Head of the hernia center: Dr. med. Ralph Lorenz, M.D.
What is an inguinal hernia?
Humans have a canal in their groin that is formed by the abdominal muscles. The spermatic cord and its accompanying blood vessels run through this canal in a man; in a woman, the round ligament runs through it. Should the abdominal muscles weaken, the canal expands, and intestines can protrude from the inside to the outside, becoming palpable and even presenting a visible bulge. An inguinal hernia can increase in size over time; this often happens with an increase in internal abdominal pressure, for example through coughing, sneezing, or straining. The inguinal hernia emerges above the inguinal ligament. In men, it can extend deep into the scrotum (a so-called scrotal hernia). Men are far more noticeably affected by inguinal hernias than women. The ratio of men to women is approximately 8:1. This can be explained by testicular migration during the fetal period. The testes are initially located in the abdominal cavity, and during that time, they pass through the abdominal wall, leaving behind a so-called „breaking point“. Many risk factors can advance the formation of an inguinal hernia. Genetic factors (Are there already abdominal wall hernias in the family?) and smoking (chronic coughing not only creates „stress“ to the abdominal wall, but nicotine also has an effect on collagen) are particular causes.
How is an inguinal hernia diagnosed?
A patient cannot always recognize an inguinal hernia by looking in the mirror. The diagnosis of an inguinal hernia usually occurs through clinical examination of the groin while standing and lying, compared to with abdominal pressure or coughing too. In addition, we often perform a dynamic ultrasound examination (sonography of the groin region) for a more accurate diagnosis. This is usually done as a dynamic examination while standing and lying, compared to with abdominal pressure. Along with an assessment of clinical conditions, the results of the ultrasound examination have significant influence over the urgency of a potential operation.
What kinds of inguinal hernias are there?
Hernias are principally distinguished by their localization (medial = direct and lateral = indirect). Quite often there are mixed forms and so-called „combined“ inguinal hernias, where there is a lateral portion in addition to a medial. All inguinal hernias have long been classified in our center using European guidelines. (EHS Classification = European Hernia Society Classification). Together with requirements, risk profiles, and the patient’s wishes, this classification serves as a guideline for decisions made during surgery.
Do you have to operate on an inguinal hernia?
Although most inguinal hernias are harmless, they nevertheless can lead to intestinal incarceration at any time, which presents a more threatening complication. This is not only extremely painful, but it also presents an emergency and must be operated on immediately! In contrast, small inguinal hernias with flat protrusions (ultrasound diagnosis) are rather harmless, particularly in younger patients with no pre-existing conditions or pain. In this case, a deferral with constant medical supervision (about 6 weeks) is possible for the purposes of „watchful waiting“.
Today, there are many surgical options to choose from to treat an inguinal hernia. In each case, we individually determine the surgical procedure to be used according to:
- the type of hernia
- the size of the hernia
- the patient’s risk profile
- age and comorbidities
- physical job requirements
- and the patient’s wishes.
Among the risk factors that further the development of an inguinal hernia are:
- genetic factors (simultaneous appearance of inguinal hernias, umbilical hernias, and incisional hernias in family members)
- presence of asthma, chronic bronchitis (COPD), and diabetes
What treatment processes are there?
It is fundamental to distinguish between hernia repair with plastic implants versus without. The classic hernia treatment according to Shouldice was thought to be the „gold standard“ in hernia surgery until the „breakthrough“ of mesh treatment. Today there are a variety of different surgical techniques that allow for a much more nuanced approach and, therefore, make „tailored“ surgery possible. Inherently, we do not have a single standard method; rather, an individually appropriate surgical procedure with or without mesh implantation is selected from a multitude of pre-operative and intraoperative options.
Overview of possible surgical procedures:
1. Open procedure with incision
In all open surgical procedures, hernia treatment either takes place with or without foreign material (plastic mesh). Surgical access is now achieved through a so-called mini-open technique, wherein a very small skin incision (4-5 cm in length) is made to the lateral lower abdomen fold or the groin. With healing and blanching in the first year following surgery, the scar typically becomes almost impossible to see. Depending on the presence of comorbidities and the age of the patient, all open surgical procedures can be performed on an outpatient or short-term inpatient basis (up to 2 days). As a rule, all currently available forms of anesthesia can be used. We usually carry out the operation by means of laryngeal mask anesthesia. It is also possible to use a local or neuraxial anesthetic.
Hernioplasty with minimal repair
This surgical technique is the method of choice, particularly for so-called „sports hernias“. In this case, management of groin pain is the priority, rather than the hernia itself. A compression of the nerves is often involved (genital branch of the genitofemoral nerve and ilioinguinal nerve), which can be caused by straining or an increase in abdominal pressure. This mainly affects athletes who play ball sports, particularly soccer players, but also runners and triathletes. In this surgical technique, the unstable area of the inguinal canal’s posterior wall is selectively strengthened using a special suture process, and, therefore, manages without the use of foreign material. This method is particularly suitable for younger, athletic, or very active patients without a significant risk profile, as well as competitive athletes with smaller, predominantly direct hernias.
Hernioplasty according to SHOULDICE
This method traces back to the Canadian surgeon Edward Earle SHOULDICE, who developed this highly successful global technique in 1944 and first published it in 1953. In this method of operation, each anatomical structure is precisely displayed, and each layer of the defect is separately treated using successive, non-absorbent sutures free of foreign material. In the process, the posterior wall of the inguinal canal is stabilized through the use of a multi-row suture technique. This method is thought to be the best suture process with a comparably low recurrence rate (rate of hernia recurrence after surgery). Having visited SHOULDICE Hospital in Toronto in September/October of 2013, we perform this method to an equally high standard. In Shouldice Hospital, approximately 7,000 hernias are surgically treated each year, most using this mesh-free technique. This method is particularly suitable for smaller indirect and direct hernias and younger patients without a significant risk profile.
Hernioplasty according to DESARDA
This method was first described in 2003 by Indian surgeon Mohan P. DESARDA from Pune. Here, stabilization of the inguinal canal’s posterior wall takes place using a mesh-free fascia flap. In numerous randomized scientific studies, very good results were obtained using this largely stress-free (and more importantly mesh-free) method. We have also used this method in our hernia center since 2011. !(DESARDA illustration)[http://www.3chirurgen.de/img/Image/Fig2.JPG] This method is particularly suitable for patients without a significant risk profile who exhibit small to mid-sized direct and indirect hernias. However, it is also suitable for any patient with reservations about plastic mesh. Regular scientific exchange has resulted from a personal visit to Prof. Desarda in Pune in May of 2012. Follow-up examination of our patients showed that this surgical method also has very low rates of postoperative pain and recurrence.
Hernioplasty with a mesh plug (PerFix Light Plug) according to RUTKOW and MILLIKAN
Technically speaking, the plug method is a very simple operation. The idea behind it is to close the hernia hole with smaller (and recently more lightweight) mesh. Highlights of this method are particularly low tissue trauma due to minimal preparation, as well as a small skin incision measuring only 4-5 cm. The mesh is securely positioned through suture fixation. This method is particularly suitable for small to mid-sized groin or leg hernias with a risk profile, or for recurring hernias. Meanwhile, there has been product improvement: Since January of 2010, the mesh material has been significantly improved through the use of lightweight large-pore mesh. We also use this new option.
Hernioplasty with the UPP System (Ultrapro Plug)
Similar to the technique used in RUTKOW and MILLIKAN’S process, this new method uses small mesh to reinforce the abdominal wall. What is new is that a partially absorbant, large-pore, lightweight, and rather laminar-oriented mesh is used. Therefore, this method is suitable for small to mid-sized groin and leg hernias, but it also allows for maximum flexibility due to the nature of the material.
Hernioplasty according to PELISSIER – The TIPP Technique (transinguinal preperitoneal mesh-plasty)
Here, an extensive lightweight mesh is set between the peritoneum and the transverse fascia (innermost abdominal muscle layer) and fixed with sutures (transinguinal preperitoneal mesh-plasty = TIPP technique). This has the distinct advantage of the mesh being placed against the abdominal wall from the inside, and it is pressed against this abdominal wall by the pressure of the abdominal organs. Since visiting Dr. Pelissier in Besancon (France) in September of 2005, we have frequently used this method. This surgical technique is particularly suitable for mid-sized to large hernias with an unstable inguinal canal posterior wall, and it offers a particularly high degree of stability.
Hernioplasty with the Polysoft Patch – The ONSTEP Technique (Open New Simplified Totally Extraperitoneal Patchplasty)
This technique was developed in 2005 and first presented in 2009 by Portuguese surgeons A. Lourenco and R. Soares da Costa. Following an international surgical training program in May of 2012 in Porto (Portugal), yet another surgical method has become available for the treatment of medium to large hernias in our hernia center. Here, a self-stretching mesh is implanted through a very small (3-4 cm) lower abdominal incision using a technically simple method. This operation method is particularly suitable for obese patients, as surgical access is very easy.
Hernioplasty using the UHS System (Ultrapro Hernia System) according to GILBERT
As with the UPP System, this new technology also uses a partially absorbent, lightweight, large-pore mesh. It also strengthens the abdominal wall, particularly from the inside (posterior process). The partial absorbency of the mesh is advantageous in that only a small amount of mesh material remains in the body following absorption of the initially stabilizing mesh portion (about 4-6 weeks). It strictly adheres to the principle: „Not as much as possible, rather as much as is necessary!“ Having visited Dr. Tim Tollens at the hernia center in Bonheiden, Belgium in April of 2008, this new method is also applied where appropriate. It is one of the favored methods at our practice. In addition, we have personal contact with Dr. Arthur Gilbert. This method is equally suitable for medium and large—especially combined—hernias. Due to the material properties, this technique also provides very high flexibility in addition to high stability.
Hernioplasty according to LICHTENSTEIN
This method was developed in 1984 by the Canadian surgeon LICHTENSTEIN. In the LICHTENSTEIN technique, the inguinal canal posterior wall remains intact, and large, tension-free mesh covers and is sewn over it. Numerous modifications for the technical improvement of this surgical technique have been described by Parviz Amid, the longtime director of the Lichtenstein Institute. There is longtime personal contact and exchange with both Dr. Parviz Amid and his successor, Dr. David Chen. This surgical method is the world’s most commonly performed surgical procedure for the treatment of an inguinal hernia. This technically simple surgical method is particularly suitable for all mid-sized to large hernias if reinforcement is not possible from the back (e.g. following vascular surgery, radiotherapy, and previous surgery to the bladder and prostate).
!(illustration of surgery according to LICHTENSETEIN)[http://www.3chirurgen.de/img/Image/OpLichtenstein.jpg]
2. Endoscopic procedures
In endoscopic procedures, hernia treatment always uses plastic mesh, usually taking place through 3 small incisions in the abdominal wall (often the navel, left and right lower abdomen). Endoscopic procedures without the use of a mesh implant do not exist for adult patients. Anchoring of the mesh to the tissue is achieved using staples, glue, self-adhesive mesh, or without fixation. Endoscopic operations mostly take place in Germany on an inpatient basis. In a global comparison, a maximum of 20% of operations are performed endoscopically. General anesthesia (intubation) is always necessary for endoscopic surgery.
Hernioplasty with TAPP or TEP
The transabdominal (TAPP) and total extraperitoneal (TEP) endoscopic techniques are surgical methods that work with large plastic mesh (a mesh size of at least 10 x 15 cm is standard today). Analogous to the TIPP technique, these are applied for logical reasons (neuromuscular/back strengthening) from the back of the abdominal wall. Both methods were developed in the early 90s and, to a great extent, have been standardized in the last few years. Both techniques are, in our opinion, particularly suitable for repeat (revision) procedures (after previous operations using mesh) or if surgical access is difficult from the outside. Overall, however, this surgical procedure is just as complex and expensive as an open surgical procedure, and is not free of risk.
What do I have to watch out for after an operation like this? Aftercare recommendations for patients of inguinal hernia surgery (hernia surgery)
What about eating and drinking? Beginning the day after surgery, you may eat easily digestible food. In any case, you should drink plenty of fluids (water and tea), because there is always an increase in metabolism following surgery. May I smoke? As a general rule, you should not smoke after surgery, because smoking has a negative effect on recuperation and additional complications could occur. In addition, smoking often triggers a cough, which at the very least may be painful right after surgery.
Will I be in pain? Depending on your sensitivity to pain, mild to moderate pain typically occurs in the groin region, particularly with movement or change in position, as well as with coughing and straining. This is quite normal in terms of wound pain. If necessary, you can take a mild pain reliever. For severe pain, you should always contact us or see your doctor immediately!
Feeling of numbness is the surgical area? After the operation, a feeling of numbness can occur in the area surrounding the scar. This is difficult to avoid due to possible injury to the small cutaneous nerves at the surgical site. In addition, many randomized scientific studies have shown that possible chronic pain can often be prevented through the deliberate separation of the lumbar plexus branch in the surgical area. Localizations in the operated areas of the body, which occasionally spread to the pubic region and in men can possibly also lead to discoloration of the testicles or penis, are in most cases harmless, and often recede within 1-2 weeks.
Swelling and bruising When treating an inguinal hernia with foreign material (plastic mesh), swelling sometimes arises after 1-2 weeks. Again, this is usually normal, and can be explained by the increased fluid retention in the surgical region in response to a foreign body. Swelling or stiffness in the surgical area can occasionally last up to 6-8 weeks and will gradually return to normal, but it is usually painless. In the first week, you should cool the surgical area with an ice pack for 10 minutes 5-6 times daily. Only in rare cases do we insert a drain to help discharge wound secretions or blood; this is usually removed after 2 days. For redness, swelling in the surgical area, and fever, you should immediately consult a doctor!
When can I shower again after the operation? You can shower 48 hours after the operation.Full baths or the use of bath additives or soaps are not recommended. A protective patch must be changed after you shower.
When do I need to visit the office for a follow-up?
In general, we recommend scheduling the first follow-up at our practice on the first or second day after surgery, particularly after an outpatient operation. We will take care of your first dressing change. For inpatient procedures, this follow-up and the first dressing change will take place during ward rounds in the hospital. Additional follow-ups should take place in line with our quality assurance as follows:
- after 1 week
- after 1 month
- after 3 months
- after 1 year
When can I resume physical activity and lifting?
Due to different hernia sizes and locations, as well as various surgical techniques, there are different decisions about lifting and carrying loads, which we will personally discuss with you after your surgery. As a rule we recommend:
- after 1-2 days: everyday activities
- in the first 1-2 weeks: light activity – lifting and carrying up to 10-15 kg, cycling, running, swimming possible after approximately 1 week
- after 2-3 weeks: increase in activity: fitness with a lighter weight load
- after about 3 weeks: increase to full activity without restrictions