A Classic Case of Inguinal Hernia

This 57-year-old patient presented to our department with inguinal hernia. In this patient’s case we performed the open inguinal hernia repair since he underwent a cardio-thoracic surgery a few months ago and laparoscopy was contraindicated in this patient. We did the open surgery, removed the abdominal contents that came into the inguinal sac and put a mesh in to strengthen his inguinal area and to prevent further herniation.

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. Some inguinal hernias have no apparent cause. Others might occur as a result of:

·        Increased pressure within the abdomen

·        A pre-existing weak spot in the abdominal wall

·        Straining during bowel movements or urination

·        Strenuous activity

·        Pregnancy

·        Chronic coughing or sneezing

Inguinal hernia signs and symptoms include:

Ø  A bulge in the area on either side of your pubic bone, which becomes more obvious when you're upright, especially if you cough or strain

Ø  A burning or aching sensation at the bulge

Ø  Pain or discomfort in your groin, especially when bending over, coughing or lifting

Ø  A heavy or dragging sensation in your groin

Ø  Weakness or pressure in your groin

Ø  Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum                                                                                         

Complications of an inguinal hernia include:

v  Pressure on surrounding tissues

Most inguinal hernias enlarge over time if not repaired surgically. In men, large hernias can extend into the scrotum, causing pain and swelling.

v  Incarcerated hernia

If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas.

v  Strangulation

An incarcerated hernia can cut off blood flow to part of your intestine. Strangulation can lead to the death of the affected bowel tissue. A strangulated hernia is life-threatening and requires immediate surgery.

An inguinal hernia repair can be carried out as either open surgery or laparoscopic (or keyhole) surgery.

Open surgery

Open inguinal hernia repair is often carried out under local anaesthetic or a regional anaesthetic injected into the spine. In some cases, a general anaesthetic is used. This means you'll be asleep during the procedure and won't feel any pain. Once the anaesthetic has taken effect, the surgeon makes a single cut (incision) over the hernia. This incision is usually about 6 to 8cm long. The surgeon then places the lump of fatty tissue or loop of bowel back into your abdomen (tummy). A mesh is placed in the abdominal wall, at the weak spot where the hernia came through, to strengthen it. When the repair is complete, skin will be sealed with stitches. These usually dissolve on their own over the course of a few days after the operation. If the hernia has become strangulated and part of the bowel is damaged, the affected segment may need to be removed and the 2 ends of healthy bowel rejoined.

Laparoscopic (keyhole) surgery

General anaesthetic is used for keyhole inguinal hernia repair, so you'll be asleep during the operation. During keyhole surgery, the surgeon usually makes 3 small incisions in your abdomen instead of a single larger incision. A thin tube containing a light source and a camera (laparoscope) is inserted through one of these incisions so the surgeon can see inside your abdomen. Special surgical instruments are inserted through the other incisions so the surgeon can pull the hernia back into place. 

There are 2 types of keyhole surgery.

1.     Transabdominal preperitoneal (TAPP)

Instruments are inserted through the muscle wall of your abdomen and through the lining covering your organs (the peritoneum). A flap of the peritoneum is then peeled back over the hernia and a piece of mesh is stapled or glued to the weakened area in your abdomen wall to strengthen it.

2.      Totally extraperitoneal (TEP)

This is the newest keyhole technique and involves repairing the hernia without entering the peritoneal cavity. Once the repair is complete, the incisions in your skin are sealed with stitches or surgical glue.

The National Institute for Health and Care Excellence (NICE), which assesses medical treatments for the NHS, says both keyhole and open surgery for hernias are safe and work well. With keyhole surgery, there's usually less pain after the operation because the cuts are smaller. There's also less muscle damage and the small cuts can be closed with glue.

Keyhole surgery tends to have a quicker recovery time in people who:

·        have been treated before and the hernia has come back (recurrent hernia)

·        have hernias on both sides at the same time (bilateral hernias)

But the risks of serious complications, such as the surgeon accidentally damaging the bowel, are higher with keyhole surgery than with open surgery. The risk of your hernia returning is similar after both operations.