Surgical Options in the Management of Groin Hernias - = January 1, 1999

(Corrections = made to Figs.=20 1, 2, 3, 4, and 8 in this article on February = 17,=20 1999.)

Surgical Options in the Management of = Groin=20 Hernias

TIM BAX, M.D., BRETT C. SHEPPARD, M.D., = and=20
RICHARD A. CRASS, M.D.=20
Oregon Health Sciences University,=20
Portland, Oregon

Inguinal and = femoral=20 hernias are the most common conditions for = which=20 primary care physicians refer patients for = surgical=20 management. Hernias usually present as = swelling=20 accompanied by pain or a dragging sensation = in the=20 groin. Most hernias can be diagnosed based = on the=20 history and clinical examination, but=20 ultrasonography may be useful in = differentiating a=20 hernia from other causes of groin swelling. = Surgical=20 repair is usually advised because of the = danger of=20 incarceration and strangulation, = particularly with=20 femoral hernias. Three major types of open = repair=20 are currently used, and laparoscopic = techniques are=20 also employed. The choice of technique = depends on=20 several factors, including the type of = hernia,=20 anesthetic considerations, cost, period of=20 postoperative disability and the surgeon's=20 expertise. Following initial herniorrhaphy,=20 complication and recurrence rates are = generally low.=20 Laparoscopic techniques make it possible for = patients to return to normal activities more = quickly, but they are more costly than open=20 procedures. In addition, they require = general=20 anesthesia, and the long-term hernia = recurrence rate=20 with these procedures is unknown.=20

Inguinal and=20 femoral hernias are the most common problems = primary=20 care physicians encounter that require = surgical=20 intervention. The treatment of these hernias = costs=20 approximately $3.5 billion every year.¹ Untreated or = recurrent=20 inguinal hernias are responsible for an = incalculable=20 loss of productivity and revenue. = Postoperative=20 convalescence also contributes to absence from = the=20 work force.

A clear understanding of the epidemiology = and=20 anatomy of inguinal hernias provides a solid=20 foundation for timely diagnosis and care. = Since=20 inguinal herniorrhaphy can be performed using = a=20 variety of techniques, the approach can be=20 individualized. This article reviews the = available=20 surgical options for herniorrhaphy and the = possible=20 complications of these procedures.

Epidemiology=20

In the United States, approximately 96 = percent of=20 groin hernias are inguinal and 4 percent are = femoral.=20 Inguinal hernias are bilateral in as many as = 20=20 percent of affected adults.¹⁼²⁰

The most common hernia in both sexes is the = indirect inguinal hernia. The male-to-female = ratio is=20 9:1 for inguinal hernias and 1:3 for femoral = hernias.=20 While inguinal hernias occur fairly equally = across=20 adult age groups, femoral hernias tend to = occur more=20 often in elderly women. The lifetime risk of = inguinal=20 herniation is approximately 10 percent.¹

Figure 1. Hesselbach's = triangle.=20 This anatomic landmark is bounded by the = rectus=20 abdominis muscle medially, the inguinal = ligament=20 inferiorly and the inferior epigastric = vessels=20 laterally. The triangle is outlined in=20 = red.

Anatomy of = Groin=20 Hernias

Inguinal hernias are broadly classified as = indirect=20 or direct, designations that refer to the = relation of=20 the herniation to the inferior epigastric = arteries on=20 the abdominal wall and the Hesselbach's = triangle. The=20 anatomic region known as Hesselbach's triangle = is=20 defined laterally by the inferior epigastric = artery,=20 medially by the lateral border of the rectus = muscle=20 and inferiorly by the inguinal ligament = (Figure 1).=20 An indirect hernia passes lateral to the = inferior=20 epigastric vessels and thus is outside of = Hesselbach's=20 triangle (Figure 2), while a direct = hernia is=20 medial to the epigastric vessels and therefore = within=20 the confines of this space (Figure 3). =

An indirect hernia is generally believed to = have a=20 congenital component. The development of this = type of=20 hernia requires a potential hernia sac, which = is=20 provided by the processus vaginalis. After the = fetal=20 testis has descended into the scrotum from the = retroperitoneum, the processus vaginalis = normally=20 obliterates, thereby removing this potential = for=20 herniation. Thus, an indirect hernia is the = result of=20 two conditions: (1) the existence of a = potential space=20 due to nonobliteration of the processus = vaginalis and=20 (2) a weakening of the fascia of the = transversalis=20 muscle fibers surrounding the exit of the = spermatic=20 cord at the internal abdominal ring.

Figure 2. Route of an = indirect=20 hernia. Note that the hernia sac passes = outside=20 of the boundaries of Hesselbach's = triangle and=20 follows the course of the spermatic=20 = cord.

Direct inguinal hernias are not generally=20 congenital. Instead, they are acquired by the=20 development of tissue deficiencies of the = transversus=20 abdominis muscle, which makes up the floor of = the=20 inguinal canal. Thus, these hernias protrude = directly=20 through a defect in the inguinal canal floor, = rather=20 than indirectly following the potential space = of the=20 processus vaginalis and the path of the = spermatic=20 cord.

The development of femoral herniation is = not well=20 understood. A femoral hernia can occur as a = result of=20 elevated intra-abdominal pressure. In this=20 circumstance, preperitoneal fat can protrude = through=20 the femoral ring, with its accompanying pelvic = peritoneum. The hernial sac can then migrate = down=20 along the femoral vessels into the anterior = thigh.=20 Women may be predisposed to femoral herniation = due to=20 weakness of the pelvic floor musculature from = previous=20 childbirth (Figure 4).

Ultrasound examination of = the=20 inguinal region with the patient in the = supine=20 and upright positions and with the = Valsalva=20 maneuver is reported to have excellent=20 diagnostic sensitivity and=20 specificity.

An understanding of the innervation of the = inguinal=20 region is important, because injury to the = nerves in=20 this area may cause significant problems. The = major=20 nerves in the inguinal region are the = ilioinguinal,=20 iliohypogastric and genitofemoral nerves. The=20 ilioinguinal nerve traverses the inguinal = canal near=20 the external inguinal ring and provides = unilateral=20 sensory innervation to the pubic region and = the upper=20 portion of the scrotum or the labia majora. = This is=20 the nerve most commonly injured during open=20 herniorrhaphy. The iliohypogastric nerve = passes=20 superior to the internal inguinal ring and = provides=20 sensory innervation to the skin superior to = the pubis.=20 The genital branch of the genitofemoral nerve = travels=20 within the spermatic cord to provide sensation = to the=20 scrotum and the medial thigh. The femoral = branch of=20 this nerve supplies sensation to the skin of = the=20 anterior thigh²⁼²⁰(Figure 5).

Figure 3. Route of a = direct=20 hernia. The hernia sac passes directly = through=20 Hesselbach's triangle and may disrupt = the floor=20 of the inguinal=20 = canal.

Diagnosis=20

Most early inguinal hernias can be = diagnosed by=20 careful physical examination. Except for pain = or a=20 dull dragging sensation in the groin, the = common=20 reducible inguinal hernia usually does not = cause=20 significant symptoms.

Sonography may be useful in diagnosing = inguinal=20 hernias in patients who report symptoms but do = not=20 have a palpable defect. Ultrasound examination = of the=20 inguinal region with the patient in the supine = and=20 upright positions and with the Valsalva = maneuver has=20 been reported to have a diagnostic sensitivity = and=20 specificity of greater than 90 = percent.³=20 The ultrasound examination may also be helpful = in=20 differentiating an incarcerated hernia from a=20 pathologic lymph node or other cause of a = firm,=20 palpable mass.

Figure 4. Route of a = femoral=20 hernia. The hernia sac follows the = potential=20 space along the femoral vessels. It may = be=20 palpable near the femoral ring or in the = medial=20 = thigh.

In the extremely rare patient with inguinal = pain=20 but no physical or sonographic evidence of = inguinal=20 herniation, computed tomographic scanning can = be used=20 to evaluate the pelvis for the presence of an=20 obturator hernia.

With=20 few exceptions, all patients who are = found to=20 have a groin hernia should undergo = surgical=20 repair.

Preoperatively, it is often difficult to=20 differentiate the common indirect hernia from = the less=20 common direct defect. Even skilled examiners = may be=20 incorrect in up to 30 percent of cases. = However,=20 indirect and direct hernias need to be = differentiated=20 during surgery, because the approach to repair = depends=20 on the defect type. A hernia that is not = repaired=20 appropriately is more likely to recur.

Diagnosing inguinal hernias in children can = be very=20 difficult. Surgical consultation is usually = warranted=20 if the parent or other caregiver reports that = the=20 child has had a groin bulge.

The diagnosis of recurrent herniation is = generally=20 straightforward. However, it may be difficult = to=20 identify this problem in patients with = scarring from a=20 previous repair. In patients who have symptoms = suggestive of recurrent herniation but no = clinical=20 findings, the diagnosis can usually be = obtained=20 through sequential serial examinations and the = judicious use of imaging modalities.

Figure 5. Global = anatomy of the=20 pelvis and inguinal trigone. Note the = lush=20 innervation of this region. Both the=20 ilioinguinal nerve and the genitofemoral = nerve=20 traverse the usual hernia-repair = operative=20 field. The femoral vein also runs just = deep to=20 the inguinal floor=20 = laterally.

Classification of Groin=20 Hernias

TABLE 1=20
Nyhus Classification of Groin = Hernias=20

Type = I--indirect=20 inguinal hernia
Internal inguinal=20 ring normal (i.e., pediatric hernia) =
Type = II--indirect=20 inguinal hernia
Dilated = internal=20 inguinal ring with posterior inguinal = wall=20 intact
Type = III--posterior=20 wall defects
Direct = inguinal=20 hernia
Indirect inguinal=20 hernia: dilated internal ring with large = medial=20 encroachment on the transversalis fascia = of the=20 Hesselbach's triangle (i.e., massive = scrotal,=20 sliding hernia)
Femoral = hernia=20
Type = IV--recurrent=20 hernia

Adapted with = permission from=20 Nyhus LM, Klein MS, Rogers FB. Inguinal = hernia.=20 Curr Probl Surg 1991; 28:418.=20

Classification systems for groin hernias = range from=20 simple schemes to more complex systems with up = to 20=20 categories. Most classification systems take = into=20 account the location of the defect (direct, = indirect=20 or femoral), the size of the defect and = whether or not=20 the herniation is recurrent.¹

While it is often difficult to = differentiate=20 hernial types preoperatively, a consistent = approach to=20 classifying hernias during surgery can provide = information that will allow institutions to = compare=20 the outcomes achieved with different types of = hernia=20 repair. If one system is universally used to = classify=20 hernias, surgeons will be able to perform=20 individualized procedures for specific = anatomic=20 defects based on sound outcome data. While a = broad=20 consensus on the best classification system = has not=20 been achieved, the Nyhus classification system = (Table 1)⁴ is=20 often referred to in the literature.

Indications = for=20 Operative Intervention

Almost all groin hernias should be = surgically=20 repaired. When the potential complications of=20 incarceration and strangulation are weighed = against=20 the minimal risks of hernia repair = (particularly when=20 local anesthesia is used), the early repair of = groin=20 hernias is clearly justified. This is = especially true=20 in the case of femoral hernias, since the = rigid=20 borders of the femoral canal increase the risk = of=20 incarceration.

Surgical repair of a hernia is not = warranted in=20 terminally ill patients with no evidence of=20 incarceration. Patients with ascites generally = should=20 not undergo elective herniorrhaphy until their = ascites=20 is controlled.

While some surgeons believe that = broad-based direct=20 hernias do not need to be repaired, the = uncertainty of=20 determining the status of a hernia = preoperatively=20 argues against this practice. The presence of=20 incarceration or strangulation usually = mandates urgent=20 operative repair.

Figure 6. McVay open = anterior=20 repair. This repair reconstructs the = inguinal=20 canal without using a mesh=20 = prosthesis.

Figure 7. Open mesh = repair. Mesh=20 is used to reconstruct the inguinal = canal.=20 Minimal tension is used to bring tissues = = together.

Surgical = Techniques=20

Based on operative intent and approach, the = many=20 different herniorrhaphy techniques can be = grouped into=20 four main categories.

GROUP 1: = OPEN ANTERIOR=20 REPAIR

Group 1 hernia repairs (Bassini, McVay and=20 Shouldice techniques) involve opening the = external=20 oblique aponeurosis and freeing the spermatic = cord.=20 The transversalis fascia is then opened, = facilitating=20 inspection of the inguinal canal, the indirect = space=20 and the direct space. The hernia sac is = usually=20 ligated, and the canal floor is subsequently=20 reconstructed (Figure 6).

The techniques in the open anterior repair = group=20 differ somewhat in their approach to = reconstruction,=20 but they all use permanent sutures to = approximate the=20 surrounding fascia and repair the floor of the = inguinal canal. When performed by skilled = surgeons,=20 these repairs provide reliable, satisfactory = results=20 and have similar recurrence rates. With very = large=20 defects or with fascia of marginal quality, = the=20 tension of the sutures can lead to recurrence. =

The techniques in group 1 are all well = suited to=20 the use of local anesthesia.

It is=20 possible to repair over 90 percent of = groin=20 hernias using only local=20 anesthetic.

GROUP 2: = OPEN POSTERIOR=20 REPAIR

Posterior repair (iliopubic tract repair = and Nyhus=20 technique) is performed by dividing the layers = of the=20 abdominal wall superior to the internal ring = and=20 entering the properitoneal space. Dissection = then=20 continues behind and deep to the entire = inguinal=20 region.

Like the anterior approach, the posterior = approach=20 provides excellent visualization of the areas = of=20 concern in herniorrhaphy. The major difference = between=20 this technique and the anterior approach is = that=20 reconstruction is performed from the "inside." =

Excellent results have been reported for = the=20 posterior techniques, but problems related to = suture=20 tension remain.

Posterior repair is often used for hernias = with=20 multiple recurrences, because the approach = avoids scar=20 tissue from previous surgeries. It is probably = best=20 performed with the patient receiving regional = or=20 general anesthesia.

GROUP 3: = TENSION-FREE=20 REPAIR WITH MESH

The group 3 hernia repairs (Lichtenstein = and Rutkow=20 techniques) use the same initial approach as = open=20 anterior repair. However, instead of suturing = the=20 fascial layers together to repair the hernia = defect,=20 the surgeon uses a prosthetic, nonabsorbable = mesh.=20 This mesh allows the hernia to be repaired = without ten=20 sion being placed on the surrounding fascia = (Figure=20 7). Excellent results have been achieved = with this=20 approach, and reported recurrence rates have = been less=20 than 1 percent.^{5 =}

Figure 8. Laparoscopic = mesh=20 repair, viewed from inside the pelvis = toward the=20 direct and indirect sites. A broad = portion of=20 mesh is stapled to span both hernia = defects.=20 Staples are not used in proximity to=20 neurovascular=20 = structures.

Some concern exists about the long-term = safety of=20 implanted prosthetic material, particularly = the=20 potential for infection or erosion. However, = extensive=20 accumulated experience with the hernia mesh = has begun=20 to alleviate many of these concerns, and = tension-free=20 repair continues to gain popularity.⁶

Tension-free repair can be performed using = any type=20 of anesthesia. This approach is well suited = for=20 outpatient herniorrhaphy performed with the = patient=20 receiving local anesthesia.

GROUP 4: = LAPAROSCOPIC=20 PROCEDURES

Laparoscopic hernia repair has become = increasingly=20 popular in the past few years, but the = technique has=20 also sparked significant controversy. Early in = the=20 development of the technique, hernias were = repaired by=20 placing a large piece of mesh over the entire = inguinal=20 region on top of the peritoneum. This approach = was=20 abandoned because of the potential for = small-bowel=20 obstruction and fistulae development caused by = the=20 exposure of bowel to mesh.

Today, most laparoscopic herniorrhaphies = are=20 performed using either the transabdominal=20 preperitoneal (TAPP) approach or the total=20 extraperitoneal (TEP) approach. The TAPP = approach=20 involves placing laparoscopic trocars in the = abdominal=20 cavity and approaching the inguinal region = from the=20 inside. This allows the mesh to be placed and = then=20 covered with peritoneum. While the TAPP = approach is a=20 straightforward laparoscopic procedure, it = requires=20 entrance into the peritoneal cavity for = dissection.=20 Consequently, the bowel or vascular structures = may be=20 injured during the procedure (Figure = 8).

TABLE=20 2
Results of Hernia Repairs at = Specialty=20 Centers

Author

Type = of=20
repair

Number =
of=20 patients

Follow-up=20
period

Complication=20
rate (%)

Hernia=20
recurrence
rate (%)

Rutledge¹⁰⁼²⁰ McVay 906 9=20 years NR 2.0

Welsh and Alexander¹¹⁼²⁰ Shouldice 214,919 1 month=20 to 40 years NR 0.1

Shouldice 2,748 35=20 years NR 1.5

Amid, et=20 al.⁵⁼²⁰ Lichtenstein 3,250 Average=20 of 4 years (range: 1 to 8 = years) NR 0.1

Rutkow=20 and Robbins¹²⁼²⁰ Rutkow 2,060 NR 0.3 0.1

Nyhus¹³⁼²⁰ Posterior iliopubic tract=20 repair 1,200 37=20 years 1 to=20 6

Felix, et al.¹⁴ Transabdominal preperitoneal=20 laparoscopic repair 733 Average=20 of 24 months (range: 1 to 44 = months) 13.0 0.3

Total=20 extraperitoneal laparoscopic = repair 382 Average=20 of 9 months (range: 1 to 44 = months) 11.0 0.3

NR=3Dnot reported. =

Information from = references 5,=20 and 10 through 14.

In the TEP approach, an inflatable balloon = is=20 placed in the extraperitoneal space of the = inguinal=20 region. Inflation of the balloon creates a = working=20 space. For most surgeons, the TEP approach to = hernia=20 repair is more technically demanding than the = TAPP=20 approach.

In both the TAPP and TEP approaches, the = hernia sac=20 is reduced, and a large piece of mesh is = placed to=20 cover the indirect, direct and femoral areas = of the=20 inguinal region. The mesh is held in place by = metal=20 staples.

The advantage of these two procedures is = that the=20 small laparoscopic incision causes less pain = and=20 disability, promoting a faster return to work. = This=20 advantage appears to be most notable in = patients who=20 do heavy manual labor.⁷ Another = advantage of the=20 TAPP and TEP approaches is that bilateral = hernias may=20 be repaired simultaneously with no apparent = increase=20 in morbidity. Finally, these approaches can be = particularly effective in patients with hernia = recurrence after traditional open = herniorrhaphy. In=20 such patients, additional open anterior = repairs have a=20 higher failure rate and an increased rate of=20 complications. The laparoscopic approach, = similar to=20 the open posterior approach, allows hernia = repair to=20 be performed in a previously untouched space. =

Early results for laparoscopic surgery are=20 promising, but information on long-term = outcomes is=20 currently unavailable. At present, the major = drawbacks=20 to laparoscopic herniorrhaphy are the cost of = the=20 laparoscopic equipment, the need for general=20 anesthesia and the absence of long-term = follow-up=20 data.

Anesthesia=20

Hernia repair may be performed using = general,=20 regional (spinal/epidural) or local = anesthesia.=20 Several studies^8,9=20 have found that, with proper preoperative = preparation,=20 more than 90 percent of groin hernias can be = repaired=20 with patients receiving only a local = anesthetic. The=20 advantages of local anesthesia include the = very short=20 recovery time and the ability to test the = repair=20 intraoperatively with a Valsalva maneuver. Use = of=20 local anesthesia also avoids the respiratory = and=20 immune depressive effects of general = anesthesia. This=20 advantage is particularly important in elderly = and=20 frail patients.

Local anesthesia alone does not allow for=20 comfortable and technically optimal = herniorrhaphy in=20 patients with a very high anxiety level. = Either=20 general or regional (spinal) anesthesia may be = used in=20 these patients. General anesthesia provides = the most=20 comfort, but it has the highest risk. Patients = occasionally respond poorly to a general = anesthetic=20 and require overnight hospitalization because = of=20 nausea, excessive sedation or urinary = retention.

Spinal anesthesia provides excellent pain = control=20 during herniorrhaphy, and it carries slightly = less=20 risk than general anesthesia. The = disadvantages of=20 spinal anesthesia include the time required = for the=20 anesthetic to be placed and the possibility of = incomplete sensory blockade. Urinary retention = or a=20 delay in the return of normal lower extremity=20 sensation may mandate overnight observation = following=20 herniorrhaphy performed with regional = anesthesia.

Operative = Results=20

Tables 2^{5,10-14 =}and 3^7,15-18 summarize = operative=20 results for common herniorrhaphy techniques. = Specialty=20 centers continue to report very low = complication and=20 recurrence rates in large series of patients. =

Most laparoscopic hernia repairs are being=20 performed by skilled laparoscopic surgeons in=20 specialty centers. Early studies showing = acceptable=20 outcomes for laparoscopic herniorrhaphy may = reflect=20 the same bias other procedure-focused centers = have=20 shown for open herniorrhaphy. Studies = conducted at=20 nonspecialty centers probably provide a more = accurate=20 view of hernia repair techniques and results. =

TABLE=20 3
Results of Hernia Repairs at=20 Nonspecialty Centers

Author

Type = of=20
repair

Number
of=20 patients

Follow-up=20
period

Complication=20
rate (%)

Hernia=20
recurrence
rate (%)

Panos, et al.¹⁵⁼²⁰ McVay 136 Average=20 of 3 years, with a range of 1 to 5 years = NR 9

Shouldice 136 Average=20 of 3 years, with a range of 1 to 5=20 years NR 7

Paul, et al.¹⁶⁼²⁰ Bassini 125 3.3=20 years 28 10

Shouldice 119 3.4=20 years 29 2

Tran, et al.¹⁷⁼²⁰ Bassini 63 2=20 years 18 14

Shouldice 65 2=20 years 18 11

Ferzli,=20 et al.¹⁸⁼²⁰ Total=20 extraperitoneal laparoscopic = repair 100 Average=20 of 12 months (range: 6 to 20 = months 6 0

Payne, et al.⁷⁼²⁰ Transabdominal preperitoneal=20 laparoscopic repair 52 Average=20 of 10 months (range: 7 to 18 = months 12 0

Lichtenstein 58 Average=20 of 10 months (range: 7 to 18 = months 18 0

NR=3Dnot reported. =

Information from = references 7,=20 and 15 through 18.

Complications=20

The complications following herniorrhaphy = are=20 generally minor and self-limited. Wound = hematomas and=20 superficial wound infections are the most = common=20 problems, and they usually respond to = conservative=20 measures. More serious complications, such as = major=20 hemorrhage, osteitis and testicular atrophy, = occur in=20 fewer than 1 percent of patients undergoing=20 herniorrhaphy.¹⁹ The=20 minor and major complications of open and = laparoscopic=20 herniorrhaphies are compared in Table = 4.

NERVE=20 ENTRAPMENT

Nerve entrapment is perhaps the most = significant=20 complication of inguinal herniorrhaphy. Most = nerve=20 entrapment syndromes are self-limited, respond = to=20 nonsteroidal analgesics and resolve with time. = However, chronic neuralgia can develop.¹⁹

Entrapment of the ilioinguinal nerve = produces pain=20 in the groin and scrotum; extension of the hip = frequently exacerbates the pain. Injury to the = genital=20 branch of the genitofemoral nerve can cause=20 hypersensitivity of the groin, scrotum and = upper=20 thigh, and can be associated with ejaculatory=20 dysfunction. Injection of a long-acting local=20 anesthetic along the course of these nerves is = often=20 helpful for diagnosing entrapment.

Following a period of nonoperative care, = some=20 patients with nerve entrapment need to be = referred for=20 surgical exploration and excision of the = involved=20 nerve. However, this corrective approach = provides=20 relief in less than 60 percent of patients. =

While laparoscopic herniorrhaphy tends to = offer=20 greater protection to the ilioinguinal and=20 iliohypogastric nerves, injuries to the = femoral or the=20 lateral femoral cutaneous nerves have been = reported.=20 Patients with such injuries present with pain = in the=20 groin and thigh. While these syndromes are = often=20 self-limited, surgery has been necessary to = remove the=20 staples that caused the neuralgia. These = procedures=20 have not provided pain relief in all patients. =

TABLE=20 4
Complications of Open and = Laparoscopic=20 Hernia Repairs

Open=20 repair

Laparoscopic=20 repair

Major=20
Hemorrhage=20
Testicular=20 atrophy=20
Vas = deferens=20 transection=20
Bowel = injury=20
Bladder = injury

Major=20
Hemorrhage=20
Bowel = injury=20
Bladder = injury=20
Major = vessel=20 injury

Minor=20
Scrotal = ecchymosis=20
Wound=20 infection=20
Urinary = retention=20
Recurrence=20
Hydrocele=20
Nerve=20 transection=20
Nerve=20 entrapment

Minor=20
Urinary = retention=20
Trocar = site=20 hernia=20
Nerve = injury=20
Wound=20 infection=20
Small-bowel=20 obstruction

Information from = reference=20 19.

HERNIA=20 RECURRENCE

Recurrence is the most common long-term=20 complication of inguinal herniorrhaphy. = Approximately=20 50 percent of hernia recurrences do not = present until=20 at least five years after the original = herniorrhaphy.=20 An additional 20 percent of recurrences may = not=20 present for 15 to 25 years.²⁰

The reported recurrence rates for = surgically=20 treated hernias vary widely, depending on the = length=20 and diligence of the follow-up period. In most = reports, the recurrence rate varies from 5 to = 8=20 percent for indirect hernias and is slightly = higher=20 for direct hernias. In some series, the = recurrence=20 rate following repair of a recurrent hernia is = as high=20 as 30 percent, which is significantly greater = than the=20 recurrence rate after initial repairs. Hernia=20 recurrence following inguinal herniorrhaphy is = usually=20 caused by the breakdown of a repair performed = with=20 tension along the fascial suture lines. This = breakdown=20 may occur because of incomplete dissection, = poor=20 tissue quality (longstanding large hernias) or = the=20 patient's too-rapid return to daily = activities.=20 Systemic comorbidity, such as obesity, steroid = use and=20 chronic obstructive pulmonary disease, = influence wound=20 healing and can affect the recurrence = rate.^21-23

Choice of = Surgical=20 Procedure

Inguinal hernias continue to be a source of = morbidity and significant health care = expenditure. No=20 mechanism of preventive care is known, and = surgical=20 repair is almost always necessary. With the = many=20 techniques available, treatment can be = individualized.=20

Most inguinal hernia repairs can be = performed=20 safely, accurately and cost-effectively using = local=20 anesthesia and an open anterior approach. = Hernia=20 recurrence rates of less than 4 percent have = been=20 reported for herniorrhaphies performed without = prosthetic mesh by skilled surgeons.²⁴ Open anterior = repair=20 performed with local anesthesia would appear = to be the=20 ideal approach in the young patient with an = indirect=20 hernia and no systemic disease.

Hernia repair using prosthetic mesh would = be a good=20 choice in the patient with a direct hernia or = in the=20 older patient with a long-standing hernia and=20 attenuated fascia. In one recent study,⁵ more than 60 = percent of=20 blue collar workers and 90 percent of desk = workers=20 returned to work within 10 days after = undergoing=20 tension-free hernia repair with mesh. = Recurrence rates=20 in these cases have been reported to be 3 = percent or=20 less.⁷

Recurrent hernias repaired with classical=20 herniorrhaphy not utilizing mesh have a = reported=20 recurrence rate of approximately 23 percent at = three=20 years.²¹ For = this=20 reason, recurrent hernias are best managed = with open=20 anterior or posterior mesh repair or, = possibly, with a=20 laparoscopic procedure. Bilateral hernias may = also be=20 addressed simultaneously, using either an open = or a=20 laparoscopic procedure. The approach is best=20 determined by local expertise.

Laparoscopic herniorrhaphy is becoming a = more=20 common procedure. Several studies have = demonstrated=20 that this approach is safe and involves only = minimal=20 use of pain medication. The recurrence rate = following=20 this relatively new technique cannot as be = completely=20 assessed, but it has been reported to be less = than 4=20 percent.^25,26

The advantages of laparoscopic = herniorrhaphy for an=20 initial repair appear to be related to speedy=20 convalescence and an earlier return to work. = However,=20 caution is advised, since a recent study²⁷ of open = herniorrhaphy=20 showed that return to work was most often = determined=20 by the patient's type of insurance coverage = rather=20 than the type of procedure used to repair the = hernia.=20 Whether this will also be true for = laparoscopic=20 herniorrhaphy remains to be seen.

Compared with other types of hernia repair, = laparoscopic herniorrhaphy is significantly = more=20 expensive. In some series, the laparoscopic = approach=20 has been 40 percent more costly than other = approaches.=20 Most current techniques for laparoscopic = herniorrhaphy=20 also subject patients to the risks and cost of = general=20 anesthesia. Performance of the laparoscopic = TAPP=20 repair also exposes patients to potential=20 intra-abdominal injury and late adhesion = formation. In=20 contrast, tension-free repair using mesh, as = well as=20 other types of hernia repair, may be = comfortably and=20 safely completed with patients receiving only = local=20 anesthesia.

Laparoscopic herniorrhaphy may be best = reserved for=20 treatment of recurrent or bilateral hernias. = However,=20 individual preference cannot be ignored, and = this=20 technique may be advisable for initial hernia = repair=20 in selected patients.

In the managed-care environment, elective=20 herniorrhaphy is under increasing pressure. = Some state=20 health plans do not reimburse for elective = hernia=20 repairs. The long-term impact of complications = secondary to untreated herniation is not fully = known.=20 A decrease in surgical repair may lead to an = increase=20 in hospitalizations related to incarceration = or=20 strangulation.

The Authors =

TIM BAX, M.D.,
is a fourth-year = resident in=20 general surgery at Oregon Health Sciences = University,=20 Portland. Dr. Bax recently completed a year of = research in general and minimally invasive = surgery.=20

BRETT C. SHEPPARD, M.D.,
is an = assistant=20 professor in the surgery division at Oregon = Health=20 Sciences University, Portland, where he = received his=20 surgical training. Dr. Sheppard also completed = a=20 two-year research fellowship at the National = Cancer=20 Institute, Bethesda, Md.

RICHARD A. CRASS, M.D.,
is professor of = surgery=20 and head of the general surgery division at = Oregon=20 Health Sciences University. Dr. Crass received = his=20 surgical training at the University of = California, San=20 Francisco, School of Medicine, and completed a = two-year research fellowship at Beth Israel = Hospital=20 and Harvard Medical School, both in Boston. =

Address = correspondence=20 to Brett C. Sheppard, M.D., Division of = General=20 Surgery, L223A, Oregon Health Sciences = University,=20 3181 S.W. Sam Jackson Park Rd., Portland, OR = 97201-3098. Reprints are not available from = the=20 authors.

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Copyright =C2=A9 1999 by = the American=20 Academy of Family Physicians.
This = content is=20 owned by the AAFP. A person viewing it = online may=20 make one printout of the material and may = use that=20 printout only for his or her personal,=20 non-commercial reference. This material may = not=20 otherwise be downloaded, copied, printed, = stored,=20 transmitted or reproduced in any medium, = whether now=20 known or later invented, except as = authorized in=20 writing by the = AAFP.

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