Hernia: Inguinal or Groin Hernia Repair

 

After reading “Hernia 101” you may suspect you need an Inguinal or Groin Hernia Repair.  What should you do next?

 

How is “inguinal” pronounced, anyway?

• First, if one needs an inguinal hernia repair, there is a matter of pronunciation.  The most common groin hernia is an inguinal hernia (though it can also be a femoral hernia).  Inguinal is pronounced In-Gwin-el as opposed to “In-Gweeen-al”.  A femoral hernia is pronounced Fem-or-el as opposed to Fem-OH-rel.

Is the hernia causing any pain or other symptoms?

• A hernia may either cause symptoms or may be something identified on a routine physical exam. Sometimes, a scan ordered for a different reason will find a hernia.  Other times, someone might notice a new bulge that wasn’t previously noticed.

What if the hernia doesn’t cause any discomfort at all?

• Hernias without symptoms:  A small, asymptomatic hernia, can be watched.  Urgent or emergency surgery is rarely needed for an asymptomatic hernia.
  • There is a 1% chance or less per year of needing sudden attention for a hernia.  These are the reasons for needing urgent evaluation:
    • Incarceration: When a hernia contents get stuck in the space created by the muscle tear.  If incarceration occurs, there is sudden increased pain, a fullness or mass noted where the hernia used to be soft, and possible nausea or vomiting.  Often, a hernia that is stuck may be pushed back in or “reduced”.   If an incarcerated hernia isn’t promptly treated, by either pushing it back in (reducing it) or by surgery, it can become “strangulated”.
      • Chronic Incarcerated Hernia:  If a hernia has been present for a long time, the contents become stuck in position, but there is no associated pain.  This means there is enough room for the the hernia to remain without sudden loss of blood flow or a blockage of the intestine.  This kind of hernia should also be evaluated by your physician.
    • Strangulation:  When the contents of an incarcerated hernia have restricted blood flow because of pressure or squeezing at the neck of the hernia, that portion of the hernia may die.  This happens when an incarcerated hernia isn’t reduced.
      • An incarcerated hernia may be reduced by massaging the area, or by a physician in an emergency room if necessary.  Reducing a hernia eliminates the need for emergency surgery.  If  reduction is ever necessary, then surgical repair is indicated as soon as possible, but not as an emergency.

What if a hernia is painful or uncomfortable at times?

• Symptomatic hernias should be evaluated, and plans for repair considered.  Once symptomatic, a hernia will not get better with exercise or time, and can progress to larger tears and more complex issues.  Groin pain or discomfort is the most common symptom.  This may get worse or better depending on activity level.  Though a hernia truss or belt may decrease discomfort, it is not a long-term solution.  A more thorough list of symptoms can be found here, courtesy WebMD.

How can it be repaired?

• There are four main approaches to repair a hernia:
  • Open repair without mesh
  • Open repair with mesh
  • Laparoscopic repair with mesh
  • Robotic Assisted Laparoscopic repair with mesh.
  • Follow this link for a comparison between open and robotic repairs using a pumpkin model

• All hernia repairs require a combination of anesthesia:
  • Local anesthesia, where “numbing” medicine is injected directly into the area of surgery;
  • Regional anesthesia, where a nerve block may be performed; and
  • General anesthesia, where medicine is injected into a vein.  In this case, one is completely “under” or asleep and wont feel or be aware of anything happening to them.  Often, general anesthesia will also include local and regional techniques.

• Most hernia repairs are done as an outpatient procedure, meaning, one goes home the same day as the operation.  Some patients may need to stay in the hospital overnight.

What is an open repair (also known as open inguinal herniorrhaphy)?

• An open repair involves making an incision or cut in the skin in the groin area.  The underlying tissues are cut and separated to gain access to the actual tear or hole in the muscle.  The tear is then fixed by sewing mesh onto the good muscle and tissue surrounding the tear.  Alternatively, the muscle can be sewn together to cover the tear.  This often is done in a mesh free repair, but because of the tension created, can require a “relaxing incision”, where the muscle is shifted over.
• Open repairs tend to require a longer recovery and typically have more pain associated with them  Partly this is because of nerves that run on the outside of the torn muscle, and the mechanics of pressure pushing out on the repair. This repair is similar to a patch placed on a tire on the outside.

Can a hernia be fixed without mesh?

• Mesh free repairs are done by sewing the muscles together over a tear or by closing the tear by bringing the torn muscle or tissue together.  In order to allow the muscle to come together, a “relaxing incision” or another cut has to be done so the tissue can slide over.  These repairs often have more associated discomfort and may have a higher recurrence rate.  This is a result of pulling the muscle together and/or the additional surgery necessary for a relaxing incision.
• There is a lot of discussion about mesh on the internet.  If you have concerns, this is best discussed at the time of your surgical consultation.

What is a Robotic Hernia Repair?

• Technically, a robotic hernia repair is a robotic assisted laparoscopic hernia repair.  It is a laparoscopic repair using the Da Vinci Surgical System.  The hernia is repaired with three small 5/16^th inch incision.  A high resolution, fiber-optic scope is placed in the abdomen through the belly button or umbilicus.  The 2 other incisions are used as operating ports.  Through these two ports, the repair is done by creating a space for the mesh so that is will be covered and separate from the abdominal content.  Then, the tissue bulging through the  repair is pulled back into the abdominal cavity and the tear or defect is covered with mesh.
• Because the mesh is placed on the inside, overlap on the surrounding structures give a stronger repair than if patched on the outside.  Pressure placed against the repair is distributed over a larger area.
• More importantly, there are fewer nerves on the inside.  Therefore, this kind of repair is associated with less pain. People generally take less pain medications and can return to work sooner as a result.
• Recovery tends to be faster.

Which repair is right for me?

• There are some instances that an open repair is a better approach for certain patients.  Most patients, however, are good candidates for a Robotic Assisted Laparoscopic repair.

If you have been diagnosed with a hernia, or believe you may have one please contact Candela Schreier Surgical for a consultation for an complete evaluation and discussion.