Herniorrhaphy

Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery.

Techniques

(Surgical incision in groin after inguinal hernia operation.)

Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery," procedure in the USA. In other countries however, it is more common to be admitted for a 2-3 day hospital stay. Almost 700,000 are performed each year in the United States.

These techniques can be divided into four groups.

Groups 1 and 2: open "tension" repair

A workable technique of repairing hernia was first described by Bassini in the 1880s; the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed.

Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVay repair.

The Shouldice techniques is a complicated four layer reconstruction, however, it has relatively low reported recurrence rates.

An operation in which the hernia sac is removed in addition to tension repair is described as a 'herniotomy'.

Group 3: open "tension-free" repair

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within several months of the operation, although up to 40% of patients will end up with chronic, debilitating pain that will require long term pain management and prescription painkillers. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair. Rates of complications are disturbingly high and they can be quite serious, and can include chronic pain, ischemic orchitis, and testicular atrophy.

Group 4: laparoscopic repair

In recent years, as in other areas of surgery, laparoscopic repair of inguinal hernia has emerged as an option. "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a faster recovery time and a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia. It is usually more expensive and consumes more O.R. time than open repair, carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs.

Comparisons

In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that lap repair has less risk of wound infection, less bleeding and less swelling after surgery (seroma). They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results however are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.

Open mesh repair or laporascopic mesh repair are good and have shown reduced recurrences or early recovery. Complications related to the use of mesh include infection, mesh migration, adhesion formation, erosion into intraperitoneal organs, and chronic pain - due probably to entrapment of nerves, vessels or the vas deferens. Such complications usually become apparent weeks to years after the initial repair, presenting as abscess, fistula, or small bowel obstruction. More recently, concerns have been raised about the possibility of obstruction of the vas deferens as a result of the fibroblastic reaction to the mesh.