HERNIA REPAIR
A hernia is an opening or weakness in the muscular structure of the wall of the abdomen. This defect causes a bulging of the abdominal wall. This bulging is usually more noticeable when the abdominal muscles are tightened, thereby increasing the pressure in the abdomen. Any activities that increase intra-abdominal pressure can worsen a hernia; examples of such activities are lifting, coughing, or even straining to have a bowel movement.
Imagine a barrel with a hole in its side and a balloon that is blown up inside the barrel. Part of the inflated balloon would bulge out through the hole. The balloon going through the hole is like the tissues of the abdomen bulging through a hernia.
A hernia is sometimes described as a rupture and is found commonly as a lump in the groin area. This type of hernia is referred to by doctors as a primary inguinal hernia. A hernia develops when a loop of the gut bulges out through a weakened part of the abdominal wall. Hernias can occur at any age and affect both men and women.
Where are hernias located?
Hernias tend to occur at places where there is a natural weakness in the wall of the abdomen. The most common location for hernias is the groin (or inguinal) area. There are several reasons for this tendency. First, there is a natural anatomical weakness in the groin region which results from incomplete muscle coverage. Second, the upright position of human posture results in a greater force occurring at the bottom of the abdomen, thereby increasing the stress on these weaker tissues. The combination of these factors over time breaks down the support tissues enlarging any preexisting hole or leads to a tear resulting in a new hole.
Several different types of hernia may occur and frequently coexist, in the groin area. These include the top of the leg (femoral hernia), ventral hernia, occurs in the midline of the abdomen, usually above the navel (umbilicus). This type of hernia is usually painless. Hernias can also occur within the navel (umbilical hernia). Some hernias occur at the site of a previous operation (incisional hernia).
Types of Hernia
- Inguinal Hernia: An inguinal hernia usually presents itself as a lump in the groin area. A portion of the intestine or internal fat protrudes through a weakness in the inguinal canal. The inguinal canal is a natural passageway through the abdominal wall in the groin. In males, the inguinal canal contains the blood vessels that go to the testicle and the duct that carries sperm from the testicle. Inguinal hernias account for 75% of all hernias and are five times more common in males than females. They may be present at birth but can develop in adults also. These hernias are divided into two different types, direct and indirect. Both occur in the groin area above where the skin crease at the top of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area.
- Femoral Hernia: This is a hernia through the passage that contains the large blood vessels (the femoral artery and vein) between the abdomen and the thigh. This type of hernia causes a bulge in the upper thigh just under the groin and is more common in women than men. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. It is more likely to become stuck than an inguinal hernia and should be repaired by surgery, promptly.
- Epigastric Hernia: A small bit of fat bulges through a weakness in abdominal muscles between the navel and breastbone. This type of hernia is caused by the weakening of the muscles in the central, upper abdomen, causing a lump or bulge to appear anywhere between the breastbone and the navel. The lump can be quite small or extremely large and tends to be more common in middle age. Most people with such hernias are men, usually between ages 20 and 50. It is best repaired by surgery.
- Umbilical Hernia: An umbilical hernia occurs at, or just around, the navel. Intestine or fat bulges through the abdominal wall under the navel. The area of weakness in the abdominal wall can be very small (less than half an inch) or it can be as large as 2 to 3 inches. Umbilical hernias are common in newborns but may disappear gradually over time. They may also occur in adults who are overweight or in women who have been pregnant many times.
- Incisional Hernia: An incisional hernia may occur at any site where an operation has been performed previously. The scar represents a weakened area, which is stretched over time, may allow the underlying intestines to bulge through. The skin has healed, but the underlying muscle has pulled apart, resulting in a hernia.
- Ventral Hernial: This is a general term that can refer to an epigastric, umbilical or incisional hernia.
Signs & Symptoms
Most hernias cause a bulge under the skin. The location of this bulge depends on the specific type of hernia. The main symptom of a hernia is the appearance of a lump in your abdomen or groin area. The lump may be painless and only be discovered during a check-up.
In some cases, you may be able to push the lump back into your abdomen. This is known as a reducible hernia. A hernia that cannot be pushed back into place is known as an irreducible hernia. People with an irreducible hernia are more likely to experience bowel obstruction, or interruption of the blood supply to the intestine, which is known as a strangulated hernia.
Treatment
Although not all hernias need to be operated on, hernias that cause symptoms or that become larger should be repaired by a surgeon. The technique used to repair your hernia depends on its type, size, and location. There are many options, including standard surgery, surgery using mesh plugs or patches, and surgery done using a telescope through a small incision (laparoscopic surgery). Through the ages, the treatment of hernia has gone through various changes and modifications. Significant changes that have taken place in the treatment of Hernia are:
- Open surgery with suturing technique: When the surgeon makes a large incision in your abdomen, but now this is obsolete.
- Open surgery with mesh technique: The mesh technique has an extremely low incidence of complications and recurrence. The ‘mesh plug’ repair represents real benefits to the patient, in terms of reduced discomfort and a more rapid recovery. This is practiced worldwide.
- Laparoscopic surgery (keyhole surgery) with mesh: This is being done in advanced centres with excellent results. Most of the hernias can be treated by laparoscopy. In this procedure, small 3-4 holes are made in the abdomen depending on the site and size of the hernia. A telescope is inserted through one of the holes and very specialized laparoscopic instruments through the other holes. Watching on a TV monitor the surgery is carried out and a mesh is placed at the site.
Advantages of Laparoscopic Hernia Repair
- Latest & better mode of treatment for a hernia is laparoscopic repair.
- Done by imported state of art miniature karl storz instrumentation.
- Done through a small hole in the abdominal wall.
- Short hospital stay.
- No scar at the hernial site.
- Cosmetically superior.
- Best for recurrent or bilateral inguinal hernias.
- Almost no pain or infection.
- A bigger hernia can be treated laparoscopically.
- Less need for medications.
- Minimal blood loss.
Advances in Miniature Laparoscopy (Needlescopy)
Needlescopy or Miniature Laparoscopy is a step beyond routing conventional laparoscopic surgery. The incision is so small (less than 3 mm), that virtually no scaring happens and can be carried as a daycare procedure.
Our surgeons perform needlescopic surgery by putting narrow tubes called trocars into these small incisions and then bypassing these miniature instruments or better called needlescopic instruments through these tubes and with added a small television monitor/camera for video-scopic guidance and vision.
All the routine procedures can be done in needlescopic way i.e. Cholecystectomy, Appendicectomy, Paediatric Hernia Repair, diagnostic procedures, etc.
In our center, we have performed needlescopic surgery in two pediatric patients, who were just at the tender age of 3 years, but presented with agonizing pain and distress in the abdomen which was unbearable for a small kid. Our Dr. H.s. Jolly, analyzed this problem and decided to operate on the patient by needlescopic surgery.
At last, it is a convening message that miniature laparoscopy can be performed for routine ailments and is being performed regularly at RG Stone Hospital with the added advantages over the routine laparoscopy.
