Inguinal canal is situated in the lower abdomen on both sides, it begins at the internal ring and ends at external ring close to midline above serotum. This canal transmits blood vessels and Vas deferens going to tests.
In women, it transmits the round ligament of uterus.
Understanding Genesis of Inguinal Hernia:
- The Testes of male person is inside the abdomen before birth and it travels down from inside the abdomen to outside and into the scrotum through inguinal canal. The sac which carries it down, gets closed at birth.
- If this sac remains open completely or even partially, it serves as an open conduit, for intestines or abdominal fat to protrude and travel down, right up till the Scrotum. Thus an indirect Inguinal Hernia forms.
- In the elderly , the muscles covering the inguinal canal can get weak, and intestine can start protruding out the canal area, causing a Direct Inguinal Hernia.
Clinical features of Inguinal Hernia:
- It can occurs at any age. At birth or in infants, it is called as “Congenital hernia”, or hydrocele, since it may contain only fluid.
- Swelling in inguinal region, sometimes even up to scrotum.
- Swelling appears in standing position or on coughing and disappears on lying down.
- Pain in Inguinal region on coughing standing working or strenuous activities.
- Sudden pain in abdomen, persisted vomiting painful swelling at inguinal region, which does not reduce, on lying down or manipulating, is suggestive of obstructed Hernia, which needs emergency surgery.
Although small Direct Hernias and a small percentage of asymptomatic Hernias can be observed or, majority of Hernias need to undergo surgery.
Surgery for Inguinal Hernia
Surgical repair of Inguinal hernia can be done by open surgery or Laparoscopically, which is a form of Telescopic surgery.
Although many different types of surgeries are done for Inguinal Hernia, the commonly done types are
Lichtenstein Repair :
- This surgery can be done under local or spinal anaesthesia.
- An incision is taken over inguinal region and inguinal canal is opened.
- Hernial sac is dissected all around, separated from chord structures and opened.
- Hernial contents like intestinal or fat is put back into the abdomen.
- Hernial sac is excised partially or completely.
- Sac opening is closed at its neck so that nothing comes out of abdomen.
- 15 X 8 cms of prolene mesh is taken and one end is cut to form two tails, to accommodate chord structures. This mesh is then fixed or the posterior wall of Inguinal canal from midline to lateral abdomen so that it forms a barrier against further recurrence of hernia.
- Inguinal canal is then closed.
- Skin incision is closed with stapler or sutures.
Shouldice Repair :
- This surgery also can be done under local or spinal anaesthesia .
- Similar incision is taken on inguinal Region and inguinal canal is opened. Hernial sac is dissected, emptied and excised and closed.
- Repair is done by creating flaps of tissues of posterior wall and suturing them on one on top of the other in double-breasting fashion.
- Outer layers are also suture done on top of the other in double-breasting fashion. This creates a strong wall, acting as barrier to prevent recreature of Hernia. No artificial mesh is used.
- Patient can go home on the same day.
First Laparoscopic Repair in the world was done by surgery Arregui in 1991, and Laparoscopic repair of Inguinal Hernia started in India by 1995.
Laparoscopic repair of Inguinal Hernia an be done in two days
- We can go to the area through the umbilicus, by entering the abdomen, and entire repair is done from inside the abdomen: this is called “Transabdominal Preperitonial Repair or TAPP.” Our centre specialises in TAPP.
- The other way is to go to Inguinal area is through extra peritoneal space, without entering abdominal cavity. This is called as “Trans Extra peritoneal Repair or TEP“.
Advantages of Laparoscopic Repair :
- Surgery is done through three small punctures near umbilicus – so only three stitches.
- No big incision on inguinal region.
- Patient goes home on same day or neat day in 24 hours.
- Early return to all physical activity including exercise.
- Very minimal pain.
- Larger mesh can be placed, and size of mesh can be increased to cover larger hernias.
- Both sides can be repair simultaneously.
Disadvantages of Laparoscopic Repair :
- Surgery has to be done under General Anaesthesia.
- Costs are more due to use of specialised Equipments, and fixation devices to fix the mesh.
- Postoperatively, fluid collection can occur at Inguinal region causing a bulge, at the site. This is called Seroma.
- Although most seromas disappear with passing time, few may need aspiration with syringe.
Procedure TAPP :
- Anaesthesia general.
- Position : steep head low.
- A 10mm incision is taken near umbilicus and Telescope is inserted into abdomen.
- Two 5 mm incisions are taken on either side of Telescope for Surgical Instruments to go inside the Abdomen.