Hernia Repair

Hernias of the abdominal wall 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. 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 groin is one of the natural weak areas in the abdominal wall. t is the
most common site for abdominal herniation. The abdominal wall is made
up of three layers of muscle, fat and other tissue that surround the
abdomen. There is a tough tissue layer, the fascia that envelops each of
these muscles in the abdominal wall. 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. #uring development the spermatic cord penetrates the
abdominal wall through an opening called the internal inguinal ring. The
cord then runs obliquely through the inguinal canal to e$it the abdominal
wall through the e$ternal inguinal ring near the scrotal sac. A similarly
placed cord, the round ligament, is found in females.
Causes of Hernia
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, in%ury, 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 ob%ects.
Types of Hernia
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. nguinal
hernias can be ndirect' the hernia sac e$its through the internal
inguinal ring and takes an oblique path, or direct' the hernia sac
e$its through the e$ternal inguinal ring directly
Femoral Hernia occur at the top of the thigh in the space
through which the femoral artery, vein, and nerve pass into the
thigh. These hernias occur most often in women and commonly
result from pregnancy and childbirth
Umbilical hernias occur in the umbilicus !belly button" and occur
most often in infants
Incisional hernias occur at the site of previous abdominal
surgery
Symptoms and Clinical Presentation
Some patients with hernias are unaware of their presence until the
hernias are pointed out to them. The patient may notice a bulge under
the skin without any associated symptoms. Symptomatic hernias produce
a wide variety of nonspecific symptoms.
#iscomfort related to the contents of the hernia sac and pressure
of the sac on the surrounding tissue
(ain when lifting a heavy ob%ect, coughing, or straining during
urination or bowel movement. n some cases the pain is a dull
ache that gets worse towards the end of the day after standing
for long periods of time and is relieved at night when you lie
down and the hernia reduces !goes back in"
)ost hernias are reducible. The contents of the hernia sac can be
squee*ed back into the abdominal cavity without difficulty. f the hernia
remains bulging for a long time or the contents of the hernia are crowded,
then it may be difficult to reduce the hernia. This is an obstructed or
incarcerated hernia. f the hernia continues to be obstructed for some
time then the contents of the hernia, which is most commonly bowel, will
become swollen and there will be compromise of the blood supply to the
bowel. This is called a strangulated hernia and is a surgical emergency.
Diagnosis
Hernias are usually easy to diagnose on physical e$amination. Typically,
a hernia sac with its contents enlarges and transmits a palpable impulse
when strain or cough. Hernias, undetectable by physical e$amination,
can be demonstrated using ultrasound, +T scan !computeri*ed
tomography", or ), !nuclear magnetic resonance imaging". A hernia
that strangulates produces intense pain in the hernia followed by marked
tenderness. -ecause of intestinal obstruction, there is abdominal pain
and vomiting.
Indications for Surgery
There are two reasons for hernia surgery. /
+orrect or prevent a dangerous strangulated hernia, and /
0liminate the pain that may be interfering with normal activity
n general, all hernias should be repaired unless there are other
conditions in the patient that preclude a safe outcome. Trusses and
surgical belts are helpful in the management of small hernias when
surgery is contraindicated.
Surgical Repair
A hernia repair is usually done on an outpatient basis. Typically, the
procedure takes less than an hour to complete. )ost patients are fully
ambulatory and able to go home after about two to four hours.
Inguinal hernia
An inguinal hernia is repaired by first making an incision %ust above the
crease where the abdomen meets the thigh. The inguinal canal is
opened, the hernia sac separated from the spermatic cord, lifted and
opened. ntestine or other tissue is then placed back into the abdominal
cavity. The e$cess sac is tied off and removed. The opening at the
internal ring may be tightened and the abdominal wall reinforced using
sutures to bring together the neighboring tissues without tension !1igures
2 3 4".
1igure 2 & The inguinal canal is opened, the hernia sac
separated from the spermatic cord and tied off.
1igure 4 & The tissues are reinforced with sutures to
strengthen the abdominal wall.
A synthetic mesh and plug may be used to repair the hernia. The tapered
shape of the plug eases insertion into the defect and fills the 5hole5 much
like a cork in a bottle. A second piece of flat mesh is placed over the plug
to help prevent future hernias at the same site. Another way of repairing
the hernia is through the laparoscope. The laparoscope is introduced
through a small incision at the navel. 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.
(ostoperatively the patient may e$perience local wound pain, scrotal
swelling, retention of urine, or bruising. These are temporary problems
and will resolve eventually.
Femoral hernia
The skin incision for a femoral hernia is similar to that for an inguinal
hernia. The hernia sac is lifted and opened. ntestine or other tissue is
then placed back into the abdominal cavity. The e$cess sac is tied off and
removed. 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
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. 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
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. The umbilical weakness is tightened with sutures or reinforced
with synthetic mesh and the navel is returned to its normal position. The
skin incision is closed with staples or sutures.
Complications
+hronic pain may result from surgical handling of the sensory
nerve in the groin area during surgery, or after surgery from
constricting scar tissue
nfection
Hemorrhage
schemic orchitis due to thrombosis of the spermatic cord and
venous congestion produces pain and swelling /
,ecurrence of the hernia due to e$cessive tension during repair,
inadequate tissue, inadequate repair, and overlooked hernias.
,ecurrence rates are 2&67
Reco!ery

1ollowing surgery you may be given medication to relieve pain in
the area of your incision. t 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 ob%ects that
you can manage easily. 8eep your back straight, and allow your
legs to do most of the work.
#riving may strain your incision. Ask your physician when you
can drive. #on5t 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. f necessary
ask your doctor about using a stool softener
9our doctor will let you know when it is okay to work again. f you
have a desk %ob, you may be able to go back to work within a
week or two. f your %ob requires more physical activity, you may
have to wait longer
9our doctor may schedule a follow&up visit in about a week.
#uring the visit, your doctor will remove stitches or staples, if
necessary, and check the progress of healing
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