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Understanding

Hernias

And Their Repair

The organs inside the abdomen are contained within a waterproof sack called the Peritoneum.  It is elastic much like an inner tube.  The peritoneum and its contents are confined and held there by the muscles of the abdominal wall in the front and sides, the spine and muscles of the back in the rear, the pelvic bones and muscles below, and the diaphragm above.  These structures act exactly like the belts, cords and treads of a tire.  When there is a weakness in this “tire” allowing the peritoneum and organs to bulge out, then this condition is known as a hernia.

Causes

 The most common cause of a hernia is an abnormality of the way the “tire” was formed during embryonic development, leading to a “defect” in the tire.  If the defect is large, the abdominal organs may be obviously bulging out at birth.  With a small defect bulging may not occur until later in life; aging causes the defect to slowly stretch and become larger.  Becoming overweight causes the tissues of the abdominal wall stretch, which is also a contributing factor.  A sudden increase in abdominal pressure, as with heavy lifting, can cause bulging through a hole that was otherwise not quite ready to allow bulging to occur spontaneously.  An injury to a muscle can cause it to atrophy, a process resulting in the muscle withering to just a thin remnant, no longer able to support the area of the “tire” for which it was responsible.  Rarely if ever is a hernia caused from a “tear” of the muscles.  A “tear” would imply that there is good strong tissue right up to the edge of a linear opening.  Hernias are usually the result of a rather circular opening which has at its margins thinned-out weak tissue.  The most common type of hernia is called an INGUINAL hernia and occurs in the groin, most often in men, but occasionally in women.  Another very common type is UMBILICAL hernia occurring in the belly button.

Repairing Hernias

 Broadly speaking, there are two types of hernia repairs:  traditional and laparoscopic.  They differ both in the way the surgeon approaches the area to be repaired, and in the method of restoring the strength at the site of the defect.  In order to explain the differences we will need to have a brief lesson in anatomy.  We will use the right side, male groin to illustrate this.  Note that in all the illustrations that follow, the skin and subcutaneous fat have been removed to show what lies underneath.  In the male, it is necessary to have an opening in the abdominal wall to allow the spermatic cord to connect the testicle, which is outside the abdomen, with the prostate and associated structures, which are inside the abdomen in the pelvis. (Fig. 1)  This opening should be snug around the cord.  It is important to note that the abdominal wall normally has a thickness of ½ to 1 inch in this area, and this thickness holds true right up to the margins of the opening. 

Fig. 1

When the opening for the spermatic cord is too large, the result of malformation or of tissue thinning out over time, then the peritoneum and abdominal organs can sneak out along the side of the cord. (Fig. 2)  Most of the time, abdominal fat comes out along the cord, but intestine can also come out, especially if the opening is larger, or if there is a lot of pressure inside pushing things out.  The important thing to note is that there is now a considerable distance from the thick, strong tissue of the abdominal wall on one side of the opening, to the strong tissue on the other side of the opening.  In other words, there is tissue missing, which should be there.  It was either never there (formed abnormally), or it has become thinned out over time and is essentially useless even if it still remains present.  Either way, the net result is that there is a considerable distance, usually at least ¾ of an inch, and sometimes as much as 2 or 3 inches, from the good, strong tissue on one side of the opening, to the good strong tissue on the other side.

Fig. 2

In a traditional hernia repair, (Fig. 3) the surgeon makes a relatively large wound on the outside, usually about 4 inches long, through the skin and fat.  Once the muscles are exposed, the outer ones are also cut open so the surgeon can reach the inner layer of tissue and muscle.  The surgeon then sews the layers back together, gathering them up as he goes, attempting to make the opening snug around the cord.  Most surgeons attempt to reinforce the repair with mesh.  After the deeper, primary repair in the muscles is sewn, then mesh is placed on top of the muscles and sewn to the surface of the muscles.  This mesh is usually about 1.5 by 3 inches in size.  Then the last layer that was cut open, a membrane called fascia, is sewn back together over the top of the mesh.  As the surgeon sews the layers back together, he is literally pulling the margins of the opening together.  Often, the tissues resist being pulled in.  They want to stay where they were formed.  This leads to tension on the suture lines in the muscle layers, and if it is excessive, the sutures will slowly and steadily cut through the tissues.  The repair will fail, and the hernia will recur, as the tissues slowly migrate back to where they were designed to be located. (Fig. 4)  Ultimately, the hernia mass lifts the mesh off the surface of the muscles, as it sneaks out under one side of the mesh. 

Fig. 3

Fig. 4

In a laparoscopic hernia repair, three openings averaging about ¾ of an inch each are made in the abdominal wall.  I usually start with the largest just below the belly button, and about an inch long.  This one is for a laparoscope.  Then two smaller ones are made below this also in the midline.  These are for a right and a left hand instrument.  The peritoneum is peeled from the undersurface of the abdominal muscles, progressively working over to the opening where the hernia is located.  The peritoneum with herniated fat and organs is pulled back into the abdomen.  A large piece of mesh, 4 x 6 inches, is placed inside, under the muscles, which not only covers the defect, but widely overlaps it. (Fig. 5)  The mesh is not inside the abdomen.  It is sandwiched between the muscles and the peritoneum.

Fig. 5

Differences Between the Repairs

A traditional repair attempts to close the defect by pulling normal tissue into the hole, often under tension.  Just as a very heavy, pierced earring will slowly cut through an ear lobe if worn too long, sutures will cut through tissue slowly, if there is too much tension.  A laparoscopic repair replaces the missing tissue with a synthetic patch.  All normal tissues are left in the position where they were originally formed, and there is absolutely no tension.  A traditional repair places a small piece of mesh on the outside of the repair.  A laparoscopic repair places a much larger piece of mesh on the inside of the repair.  Think of the tire analogy.  Would anyone really try to fix a hole in a tire by placing a patch on the outside of a tire?  The forces at play are the same for a tire and for the abdomen.  When the patch is placed on the outside, the pressure from the inside pushes the patch off.  But when the patch is placed on the inside, the pressure holds it in place.  Would anyone try to put a patch anywhere into a tire by cutting the hole bigger and putting the patch through the hole to get it on the inside?  Of course not!  The tire would be weaker after the patch repair, than it was before the patch repair.  So too is the abdominal wall further weakened when the muscles are cut open during a traditional repair.  A traditional repair relies on proper healing of the muscle layers for its strength.  A laparoscopic repair is strong immediately.  The pressure holds the mesh in place.  The mesh is polypropylene.  It has been used for decades.  There are no reported cases of the mesh fragmenting with, or dissolving, or in any other way failing to outlast the patient!

Patients experience more pain after traditional repairs.  The incision is larger.  There is more tissue dissection and suturing, and there is more overall trauma to the patient’s tissues.  Furthermore, if both sides need to be done, a second 4 inch incision is needed.  Both sides can be repaired through the same three openings with a laparoscopic repair, and combined the three openings amount to about 2 inches of incision. 

Patients must be careful after a traditional repair.  Heavy lifting, sports, etc. are prohibited for weeks to allow the tissues to heal strongly before they are stressed.  In truth most patients having traditional hernia repairs don’t feel well enough to even play golf for several weeks.  After laparoscopic hernia surgery, there are no restrictions at all on activity.  The repair is immediately strong.  Even frail patients feel well enough to play golf in 4-6 days; most engage in even more vigorous activity sooner than this.  They feel well enough to do this, and there is no fear of injuring the hernia repair.  All of my patients have permission to lift weights at the gym as soon as they feel up to it.

Results

Ask almost any surgeon what his failure rate is using traditional hernia repair, and you will usually get a response of “2-3%.”  Various authors have reported on the results of hernia surgery in America.  Typical recurrence (failure) rates are 10–15%. [1, 2]   One paper reported that 15% of all hernia surgery performed in America is scheduled as “Repair of Recurrent Hernia”. [3]  And what of complications.  Vascular injury to the iliac/femoral vessels, nerve injury, and testicular atrophy are among the serious complications that have been reported by authors. [1]  Heart attack, stroke, and even death have been reported.  Traditional hernia repair carries with it a typically reported complication rate of 10% [4]  Fortunately, most of these are relatively minor problems, but serious complications do occur at times.  Any hernia repair can be a disaster when not properly performed.

I reported a series of 500 consecutive hernia repairs, all of them inguinal hernias in men.  This paper was accepted for publication by an internationally distributed, peer-reviewed journal, “Surgical Endoscopy”.  It is the official journal of The Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and also the official journal of The European Association for Endoscopic Surgery.  I was invited to present this paper at the annual meeting of SAGES in 1999, and at the World Congress of Endoscopic Surgeons, in Singapore in 2000.  It appears in Volume 16, Number 6, June 2002, pages 931–935.  In this publication I reviewed my technique for performing laparoscopic hernia surgery.  In this series of patients, there was but one recurrence over a six year follow-up period, for a failure rate of 0.2%.  There were three complications, all of them minor, for a complication rate of 0.6%.  Other authors have reported higher failure rates and complication rates for laparoscopic hernia surgery, similar to those for conventional hernia surgery.  Laparoscopic hernia surgery is technically demanding, and not easily mastered.  The point of my article was to demonstrate that, when properly performed, laparoscopic inguinal hernia surgery can be both extremely reliable and very safe.  I also reported the technique that I use, in great detail, even elaborating on which instruments and disposables I use.  The point of this was to show that even a high tech method could be done inexpensively, a major concern in this era!

References

1. Nyhus LM, Condon RE (1995) Hernia, 4^th ed. Lippincott, pp 253-268

2. Rand Corporation (1983) Conceptualization and measurement of physiologic health for
    adults, Publication No. 15, Santa Monica, CA, p3

3. Morfesis FA (1996) The recurrence rate in hernia surgery. Archives of Surgery 131:  107

4. Miguel PR, et al (1998) Laparoscopic hernia repair – complications.  JSLS 2:  35 - 40

 © 2002 F. J. Fazzio, Jr. MD.

I've spent over 25 years studying and perfecting ways to turn big operations into small operations

Minimally Invasive Treatments For

Acid Reflux, Hernia, Varicose Veins, Hemorrhoids, Gallstones

Endoscopy, Laser, Radiofrequency, Ultrasound, Lithotripsy, Laparoscopy

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