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5/5/2015 Treatment of Hernias

http://fitsweb.uchc.edu/student/selectives/Luzietti/hernia_treatment.htm 1/5

Treatment

General

Unfortunately, hernias are not typically amenable to medical therapy. Occasionally, for an uncomplicated hernia (not incarcerated orstrangulated), palliation can be maintained with the use of a truss (a fist-sized ball of leather, rubber, or fabric) that is fastened in place over thehernia bulge. However, since hernia defects never close spontaneously,the use of a truss only prolongs the problem, leading to a greater chanceof possible incarceration later. Thus, early diagnosis and surgical repairof hernias is the mainstay of treatment.

The repair of a hernia is conceptually simple. Regardless of the type(inguinal, femoral, ventral, etc.), the goal is to return the herniatedcontents to their anatomic position and restore the continuity of the abdominal wall.

Surgical Repair

The surgical repair of hernia is known as herniorrhaphy. It involves making a small incision over thehernia, pushing the bulging tissue back into place and removing the hernia sac. The muscles or similartissues are then sewn together firmly over the hernial orifice. As described below, there are a numberof open repairs that have been created, some which are still used today.

Typical recovery time to return to normal activities is four to six weeks for hernias resulting from stressor strain. The chance that the hernia will reappear can be as much as 10-15 percent. The surgery isusually performed on an outpatient basis, but rarely the physician will recommend a one or two daystay.

Bassini Repair

Until recently, the Bassini repair was the most widely used surgical repair of inguinal hernias. In thissuperficial repair, the external oblique aponeurosis is opened over the inguinal canal and the spermaticcord is visualized. Any indirect hernia sac is ligated under direct vision at the level of the internal ring.Originally a triple layer repair was performed where the transversalis fascia was opened and includedwith the internal oblique muscle and transverse abdominus aponeurosis and fascia and sewn to theiliopubic tract and inguinal ligament. Most surgeons do not incise the transversalis fascia and include itin this repair and subsequently use a variation of the original procedure. Suture line tension probablyaccounts for most recurrences after the Bassini repair.



McVay (Cooper's Ligament) Repair

The McVay Repair requires that the medial portion of the iliopubic tract be excised to expose themedial edge of the femoral sheath and iliopectineal (Cooper's) ligament for the placement of sutures.This repair always requires a relaxing incision at the point of fusion of the external oblique aponeurosisand the anterior rectus sheath to reduce tension. The repair begins at the pubic tubercle by anchoringthe transverse abdominus aponeurosis and the transversalis fascia to Cooper's ligament. This line ofsutures is carried to the femoral sheath. The repair is then continued laterally using the iliopubic tractto anchor the transversalis fascia and transverse abdominus aponeurosis. The suture line is continueduntil the internal ring reapproximation admits only a fingertip alongside the spermatic cord. The cordstructures are replaced in the normal anatomical position within the inguinal canal and the externaloblique aponeurosis is closed over the cord.

Shouldice Repair

The Shouldice repair can be thought of as a combination of a Bassini and McVay repair. First, thetransversalis fascia is divided from the internal inguinal ring to the pubic tubercle. The posterior wallrepair is accomplished by imbricating the lateral and medial leaves of the divided transverseaponeurotic fascial fibers with a continuous suture. The superomedial flap is brought over theinferolateral flap. The first suture line begins at the pubic tubercle and is sewn in a continuous fashionup to the internal ring, suturing the free edge of the inferolateral flap to the underside of thesuperomedial flap. At the internal inguinal ring, the cranial portion of the cremaster may be included inthe suture line. This gives additional strength to the internal inguinal ring. The suture line is thendoubled back bringing the leading edge of the superomedial flap to the edge of the inguinal ligament.The lacunar ligament is included in this suture line to obliterate the dead space medial to the femoralvessels. A second suture, beginning at the internal ring, brings the internal oblique and transversusmuscles down to the deep surface of the inguinal ligament. At the level of the pubic bone, this suturedoubles back, attaching the same structures in a more superficial plane and the suture is tied to itself atthe internal ring.



Tension Free (Mesh) Repairs

The use of synthetic sheets of meshed material (mainly polypropylene (Marlex) andpolytetrafluoroethylene (Gore-Tex)) was made popular by Lichtenstein around 1976. He began usingmesh in all primary hernia repairs mainly as prophylaxis against recurrent direct herniation followingrepair for indirect herniation. Because of their space filling properties, these materials not only providestrength to the repair, but also release tissue tension on anatomic structures.

Available as patches, plugs, or customized patterns, these materials do not alter the anatomic features ofthe repair and do not require the use of tension on adjacent structures. An onlay patch is placed on theanterior surface of the posterior wall of the inguinal canal from the pubic tubercle to above the internalring. A slit made in the mesh permits egress of the spermatic cord and the tails of the mesh areoverlapped. Some surgeons also place a mesh plug (similar to a badminton shuttlecock) into theinternal ring as reinforcement. Over time the muscles and tendons send out fibrous tissue which growsaround and through the mesh.

Although the infection rate using mesh does not appear to be increased over older methods, an infectionwhich does involve these materials can be severe, and warrant mesh removal.

This surgery is also an outpatient procedure, and usually takes less than an hour. After about 45minutes it is quite common for the patient to be able to get up, go up and down stairs, go for a walk,and even ride an exercise bicycle. Returning to normal activity depends upon a number of factors.Typically the patient can return to "office" routines in about three days and "physical" occupationswithin two weeks.



Laparoscopic Repairs

The latest addition to the general surgeons armamentarium for hernia repair has been the introductionof laparoscopy. Like tensionless repairs, laparoscopic methods have been developed in an effort toreduce the long term recurrence rate of an anterior repair while improving the short term disability.

Today, most laparoscopic herniorrhaphies are performed using either the transabdominal preperitoneal(TAPP) approach or the total extraperitoneal (TEP) approach. The TAPP approach involves placinglaparoscopic trocars in the abdominal cavity and approaching the inguinal region from the inside. Thisallows the mesh to be placed and then covered with peritoneum. While the TAPP approach is astraightforward laparoscopic procedure, it requires entrance into the peritoneal cavity for dissection.Consequently, the bowel or vascular structures may be injured during the procedure.

In the TEP procedure, an inflatable balloon is insufflated in the preperitoneal (aka extraperitoneal)space of the inguinal region, so as to push the peritoneum posteriorly, creating a working space for thelaparoscope. The repair is similar to the TAPP approach, except that the peritoneum is never entered,eliminating risk of injury to the bowel.

In both the TAPP and TEP approaches, the hernia sac is reduced, and a large piece of mesh is placedover the area in order to cover any indirect, direct, or femoral hernia found. The mesh can be held inplace using staples, or by the pressure of the peritoneum alone (after removing the balloon).

The laparoscopic approach has several advantages over previous repairs. They include smallerincisions, less pain and disability, a quicker return to work, and less recurrence.

Others

Other hernia repairs (ventral, umbilical, femoral, etc.) are done in similar fashion to inguinal repairs. They can be done open (via laparotomy) or laparoscopically. Similarly, they can be closed primarilywith sutures or via tension-free techniques with mesh. A photo of a laparoscopic, ventral repair usingmesh is shown below.



Complications

Complications following hernia repair differ among various the different operative procedures. Ingeneral, they include hemorrhage, injury to the vas, nerve injury, bladder injury, wound infection andrecurrence.

Hemorrhage during herniorrhaphy commonly may occur from the pubic branch of the obturator artery,the inferior deep epigastric vessels, the deep circumflex iliac vessels, the cremasteric artery, and theexternal iliac vessels. Injury to all but the external iliac vessels can be ligated because of extensivearterial collateralization.

In addition, injury to nerves in the area (particularly the ilioinguinal nerve) can cause pain in the L1dermatome (see Anatomy section on previous page).

Recurrence is probably the most common postoperative complication following repair of inguinalhernia. Representative recurrence rate after three to six years are 1-5% for indirect inguinal hernias, 2-8% for direct inguinal hernias, and 2-20% for recurrent inguinal hernias. Factors that determinerecurrence rate include missed hernias, technical errors, suture line tension, and biologic factors such ascollagen turnover and deposition.

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