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.
- Inguinal Region of both sides is inspected for presence, type and size of Hernia.
- Hernial contents are pulled back into abdomen to empty the sac.
- In incision is taken 5cms above the hernia opening on peritoneum, the innermost layer and peritoneum along with Hernial sac is peeled away and dissected away from abdominal wall. The hernia sac is dissected away from chord structures, the Vas deferens and vessels.
- Dissection is done from lateral edge to midline and even beyond midline.
- Urinary bladder is dissected away from abdominal wall and space created for placement of mesh. This space is very large as compared to space created in open surgery.
- The Hernial opening as well as all the openings around this which could cause hernia in future care laid bare.
- Type of mesh to be used is choose, and it is cut to desired size. Minimum size used is 12cms X 15cms.
- Mesh is rolled into a tight roll and put inside the abdomen through the camera port.
- Mesh is unrolled and spread and placed on the Inguinal region covering the Hernial opening and all other openings where a future Hernia could occur.
- Mesh is fixed to abdominal wall using sutures, special, screws, or glue.
- Peritoneal flap is sutured to abdominal wall to cover entire mesh.
- Camera and instruments are taken out and the three openings are closed.
Types of Mesh Used :
- Polyprolene heavy weight / normal weight
- Polypolene light weight
- Polyester meshes?
- Large pore mesh
- Composite, partially absorbable meshes.
- 3-D meshes which fit the shape of inguinal region.
- Self fixing meshes , which do not need any fixing sutures or screws.
- Metal Tackers
- Absorbable tackers
- Seroma-swelling at inguinal region due to accumulation of fluid.
This disappears on its own.
- Pain at the site. Ninety percent of pain disappears within one to three months pain persisting after three months is called as “chronic groin pain” or Inguinodynix.
- Nerve injury
- Testicular pain
- Pain due to tackers
- Osteitis pubis
- Management is complex and multifactorial.
- This can manifest as pain, swelling and fever.
- Sometimes discharging sinuses.
- This is rare but dreaded complication.
- Removal of mesh is necessary in almost all patients.
- Anaesthesia : General
- Position : Headlow
- Procedure : incision is taken on one side of umbilical.
- Rectus sheath is opened.
- Rectus muscle is retracted and extra peritoneal space is entered.
- Extra peritoneal space is enlarged by using various methods like
- Using a ballon – commercial or simle ballon made of gloves
- Using CO2 gas
- Using telescope to dissect the space
- Telescope is inserted and Two more instruments are inserted under vision.
- Extra peritoneal space is enlarged by dissecting in midline as well as laterally.
- Hernial sac is dissected off chord structures and abdominal wall.
- In indirect hernia, sac has to be cut and ligated leaving part of sac in the serotum.
- Mesh is selected, cut to desired size minimum being 12 X 15cm.
- Mesh is rolled and inserted through camera port.
- Mesh is spread in the space, against abdominal wall to cover all defects.
- Mesh is fixed at two or three places.
- Some surgeons do not fix the meshIt stays in place since it is sandwitched between two layers.
- CO2 gas is removed and the port openings are closed.