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Surgical procedures
In open inguinal hernia repair procedures, the patient
is typically given a light general anesthesia of short duration. Local or
regional anesthetics may be given to some patients. Open surgical repair of an
indirect hernia begins with sterilizing and draping the inguinal area of the
abdomen just above the thigh. An incision is made in the abdominal wall and
fatty tissue removed to expose the inguinal canal and define the outer margins
of the hole or weakness in the muscle. The weakened section of tissue is
dissected (cut and removed) and the inguinal canal opening is sutured closed
(primary closure), making sure that no abdominal organ tissue is within the
sutured area. The exposed inguinal canal is examined for any other trouble spots
that may need reinforcement.
Closing the underlayers of tissue
(subcutaneous tissue) with fine sutures and the outer skin with staples
completes the procedure. A sterile dressing is then applied. An open repair of a
direct hernia begins just as the repair of an indirect hernia, with an incision
made in the same location above the thigh, just large enough to allow
visualization of the hernia. The surgeon will look for and palpate (touch) the
bulging area of the hernia and will reduce it by placing sutures in the fat
layer of the abdominal wall. The hernial sac itself will be closed, as in the
repair of the indirect hernia, by using a series of sutures from one end of the
weakened hernia defect to the other.
The repair will be checked for
sturdiness and for any tension on the new sutures. The subcutaneous tissue and
skin will be closed and a sterile dressing applied. Laparoscopic procedures are
conducted using general anesthesia. The surgeon will make three tiny incisions
in the abdominal wall of the groin area and inflate the abdomen with carbon
dioxide to expand the surgical area. A laparoscope, which is a tube-like
fiber-optic instrument with a small video camera attached to its tip, will be
inserted in one incision and surgical instruments inserted in the other
incisions. The surgeon will view the movement of the instruments on a video
monitor, as the hernia is pushed back into place and the hernial sac is repaired
with surgical sutures or staples. Laparoscopic surgery is believed to produce
less postoperative pain and a quicker recovery time. The risk of infection is
also reduced because of the small incisions required in laparoscopic surgery.
The use of surgical (prosthetic) steel mesh or polypropylene mesh in the
repair of inguinal hernias has been shown to help prevent recurrent hernias.
Instead of the tension that develops between sutures and the skin in a
conventionally repaired area, hernioplasty using mesh patches has been shown to
virtually eliminate tension. The procedure is often performed in an outpatient
facility with local anesthesia and patients can walk away the same day, with
little restrictions in activity. Tension-free repair is also quick and easy to
perform using the laparoscopic method, although general anesthesia is usually
used. In either open or laparoscopic procedures, the mesh is placed so that it
overlaps the healthy skin around the hernia opening and then is sutured into
place with fine silk. Rather than pulling the hole closed as in conventional
repair, the mesh makes a bridge over the hole and as normal healing take place,
the mesh is incorporated into normal tissue without resulting tension.
Diagnosis/Preparation
Diagnosis
Reviewing the patient’s symptoms
and medical history are the first steps in diagnosing a hernia. The surgeon will
ask when the patient first noticed a lump or bulge in the groin area, whether or
not it has grown larger, and how much pain the patient is experiencing. The
doctor will palpate the area, looking for any abnormal bulging or mass, and may
ask the patient to cough or strain in order to see and feel the hernia more
easily. This may be all that is needed to diagnose an inguinal hernia. To
confirm the presence of the hernia, an ultrasound examination may be performed.
The ultrasound scan will allow the doctor to visualize the hernia and to make
sure that the bulge is not another type of abdominal mass such as a tumor or
enlarged lymph gland. It is not usually possible to determine whether the hernia
is direct or indirect until surgery is performed.
Preparation
Patients will have standard preoperative blood and urine tests, an
electrocardiogram, and a chest x ray to make sure that the heart, lungs, and
major organ systems are functioning well. A week or so before surgery,
medications may be discontinued, especially aspirin or anticoagulant
(blood-thinning) drugs. Starting the night before surgery, patients must not eat
or drink anything. Once in the hospital, a tube may be placed into a vein in the
arm (intravenous line) to deliver fluid and medication during surgery. A
sedative may be given to relax the patient.
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