Herniorrhaphy

Interventions infobox
Name = Herniorrhaphy


Caption =
ICD10 =
ICD9 = 53
MeshID =
OtherCodes =

Herniorrhaphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery.

Techniques

Herniorraphy, or hernioplasty, is now often performed as an ambulatory, or "day surgery," procedure in the USA. In other countries however, it is more common to be admitted for a 2-3 day hospital stay. Almost 700,000 are performed each year in the United States.fact|date=March 2008

These techniques can be divided into four groups.cite web |url=http://www.aafp.org/afp/990101ap/143.html |title=Surgical Options in the Management of Groin Hernias - January 1, 1999 - American Academy of Family Physicians |accessdate=2007-11-21 |format= |work=]

Groups 1 and 2: open "tension" repair

A workable technique of repairing hernia was first described by Bassini in the 1880s; [WhoNamedIt|doctor|3213] [Bassini E., Nuovo metodo operativo per la cura dell'ernia inguinale. Padua, 1889. ] the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed. cite web |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2059571 |title=Bassini's Operation for Inguinal Hernia |accessdate=2007-11-21 |format= |work=]

Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVay repair.cite journal |author=Mittelstaedt WE, Rodrigues Júnior AJ, Duprat J, Bevilaqua RG, Birolini D |title= [Treatment of inguinal hernias. Is the Bassani's technique current yet? A prospective, randomized trial comparing three operative techniques: Bassini, Shouldice and McVay] |language=Portuguese |journal=Revista da Associação Médica Brasileira (1992) |volume=45 |issue=2 |pages=105–14 |year=1999 |pmid=10413912 |doi=] cite book |author= |title=Complications in Surgery |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year= |pages=533 |isbn=0-7817-5316-3 |oclc= |doi=]

The Shouldice techniques is a complicated four layer reconstruction, however, it has relatively low reported recurrence rates.cite journal |author=Arlt G, Schumpelick V |title= [The Shouldice repair for inguinal hernia--technique and results] |language=German |journal=Zentralblatt für Chirurgie |volume=127 |issue=7 |pages=565–9 |year=2002 |pmid=12122581 |doi=10.1055/s-2002-32844]

An operation in which the hernia sac is removed in addition to tension repair is described as a 'herniotomy'.

Group 3: open "tension-free" repair

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect) [cite journal |author=Lichtenstein I, Shulman A |title=Ambulatory outpatient hernia surgery. Including a new concept, introducing tension-free repair |journal=Int Surg |volume=71 |issue=1 |pages=1–4 |year= |pmid=3721754] , Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within several months of the operation, although up to 40% of patients will end up with chronic, debilitating pain that will require long term pain management and prescription painkillers. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair. Rates of complications are disturbingly high and they can be quite serious, and can include chronic pain, ischemic orchitis, and testicular atrophy. [ Wantz, G.E. (1993). Patients should always follow a conservative approach and only use this form of surgical repair as a last resort due to the severe long term chronic pain complications associated with the introduction of a foreign body (mesh). [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8497804&query_hl=1&itool=pubmed_docsum Testicular atrophy and chronic residual neuralgia as risks of inguinal hernioplasty.] "Surg Clin North Am." Jun; 73(3): 571 81.] [ Ridgway, P.F., Shah, J., & Darzi, A.W. (2002). [http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15798455&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus Male genital tract injuries after contemporary inguinal hernia repair.] "BJU International." 90 (3), 272-276.]

Group 4: laparoscopic repair

In recent years, as in other areas of surgery, laparoscopic repair of inguinal hernia has emerged as an option. "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a faster recovery time and a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia. It is usually more expensive and consumes more O.R. time than open repair, carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs.

Comparisons

In the UK a government committee called NICE [ cite web|url=http://www.nice.org.uk/guidance/TA83 |title=Hernia - laparoscopic surgery (review) |accessdate=2007-03-26 |month=September | year=2004 |work=National Institute for Health and Clinical Excellence ] re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that lap repair has less risk of wound infection, less bleeding and less swelling after surgery (seroma). They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study [Neumayer, L., Giobbie-Hurder, A., Jonasson, O., "et al." (2004). [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15107485&query_hl=2&itool=pubmed_docsum Open mesh versus laparoscopic mesh repair of inguinal hernia.] "N Engl J Med." Apr 29; 350(18):1819-27.] found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results however are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.

Open mesh repair or laporascopic mesh repair are good and have shown reduced recurrences or early recovery. Complications related to the use of mesh include infection, mesh migration, adhesion formation, erosion into intraperitoneal organs, and chronic pain - due probably to entrapment of nerves, vessels or the vas deferens. [Crespi G., Giannetta E., Mariani F., "et al." (2004). [http://www.minervamedica.it/index2.t?show=R24Y2004N07A0107 Imaging of early postoperative complications after polypropylene mesh repair of inguinal hernia.] "Radiol Med (Torino)." 108 (1-2): 107-115.] Such complications usually become apparent weeks to years after the initial repair, presenting as abscess, fistula, or small bowel obstruction. [Parra, J.A., Revuelta, S., Gallego, T., "et al." (2004). [http://bjr.birjournals.org/cgi/content/full/77/915/261 Prosthetic mesh used for inguinal and ventral hernia repair: normal appearance and complications in ultrasound and CT.] "British Journal of Radiology" 77, 261-265.] [Aguirre, D.A., Santosa, A.C., Casola, G., & Sirlin, C.B. (2005). [http://radiographics.rsnajnls.org/cgi/content/full/25/6/1501 Abdominal Wall Hernias: Imaging Features, Complications, and Diagnostic Pitfalls at Multi–Detector Row CT1.] "RadioGraphics" 25:1501-1520.] More recently, concerns have been raised about the possibility of obstruction of the vas deferens as a result of the fibroblastic reaction to the mesh. [Shin, D., Lipshultz, L.I., Goldstein, M., "et al." (2005) [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15798455&dopt=Abstract Herniorrhaphy With Polypropylene Mesh Causing Inguinal Vasal Obstruction: A Preventable Cause of Obstructive Azoospermia.] "Ann Surg." 241(4): 553-558.] [ Weyhe, D., Belyaev, O., Müller, C., "et al." (2007). [http://www.springerlink.com/content/352u7pv872rv71x7/ Improving Outcomes in Hernia Repair by the Use of Light Meshes - A Comparison of Different Implant Constructions Based on a Critical Appraisal of the Literature.] "World Journal of Surgery." 31(1): 234-244.]

References

External links

* [http://www.medscape.com/viewarticle/535575 American College of Surgeons article on Open Hernia Repair]
* [http://www.medscape.com/viewarticle/535576 American College of Surgeons article on Laparoscopic Hernia Repair]