Inguinal hernia surgery

Surgical repair of a right inguinal hernia

Inguinal hernia surgery refers to a surgical operation for the correction of an inguinal hernia. Surgery is not generally advised in most cases if the Hernia produces no symptoms; watchful waiting being the recommended option. In particular, elective surgery is no longer recommended for the treatment of minimally symptomatic hernias due to the significant risk (>10%) of chronic pain (Post herniorraphy pain syndrome) and the low risk of incarceration (ca. 2% per year). As general advice in surgery, the choice of the surgeon and hospital are more important than the choice of a particular surgical technique or material.

Mesh repairs

Open repair (Lichtenstein, Shouldice, Bassini)

The most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect.

It is a "tension-free" repair that does not put tension on muscles, contrary to Bassini and Shouldice suture repairs (but there are also tension-free suture repairs, like Desarda). It involves the placement of a mesh to strengthen the inguinal region. Patients typically go home within a few hours of surgery, often requiring no medication beyond paracetamol (Tylenol/acetaminophen). Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation. Complications include chronic pain (varying from 10-50% depending on source), foreign-body sensation, stiffness, ischemic orchitis, testicular atrophy, dysejaculation, anejaculation or painful ejaculation in around 12%. They are often under-reported. Recurrence rate is low, <2%.. In contrast to this however, benefits for patients with pre-existing erectile dysfunction or general sexual dysfunctions have been reported.

Laparoscopic repair

Intraoperative view by TEP Operation. 1. Genital ramus of genitofemoral nerve. 2. Preperitoneal lipom and spermatic cord.

There are mainly two methods of laparoscopic repair: transabdominal preperitoneal (TAPP) and totally extra-peritoneal (TEP) repair. When performed by a surgeon experienced in hernia repair, laparoscopic repair causes fewer complications than Lichtenstein, particularly less chronic pain. However, if the surgeon is experienced in general laparoscopic surgery but not in the specific subject of laparoscopic hernia surgery, laparoscopic repair is not advised as it causes more recurrence risk than Lichtenstein while also presenting risks of serious complications, as organ injury. Indeed, the TAPP approach needs to go through the abdomen. All that said, many surgeons are moving to laproscopic methodologies as they cause smaller incisions, resulting in less bleeding, less infection, faster recovery, reduced hospitalization, and reduced chronic pain.

Laparoscopic mesh surgery, as compared to open mesh surgery

Advantages	Disadvantages
Quicker recovery Less pain during first days Fewer postoperative complications such as infections, bleeding and seromas Less risk of chronic pain	Needs surgeon highly experienced (>200 operations/year) in inguinal hernia repairs Longer operating time Increased recurrence of primary hernias if surgeon not experienced enough

There is no difference in cost between laparoscopic and open repair as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical when laparoscopy is performed by an experienced surgeon. When performed by a surgeon less experienced in inguinal hernia lap repair, recurrence is larger than after Lichtenstein.

Meshes

Inguinal Hernia Patch. Animation in the reference.

Permanent mesh

Commercial mesh

Polypropylene mesh used for inguinal hernia surgery

Commercial meshes are typically made of polypropylene or polyester. Marlex, Gore-Tex or Teflon meshes are sold by some companies. Lightweight meshes seem to cause less discomfort than heavyweight meshes. Some repair kits combine a plug and a patch. Some plug-and-patch kits combine an absorbable plug with a nonabsorbable patch, like Bio-A, manufactured by W. L. Gore & Associates.

Mosquito-net mesh

Meshes made of mosquito net cloth, in copolymer of polyethylene and polypropylene have been used for low-income patients in rural India and Ghana. Each piece costs $0.01, 3700 times cheaper than an equivalent commercial mesh. They give results identical to commercial meshes in terms of infection and recurrence rate at 5 years.

Therefore, it remains to be shown that despite their considerably higher cost, standard commercial meshes could offer any practical improvement over mosquito-net cloth in inguinal hernia surgery.

Complications

See also: Post herniorraphy pain syndrome

Complications are frequent (>10%). They include, but are not limited to: foreign-body sensation, chronic pain, ejaculation disorders, mesh migration, mesh folding (meshoma), infection, adhesion formation, erosion into intraperitoneal organs. Such complications usually become apparent weeks to years after the initial repair, presenting as abscess, fistula, or bowel obstruction.

In the long term, polypropylene meshes face degradation, due to heat effects. This increases the risk of stiffness and chronic pain. Persistent inflammation and increased cell turnover at the mesh-tissue interface raised the possibility of cancer transformation.

Cases of obstructive azoospermia have been related with the use of polypropylene mesh, due to the obstruction of the vas deferens as a result of the fibroblastic reaction to the mesh. However, a recent study finds that this risk seems to be less than 1% and therefore, it does not need to be notified in an informed consent.

Absorbable mesh

Main article: Biomesh

Biomeshes are increasingly popular since their first use in 1999 and their subsequent introduction on the market in 2003. Their use is an instance of regenerative medicine. Contrary to synthetic non-absorbable meshes, they are absorbable and they can be used for repair in infected environment, like for an incarcerated hernia. Moreover, they seem to improve comfort and presumably, they reduce the risk of inguinodynia. They have been tested after mesh-related inguinodynia. Some meshes have a comparable price to high end of synthetic meshes, the cheapest ($500) being Surgisis-Biodesign, manufactured by Cook Group, made from the extra cellular matrix of pig small intestinal submucosa. Currently, there exist also one synthetic totally absorbable mesh, Tigr Matrix, manufactured by Novus Scientific, on the US market (510(k) Food and Drug Administration clearance) since 2010 and on the EU market since 2011. It only has one 3-year pre-clinical evidence on sheep.

Though their benefit is not fully established yet, the market of biological meshes is exploding, and if the current trend is confirmed, they may replace synthetic meshes in the US by 2016

Suture repairs

Tension repairs

Bassini

Bassini technique, first suture. 1. Aponeurosis musculi obliq. ext.; 2. Musculus obliquus internus; 3. Musculus transversalis; 4. Fascia transversalis; 5. Peritoneum; 6. Ligamentum inguinale.

The first efficient inguinal hernia repair was described by Edoardo Bassini in the 1880s. The Bassini technique is a "tension" repair, in which the edges of the defect are sewn back together, without any mesh. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis and internal oblique muscles) is approximated to the inguinal ligament and closed. Today, Bassini's main interest is historical. It remains performed in some developing countries, if surgeons do not have knowledge of the mosquito-net alternative to commercial meshes in Lichtenstein repair, or if they ignore more efficient suture-based repairs.

McVay/Cooper's ligament

The floor of the canal is reinforced by approximating the transversus abdominal aponeurosis and transverse fascia to pectineal (Cooper's) ligament medially from the pubic tubercle to the femoral vein. Lateral to this the floor is restored by approximating the femoral sheath to the inguinal ligament. It is also used in femoral hernia repairs.

Shouldice

The Shouldice technique is the mainstream suture-based repair. It is a relatively difficult four layer reconstruction of fascia transversalis; however, it has relatively low reported recurrence rates in the hand of a surgeon experienced with this method.

Shouldice repairs are less commonly used today than in previous years, especially in developed countries. This is mostly due to the fact that mesh-based Lichtenstein method is easier to perform. The Shouldice repair has a higher rate of hernia recurrence in the hands of surgeons inexperienced with them (<200 operations/year). Another drawback is the post-operative pain due to the tension on muscles, which generally lasts some weeks. However, this pain is well-managed with analgesics, and this short-term pain must be balanced with the much lower risk of long-term pain of the Shouldice technique, which is half Lichtenstein (but similar to laparoscopic). This is why few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVay repair.

The main advantage of the Shouldice technique remains the relatively low report of chronic pain (10% incidence), as compared with mesh-based open repair (Lichtenstein) (20% incidence). However, the risk of chronic pain with this method is comparable to a laparoscopic repair performed by a surgeon experienced with inguinal hernia repair (i.e. >200 hernias/year) (8% incidence) (and not simply a surgeon experienced with laparoscopy. This difference is important).

Moreover, if the surgeon is not experienced enough with the Shouldice technique, as is the case for most surgeons nowadays, mesh-based repair can be advised. For example, in developing countries, where commercial meshes are expensive, but where surgeons might also be less qualified, a mosquito-net mesh open repair can be better than Shouldice. Indeed, both have a similar cost (a mosquito-net mesh costs less than $0.01. Its sterilization costs less than $1), and mesh repair is easier to perform than Shouldice. Desarda repair is also another option, but it is less widely known.

Another advantage of suture-based repairs over permanent mesh repairs is that they do not introduce significant permanent foreign-body material, at worst, only polypropylene non-absorbable sutures. Permanent meshes can cause additional long-term complications due to this fact.

Tension-free repairs

Desarda

The Desarda technique is an emerging suture-based technique. It can be performed with absorbable sutures. It is simpler and faster to perform than Shouldice and Lichtenstein. It also gives similar results to Lichtenstein in terms of recurrence, with the significant benefit of not introducing permanent foreign-body material. Moreover, this technique is tension-free, mesh-free, and it pays attention to the physiology. Other techniques using a flap from the external oblique aponeurosis were proposed independently by other surgeons.

Guarnieri

Guarnieri technique appeared in 1988. It can be used with or without mesh. Like Desarda technique, the Guarnieri method pays attention to the physiology, and it is also tension-free.