Wednesday, December 12, 2007
We see a lot of referrals for inguinal hernia in private practice. Other than lap chole, inguinal hernia repair is the most common operation done in America. What people don't realize is the anatomic complexity that must be understood and navigated when undertaking the repair. Surgical residents don't really "figure out" groin hernias until sometime in the third or fourth year. It requires thinking three dimensionally in a small space. Suddenly, something clicks and everything makes sense. You could watch three colon resections and have a good handle on how to do the case, but inguinal repairs need to be watched over and over. It's very subtle.
Given that surgeons have a hard time grasping groin hernias, it's no surprise that patients struggle to articulate what is happening to them. I hear various descriptions of something going on that isn't quite right. "I got a problem 'down there'". "My ball is swollen." "Something keeps jumping out when I cough." "It pinches when I work." "Something keeps going in and out." "My doctor says I got a hernial." I've heard it all. So let's do a question and answer session and clear some things up.
What is an inguinal hernia?
Hernia comes from the Latin for "rupture". It's basically a defect in the strong fascial component of the abdominal wall. The inguinal canal contains the spermatic cord and its associated blood vessels. The testicle starts out embryologically up near the kidney. As the fetus develops, it migrates from the abdominal cavity through the abdominal wall via the inguinal canal into its final resting place in the scrotum. The membranous connection to the peritoneal cavity is called the processus vaginalis. If this remains patent, one is susceptible to indirect inguinal hernias. Indirect inguinal hernias occur lateral to the inferior epigastric vessels. Conversely, direct inguinal hernias are not congenital. They occur through attenuated tissue medial to the inferior epigastric vessels. These are the hernias of "wear and tear" and heavy lifting. Differentiating direct from indirect is not always possible pre-operatively, but the approach is the same for each one.
Why should I worry about my groin hernia?
Several reasons. Number one, you worry about bowel slipping into the hernia and getting trapped (incarcerated). This can lead to bowel obstructions and even gangrene of the affected bowel. Fixing hernias in the setting of bowel obstruction or ischemic intestine can be quite problematic and morbidity/mortality rates are substantial. So it's wise to consider repair on an elective basis; before such complications arise. Number two, hernias don't improve with time. They get worse. If you're having a hard time now, it's not going to be any better in two years.
So should all hernias be fixed?
This is a little controversial. Asymptomatic inguinal hernias can probably be watched in most men. There's a good study from the Hines VA in Chicago that addresses this. Any symptomatic groin hernia should be repaired. Symptoms can vary from patient to patient. Anything from a dull ache at the end of a work day to a sharp, acute pinch with lifting can be described. Any hernia that you see bulging yourself should be repaired. All hernias in women should be repaired. Hernias in children ought to be repaired with high ligation of the sac.
How are you going to fix my hernia?
Inguinal hernia repairs have undergone quite an evolution over the past hundred years or so. Bassini perfected a technique that still bears his name in 1887. This involved suturing the conjoint tendon/internal oblique/transversalis musculature laterally to the inguinal ligament. McVay modified the technique by adding a relaxing incision in the rectus fascia and utilizing Coopers ligament for some of the sutures. The Shouldice repair is another tissue repair that closes/reinforces the inguinal canal in four running suture layers. The problem with all of these tissue repairs, however, can be summed up in one word: Tension. Tissues brought together under tension are doomed to breakdown. Recurrence rates with tissue repairs are as high as 50-60%. Tension also substantially increases post-operative pain. Patients were often hospitalized for 4 or 5 days after hernia repair in the days prior to the use of mesh.
So you use mesh?
Absolutely. Mesh allows for tension-free repair of the defect. Tension free repairs have reduced recurrence rates to around 1-5%. Post operative pain is now manageable on an outpatient basis; 95% of patients go home the day of surgery.
Isn't mesh dangerous? What about recalls?
Mesh infection rates are usually quoted as being less than 1%. I do these operations sterilely in the OR and peri-operative antibiotics are always given. The Kugel Composix Patch was the one recalled. I never used that particular brand.
What are the kinds of mesh repairs?
There's the Lichtenstein repair, the Plug and Patch technique, and the pre-peritoneal repair. All of them involve returning any indirect sacs to the preperitoneal space and reinforcing the inguinal floor with a non-absorbable, inert mesh. For open repairs I generally utilize the Modified Millikan technique (a Robbins/Rutkow modification) using a plug inserted through the internal ring into the preperitoneal space and fixed to the internal oblique, conjoined tendon and inguinal ligament with non-absorbable sutures. The floor is then reinforced with an onlay patch.
What about laparoscopic repairs?
There are two techniques to consider when discussing the laparoscopic approach: TEPP and TAPP. TEPP stands for total extraperitoneal patch. TAPP stands for transabdominal peritoneal patch. The best way of thinking about the laparoscopic approach is to imagine a hole in your windshield. Patching that hole from the outside is comparable to what happens during an open, anterior approach. The laparoscopic approach is like fixing that hole from the inside of the car. Same end result, just a different way of approaching it. We now have good evidence that laparoscopic inguinal hernia repair is comparable to the open approach in terms of recurrence rates. Moreover, there is also accumulating evidence that patients recover much quicker with the laparoscopic approach and are able to resume activities sooner. The problem is that you have to give the patient general anesthesia for these operations. It's also more expensive.
So who do you offer laparoscopic repair to?
Recurrent hernias and bilateral hernias are the best candidates for the laparoscopic approach. You don't want to have to dissect through previously disturbed tissue planes in recurrent hernias; the laparoscopic approach allows one to address the defect through fresh, undisturbed tissue. Bilateral hernias can be fixed simulataneously through the same laparoscopic incisions without much added operative time. I also consider laparoscopic hernia repair at patients request. Young athletes who want to get back to training as soon as possible seem to bounce back quicker with the laparoscopic technique. For run of the mill, unilateral inguinal hernia, I find it hard to justify laparoscopic repair. It's costlier and cardiovascular events are certainly increased anytime you subject a patient to general anesthesia. The open approach has a low recurrnce rate, allows the patient to go home the same day, and utilizes fewer resources. That's a tough combo to ignore.
How am I going to feel afterwards?
You're going to be sore. I usually write for prescription-strength pain medications for the first three to five days. Everyone recovers a bit differently. Some guys are ready for work in three days. Others need a bit more time. Some other things to expect: scrotal swelling, numbness over the incision, burning with urination, and prickling sensations that radiate into the upper leg. Almost universally, these issues are self limited and will resolve with time.
Any restrictions afterwards?
No lifting anything more than 25 pounds for at least three weeks. Other than that I encourage resumption of normal activities as soon as possible. At six weeks, the scar tissue that forms will be about as strong as it ever will be, so until that time avoid power lifting or any similar ultra-strenuous activities.