Inguinal Hernia

What is an abdominal hernia?

An abdominal hernia arises from a weak point within the abdominal wall. Covered by the peritoneum and skin, the abdominal organs (most of the times gut and fatty tissue) bulge through a gap between the muscles and the connective tissue. If the abdominal hernia arises above the groin ligament, it is called groin rupture (hernia inguinalis). In case of a hernia below the inguinal ligament, it is called femoral rupture (hernia femoralis). The inguinal as well as the femoral hernia are inherent weak spots within the tissue, which by time extend until a hole gapes open within the tissue.

What kinds of risks are connected to an abdominal hernia?

Initially a hernia causes local discomforts like: ache at the site of rupture, burning, feelings of pressure and emanating pain. As time goes by, the hernia grows bigger. The main risk of a hernia is connected to the possible risk of a strangulated hernia. As the hernia includes most of the time small bowel, in case of constriction of the groin ring, a bowel obstruction (ileus) as well as circulatory disorders of the bowel, leading to an intestinal perforation may occur. In these emergency situations, a prompt surgery is needed in order to prevent an inflammation of the peritoneum (peritonitis). An untreated peritonitis leads to death in most of the cases. One must consider that, wearing supporting bandages do not eliminates the hernia but weakens the muscles and thereby promotes an extension of the gap within the abdominal wall.

How is an inguinal and a femoral hernia being treated?

A surgery is the first choice of treatment. Several possible operative procedures are available. The most suitable method is offered depending on the patient, level of risk, previous surgery and individual life planning. For example a repair of the hernia with suture is suitable in case of treating children, most of the times. When treating a woman who is not ready with her family planning, I would advise to perform a repair without prosthetic mesh, for instance Shouldice repair. In case of a patient who is not suitable for narcosis, a repair in the manner of Rutkov (plug and patch) with local anesthesia would be possible.

The operative methods where prosthetic meshes are used have been established in order to treat a rupture within the last years. The mesh thickens the abdominal wall, allows a tension free occlusion of the hernial gap and thereby contributes to a better long- term clinical result. The meshes must be light in weight and coarsely porous, in order to prevent negative reactions with the human body. The meshes are made of polyester or polypropylene. The most established methods of treatment as open surgery are the procedures in the manner of Lichtenstein and Rutkov. Minimal invasive methods are the TEP (P) and the TAP procedure. The advantages of the minimal invasive methods are small wounds and hence less pain. Already ten days after the surgery, sport activities can be performed again, where as the healing process could take several weeks after an open performed surgery.

What is the TAP method?

TAP means transabdominal plasty. The rupture is sealed from inside with a prosthetic mesh, by operating through three minor holes. The advantage of the TAP method in comparison to the TEP method is the possibility to examine the organs within the abdomen. The TAP method can also be possibly applied on patients with a history of surgery in the section of the lower abdomen.

What is the TEP(P) method?

TEP or TEPP means total extra peritoneal plasty. With this procedure three small incisions are made as well, though the peritoneum is not being harmed. A space between the peritoneum and the abdominal muscles is created. The procedure will be performed within that space. The hernia sac is released from the adherences with organs like the spermatic chord and is being pushed back. In case of a large hernia gap, it is sealed with a suture. Subsequently a mesh is being laid over the gap and thereby a coverage and protection is build. The advantage of this method in comparison to the TAP method is the not existing need to open the peritoneum. The risk of injuries of the abdominal organs or later complaints due to adhesions is limited to a minimum. The risk of nerve injury is as well limited, because of the staple free performance. Different from the TAP method a later trocar site rupture is excludable with the TEP procedure because of the oblique main entrance through the abdominal wall.

Autor: Dr. Andreas Franczak, Facharzt für Chirurgie, Gefässchirurgie und Visceralchirurgie

 

 

 

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