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How to Treat Inguinal and Femoral Hernias


How to Treat Inguinal and Femoral Hernias

The bulging out of a small tissue through an opening in the muscles results in a hernia. Any part of the fibromuscular tissues of the body wall can weaken or get disrupted and develop hernia, though the most commonly affected sites are the naval (umbilical), the groin (inguinal) and a previous incision site.

Performing a surgical operation is the only effective way to repair a hernia, and inguinal hernia repair is among the most common general surgical procedures. Yet, the optimal therapeutic operation is controversial. When all groin hernias are taken into account, femoral hernias are considered to be less than 10% of them and are more common in women, but include a greater risk of strangulation or incarceration. In fact, hernias of shorter duration, whether it is femoral or inguinal, carry a high risk of strangulation as well.

 

Inguinal hernia

Inguinal hernia is more common in men and is apparent as a bulge in the groin or scrotum. The type of operation depends on the following: 

 

  • Size
  • Location
  • Patient’s age
  • Patient’s health
  • Surgeon’s expertise
  • Anesthesia risk

 

Most patients who are experiencing significant symptoms associated with a hernia are recommended to have surgery, while others who have minimal or no symptoms may delay surgery; this is because the risk of incarceration is greatest soon after the hernia manifests itself. The cumulative probability of strangulation in one series of 439 inguinal hernias was 2.8% at 3 months; and it was 4.5% at two years. The incarceration rate reduces as the hernia increases in size since there’s a less likelihood of intestinal or visceral contents to become caught within a large sac.

 

According to the largest study made to evaluate the strategy of watchful waiting, the WW trial, 720 men suffering from an inguinal hernia were randomly selected for a strategy of watchful waiting or open tension-free hernia repair. The men were at least 18 years of age (the majority were between the ages of 40 to 65), and were either asymptomatic or had only minimal symptoms, they didn’t have hernia-related pain or discomfort that limited their usual activities, and no difficulty in decreasing the hernia within 6 weeks of screening.

 

There wasn’t any sufficient difference between the two groups in the primary end points of pain to limit activity or change in physical health scores at 2 years follow-up. 23% of patients in the watchful waiting group had surgery within 2 years and 31% at 4 years. There wasn’t any significant difference in the rates of complications between patients who were assigned to watchful waiting and then crossed over to receive surgical repair and those who were assigned to and received surgical repair (27.9% vs. 21.7%). Significant hernia complications are rare but can occur in patients being watched. Overall, there were 0.0018 hernia-related adverse events per patient-year.

 

Femoral Hernia

Femoral hernia appears as a bulge in the groin, upper thigh, or labia (skin folds surrounding the vaginal opening), they need to be surgically repaired because they contain a high risk of strangulation. Accounting for 2-4% of groin hernias, femoral hernias are more common in women, and they are more likely to present with strangulation and require emergency surgery. The Swedish hernia register documented 3980 femoral hernia repairs (2524 elective and 1409 emergent) between 1992 and 2006. Femoral hernia procedures accounted for 23% of groin hernia procedures in women, as compared with 1% in men. The rate of emergency repairs in women was 40%, while it was 28% in men. Bowel resection was required in 23% of emergent femoral hernia repairs, but only 0.6% of elective repairs. The risk of mortality for emergency operations was significantly higher than for elective operations as well (OR 5.37, 95% CI 3.24-8.91). This study highlights in an elective setting and suggests that watchful waiting is not a prudent strategy in patients with femoral hernias, even those who are asymptomatic. Watchful waiting is suggested by this study not to be a prudent strategy in patients with femoral hernias, even those who are asymptomatic. The importance of repairing femoral hernias in an elective setting is also highlighted.

 

REPAIR OF INGUINAL HERNIA:

 

OPEN REPAIR:

There aren’t sufficient data to enable comparing the recurrence rate of open mesh against open non-mesh methods. An attempted meta-analysis concluded that mesh repair was related to fewer recurrences, even though it was admitted that formal meta-analysis was limited due to the lack of present study data. An open repair can be done with local anesthesia; the surgeon makes an incision near the hernia site and repairs the weak muscle area.

 

Mesh can be sutured (sewn) or stapled to strong tissues next to the hernia site. Mesh plugs that fill the open site can be additionally positioned into the inguinal or femoral hernia space where sutures may not be required.

 

In a non-Mesh hernia repair, the hernia opening is sutured together and the tissue around the site is used to strengthen the weak area. Open repair without mesh is primarily used to repair strangulated or infected hernias, for single small hernias (less than 3 cm), or for simple infant or pediatric hernias. An orchidopexy (moving down the undescended testicle into the scrotum) may be performed with infant hernia repair in case it is required.  

 

Mesh repairs have a lower reoperation rate than conventional open repairs, according to a review of 26,304 herniorrhaphies performed in Denmark published after the meta-analysis.
The standard component of both primary and recurrent hernia repairs is polypropylene mesh. Lichtenstein and the plug and patch repair are the two most common open prosthetic repairs. The Kugel repair takes the place of the mesh in a properitoneal position instead of anterior to the transversus.

 

The Shouldice method that involves division of all layers of the floor of the canal followed by reconstruction in a 4 layer overlap method utilizing ongoing fine wire sutures is commonly used for open repair of inguinal hernias that are done without mesh, allowing the defect to be closed with multiple layers, none of which are positioned with inordinate tension. The defect in the canal is completely obliterated by this.

 

The recurrence rate has been calculated according to the level of surgical expertise; in one report of 183 inguinal hernias repaired under local anesthesia, the recurrence rates for beginners (less than six repairs under local anesthesia) vs. more experienced surgeons were 9.4% and 2.5%, respectively. This method was used on selected patients and recurrence rates of less than 2% were reported. Their results haven’t been equaled by any non-prosthetic repair, and recurrence rates haven’t been achieved so low by other surgeons.

 

LAPAROSCOPIC REPAIR:

There’s less pain and numbness involved in the laparoscopic repair, and it’ll enable the patient to go back to their usual activities in a shorter period of time when compared with the open repair. There are three different laparoscopic repair procedures, the most popular of which is the totally extraperitoneal (TEP) repair that is done in the preperitoneal, instead of the peritoneal. A space is developed between the peritoneum and the anterior abdominal wall by a surgeon to prevent the peritoneum from being violated. When done by an experienced surgeon, this approach may prevent the risk of intraabdominal adhesion formation, because visualization may be too difficult for an inexperienced surgeon.

 

The second of the three procedures is the transabdominal properitoneal patch (TAPP) repair that is done by placing the mesh in a preperitoneal position covered by peritoneum; the mesh is kept away from the bowel. A larger piece of mesh is used in TAPP where intraperitoneal mesh is not left behind as a benefit of this kind of repair, which contributes to significantly lower recurrence rates when compared with the IPOM.

 

The last of the three procedures that is seldom used nowadays for having the risk of adhesive complications from abdominal mesh is the IPOM, Intraabdominal properitoneal onlay mesh repair where a patch of mesh is laid across the defect in an intraabdominal position.

 

A huge, multicenter trial was done similar to the above mentioned systematic reviews, where similar conclusions were drawn from 1983 patients who were randomly selected to receive either an open mesh or laparoscopic mesh repair.

 

The advantages of Laparoscopic repair:

  • The patient may experience less postoperative pain on the day of surgery and at two weeks
  • The patient may go back to their usual activities one day earlier than the open repair

 

The disadvantages of Laparoscopic repair

Serious complications may occur involving:

 

  • Nerve and major vascular injury
  • Bladder injury
  • Bowel obstruction

 

In addition to laparoscopic repair being a technical challenge for a patient who has had a prior prostatic surgery. TEP repair also makes it hard for a future prostatic surgery to be performed.

 

Significantly more recurrences occurred within two years of undergoing laparoscopic repair (10.1 versus 4.9 %). Surgeons who had performed more than 250 laparoscopic repairs had only half the rate of recurrence of surgeons who had performed fewer repairs; no similar relation to experience was noticed for the simpler open repairs. Additionally, laparoscopic repair was associated with more complications (39 versus 33.4 %), as well as life-threatening complications (1.1 versus 0.1 %).

 

Unlike some earlier trials that found lower recurrence rates with laparoscopic repair, all the open repairs in this trial were performed as tension-free repairs with mesh. Patients were older (average age 58) and less healthy (only 34% were ASA class I) than the general population.

 

Deciding to perform a laparoscopic repair may be advantageous in terms of a faster return to work in cases of patients who perform heavy manual labor, while using an open repair may be better in the older less healthy population. Overnight hospital stay isn’t required by either of these methods.

 

REPAIR OF FEMORAL HERNIA

The simplest of the two approaches available for repairing a femoral hernia is anterior to the inguinal ligament and caudad towards the upper aspect of the leg. If the hernia sac is small, it can usually be found at this location along with its contents, and be dissected and reduced. Mesh or direct suture can be used to repair this defect. To reduce the hernia, the contents of the sac, such as fat, may have to be resected if the defect is particularly small.

 

The second approach is preperitoneal aspect of the inguinal canal that is best used when either a large volume of intraabdominal contents has protruded into the sac or in case there is bowel in the defect. The transverses abdominis and transversalis fascia are divided and any intraabdominal contents are cleared away from the hernia. This approach also allows inspection and insurance of the bowel’s viability, which is essential in case a strangulated hernia is found.

 

Anesthesia:

Most commonly, the open repairs of inguinal or femoral hernias are done using spinal anesthesia, ongoing epidural anesthesia or a local one with or without sedation. However it can be performed under general anesthesia, although generally it isn’t favored unless the patient has a compelling desire to be totally anesthetized. Depending on the case, general, regional (spinal or epidural) or local anesthesia may be done. For instance, laparoscopic repairs using the IPOM or TAPP approach need general anesthesia and its attendant risks. As for TEP repairs, they can either be performed under spinal or epidural anesthesia or under general anesthesia.

 

Monitored anesthesia care (MAC) is known as local anesthesia with sedation. It is simple and easy to perform and there’s no need for prolonged postoperative observation; it also has the benefit of being totally manageable. The major disadvantage of local anesthesia is that it may be inadequate for large hernias. Sedation may not be used in local anesthesia only in patients who are particularly motivated and not obese. The benefits of the sedative component of MAC anesthesia are that it is able to be individualized to the patient’s specific desires for wakefulness and can be quickly reversed at the end of the case. In case sedation is used, the patient must always be accompanied upon leaving the surgical suite.

 

There are two different ways to use the local anesthesia; it’s either used as direct infiltration into the proposed incision site, or as a nerve block of the ilioinguinal and iliohypogastric nerves; this method has the benefit of not resulting in significant soft tissue edema, though it may be harder to achieve.

 

The surgeon may discreetly add up epinephrine to the local anesthetic, but it usually is omitted in patients who have noticeable cardiac risks. Reliable anesthesia may be provided with spinal or ongoing epidural anesthesia that allows the surgeon a greater amount of maneuverability since the anesthetized area is significantly larger than the operative field. Disadvantages include:

 

  • Prolonged anesthesia
  • Hypotension
  • Urinary retention
  • Incomplete anesthesia
  • Longer time in the recovery area
  • Spinal headache

 

A randomized trial of local, regional, and general anesthesia in 616 adult patients in 10 hospitals undergoing open inguinal hernia repair found that local anesthesia was superior in the early postoperative period. Patients who received local anesthesia had less postoperative pain and nausea, shorter time spent in the hospital (3.1 versus 6.2 hours with regional and general anesthesia), and fewer unplanned overnight admissions (3 versus 14 and 22 percent, respectively). Another multicenter randomized trial compared spinal and local anesthesia in 100 patients undergoing open hernia repair and also found local anesthesia was associated with less postoperative pain, shorter operating time, and fewer overnight stays.

 

REPAIR OF STRANGULATED HERNIA

Loss of bowel may be prevented in a strangulated hernia with an emergency surgery performed within four to six hours. The Shouldice operative method is recommended when bowel perforation has occurred because of necrosis resulting from prolonged strangulation. However, when there is gross contamination mesh shouldn’t be used, but it could be considered where contamination is minimal and broad-spectrum antibiotics administered during and for several days following surgery.

 

Patients experiencing significant symptoms associated with hernia should be referred for surgical repair because surgery is the only effective treatment for hernias. Avoiding the use of a truss in lieu of surgery may be suggested, except for rare cases. In patients suffering from an asymptomatic or minimally symptomatic inguinal hernia, watchful waiting may be a more suitable option than surgical referral, as long as they are aware of the small risks of hernia complications such as incarceration and strangulation, and understand the need for prompt medical attention in case symptoms of these complications come up. In small hernias and soon after a hernia develops, the risk of incarceration is highest.

 

Elective surgical repair may be recommended for those who suffer from asymptomatic and minimally symptomatic inguinal hernia. Patients who have no desire in having surgery can reasonably be treated with watchful waiting. Successful hernia repair depends upon a tension-free closure that may be done as an open or laparoscopic operation and is commonly achieved by placement of prosthetic mesh at the site of the defect. With laparoscopic repair, the patient will be able to return to their usual activities earlier, though there’s a greater likelihood of rare complications when compared with open repair. Patients should undergo open repair if the above aspects do not clearly favor one surgical approach.  Loss of bowel could be prevented in a strangulated hernia with an emergency surgery that’s performed within four to six hours. Conflicting consequences were drawn from randomized trials regarding the role of antibiotic prophylaxis for routine hernia surgery. Lastly, the administration of parenteral antibiotics isn’t recommended.

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Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian


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