Inguinal Hernia
DR. THOMAN INGUINAL HERNIA REPAIR
The front of your abdomen is encased in a muscular wall. The strength of this muscular wall is the coating of it called the fascia. When you cut a steak and run into the tough grissly part, that’s the fascia. Unfortunately, the way the different muscle groups come together leaves potential weak spots in the fascia. A hernia occurs when a weak spot breaks down and forms a hole. People often wonder why I examine multiple places in the abdomen when they obviously have a bulge in just one spot. It’s because a hernia is a sign of weak fascia, and if a break down occurs in one spot it may have occurred in another as well. Your fascia is weak because of a defect in the way collagen is used to construct it. You were born with this defect and it is typical to have other family members with hernias. The exception to this is incisional hernias, these only occur after a prior surgery, where they cut through your abdominal wall. These require a different technique.
Your abdomen is like a full sack, when you pick it up the stuff inside pushes to get out. The hernia gives a place for the fat and intestines to squirt out. That’s why when you stand up it bulges out and when you lay down it typically recedes. The symptoms of a hernia are quite variable. I see people with small little holes who can barely stand the pain and beg to be scheduled right away. While others have giant holes with intestines squirting through them and down into a basketball-sized scrotum who only bothered to come in because a family member forced them, noting that something has got to be wrong!
It is important to know that a hernia will never heal itself. Once formed, the pressure in your abdomen continually pushes out against it causing it to only enlarge over time. The worst thing that can happen to a hernia is to have part of your intestine squirt out the hole and get squeezed. When this happens, and you cannot push it back in, it is called incarcerated. This is an emergency because if the squeezing cuts off the blood flow to the intestine it can die and take you with it. When the blood flow is cut off it is called a strangulated hernia and you need surgery right away. Where the hernia occurs determines what we call it, and if it’s in your groins, that’s called inguinal. At your belly button is umbilical, in the upper abdomen is epigastric.
INGUINAL HERNIA
Inguinal hernias occur in your groins or inguinal region. As mentioned, these occur mostly from a congenital weakness. Some people are born with them and they are typically fixed as a child but can also present in the teens, these can be treated differently than adult hernias. Most adult hernias occur slowly over time, but occasionally lifting something heavy will cause a hernia to blow out for the first time. A large study done in the VA hospitals showed that it is safe to watch inguinal hernias that do not cause any symptoms. Meaning the risk of incarceration is quite low. Once you develop discomfort at the hernia your risks go up and you need to have it fixed. Typical symptoms from an inguinal hernia are dull ache with standing or exercise in the groin region. This pain can also go down into the testicle or down the inside of your leg.
OPTIONS FOR REPAIR
There are many different approaches to fixing an inguinal hernia and I have performed all of the ones that work. The first decision is open or laparoscopic.
- If you choose laparoscopic you will have to have general anesthesia, meaning you are completely out.
- If you choose open this can be done with you awake after numbing the area with local anesthetic.
- If you have serious heart or lung issues using a local may be best, although general anesthesia is actually incredibly safe.
OPEN INGUINAL HERNIA REPAIR
An incision is made in the groin, the hernia sac is reduced and a mesh screen is sewn into the muscle to strengthen the area. The advantage is any general surgeon can perform this operation and it can be done by numbing the area and avoiding general anesthesia. The disadvantage is there is a higher risk of wound infections and injury to the nerves as well as more pain than with the minimally invasive approach. The nerves lay on top of the muscle and can be injured with this approach. The laparoscopic approach goes behind the muscle and avoids the nerves.
LAPAROSCOPIC HERNIA REPAIR
There are a few different ways to approach this laparoscopically, but I perform what’s called a TEP repair almost exclusively. The advantage to this approach is there is no need to tear holes in the lining of your abdomen called the peritoneum. This is how robotic and TAPP repairs are done and these holes can lead to adhesions and bowel blockages down the road. The only advantage to the robotic or TAPP approach is they are easier to learn and perform then the TEP. However, once you get good at TEP it can be done faster and more easily then the TAPP. The average time it takes surgeons to perform a robotic or TAPP repair on both groins is around 2 hours. My average time to fix both sides with TEP is 30 minutes. Briefly, the space between the muscle and peritoneum is accessed with a balloon and then inflated with CO2 gas to create a working space as shown.
Once this space is revealed all of the potential areas of weakness can be seen. The grey areas in next illustration show where the direct, indirect and femoral hernias occur. This entire area is reinforced with a 6 x 6 inch lightweight plastic screen placed on each side. If the defect is large, the screen is anchored to the bone with tiny titanium screws, the size of an eyelash, that will not set off alarms or interfere with an MRI. These are necessary around 25% of the time in my hands. While I have performed over 3000 laparoscopic hernia repairs, for the last 1000 I have used a proprietary design that involves a suturing process to lock it in place so that tacks can be avoided. The advantages of the laparoscopic approach include less pain, fewer wound complications, faster return to full activity and less chance of nerve injury. The only disadvantage is it requires a full general anesthetic.
DO I HAVE TO HAVE MESH?
If you watch daytime TV you will have heard the lawyers asking you to urgently call if you have ever had mesh implanted. As a result, there is an incredible amount of misinformation out there. As I mentioned, these hernias occur because of a weakness in the tissue. If I simply go in and sew that tissue together it will eventually fail. The weak area must be reinforced with a plastic netting that has been in use since the 1960’s. I use a flat sheet of medium weight polypropylene mesh that I cut and sew in a particular fashion. I have never had a piece get infected or need to be removed because of some “reaction.” Years ago when someone demanded a repair without mesh and I couldn’t talk them out of it I went ahead and did it. I have since decided this is simply not in your best interest and will encourage you to find another surgeon willing to do it with suture alone. Incidentally, the suture is made of the same material as the mesh so you are getting it implanted one way or another!
COST
Hernia repair is almost always covered by insurance. Your out of pocket costs will depend on your plan. I perform the majority of hernia repairs at an Ambulatory Surgery Center which is much cheaper than any hospital.
RECOVERY
Regardless of approach, hernia surgery can almost always be performed outpatient in around 3 hours including preparation, surgery and recovery. A local anesthetic is injected at surgery and pain is usually not excessive. Around 50% of patients never take narcotic pain medicine. A prescription is given and filled if needed. We recommend using Ibuprofen or Naproxen for several days. Ice or heat could be applied based on comfort. Bruising and swelling is expected and can be extensive, particularly in those over 60 and can extend into the penis and scrotum. Do not panic. It goes away 100% of the time and is usually not a problem. Arnica, taken as directed, has been shown to decrease bruising if you are interested. Ambulating is encouraged right away, but lifting or straining should be avoided. A general guide is no lifting more than 10 pounds for 2 weeks. In 5 or 6 days most people can return to light aerobic activity such as swimming, jogging or biking. It’s important to go slow, listen to your body and follow common sense. It takes around 6 weeks for your body to form a tough scar around the mesh and until then caution is advised. Heavy lifting and straining should be avoided. I’m not giving you a specific weight because if you are a 6’4” professional athlete you will be able to safely lift more than if you are a 100 pound grandmother.
RECURRENCE
My personal recurrence rate for open or laparoscopic is around 1%. Failure can occur at any time over the rest of your life and would require another repair. The larger the hernia the higher the risk.
WHAT TO LOOK FOR AFTER
By far the most common issue is trouble urinating. Particularly if you are a man over 50, like me, your prostate is no longer your friend. First try a warm water bottle over your bladder and walking around. But if this doesn’t work and it’s been more then 8 hours since you last went, you will need to go to an urgent care or emergency room to get a catheter. Sorry. This happens less then 1% of the time in my practice. Your wounds will be raised and look bad until the glue falls off in around 2 weeks, but if there is redness extending a few inches around the wound and you are really itchy, you may be having an allergic reaction to the glue and you have to immediately take it off. You can take Benadryl for the itching. I see this around 2% of the time. If you are not sure just text me a picture of your wounds. Infection is incredibly rare after this surgery. You will have a hard lump to the left of your navel that is normal and goes away in 6 weeks. It is not where the incision is because I purposely hid the scar in your belly button. And, again, you may turn black and blue. It gets better.