Hernia refers to a medical condition wherein the contents of a body cavity bulge through a weak spot in the wall of that cavity. This HealthHearty write-up explains the surgical procedure and recovery for inguinal hernia, which is a type of hernia that is characterized by the protrusion of a part of the small intestine through a tear or weakness in the inguinal canal in the groin.
Did You Know?
It was an American surgeon named Francis C. Usher who first described the use of Marlex mesh for inguinal hernia repair in 1950s.
Inguinal hernia accounts for about 75% of all hernias. The incidence of this form of hernia is much higher in men, with the male-female ratio being 8:1. This condition is characterized by the bulging or the herniation of the intra-abdominal contents (part of the small intestine or preperitoneal fat) through a weak spot in the fascia of the lower abdominal wall or the inguinal canal. A short passage that runs above and parallel to the inguinal ligament on each side of the lower abdomen, the inguinal canal extends inferiorly and medially, through the lower abdominal wall. The inguinal canal is a common site for herniation. Thus, excess pressure should not be placed on this region.
Inguinal hernia is classified into indirect (congenital) and direct hernia. In case of the former, the peritoneal sac enters the inguinal canal through the deep inguinal ring, whereas the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal in case of the latter. Thus, this condition can be congenital or might develop later in life. It is characterized by symptoms such as the presence of a bulge in the groin or scrotum. Though not all patients might experience pain, sometimes, the bulge might be accompanied by pain that worsens with coughing, bending, lifting weights, straining, or laughing. Often, the symptoms disappear when the affected individual is lying down.
The terms ‘herniorrhaphy’ and ‘hernioplasty’ refer to the surgical repair of hernia and the surgical repair of hernia with a mesh, respectively. Such procedures might become a necessity in case of complications such as incarceration and strangulation. In case of incarceration, a part of the intra-abdominal fat or small intestine gets lodged in the groin or scrotum, and doesn’t go back into the abdomen. Strangulation is a medical emergency wherein an untreated incarcerated hernia obstructs the blood supply to the small intestine, which can cause that section of the small intestine to die.
Inguinal Hernia Repair Surgery
An Italian named Edoardo Bassini (1844-1924) is often referred to as the father of modern-day hernia surgery, as he came up with the concept of tissue-based hernia repair on the basis of anatomical dissection and reconstruction of the inguinal canal. While Bassini’s contribution is very important, varied ideas were put forth later. While Marcy used animal sinew for repair (with little success), Halstead came up with the concept of the reconstruction of the posterior inguinal floor. The early 1950s saw the development of a suture-based technique called Shouldice repair which involved the four-layer reconstruction of the fascia transversalis. Basically, the surgical repair can be classified into open repair and laparoscopic repair.
Open Hernia Repair
The introduction of Marlex (monofilament knitted polyethylene mesh) in 1958 and Prolene mesh in 1962 paved way for the major advancements in the field of hernia surgery. Inguinal hernia repair by open surgery is often classified into two categories:
➠ Suture-only open repair (without the use of a mesh)
➠ Open repair with a mesh
The major issue with open suture repair was that the tension that would build up on the suture line could put one at a greater risk of a recurrence. Over time, the ‘tension-free’ repair with mesh gained popularity. It was observed that the recurrence rate is quite low and postoperative pain is less with the use of synthetic mesh by both open, as well as laparoscopic method. The recovery time for open hernia repair is about three weeks. Usually, the patient can drive after a couple of weeks and perform routine activities. However, he should refrain from performing strenuous activities for at least 6 weeks.
Open Repair with Mesh
In an open surgery, an incision is made near the hernia site, so as to remove the hernia sac or push the bulging tissue back into the abdomen. Thereafter, the surgical mesh is placed over the site of herniation. To keep the mesh in place, it is attached with sutures which are sewn into the stronger tissue that surrounds the site. Surgeons might also choose to place mesh plugs into the inguinal space and the plug is then sutured to the surrounding tissue. The surgeon might also place a flat mesh patch over it. They might use an absorbable plug with an non-absorbable patch.
In case of a suture-only repair, an incision is made and the hernia sac is removed. Thereafter, the tissue along the edge of the muscle is sewn together. This method is employed for repairing small defects or strangulated hernias. If the hernia is large, surgeons are more likely to use a mesh, so as to lower the risk of recurrence.
Besides the use of mesh, tension-free repairs involve the use of plug-and-patch devices. In case of the PROLENE (Polypropylene hernia system), a 3-in-1 bilayer patch device is used. This device comprises a round disc (underlay patch) and an oblong-shaped onlay component. While the round underlay patch is positioned in the preperitoneal space of Bogros, the onlay component is placed over the inguinal floor. The internal ring has a cylindrical connector that joins the underlay patch and onlay component. This procedure has been found to be effective for repairing direct and indirect inguinal hernias.
In case of laparoscopic hernia repair, a small incision is made at the belly button through which a laparoscope (a small device that is connected to a tiny video camera that projects the view of the internal organs to a video monitor) is inserted. In order to get a better look at the organs, the abdomen is inflated with carbon dioxide. The surgeon cuts the inner lining of the abdomen to access the herniated sac. It is removed or pushed back, and a mesh patch is applied on the weak spot under the inner lining of the abdomen. The inner lining is then closed with sutures. The incision at the navel is closed with stitches or surgical tape.
Hernia surgery recovery would vary, depending on the type of procedure that has been used. One might take longer to recover if complications arose during the procedure. In case of a laparoscopic surgery, one is likely to recover in a week. Since the incisions are small, the hospital stay is shorter. Moreover, there’s less risk of bleeding and infection. More often than not, the patient is discharged the same day. The postoperative pain is also less. However, the surgery has to be performed by an experienced surgeon. While the patient can resume the normal activities, it’s best to refrain from performing activities that might put stress on the abdominal and groin region. Following the aftercare instructions suggested by the surgeon will help speed up the recovery and lower the risk of complications.
If a person has undergone this surgery, then he/she must follow these self-care measures:
➠ The patient needs to get adequate rest till the effects of anesthesia last.
➠ The effects of anesthesia can sometimes be felt up to a week. So, the patient should not drive himself home after the procedure. He should resume driving, only if he feels that he is ready.
➠ Those who have undergone the laparoscopic procedure are able to resume work within a week.
➠ Adequate care must be taken to ensure that the stitches don’t open up.
➠ Usually, the site of incision becomes a bit hard and might swell up after the surgery. This is a sign that the wound is healing. It will go away in a couple of months.
➠ Skin discoloration around the incision is due to the collection of blood. It is normal and will resolve in some time.
➠ In case of a laparoscopic procedure, the patient can shower 24-36 hours after the procedure. However, care must be taken to dry the incisions gently.
➠ Keep a pillow with you, so that you can place it against your abdomen for support, when you cough or sneeze.
➠ The patient should avoid lifting anything for at least the first few days. Then, he should lift very light objects that are easy to manage. Make sure that you use your knees and your back, and not the abdominal muscles while lifting anything.
➠For at least 2 weeks after the operation, the patient’s diet should include plenty of vegetables, fruits, and high fiber foods. This is to avoid strain on the abdominal muscles due to constipation.
➠ For the first few days after the surgery, the individual must sit at an incline to avoid putting pressure on the stitches.
➠ Don’t fail to make arrangements for a follow-up visit.
Do follow the aforementioned measures and the guidelines regarding drug therapy and diet to pave way for a speedy recovery. If you experience any untoward symptoms such as significant bleeding, chills, high fever, difficulty breathing, pus at the site of incision, inability to pass urine, pain, or any other sign of infection, it would be best to seek medical help at the earliest. Hernia could recur, if one fails to follow the aftercare measures. While you can resume work within a week, it would be best to consult a doctor, before you start exercising. Care must be taken not to put too much strain on the operated area.
Disclaimer: The information provided in this article is solely for educating the reader. It is not intended to be a substitute for the advice of a medical expert.