Therapy | Inguinal hernia – symptoms and therapy

Therapy

As a rule, inguinal hernias always require surgical therapy. All operations have in common that the incision runs just above the inguinal canal, the hernia is reduced back into the abdominal cavity and the hernia sac is removed. There are different methods for closing the hernial orifices.

Laparoscopic procedures are also used. Inguinal hernias are among the most frequently surgically treated diseases in Germany. They are usually treated surgically, since conservative (i.e. non-surgical) treatment does not promise long-term success.

The operation usually takes between 20 and 30 minutes. In the case of an uncomplicated inguinal hernia, the time of surgery can be freely determined by the patient. The exception is the incarcerated inguinal hernia, which is an emergency indication.

In this case, surgery must be performed as soon as possible to prevent intestinal tissue from dying off (necrosis). If general anesthesia is not required, the operation is usually performed under local anesthesia, i.e. the patient is awake during the operation, but his pain sensation is switched off at the affected region. Nowadays there are numerous surgical procedures for the treatment of inguinal hernia.

However, the aim of all of them is essentially the same, namely to first push back the contents of the hernia sac to its original place (reduction) and then to strengthen the posterior wall (fascia transversalis) of the inguinal canal. A distinction is made between open surgical procedures, in which a skin incision is made, and minimally invasive laparoscopic procedures (keyhole technique), in which very small skin incisions are made. In open surgical procedures, some work exclusively by means of a suture, while others lead to the closure of the hernial orifice and the reinforcement of the posterior wall by the insertion of plastic mesh.

In this case, the hernial orifice is covered by an 8×12 cm plastic net. There are two differences in the minimally invasive procedures: Transabdominal reticulation (TAPP) (see below) and total extraperitoneal reticulation (TEP). In both procedures a plastic mesh is inserted.

In TEP, the mesh is inserted via a mirror image of the peritoneum, so the abdominal cavity does not have to be opened. In addition, no sutures or clips are required, since the mesh is held in place by the internal abdominal pressure and the counterpressure of the muscles. The disadvantage of minimally invasive procedures compared to open procedures is that they require a general anaesthetic.

The operation according to Lichtenstein describes one of the most common procedures for the treatment of an inguinal hernia. It is a small open operation, in which, in contrast to the minimally invasive procedures, the operating area is covered by an approx.five to ten cm large cut is opened in the bar. The special feature of the surgical procedure according to Lichtenstein is that the hernial orifice is closed by inserting a small plastic net.

This is sutured to the groin ligament and the abdominal muscles so that it cannot slip. The integrated mesh remains in the body and does not have to be removed if healing proceeds without complications. The operation according to Lichtenstein usually only requires a local anaesthetic.

Since general anesthesia is usually not required, the Lichtenstein procedure can often be performed on an outpatient basis to correct inguinal hernia in otherwise healthy patients. For example, if the inguinal hernia has reoccurred and surgery has already been performed (recurrence), a mesh should always be inserted. According to Lichtenstein, this can then be performed as open surgery or minimally invasive.

In the case of an inguinal hernia, often only a small operation is necessary, which can therefore be performed on an outpatient basis in some cases. This is especially true for younger and otherwise healthy patients. In principle, outpatient surgery is possible for open surgery forms, since in contrast to the minimally invasive (“keyhole technique”) procedures, general anesthesia is often not required.

Whether or not an outpatient operation is suitable, the treating physician and the patient must therefore decide in consideration of all factors. If there are reasons against outpatient care, the procedure can often be performed during a short inpatient stay of two days. TAPP is a surgical procedure for the treatment of inguinal hernias.

It is one of the minimally invasive laparoscopic procedures, i.e. it is operated using the keyhole technique. The aim is to strengthen the posterior wall of the inguinal canal by inserting a plastic mesh. Today, the TAPP procedure is mainly used for recurrent hernias (i.e. reappearing hernias that were previously treated surgically) and bilateral hernias.

The operation is performed under general anesthesia (intubation anesthesia).

  • It begins with an approximately 1 cm long skin incision in the area of the navel. An instrument is inserted through this and gas is introduced into the abdominal cavity.

    This is necessary so that the surgeon has a sufficiently good view of the surgical area.

  • A camera is then inserted through the existing incision, and a further instrument is inserted through a small skin incision on both sides of the abdominal wall.
  • Now the contents of the hernia sac are carefully reduced, i.e. put back where they belong. After preparation of the peritoneum, the surgeon reaches the inguinal canal. Here the plastic mesh is now inserted, placed over the hernial orifice and fixed with a few clamps.
  • Most of the gas is released from the abdominal cavity and the opened peritoneum is closed again with staples or sutures.
  • The instruments are now pulled out and the small skin incisions are sutured after the remaining gas has been released.

    The operation is now complete.

Complications are rare, but the patient must be informed about the possibility of their occurrence before each procedure. This may result in injury, constriction or irritation of nerves in the groin region. As with any surgical procedure, complications can occur during the operation.

Among the most frequent ones:

  • Injury to the spermatic cord, intestine and bladder
  • Injury to the vessels
  • Injury of nerves
  • Post-bleeding
  • Wound healing disorders
  • Thrombosis with subsequent pulmonary embolism
  • Disturbances in the area of the testicles, e.g. in the form of swelling or atrophy
  • Nausea, vomiting, abdominal and shoulder pain
  • Reduced intestinal activity
  • Recurrences (recurrence of an inguinal hernia)
  • Infections
  • Chronic groin pain

An inguinal hernia operation can be performed as an outpatient procedure, which means that the patient can be discharged home the same day. However, this of course depends on the overall condition of the patient and the type of surgical procedure. Following the operation, heavy physical stress such as lifting loads should be avoided for a few weeks.

Again, the exact behavioral requirements depend on the surgical procedure. If pain therapy is necessary, it is usually carried out with non-steroidal anti-inflammatory drugs such as ibuprofen. For thrombosis prophylaxis, treatment with Herapin should be continued until full mobilization.This mobilization should take place as quickly as possible, but should be pain-adapted. After the operation, the patient can eat normally immediately, depending on his or her wishes. A sick leave of 1-2 weeks is the rule.