal is a passage in the anterior abdominal wall which in men conveys the spermatic cord and in women the round ligament...
and closed.
Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the
Cooper's ligamentThe pectineal ligament is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone.It was characterized by Cooper in 1804.-External links:...
/McVay repair.
The Shouldice techniques is a complicated four layer reconstruction; however, it has relatively low reported recurrence rates.
Group 3: open "tension-free" repair
Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from
polypropylenePolypropylene or polypropene is a thermoplastic polymer, made by the chemical industry and used in a wide variety of applications, including packaging, textiles , stationery, plastic parts and reusable containers of various types, laboratory equipment, loudspeakers, automotive components, and...
or
polyesterPolyester is a category of polymers which contain the ester functional group in their main chain. Although there are many polyesters, the term "polyester" as a specific material most commonly refers to polyethylene terephthalate...
, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond
aspirinAspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication....
or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and they can usually resume all their normal activities within a week or two of the operation. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair. Rates of
complicationComplication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems...
s are generally low but they can be quite serious, and can include
chronic painChronic pain is defined as pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process....
,
ischemic orchitisOrchitis or Orchiditis is an often very painful condition of the testes involving inflammation, swelling and frequent infection.-Symptoms:Symptoms of orchitis are similar to those of testicular torsion...
, and
testicular atrophyTesticular atrophy is a medical condition in which the male reproductive organs diminish in size and may be accompanied by loss of function. This does not refer to temporary changes, such as those brought on by cold.Some medications can cause testicular atrophy...
.
Group 4: laparoscopic repair
In recent years, as in other areas of surgery, laparoscopic repair of inguinal hernia has emerged as an option. "Lap" repairs (sometimes called "keyhole" surgery or minimally invasive surgery) are also tension-free, although the mesh is placed within the pre-peritoneal space behind the defect as opposed to in or over it. Advantages of lap over the open method include a faster recovery time and a lower post-operative pain score.
Like the open method, laparoscopic surgery may involve local or general anesthesia, depending on the size and related factors of the hernia. Lap is usually more expensive as it requires more Operating Room time than open repair, but a shorter hospitalization period.
There is no definitive consensus as to the comparative risk of complications, or comparative rate of recurrence compared to the open tension-free repairs. However, nearly all surgeries are moving to lap methodologies, as the smaller incisions used result in less bleeding, less infection, faster recovery, reduced hospitalization and reduced pain. and
Comparisons
In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that lap repair has less risk of wound infection, less bleeding, and less swelling after surgery (
seromaA seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep out; inflammation caused by dying injured cells also contributes to the fluid....
). They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results, however, are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.
Mesh repairs have shown reduced recurrences or early recovery compared to tension repairs. Mesh repair complications include
infectionAn infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply, usually at the expense of the host. The infecting organism, or pathogen, interferes with the normal functioning of the...
, mesh migration,
adhesionAdhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue. In the case of frozen shoulder adhesions grow between the shoulder joint surfaces, restricting motion.Adhesions form as a natural part of...
formation, erosion into intraperitoneal organs, and chronic pain - due probably to entrapment of nerves,
vesselsThe blood vessels are the part of the circulatory system that transport blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart, the capillaries, which enable the actual exchange of water and chemicals between the blood and...
, or the
vas deferensThe vas deferens , also called ductus deferens, , is part of the male anatomy of some species; they transport sperm from the epididymis in anticipation of ejaculation.-Structure:...
. Such complications usually become apparent weeks to years after the initial repair, presenting as
abscessAn abscess is a collection of pus that has accumulated in a cavity formed by the tissue on the basis of an infectious process or other foreign materials...
,
fistulaIn medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Location of fistulas:Fistulas can develop in various...
, or small bowel obstruction. More recently, concerns have been raised about the possibility of obstruction of the vas deferens as a result of the
fibroblastA fibroblast is a type of cell that synthesizes the extracellular matrix and collagen, the structural framework for animal tissues, and plays a critical role in wound healing...
ic reaction to the mesh.
External links