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Home  ›  What Is The Most Successful Method To Repair An Inguinal Hernia

What Is The Most Successful Method To Repair An Inguinal Hernia

Written By Tuesday, 5 April 2022 Add Comment Edit

Medical procedure

Inguinal hernia surgery
Right Inguinal Hernia.JPG

Open surgical repair of a right inguinal hernia
Specialty gastroenterology

[edit on Wikidata]

Inguinal hernia surgery is an functioning to repair a weakness in the intestinal wall that abnormally allows abdominal contents to sideslip into a narrow tube called the inguinal culvert in the groin region.

Surgery remains the ultimate treatment for all types of hernias as they will not become better on their own, however not all require immediate repair.[1] [ii] Constituent surgery is offered to nigh patients taking into account their level of pain, discomfort, degree of disruption in normal activity, as well as their overall level of health.[1] Emergency surgery is typically reserved for patients with life-threatening complications of inguinal hernias such as incarceration and strangulation. Incarceration occurs when intra-abdominal fat or pocket-size intestine becomes stuck inside the canal and cannot slide back into the abdominal cavity either on its own or with manual maneuvers. Left untreated, incarceration may progress to bowel strangulation equally a result of restricted blood supply to the trapped segment of small intestine causing that portion to die.[3] Successful outcomes of repair are usually measured via rates of hernia recurrence, pain and subsequent quality of life.[four]

Surgical repair of inguinal hernias is 1 of the most commonly performed operations worldwide and the almost ordinarily performed surgery within the United States. A combined twenty million cases of both inguinal and femoral hernia repair are performed every yr around the world with 800,000 cases in the US as of 2003. The UK reports around 70,000 cases performed every year.[5] Groin hernias account for almost 75% of all intestinal wall hernias with the lifetime risk of an inguinal hernia in men and women being 27% and 3% respectively. Men business relationship for nearly 90% of all repairs performed and accept a bimodal incidence of inguinal hernias peaking at ane year of age and again in those over the historic period of 40. Although women account for roughly 70% of femoral hernia repairs, indirect inguinal hernias are still the most mutual subtype of groin hernia in both males and females.[6]

Indications for surgery [edit]

Lodge guidelines recommend that indications for surgery take into business relationship the severity of symptoms, the type of hernia, previous surgeries, hernia size, bowel incarceration (bowel tin no longer render to the abdomen) and the overall general wellness of the person.[four] [1] [7] [viii]

Not-urgent repair [edit]

Constituent surgery is planned in order to help relieve symptoms, respect the person'due south preference, and forbid future complications that may require emergency surgery.[9] [ten]

Surgery is offered to the majority of people who:

  • have symptoms that interfere with their normal level of action.[7] [2]
  • accept hernias that go increasingly difficult to reduce.[2] [7]
  • are female person as it is oftentimes difficult to classify the subtype of hernia based on an exam alone.[2] [7]

Symptomatic hernias tend to crusade pain or discomfort within the groin region that may increase with exertion and improve with rest. A swollen scrotum within males may coincide with persistent feelings of heaviness or generalized lower abdominal discomfort. The sensation of groin pressure tends to exist near prominent at the end of the day besides as after strenuous activities. Changes in sensation may be experienced along the scrotum and inner thigh.[11]

Urgent repair [edit]

A hernia in which the small intestine has become incarcerated or strangulated constitutes a surgical emergency. Symptoms include:[9] [3] [11]

  • Fever
  • Nausea and vomiting
  • Farthermost pain in the expanse of the hernia
  • Warm hernia bulge with surrounding skin redness
  • Can no longer laissez passer gas or stool

Surgical repair within 6 hours of the above symptoms may be able to save the strangulated portion of the intestine.[ii]

Contraindications to surgery [edit]

The person with the hernia should be given an opportunity to participate in the shared decision-making with their physicians as almost all procedures carry significant risks. The benefits of inguinal hernia repair tin can go overshadowed past risks such that elective repair is no longer in a person'south all-time interest. Such cases include:[xi] [2] [4]

  • People with unstable medical conditions
  • Repair using mesh is withheld if a person has an active infection inside the groin or within the blood stream
  • Elective repair is delayed in pregnant women until four weeks afterwards delivery

Additionally, certain medical conditions tin foreclose people from being candidates for laparoscopic approaches to repair. Examples of such include:[nine] [2] [4]

  • People who are unable to undergo general anesthesia
  • Prior major open abdominal surgery
  • People who have ascites
  • Previous radiations therapy to the pelvis
  • A complex hernia

Surgical approaches [edit]

Techniques to repair inguinal hernias fall into ii broad categories termed "open" and "laparoscopic". Surgeons tailor their approach past taking into business relationship factors such as their own experience with either techniques, the features of the hernia itself, and the person's anesthetic needs.[9] [11]

The cost associated with either arroyo varies widely beyond regions, merely updated guidelines published by the International Endohernia Order (IES) bandage doubt on the comprehensiveness of toll comparison studies due in part to the complexity inherent in calculating costs beyond institutions.[ citation needed ] The IES asserts that hospital and societal costs are lower for laparoscopic repairs as compared to open approaches. They recommend the routine utilize of reusable instruments as well as improving the proficiency of surgeons to aid farther decrease costs as well as time spent in the OR.[12] However, as an example, the United kingdom's National Health Service spends £56 one thousand thousand a twelvemonth in repairing inguinal hernias, 96% of which were repaired via the open mesh approach while only four% were done laparoscopically.[5]

Open up hernia repair [edit]

All techniques involve an approximate x-cm incision in the groin. Once exposed, the hernia sac is returned to the intestinal cavity or excised and the abdominal wall is very often reinforced with mesh.[3] In that location are many techniques that do not utilize mesh and have their own situations where they are preferable.[thirteen] [7]

Open repairs are classified via whether prosthetic mesh is utilized or whether the patient's own tissue is used to repair the weakness. Prosthetic repairs enable surgeons to repair a hernia without causing undue tension in the surrounding tissues while reinforcing the intestinal wall. Repairs with undue tension have been shown to increase the likelihood that the hernia will recur. Repairs non using prosthetic mesh are preferable options in patients with an above-boilerplate chance of infection such as cases where the bowel has become strangulated (blood supply lost due to constriction).[11]

One large benefit of this approach lies in its ability to tailor anesthesia to a person'due south needs. People tin can exist administered local anesthesia, a spinal block, as well as general anesthesia.[9] Local anesthesia has been shown to cause less pain after surgery, shorten operating times, shorten recovery times besides every bit decrease the need to return to the hospital. Nonetheless, people who undergo general anesthesia tend to exist able to go home faster and experience fewer complications.[xiv] [fifteen] [2] The European Hernia Society recommends the use of local anesthesia specially for people with ongoing medical conditions.[4]

Open up mesh repairs [edit]

Polypropylene mesh used for inguinal hernia surgery

Inguinal Hernia Patch. Animation in the reference.

Repairs that utilize mesh are commonly the get-go recommendation for the vast majority of patients including those that undergo laparoscopic repair.[4] Procedures that employ mesh are the about commonly performed equally they have been able to demonstrate greater results as compared to non-mesh repairs.[xi] Approaches utilizing mesh have been able to demonstrate faster return to usual action, lower rates of persistent hurting, shorter hospital stays, and a lower likelihood that the hernia volition recur.[16] [4] [17] [18] [19] [20] [ excessive citations ]

Options for mesh include either synthetic or biologic. Synthetic mesh provides the option of using "heavyweight" as well every bit "lightweight" variations according to the diameter and number of mesh fibers.[21] Lightweight mesh has been shown to have fewer complications related to the mesh itself than its heavyweight counterparts.[22] It was additionally correlated with lower rates of chronic pain while sharing the same rates of hernia recurrence as compared to heavyweight options.[23] [24] [25] This has led to the adoption of lightweight mesh for minimizing the chance of chronic pain later on surgery.[xi] Biologic mesh is indicated in cases where the risk of infection is a major concern such as cases in which the bowel has become strangulated. They tend to have lower tensile strength than their synthetic counterparts lending them to college rates of mesh rupture.[26]

Biomeshes are increasingly popular since their showtime use in 1999[27] and their subsequent introduction to the market place in 2003. Some accept a similar toll to high end synthetic meshes. They can be produced from absorbable, beast-sourced extra cellular matrix, or past other means. Synthetic absorbable meshes are too available.

Meshes fabricated of mosquito net cloth, in copolymer of polyethylene and polypropylene have been used for low-income patients in rural Bharat and Ghana.[28] Each slice costs $0.01, 3700 times cheaper than an equivalent commercial mesh.[29] [xxx] They give results identical to commercial meshes in terms of infection and recurrence rate at v years.[29]

Lichtenstein technique [edit]

The Lichtenstein tension-free repair has persisted every bit ane of the most commonly performed procedures in the world. The European Hernia Lodge recommends that in cases where an open approach is indicated, the Lichtenstein technique be utilized as the preferred method.[4] Recent studies take indicated that mesh attachment with the apply of adhesive glue is faster and less likely to cause postal service-op pain as compared to attachment via suture fabric.[31] [32] [33]

Plug and patch technique [edit]

The plug and patch tension-free technique has fallen out of favor due to higher rates of mesh shift along with its tendency to irritate surrounding tissue. This has led to the European Hernia Society recommending that the technique non be used in nigh cases.[4]

Other open mesh repair techniques [edit]

A variety of other tension-free techniques have been adult and include:[9] [11]

  • Prolene mesh system (PHS)
  • Kugel (preperitoneal repair)[34]
  • Stoppa
  • Trabucco (Hertra mesh)
  • Wantz
  • Rutkow/Robbins
  • Modified APP

Open up non-mesh repairs [edit]

Techniques in which mesh is not used are referred to as tissue repair technique, suture technique, and tension technique. All involve bringing together the tissue with sutures and are a viable culling when mesh placement is contraindicated.[nine] Such situations are most commonly due to concerns of contamination in cases where at that place are infections of the groin, strangulation or perforation of the bowel.[11] [2]

Shouldice technique [edit]

The Shouldice technique is the about constructive not-mesh repair thus making it 1 of the most commonly utilized methods.[sixteen] Numerous studies have been able to validate the decision that patients take lower rates of hernia recurrence with the Shouldice technique as compared to other not-mesh repair techniques.[35] However this method frequently experiences longer procedure times and length of hospital stay. Despite being the superior not-mesh technique, the Shouldice method results much higher rates of hernia recurrence in patients when compared to repairs that use mesh.[four] [35]

Bassini technique, first suture. one. Aponeurosis musculi obliq. ext.; 2. Musculus obliquus internus; 3. Musculus transversalis; four. Fascia transversalis; five. Peritoneum; vi. Ligamentum inguinale.

Bassini technique [edit]

The Bassini technique, described by Edoardo Bassini in the 1880s, was the starting time efficient inguinal hernia repair.[36] [37] In this technique, the conjoint tendon (formed by the distal ends of the transversus abdominis and internal oblique muscles) is approximated to the inguinal ligament and closed.[38]

Other open not-mesh techniques [edit]

The Shouldice technique was itself an evolution of prior techniques that had greatly advanced the field of inguinal hernia surgery. Such classic open non-mesh repairs include:[11] [9]

  • McVay technique
  • Halsted
  • Maloney darn
  • Plication darn
  • Desarda technique[39] A i–2 cm strip of the external oblique aponeurosis is stitched beneath to the inguinal ligament and in a higher place to the muscle arch without agonizing its continuity at either stop.No mesh inguinal hernia repair-By courtesy from world wide web.hernientage.de This gives immediate protection so no restrictions on activities is required. This is a very simple mesh free and tension costless repair based on the physiological principle with very depression recurrences and complications.[40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [l] [ excessive citations ]

Laparoscopic repair [edit]

Port sites for inguinal hernia repair

Intraoperative view past TEP Performance. 1. Genital ramus of genitofemoral nervus. two. Preperitoneal lipom and spermatic cord.

There are two master methods of laparoscopic repair: transabdominal preperitoneal (TAPP) and totally extra-peritoneal (TEP) repair. When performed by a surgeon experienced in hernia repair, laparoscopic repair causes fewer complications than Lichtenstein, particularly less chronic pain. Withal, if the surgeon is experienced in general laparoscopic surgery simply not in the specific discipline of laparoscopic hernia surgery, laparoscopic repair is not brash as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. All that said, many surgeons are shifting to using laparoscopic techniques equally they require smaller incisions, and result in less bleeding, lower infection rates, faster recovery, shorter hospitalization periods, and reduced chronic pain.[51] [52]

Laparoscopic mesh surgery, as compared to open mesh surgery
Advantages Disadvantages
  • Quicker recovery[52] [53]
  • Less pain during the first few days following the procedure[52]
  • Fewer postoperative complications[53] such as infections, bleeding and seromas[52]
  • Lower take a chance of chronic pain[52]
  • Needs a surgeon who is highly experienced in inguinal hernia repair (>200 operations/twelvemonth)[ commendation needed ]
  • Longer operation time[53]
  • Increased recurrence of primary hernias if a surgeon is not experienced enough[53]

Recurrence rates are identical when laparoscopy is performed past an experienced surgeon.[52] When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than later Lichtenstein.[54]

Non-surgical management [edit]

Studies have demonstrated that men whose hernias cause fiddling to no symptoms tin can safely continue to delay surgery until a time that is about convenient for patients and their healthcare team. Inquiry shows that the hazard of inguinal hernia complications remains under 1% within the population.[55] [10] [1] [11] Watchful waiting requires that patients maintain a shut follow-up schedule with providers to monitor the class of their hernia for any changes in symptoms and tin can be safely offered for up to 2 years.[56] [3]

Patients who practice elect watchful waiting eventually undergo repair within v years as 25% will experience a progression of symptoms such as worsening of pain. Constituent repair discussions should be revisited if patients begin to avoid aspects of their normal routine due to their hernia.[iv] [57] [2] Subsequently 1 year information technology is estimated that sixteen% of patients who initially opted for watchful waiting will eventually undergo surgery. Furthermore, 54% and 72% will undergo repair at 5-year and vii.5-year marks respectively.[58] [7]

The utilize of a truss is an additional non-surgical choice for men. It resembles a jock-strap that utilizes a pad to exert pressure at the site of the hernia in order prevent circuit of the hernia sack. Information technology has piffling evidence to support its routine use and has non been shown to prevent complications such as incarceration (bowel can no longer slide back into abdomen) or strangulation of bowel (constriction causing loss of blood supply). However some patients practise written report a soothing of symptoms when utilized.[ citation needed ]

Complications and prognosis [edit]

Inguinal hernia repair complications are unusual, and the process as a whole proves to be relatively safe for the bulk of patients. Risks inherent in almost all surgical procedures include:[i]

  • bleeding
  • infection
  • fluid collections
  • damage to surrounding structures such as blood vessels, nerves, or the bladder
  • urinary retention requiring a catheter

Risks that are specific to inguinal hernia repairs include such things as:[ane] [7] [11]

  • recurrence of the hernia
  • impairment of sexual activity, such as genital or ejaculatory pain[59]
  • in males, injury to the tube that conveys sperm from the testicle to the penis
  • in males, bruising and swelling of the scrotum
  • chronic regional pain (also known every bit mail service-herniorrhaphy inguinodynia, or chronic postoperative inguinal pain)

Post-herniorraphy hurting syndrome [edit]

Post-herniorrhaphy inguinodynia is a status where x-12% of patients experience severe pain afterwards inguinal hernia repair, due to a complex combination of unlike forms of pain signals.[60] [61] [4] It can occur with any inguinal hernia repair technique, and if unresponsive to pain medications, further surgical intervention is often required.[62] Removal of the implanted mesh, in combination with bisection of regional fretfulness, is commonly performed to address such cases.[63] [64] [65] In that location remains ongoing word amongst surgeons regarding the utility of planned resections of regional nerves as an endeavor to prevent its occurrence.[65] [66]

Mortality rates [edit]

Bloodshed rates for non-urgent, elective procedures was demonstrated equally 0.one%, and around 3% for procedures performed urgently.[67] [2] Other than urgent repair, run a risk factors that were as well associated with increased mortality included existence female person, requiring a femoral hernia repair, and older age.[68] [69] [70]

Follow-up [edit]

Upon enkindling from anesthesia, patients are monitored for their ability to drink fluids, produce urine, equally well equally their ability to walk after surgery. Near patients are then able to return dwelling one time those conditions are met.[7] It is not uncommon for patients to experience residual soreness for a couple of days after surgery.[71] [13] Patients are encouraged to brand stiff efforts in getting up and walking around the day after surgery.[4] Well-nigh patients can resume their normal routine of daily living inside the week such as driving, showering, calorie-free lifting, also every bit sexual action.[1] Long piece of work absences are rarely necessary and length of sick days tend to be dictated by respective employment policies.[four] [two]

In general, it is not recommended to administer antibiotics as prophylaxis after elective inguinal hernia repair. However, the rate of wound infection determines the appropriate use of the antibiotics.[72]

Mail-op development of any of the following should warrant timely reporting via telephone:[13] [7]

  • fever greater than 39C/101F
  • progressive swelling of the surgical site
  • severe pain
  • recurring nausea or vomiting
  • worsening redness around incisions
  • drainage of pus from incisions
  • difficulty or lack of producing urine
  • new-onset shortness of breath

Prevention and screening [edit]

Well-nigh indirect inguinal hernias in the abdominal wall are not preventable. Straight inguinal hernias may be able to exist prevented by maintaining a healthy weight, refraining from smoking, preventing straining during bowel movements, and maintaining proper lifting techniques when heavy lifting.[7] [1] There is no evidence that indicates physicians should routinely screen for asymptomatic inguinal hernias during patient visits.[73]

References [edit]

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Source: https://en.wikipedia.org/wiki/Inguinal_hernia_surgery

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