Herniotomy
Herniotomy (synonym: hernia surgery) is an operation to remove or correct a hernia. The indication for surgical treatment is the risk of incarceration in the absence of symptoms and increase in size. In asymptomatic inguinal hernia type A and B (see below Hernia inguinalis/medical device diagnostics/sonography (ultrasound)), observational waiting (so-called “watchful waiting”) is sufficient. Notice:
- In asymptomatic and nonprogressive (progressive) inguinal hernia in men, a recommendation for surgical therapy may no longer be made (level of evidence 1).Meanwhile, the HerniaSurge guideline states; that most patients with asymptomatic or minimally symptomatic inguinal hernias develop symptoms in the course and should therefore be operated on. Prompt surgery is recommended in patients with femoral hernias [see below Guidelines: HerniaSurge 2018].
- Primary surgery should be performed for a primary female hernia according to the European Hernia Society (EHS) guideline. The reason is the possibility of femoral hernia (femoral hernia; femoral hernia; thigh hernia), which is not clearly diagnosable clinically and by medical device and also incarcerates in up to 30% of cases (level of evidence 2, recommendation grade B).
The symptomatic inguinal hernia requires surgical therapy in any case (the asymptomatic form only in the presence of type C). A distinction can be made between different forms of surgery, which can be performed either conventionally with an abdominal incision or laparoscopically (minimally invasive via keyhole surgery). An attempt is made to close the hernial orifice with a mesh. For details, see “Surgery for an inguinal hernia”. The laparoscopic procedure is the method of first choice. This procedure also has the lowest rate of postoperative wound infections. Contradiction: there is no best technique for unilateral primary inguinal hernia. A Canadian hernia center (7,000 inguinal hernias per year), Shouldice Hospital (Ontario) achieves long-term recurrence rates of 1.2% with approximately only 10% of procedures endoscopic. Standardization of surgical technique is crucial, he said. According to the current HerniaSurge guideline, men and women with primary unilateral femoral and inguinal hernias should be treated primarily with laparoendoscopic procedures because of a lower postoperative and chronic pain incidence [see Guidelines: HerniaSurge 2018 below]. Perioperative management/antibiotic therapy.
- Antibiotic prophylaxis is recommended open repair procedures in patients at increased risk for infection.
- If there are no risk factors, antibiotic prophylaxis should not be performed as a rule
- For laparoendoscopic surgical procedures, antibiotic prophylaxis is not recommended – regardless of existing risk factors.
Further notes
- Approximately one in ten inguinal hernias is incarcerated (hernia with critical entrapment of hernial contents in the hernial orifice) at the time of diagnosis.
- Mesh-based surgical procedures (mesh implants) do not have a higher risk of infection than a surgical method without mesh. According to current HerniaSurge guidelines, mesh-based procedures are recommended in the management of symptomatic inguinal hernias [see guidelines below: HerniaSurge 2018].
- Hernia care with IPOM (intraperitoneal onlay mesh) is also considered for incarcerated hernias as long as there is no peritonitis (inflammation of the peritoneum).
- A mesh insert offers the best guarantee against early recurrence (recurrence of the disease). However, based on the “Dansk Herniedatabase”, mesh-based repair showed continuously increasing complications (ileus (intestinal obstruction), intestinal perforations, chronic infections in the surgical area or sinus tract) with increasing follow-up time: open surgery 5.6% complications requiring treatment, after laparoscopic hernia repair was 3.7%.
- When the Onstep technique (= Open New Simplified Totally Extraperitoneal Patchplasty) was used, the proportion of men with postoperative reported pain during sexual activity was 13.1%, significantly better than the Lichtenstein group (23%). In the Onstep technique, the 3-4 cm lower abdominal incision is followed by implantation of a self-tensioning mesh. Fixation is omitted in the process.The mesh is placed with its medial part preperitoneal (“in front of the peritoneum“) and with its lateral part between the two Mm. obliqui (externus and internus), thereby enclosing the funiculus spermaticus (spermatic cord).
- In women, the recurrence rate after inguinal hernia surgery is greater after an open procedure than after laparoscopic surgery (2.4% (open) versus 1.2% (laparoscopic) at a mean follow-up of 36 and 24 months, respectively). At reoperation, femoral hernia was detected in 43% of recurrent cases.
