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by Rosalyn Carson-DeWitt, MD

Anatomy and Physiology
The abdominal wall consists of layers of skin, fat, muscle, fascia, and membranes. The fascia is a layer of fibrous tissue that surrounds the body beneath the skin and fat. Each layer is designed to protect the abdominal organs and hold them in place.

The fascia is not of the same strength in all areas of the abdominal wall. One of the weaker places is in the groin, or inguinal, area. Due to its relative weakness, this location is particularly prone to hernias.

Reasons for Procedure
An inguinal hernia is a defect in the fascia that allows contents from the abdomen, such as a piece of intestine, to push out under the skin. There are two basic types of inguinal hernias, direct or indirect, depending on where the protrusion takes place relative to the inguinal canal.

Uncomplicated inguinal hernias often do not cause any symptoms, but some patients notice pressure in the groin area, which may increase over time. A bulging in the groin may appear and disappear as the abdominal contents pass in and out of the hernia opening. The bulge usually becomes more noticeable when standing or straining, and disappears when lying down.

An inguinal hernia can become incarcerated, or closed off, if a piece of intestine or fat becomes trapped in the hernia opening.

If a piece of intestine is incarcerated, the flow of materials inside the intestine can become obstructed. In a strangulated hernia, the blood supply gets cut off and part of the intestine may die. Surgeons often recommend repairing an inguinal hernia before these complications have a chance to occur.

A strangulated hernia, or intestinal obstruction, can cause severe symptoms, including: pain at the hernia site, nausea or vomiting, inability to pass gas or have a bowel movement, fever and chills, and/or abdominal swelling.

Treatments
If you have an uncomplicated inguinal hernia, your doctor may try to temporarily reduce it by pushing the protrusion back into your abdomen. In addition, your doctor will most likely advise you to schedule surgery to repair the hernia before complications develop.

If your doctor suspects a complicated hernia, such as a strangulation, he or she will start IV antibiotics and schedule emergency surgery.

The two most common types of operations used to repair an inguinal hernia are: traditional open repair, which requires a relatively large incision; laparoscopic repair, which requires several tiny incisions; a third type of repair, called a Prolene Hernia System, is similar to a traditional open repair except that it requires only local anesthesia.

A laparoscopic repair is performed through several tiny "keyhole" incisions. Surgical instruments are slipped through the other openings.

Laparoscopic hernia repair is generally less painful and requires a shorter recovery period than a traditional open repair.

Procedure
In the days leading up to your procedure: Arrange for a ride to and from the hospital and for help at home as you recover. The night before, eat a light meal and do not eat or drink anything after midnight. Shower the evening before or the morning of your procedure. If you regularly take medications, herbs, or dietary supplements, ask your doctor about the need to temporarily discontinue them. Do not start taking any new medications, herbs, or dietary supplements before consulting your doctor. Depending on the type of procedure you have, you may receive general, spinal, or local anesthesia. If you receive general anesthesia, you will be unconscious throughout the procedure. If you receive spinal or local anesthesia, you will remain awake, but sedated, during the surgery.

Your surgeon will begin by making the type of incision necessary for the chosen procedure: a single larger incision for an open repair, or several small openings for a laparoscopic repair. The exact location of the laparoscopic incisions will vary.

In laparoscopic hernia repair, your surgeon will use an instrument called a trocar to first create an opening near your navel. Carbon dioxide gas will be pumped through this opening to separate the layers of your abdominal wall. This will allow the hernia and surrounding structures to be viewed more easily. Your surgeon will then go on to create the additional openings.

Next, your surgeon will insert the laparoscope through the opening at your navel. Images from a camera at the end of this laparoscope will be projected onto a video monitor. Your surgeon will then pass surgical instruments through the other keyhole openings to perform the operation.

There are two types of laparoscopic repairs: The more common Preperitoneal approach and the less common Transabdominal approach. In either method, the intestinal protrusion is pushed back into the abdomen, and a piece of mesh is sewn into place in the abdominal wall to reinforce the repair and help prevent recurrent hernias.

Upon completion of the repair, the incisions are closed with sutures, or other materials, and dressed with a bandage.

Risks and Benefits
The possible complications of inguinal hernia repair are the same for both open and laparoscopic techniques. They include: side effects from anesthesia, wound infection, excessive bleeding, damage to blood vessels, nerves, or organs in the area, difficulty urinating, swelling of the scrotum, excess scar tissue formation, and/or recurrent hernia.

Benefits of inguinal hernia repair include: resolution of inguinal discomfort, elimination of hernia complication risk.

In an inguinal hernia repair, or any procedure, you and your doctor must carefully weigh the risks and benefits to determine whether it's the most appropriate treatment choice for you.

After the Procedure
Most patients who have uncomplicated inguinal hernia repairs are sent home from the hospital on the same day as their surgery.

Following your operation, you will usually be advised to: keep the incision or incisions clean and dry, drink plenty of fluids and eat fiber-rich foods to avoid constipation, move your bowels as soon as you feel the urge, get up and walk around the day after your surgery, avoid lifting.

Be sure to call your doctor immediately if you notice: signs of infection, such as fever and chills, redness, swelling, increased pain, excessive bleeding, or discharge from the incision sites, difficulty urinating, nausea or vomiting, constipation, pain that isn't relieved by medication, cough, shortness of breath, or chest pain.

Sources:

  • Eubanks, SW. Sabiston Textbook of Surgery. 16th ed. Philadelphia: W.B. Saunders Company; 2001: 783-802. Hernia Repair. American College of Surgeons. Available at: http://www.medem.com/search/article_display.cfm?path=n:&mstr=/ZZZBTQW1RWC.html&soc=ACS&srch_typ=NAV_SERCH. Accessed February 5, 2004.
  • Inguinal Hernia. Mayo Clinic Website. Available at: http://www.mayoclinic.com/invoke.cfm?id=DS00364. Accessed February 5, 2004.
  • Inguinal Hernia. National Library of Medicine. Available at: http://www.nlm.nih.gov/medlineplus/tutorials/_instruct/instructions.html?ModuleURL=inguinalhernia&LMModuleID=gs049201&x=103&y=14. Accessed February 5, 2004.
  • Laparoscopic Hernia Repair: Is It For You? Mayo Clinic Website. Available at: http://www.mayoclinic.com/invoke.cfm?objectid=D0CCC478-28E1-41B5-8DA7065B8461EED7&locID=. Accessed February 5, 2004.


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