Hernia repair

Overview

Abdominal hernias are described as the abnormal protrusion of intra-abdominal contents through congenital/acquired sites of abdominal wall weakness. Anatomically, abdominal hernias are categorized into four types: ventral hernias (e.g., epigastric, umbilical, and incisional hernias), groin hernias (inguinal and femoral hernias), pelvic hernias (obturator, sciatic, and perineal hernias), and flank/lumbar hernias.

Consistently elevated intra-abdominal pressure (e.g., ascites, pregnancy, intra-abdominal tumors, chronic cough, etc.) raises the likelihood of developing an abdominal hernia.

Hernia repairs are one of the most common procedures performed in the UK. Most hernias can only be repaired surgically, which can ease your discomfort while also preventing more serious consequences from occurring.

Open surgery or laparoscopic surgery can be used to repair the defect. Open surgery has the advantage of being able to be performed under local anesthetic rather than general anesthesia. Following laparoscopic surgery, patients often experience less discomfort. A hiatus hernia can be addressed with lifestyle modifications such elevating the head of the bed, losing weight, and changing eating habits. H2 blockers and proton pump inhibitors are two drugs that may be beneficial. If drugs do not alleviate the symptoms, a procedure called as laparoscopic Nissen fundoplication may be a possibility.

Are hernias common among general population?

About 27% of males and 3% of females develop a groin hernia at some time in their lives. In 2013 about 25 million people had a hernia. Inguinal, femoral and abdominal hernias resulted in 32,500 deaths globally in 2013 and 50,500 in 1990.

What are the types of hernias?

When an organ or tissue pushes through a weak point in the surrounding tissue or muscle, this is referred to as a hernia. This frequently occurs via the abdominal wall. You may detect a swelling or lump in the affected region. Hernias are classified according to where they are located in your body. Here are a few examples of the most common types:

Inguinal hernia: Inguinal hernias are by far the most common hernias (up to 75% of all abdominal hernias), which are further classified into the more common indirect inguinal hernia, in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia, in which the hernia contents push through a weak spot in the back wall of the inguinal canal In both men and women, inguinal hernias are the most prevalent kind of hernia. In some circumstances, surgery may be necessary.
Femoral hernia: When abdominal contents enter into the weak region at the posterior wall of the femoral canal, a femoral hernia develops right below the inguinal ligament. They can be difficult to identify from inguinal hernias (particularly when ascending cephalad), although they normally seem more rounded, and, unlike inguinal hernias, femoral hernias have a significant female preponderance. Strangulation is a common complication in femoral hernias. Repair procedures for femoral and inguinal hernias are comparable. Cooper's hernia is a type of femoral hernia that has two sacs, one in the femoral canal and the other flowing via a gap in the superficial fascia and emerging virtually immediately beneath the skin.
Umbilical hernia: They involve the protrusion of intra-abdominal contents due to a weakness at the site of the umbilical cord's passage through the abdominal wall. Adults with umbilical hernias are mostly acquired, and they are more common in obese or pregnant women. Fiber decussation at the linea alba may be a significant factor.
Incisional hernia: An incisional hernia develops as a result of an incompletely healed surgical wound. Ventral hernias are those that arise in median laparotomy incisions in the linea alba. Because the repair uses already attenuated tissue, they might be the most aggravating and toughest to cure. These occur in around 13% of persons two years after surgery.
Diaphragmatic hernia: An (internal) "diaphragmatic hernia" occurs higher in the abdomen when part of the stomach or intestine protrudes into the chest cavity through a hole in the diaphragm. A hiatus hernia is a type of hernia in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional "defect," allowing part of the stomach to "herniate" into the chest on a regular basis. Hiatus hernias can be sliding (the gastroesophageal junction slides through the defect into the chest) or non-sliding (also known as para-esophageal), in which the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding hernias, also known as para-esophageal hernias, can be harmful because they allow the stomach to rotate and block. Repair is typically recommended.
Epigastric hernias: these hernias develop in the centre of your body, between your belly button and breastbone.

Why do I need a hernia repair?

Sometimes a hernia can simply be pushed back into place. However, you will soon be unable to do so. The majority of hernias require surgery to be repaired permanently. Hernia repair surgery is putting the lump back into place and mending the weak region in your muscular wall with sutures or mesh to prevent it from happening again.

If a hernia is not corrected, it might become strangulated. This indicates that the hernia's contents are totally confined, and the blood supply is decreased or shut off. This can cause the tissue to get infected or die, as well as other issues. This is then considered an emergency.

How to get a hernia repair?

A hernia repair can be done privately or on the NHS. Many private health care providers deliver hernia treatment as soon as possible. Check your health insurance to see if hernia repair is covered.

The NHS has different criteria and waiting times for hernia repair depending on where you reside. For example, in some areas, hernia repair may be available only if the hernia is growing in size or displaying signs of strangulation. If you have a strangulated hernia, it is considered a medical emergency.

What are preoperative precautions of hernia repair?

It is critical that you are as healthy as possible prior to hernia repair surgery. If you smoke, it is preferable to quit before the operation. It's also a good idea to shed any excess weight and keep a healthy diet if feasible. Maintaining physical activity before to surgery is also recommended.

Depending on the type of hernia, a hernia repair may be performed under local or general anesthesia. Your surgeon will tell you which and whether there are any pre-operative instructions you must follow. You may be able to leave the hospital on the day of your hernia repair, but this will depend on the type of procedure. Large hernias or more difficult surgeries may need a few days in the hospital. You'll need to arrange for someone to drive you home.

What happens during hernia repair surgery?

Surgical repair for most types of hernia can be done by any one of the following procedures:

Truss:

The advantages of using an external device to sustain hernia reduction without fixing the underlying defect (such as hernia trusses, trunks, belts, and so on) remain uncertain.

Surgery:

Some hernias require surgery to prevent problems such as bowel obstruction or tissue strangulation, but umbilical hernias and hiatus hernias can be observed or treated with medication. Most abdominal hernias can be corrected medically, although surgery entails risks. When hernias are operated on laparoscopically, the time required for recovery following treatment is shortened. However, open surgery can occasionally be performed without the need of general anesthetic. Robot-assisted hernia surgery is also gaining favor as a safe alternative to open surgery.

Uncomplicated hernias are primarily repaired by pushing back the herniated tissue, or "reducing," and then repairing the weakening in muscular tissue (an operation called herniorrhaphy). If difficulties arise, the surgeon will assess the viability of the herniated organ and, if required, remove a part of it.

Synthetic materials are often used in muscle reinforcement treatments (a mesh prosthesis). The mesh is either put over the defect (anterior repair) or beneath the defect (posterior repair). Staples are sometimes used to keep the mesh in place.

These mesh repair procedures are sometimes referred to as "tension free" repairs because, unlike certain suture methods, muscle is not pushed together under tension. However, this often used nomenclature is deceptive because there are various tension-free suture procedures that do not include mesh (e.g., Desarda, Guarnieri, Lipton-Estrin, etc.).

When compared to tension suture procedures, evidence shows that tension-free methods (with or without mesh) have a lower rate of recurrences and a shorter recovery duration. However, prosthetic mesh use appears to have a greater frequency of chronic discomfort and can potentially induce infections, among other potential consequences.

How inguinal hernia can be repaired?

Inguinal hernias require surgical repair as the only choice. All symptomatic inguinal hernias should be corrected whenever possible. Watchful waiting may be an option in certain asymptomatic or minorly painful hernias. There are several procedures for hernia repair, each with its own set of complications and recurrence rates.

Open Approach

1. Tissue Repairs:

Tissue repairs are those in which suture is utilized to seal the hernia defect and no mesh is employed. These repairs are used when the operating field is polluted or when the viability of the hernia contents is in doubt. The Bassini, Shouldice, and McVay are the three basic fundamental tissue repairs. When competent surgeons execute tissue repairs on the Shouldice, the recurrence rate is the lowest. McVay is the only procedure that can be utilized to treat a femoral hernia. Because a primary repair is likely to be the only choice in a contaminated case, all surgeons should be well-versed in the technical elements of these surgeries.

2. Prosthetic Repairs:

Because prosthetic repairs are tension-free, they have a lower hernia recurrence rate than tissue repairs. The Lichtenstein tension-free repair, plug and patch, and Prolene Hernia System are the prosthetic repairs (PHS). Lichtenstein repair is the most common and widely utilized all over the world. The Prolene Hernia System repair is the only one of the three that uses an open repair to implant a mesh in the preperitoneal area. Due of the high probability of infection, mesh repairs are not recommended in a polluted field.

Laparoscopic Repairs

1. Transabdominal Preperitoneal Procedure (TAPP):

Transabdominal preperitoneal surgery TAPP is a hernia repair procedure that uses an intraperitoneal approach. TAPP can be used to treat bilateral hernias, massive hernia defects, and recurrence following open surgery. With this method, a huge mesh encompassing the direct, indirect, and femoral spaces may be inserted. The disadvantage of this method is that it might cause complications with other intraperitoneal viscera and structures. For laparoscopic procedures, the patient must be able to tolerate pneumoperitoneum.

2. Total Extraperitoneal Procedure (TEP):

The laparoscopic extraperitoneal surgery is a hernia repair approach that does not need intraperitoneal infiltration. When compared to a TAPP repair, this reduces the chance of harm to intraperitoneal viscera and structures. The TEP method also eliminates intraperitoneal adhesions caused by previous surgery, making the dissection faster and simpler. The downside of the TEP method is that the surgeon is confined to a small amount of area during dissecting. When compared to TAPP repair, visualization of the surrounding anatomy is limited. If the peritoneum is breached during the surgery, conversion to TAPP may be necessary.

When compared to open procedures, laparoscopic repairs had the same recurrence rate. In comparison to open repair, the laparoscopic method has been found to reduce postoperative discomfort and allow patients to resume regular activities sooner. Laparoscopic repair, on the other hand, is associated with increased operation expenses, and technical expertise might be difficult to obtain. According to some research, a surgeon may need as many as 250 laparoscopic hernia repairs before achieving optimum proficiency.

Prevention of hernia recurrence

The type of hernia affects whether and how it may be prevented. It's a good idea to limit strain from things like moving heavy objects after surgery at initially to prevent incisional hernias. A synthetic mesh can be used as a prophylactic strategy if the risk of recurrence is very high.

Losing weight can reduce the likelihood of incisional and umbilical hernias .However, losing weight will not reduce the likelihood of inguinal hernias. It is unclear if carrying large things increases the risk of inguinal hernias.

Stopping smoking can help surgical wounds heal better, which probably lowers the risk of incisional hernias. It is also important to make sure that medical conditions like diabetes and anemia are treated properly because they can affect how well wounds heal too.

Recovery and what to expect after hernia repair?

You will most likely experience some pain and discomfort while recovering after hernia repair. You will be given pain medication to help you deal with this. To avoid constipation and straining, you may be recommended to consume a high-fiber diet as well as stool softeners and laxatives.

You can gradually increase your activities, including returning to work, when you feel ready. But don't push yourself too hard — it might take many weeks to fully heal. For at least six weeks, you should avoid intense activity and heavy lifting.

Complications of hernia repair

Every surgical procedure has some level of risk of complications. These will differ based on the specific procedure you are having. However, some of the most frequent complications associated with hernia repair are listed below.

Difficulty passing urine after surgery (urinary retention).
Collection of blood or fluid in the tissues. It is possible that you will require treatment to get rid of this.
Your hernia might reappear. If your surgeon utilized mesh in your repair, this is less likely.
Injuries to other organs, such as the bowel. During the procedure, your surgeon may be able to correct this.
Chronic discomfort following surgery, this is a specific issue with inguinal hernia.
Infection of your wound or the mesh utilized during the procedure.
Complications of any operation can include allergic reactions to the anaesthetic and blood clots developing in your legs or lungs.

Hernia repair costs and fees

Hernia repair is frequently covered by private medical insurance. Check with your insurance company to see if they will cover it.

You can also choose to pay for this procedure yourself. An initial consultation with the surgeon will typically cost between £150 and £250. The cost of hernia surgery will vary based on the type of hernia and the specific surgery required. Hernia repair expenses vary based on where you reside in the UK. If you proceed with the procedure, you will be given one of the following options:

An all-inclusive ‘package price’, where you know the full costs before undergoing treatment. Not all consultants and hospitals offer this.
A ‘fee-per-service’ deal, where you receive different invoices from the surgeon, the anaesthetist and the hospital. You often won’t know the full costs until you receive the invoices.

Conclusion

In 2013 about 25 million people had a hernia. Inguinal, femoral and abdominal hernias resulted in 32,500 deaths globally in the same year.

A hernia is the abnormal protrusion of tissue or organs, such as the intestine, through the wall of the cavity in which they ordinarily reside. Hernias of several types can develop, with the most frequent affecting the abdomen and, more especially, the groin. Groin hernias are most usually inguinal, but they can also be femoral.

Smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and prior open appendectomy are all risk factors for hernia formation. Hernias are hereditary and occur more often in some families.

Male groin hernias that do not produce symptoms do not require correction. Repair, on the other hand, is often suggested in women due to the larger occurrence of femoral hernias, which are more complicated. Strangulation necessitates emergency surgery.