An inguinal hernia is the protrusion of the abdominal cavity contents through a gap (defect) in the abdominal wall. This gap occurs either on some compressible point of the abdominal wall (inguinal duct, femoral ring), or is caused secondarily (e.g. by a surgical operation).
Based on the anatomical structure where the gap is localized, hernias are distinguished into inguinal hernias, umbilical hernias, epigastric hernias, the lumbar triangle, etc.
Based on the mechanism of gap, they are distinguished into congenital and acquired (postoperative hernias, sportsman’s hernias -athletic pubalgia, etc.). A special category is the so-called internal hernias where the gap is located within the abdomen (peritoneal cavity) at some anatomical structure (mesentery, omentum).
Hernias are quite frequent in the general population, both in men and women. Hernias of the femoral inguinal area are the most frequent ones, and they are followed by postoperative hernias, umbilical hernias, etc.
When the content of the hernia sac is squeezed back into the peritoneal cavity automatically or using surgical maneuver, the hernia is called retractable, and when this not possible it is called non-retractable. When the contents of the hernia consist of a hollow visceral organ (intestine) and its lumen is obstructed, the hernia is strangulated and has to be treated immediately since it involves the risk of ileum, ischemia, intestine necrosis and rupture, and fecal peritonitis, which are all life threatening conditions. Laparoscopic surgery has its place in the treatment of these conditions, provided that emergency laparoscopic surgery specialists have the experience required. Morbidity, is however, higher in such cases and that is why the surgical repair of a hernia should be done early to prevent the occurrence of such serious conditions. Laparoscopic surgery offers significant advantages for all types of hernia, if surgeons have the necessary experience. A short reference is made below to the most frequently occurring hernias and their laparoscopic treatment.
Epigastric hernia
Epigastric hernia occurs along the linea alba (the site of junction between fibers of the aponeuroses of the two rectus abdominal muscles). In practice, it occurs along the midline, over the navel. Its contents usually consist of fat or omentum and, less frequently and in large hernias, even parts of large intestine (transverse colon). It affects 1-2% of the population and its predisposing factors include obesity, constipation, ascites, intraabdominal masses, trauma, and violent coughing.
Epigastric hernias are treated with surgical intervention with retraction of the content of the hernia, closing of the gap which is followed or not by the placement of a mesh. The laparoscopic approach offers all the advantages of laparoscopic surgery (smaller wound, less postoperative pain, shorter hospital stay). The placement and fixing of the mesh takes place under immediate laparoscopic viewing offering maximum sealing and stabilization, while the smaller incision reduces the risk of suppuration of the wound and the underlying mesh. The laparoscopic approach is indicated in cases of obese patients, in large hernias, and in the case of concurrent health problems.
Umbilical hernia
Umbilical hernia in adults is considered as acquired and is caused by the opening of the umbilical ring caused by the weakening of the fibrous connective tissue. It usually contains fat or omentum. Risk factors include obesity, multiple pregnancies, ascites, etc. It is treated by surgery with retraction of the hernia content, defect closure (Mayo technique) and in relatively large hernias meshplasty is used. Special care should be taken in preoperative umbilical antisepsis due to high germ concentration at this site. Laparoscopic repair method with meshplasty under immediate laparoscopic viewing presents all the advantages of laparoscopic surgery. It is the method of choice for defects exceeding 2cm in diameter requiring mesh plasty.
Inguinal hernias
Inguinal hernias are the most frequently occurring type of hernias. They are caused by the protrusion of the hernia sac through the deep inguinal ring or other weak spot of the inguinal area of the abdominal wall. It is more frequent in men (90%), however, it occurs in both male and female. It is distinguished in straight and oblique inguinal hernias depending on the anatomical site of the hernia sac prolapse.
Risk factors include anatomical disorders (e.g. weak – wide deep inguinal ring), structural disorders (synthesis disorders – collagen decomposition), and conditions causing increase of the intra-abdominal pressure (obesity, chronic coughing, constipation, pregnancy, heavy object lifting etc.). Typically, it appears as bulging in the inguinal area and mild pain aggravating with the increase of intra-abdominal pressure (e.g.coughing, weight lifting). In case of strangulation, the pain becomes intense and immediate intervention is required.
Inguinal hernias can be repaired using various methods, either using open surgery (dozens of various techniques have been described), or laparoscopically. Laparoscopic procedures include the following:
Α) The laparoscopic technique of Total Extraperitoneal Repair – TEP via the muscular layers of the abdominal wall without accessing the peritoneal cavity.
B) The laparoscopic technique of transabdominal properitoneal repair –TAPP, with access to the peritoneal cavity.
Current mainstream techniques include the conventional Lichtenstein method of reinforcing the abdominal walls with a mesh and laparoscopic TEP. It is worth noting that TEP is a technique requiring high level surgical skills with a long learning curve. There are several points that render this technique difficult. The surgeon has to learn to enter the peritoneal space through a 10mm incision below the navel and then prepares the preperitoneal space of the lower abdomen using the laparoscope itself. When the surgeon is adequately familiar with this method, procedural time is short (~30min) and the mesh used is larger (~10x15cm) compared to open surgery.
TEP, despite the experience and the special skills required is the method of choice due to the numerous advantages it presents:
- It is performed in the peritoneal space, i.e. inside the peritoneal cavity, under the muscles, precisely in the area where hernia has been created. This way, no maneuvers in the intraabdominal organs are required excluding any possibility for the mesh to be in contact with the viscera.
- It allows for the concurrent treatment of bilateral inguinal hernia and femoral hernia.
- It is the ideal procedure to treat recurrent inguinal hernia using the conventional procedure with or without a mesh.
- It presents lower rates of relapse, suppuration and hematomas that are statistically significant in a number of studies.
- It may be performed through two incisions of 5 mm each, or even through a single incision (Single-Incision Laparoscopic Surgery-SILS).
- It presents all the advantages of minimally invasive surgery via a minimum number of small incisions (less postoperative pain, shorter hospital stay, fast resumption of physical activity, better esthetic results). The patient is usually discharged from hospital on the first day post surgery.
Femoral hernia
Femoral hernia is a hernia where the prolapsed organ (e.g. gut) protrudes via the femoral ring. The femoral ring is an anatomical structure – canal through which pass large vessels and nerves (femoral) directed to the upper end, the origin of the thigh (root of the thigh). Femoral hernia affects women more often than men (30% of hernias) and it is quite rare in men.
Its surgical repair is performed by open or laparoscopic surgery. The laparoscopic method has the advantages of smaller surgical wound, less postoperative pain, faster return to work and daily activities. It is performed through small incisions on the abdominal wall; this area is accessed internally, the hernial sac is retracted and followed by a meshplasty. The patient is usually discharged from hospital on the first day post surgery.
Varicocele
A varicocele is an abnormal enlargement of the testicular (spermatic) veins in the spermatic or pampiniform plexus of the scrotum. Varicocele occurs more frequently on the left ventricle, due to the different anatomy of the venous drainage (anatomically, the left spermatic vein ends up vertically to the left renal vein and right on the lower vena cava at an acute angle). Varicocele is one of the main infertility causes in younger men. Its frequency in the general population is 15% and 20-40% in infertile persons. Moreover, it may be the early manifestation of some malignancies (e.g. nefroblastoma) or hydronephrosis. It is, therefore, imperative to early diagnose and treat them effectively.
Diagnosis is achieved using clinical examination (palpation, Valsalva test) and the ultrasound (color flow Doppler) which depicts an image of varicocele enlargement of the testicular venous network. Depending on its grade, it is classified as small (grade I – idientifiable using Valsalva test), medium (grade II-palpable, no Valsalva test) and large (grade III – visible as a space consuming process). Sperm analysis may show a change in the number and mobility of spermatozoa.
Varicocele is surgically treated. Conventional repair procedures are the Ivanissevich technique (ligation of spermatic veins via inguinal approach), the Palomo technique (ligation of the spermatic artery and vein, over the deep inguinal ring), and the laparoscopic approach in recent years.
Varicocele laparoscopic repair includes the creation of pneumoperitoneum (instilling air within the peritoneal cavity) via 3 small incisions. The spermatic vein is then prepared and ligated with clips, preserving the spermatic artery. It is followed by peritoneum closure using endo-loop. Interoperative pain is low (20-30 minutes) and the patient is usually discharged from hospital on the first day post surgery. It is a very safe procedure with very low relapse rates, combining the advantages of laparoscopic surgery.
Sportsman’s hernia
The sportsman’s hernia or groin Gilmore is a natural condition of the inguinal area that affects mainly athletes or people who exercise. Injuries occurring in the inguinal region account for 2 to 5% of all the sports injuries. Early diagnosis and right treatment are of utmost importance in order to prevent these conditions from becoming chronic with catastrophic consequences for the athletes’ careers. Adductor fatigue and adhesion inflammation are the most frequent myoskeletal causes of groin pain in athletes. These two conditions are similar and difficult to diagnose.
Sports hernia is a syndrome characterized by chronic pain in the inguinal area in athletes and a dilated superficial ring of the inguinal canal. Football players are very frequently affected and professional athletes may also be affected. Officially, the presence of a hernia cannot be identified in clinical examination or medical imaging and is difficult to detect during a conventional open surgical operation. The term “hernia” is still used given that surgical repair techniques are similar to those applied for inguinal hernias are often efficient for “sportsman hernias” also.
ΤΕΡ is performed via an incision of few millimeters without dissecting muscles and is considered to be superior to conventional open surgery. Bilateral hernias may be repaired concurrently Laparoscopic repair using extraperitoneal approach depicts the anatomy of the deep and the superficial ring of the inguinal canal, monitors optimally the course of the peritoneal sac identifying any early signs or even an actual hernia, whether straight or oblique, and any loosening of the posterior wall – transverse fascia that may be underestimated with clinical examination or open surgery. This technique is similar to extraperitoneal repair of inguinal hernia and includes the enhancement of the abdominal wall with mesh plasty. Patients soon resume their daily and sports activities.