inguinal herniorrhaphy

Inguinal Herniorrhaphy

Group 7

Submitted to :

Mrs. Therisita Cruz

Submitted by :

Atienza,Ma. Ana

Bantuas,Sahara L.

Bernardo,Sittie Areej

Introduction

Inguinal herniorrhaphy is a common day care surgical procedure and can be performed safely under regional or general anaesthesia. 1 Since inguinal hernia is rarely associated with serious complications, it is an ideal surgical procedure for ambulatory settings. Outpatient inguinal herniorrhaphy has been associated with remarkable reductions in cost without any obvious increase in complication rates or recurrence of hernia.  An ideal outpatient anaesthetic technique would provide for excellent operating conditions, a rapid recovery, no postoperative side effects and high patient satisfaction. In addition to increasing the quality and improving the operating room efficiency, the ideal anaesthetic technique would also decrease the costs of the anaesthetic services in the form of rapid turnover of the patients and provide for an early discharge. 

About 75% of all hernias are classified as inguinal hernias, which are the most common type of hernia occurring in men and women as a result of the activities of normal living and aging. Because humans stand upright, there is a greater downward force on the lower abdomen, increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia). According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men.

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.

An operation in which the hernia sac is removed without any repair of the inguinal canal is described as a 'herniotomy'. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with autogenous (patient's own tissue) or heterogeneous (like steel or prolene mesh) material it is termed Hernioplasty as opposed to herniorrhaphy in which no autogenous or heterogeneous material is used for reinforcement.

We therefore, conducted this case analysis study for daycare inguinal hernia repair, with respect to preparation and discharge times as well as cost effectiveness in patients’

Inguinal hernia

 (pronounced / ˈɪ ŋ ɡ w ɨ nəl ̍ h ɜ rniə/ ) is a protrusion of abdominal-cavity contents through the inguinal canal. They are very common (lifetime risk 27% for men, 3% for women[1]), and their repair is one of the most frequently performed surgical operations.

Inguinal hernia repair, also known as herniorrhaphy, is the surgical correction of an inguinal hernia. An inguinal hernia is an opening, weakness, or bulge in the lining tissue (peritoneum) of the abdominal wall in the groin area between the abdomen and the thigh. The surgery may be a standard open procedure through an incision large enough to access the hernia or a laparoscopic procedure performed through tiny incisions, using an instrument with a camera attached (laparoscope) and a video monitor to guide the repair. When the surgery involves reinforcing the weakened area with steel mesh, the repair is called hernioplasty.

There are two types of inguinal hernia, direct and indirect, which are defined by their relationship to the inferior epigastric vessels. Direct inguinal hernias occur medial to the inferior epigastric vessels when abdominal contents herniate through the superficial inguinal ring. Indirect inguinal hernias occur when abdominal contents protrude through the deep inguinal ring, lateral to the inferior epigastric vessels; this may be caused by failure of embryonic closure of the processus vaginalis.

In the case of the female, the opening of the superficial inguinal ring is smaller than that of the male. As a result, the possibility for hernias through the inguinal canal in males is much greater because they have a larger opening and therefore a much weaker wall for the intestines to protrude through.

Type Description

Relationship to inferior epigastric vessels

Covered by internal spermatic fascia?

Usual onset

indirect inguinal hernia

protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal inguinal ring after the testicle passes through it

Lateral Yes Congenital

direct inguinal hernia

enters through a weak point in the fascia of the abdominal wall (Hesselbach triangle)less common 25%-30% of inguinal hernia . most occur in men at 40 years and above .

Medial No Adult

PurposeInguinal hernia repair is performed to close or mend the weakened abdominal wall of an

inquinal hernia.

DemographicsThe majority of hernias occur in males. Nearly 25% of men and only 2% of women in the

United States will develop inguinal hernias. Inguinal hernias occur nearly three times more often in African American adults than in Caucasians. Among children, the risk of groin hernia is greater in premature infants or those of low birth weight. Indirect inguinal hernias will occur in 10–20 children in every 1,000 live births.

DescriptionAbout 75% of all hernias are classified as inguinal hernias, which are the most common

type of hernia occurring in men and women as a result of the activities of normal living and aging. Because humans stand upright, there is a greater downward force on the lower abdomen, increasing pressure on the less muscled and naturally weaker tissues of the groin area. Inguinal hernias do not include those caused by a cut (incision) in the abdominal wall (incisional hernia). According to the National Center for Health Statistics, about 700,000 inguinal hernias are repaired annually in the United States. The inguinal hernia is usually seen or felt first as a tender and sometimes painful lump in the upper groin where the inguinal canal passes through the abdominal wall. The inguinal canal is the normal route by which testes descend into the scrotum in the male fetus, which is one reason these hernias occur more frequently in men.

Hernias are divided into two categories: congenital (from birth), also called indirect hernias, and acquired, also called direct hernias. Among the 75% of hernias classified as inguinal hernias, 50% are indirect or congenital hernias, occurring when the inguinal canal entrance fails to close normally before birth. The indirect inguinal hernia pushes down from the abdomen and through the inguinal canal. This condition is found in 2% of all adult males and in 1–2% of male children. Indirect inguinal hernias can occur in women, too, when abdominal pressure pushes folds of genital tissue into the inquinal canal opening. In fact, women will more likely have an indirect inguinal hernia than direct. Direct or acquired inguinal hernias occur when part of the large intestine protrudes through a weakened area of muscles in the groin. The weakening results from a variety of factors encountered in the wear and tear of life.

Inguinal hernias may occur on one side of the groin or both sides at the same or different times, but occur most often on the right side. About 60% of hernias found in children, for example, will be on the right side, about 30% on the left, and 10% on both sides. The muscular weak spots develop because of pressure on the abdominal muscles in the groin area occurring during normal activities such as lifting, coughing, straining during urination or bowel movements, pregnancy, or excessive weight gain. Internal organs such as the intestines may then push through this weak spot, causing a bulge of tissue. A congenital indirect inguinal hernia may be diagnosed in infancy, childhood, or later in adulthood, influenced by the same causes as direct hernia. There is evidence that a tendency for inguinal hernia may be inherited.

A direct and an indirect inguinal hernia may occur at the same time; this combined hernia is called a pantaloon hernia.

A femoral hernia is another type of hernia that appears in the groin, occurring when abdominal organs and tissue press through the femoral ring (passageway where the major femoral artery and vein extend from the leg into the abdomen) into the upper thigh. About 3% of all hernias are femoral, and 84% of all femoral hernias occur in women. These are not inquinal hernias, but they can sometimes confusethe diagnosis of inguinal hernias because they curve over the inguinal area. They are more often accompanied by intestinal obstruction than inguinal hernias.

Because inguinal hernias do not heal on their own and can become larger or twisted, which may close off the intestines, the prevailing medical opinion is that hernias must be treated surgically when they cause pain or limit activity. Protruding intestines can sometimes be pushed back temporarily into the abdominal cavity, or an external support (truss) may be worn to hold the area in place until surgery can be performed. Sometimes, other medical conditions complicate the presence of a hernia by adding constant abdominal pressure. These conditions, including chronic coughing, constipation, fluid retention, or urinary obstruction, must be treated simultaneously to reduce abdominal pressure and the recurrence of hernias after repair. A relationship between smoking and hernia development has also been shown. Groin hernias occur more frequently in smokers than nonsmokers, especially in women. A hernia may become incarcerated, which means that it is trapped in place and cannot slip back into the abdomen. This causes bowel obstruction, which may require the removal of affected parts of the intestines (bowel resection) as well as hernia repair. If the herniated intestine becomes twisted, blood supply to the intestines may be cut off (intestinal ischemia) and the hernia is said to be strangulated, a condition causing severe pain and requiring immediate surgery.

Anatomy

Pathophysiology

Indirect inguinal hernias usually occur because of a persistent process vaginalis. As the hernia emerges through the deep internal ring, it carries with it fascial linings of the tissue it transverses. The hernia courses along the inguinal canal lateral to the epigastric arteries and emerges through the external ring slightly lateral to the pubic tubercle. Contents of this hernia then follow the tract of the spermatic cord down into the scrotal sac in men, or follows the round ligament in females.

Direct hernias are always acquired and therefore unusual in the young. They typically affect middle-aged or elderly patients. A direct inguinal hernia occurs because of degeneration and fatty changes in the aponeurosis of the transversalis fascia in the Hesselbach triangle area. The Hesselbach triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries and medially by the lateral border of rectus abdominus.

Because of the wide neck of a direct hernia, it rarely strangulates. Strangulation is more common with indirect hernia, which has a narrow neck. As segments of the intestine prolapse through the defect in the anterior abdominal wall, they cause sequestration of fluid within the lumen of the herniated bowel.

This initially impairs the lymphatic and venous drainage, which further compounds the swelling, and over time the arterial supply becomes involved. The increased intraluminal pressure causes the wall of the affected segment to become congested, which leads to extravasations of blood into the hernia sac.

The normal pinkish and shining color of the bowel wall is lost and replaced with a dull congested bowel segment, followed by loss of tone within the bowel wall. This favors bacterial proliferation and subsequent infection of the blood-stained fluid in the hernia sac. Gangrene ensues and, if left untreated, perforation occurs. Peritonitis occurs initially within the sac and then spreads to the peritoneal cavity.

Surgical (Direct Inguinal Hernia)

(Indirect inguinal hernia)

After Surgical procedures

Surgical incision in groin after inguinal hernia operation.

Surgical correction of inguinal hernias, called a herniorrhaphy or hernioplasty, is now often performed as outpatient surgery. There are various surgical strategies which may be considered in the planning of inguinal hernia repair. These include the consideration of mesh use, type of open repair, use oflaparoscopy, type of anesthesia, appropriateness of bilateral repair, etc. During surgery conducted under local anaesthesia, the patient will be asked to cough and strain during the procedure to help in demonstrating that the repair is "tension free" and sound

In open inguinal hernia repair procedures, the patient is typically given a light general anesthesia of short duration. Local or regional anesthetics may be given to some patients. Open surgical repair of an indirect hernia begins with sterilizing and draping the inguinal area of the abdomen just above the thigh. An incision is made in the abdominal wall and fatty tissue removed to expose the inguinal canal and define the outer margins of the hole or weakness in the muscle. The weakened section of tissue is dissected (cut and removed) and the inguinal canal opening is sutured closed (primary closure), making sure that no abdominal organ tissue is within the sutured area. The exposed inguinal canal is examined for any other trouble spots that may need reinforcement. Closing the underlayers of tissue (subcutaneous tissue) with fine sutures and the outer skin with staples completes the procedure. A sterile dressing is then applied.

An open repair of a direct hernia begins just as the repair of an indirect hernia, with an incision made in the same location above the thigh, just large enough to allow visualization of the hernia. The surgeon will look for and palpate (touch) the bulging area of the hernia and will reduce it by placing sutures in the fat layer of the abdominal wall. The hernial sac itself will be closed, as in the repair of the indirect hernia, by using a series of sutures from one end of the weakened hernia defect to the other. The repair will be checked for sturdiness and for any tension on the new sutures. The subcutaneous tissue and skin will be closed and a sterile dressing applied.

Laparoscopic procedures 

are conducted using general anesthesia. The surgeon will make three tiny incisions in the abdominal wall of the groin area and inflate the abdomen with carbon dioxide to expand the surgical area. A laparoscope, which is a tube-like fiber-optic instrument with a small video camera attached to its tip, will be inserted in one incision and  surgical instruments  inserted in the other incisions. The surgeon will view the movement of the instruments on a video monitor, as the hernia is pushed back into place and the hernial sac is repaired with surgical sutures or staples. Laparoscopic surgery is believed to produce less postoperative pain and a quicker recovery time. The risk of infection is also reduced because of the small incisions required in laparoscopic surgery.

The use of surgical (prosthetic) steel mesh or polypropylene mesh in the repair of inguinal hernias has been shown to help prevent recurrent hernias. Instead of the tension that develops between sutures and the skin in a conventionally repaired area, hernioplasty using mesh patches has been shown to virtually eliminate tension. The procedure is often performed in an outpatient facility withlocal anesthesia and patients can walk away the same day, with little restrictions in activity. Tension-free repair is also quick and easy to perform using the laparoscopic method, although general anesthesia is usually used. In either open or laparoscopic procedures, the mesh is placed so that it overlaps the healthy skin around the hernia opening and then is sutured into place with fine silk. Rather than pulling the hole closed as in conventional repair, the mesh makes a bridge over the hole and as normal healing take place, the mesh is incorporated into normal tissue without resulting tension.

DiagnosisReviewing the patient's symptoms and medical history are the first steps in diagnosing a

hernia. The surgeon will ask when the patient first noticed a lump or bulge in the groin area, whether or not it has grown larger, and how much pain the patient is experiencing. The doctor will palpate the area, looking for any abnormal bulging or mass, and may ask the patient to cough or strain in order to see and feel the hernia more easily. This may be all that is needed to diagnose an inguinal hernia. To confirm the presence of the hernia, an ultrasound examination may be performed. The ultrasound scan will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumoror enlarged lymph gland. It is not usually possible to determine whether the hernia is direct or indirect until surgery is performed.

Signs and symptoms

Frontal view of an inguinal hernia (area shaved prior to hospitalisation and surgical repair procedure).

Hernias present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. They are rarely painful, and the bulge commonly disappears on lying down. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is 'incarcerated' which requires surgery to correct.

Significant pain is suggestive of strangulated bowel (an incarcerated indirect inguinal hernia).

As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed "strangulated," and gut ischemia and gangrene can result, with potentially fatal consequences. The timing of complications is not predictable. Some hernias remain static for years, others progress rapidly from the time of onset. Provided there are no serious co-existing medical problems, patients are advised to get the hernia repaired surgically at the earliest convenience after a diagnosis is made. Emergency surgery for complications such as incarceration and strangulation carry much higher risk than planned, "elective" procedures.

Differential diagnosis   of the symptoms of inguinal hernia mainly includes the following potential conditions:[2]

Femoral hernia

Epididymitis

Testicular torsion

Lipomas

Inguinal adenopathy (Lymph node Swelling)

Groin abscess

Saphenous vein  dilation, called Saphena varix

Vascular aneurysm or pseudoaneurysm

Hydrocele

Varicocele

Cryptorchidism  (Undescended testes)

Causes:

The weakness in the abdominal wall can be congenital injures and certain abdominal operation may increase hernia.

Other Factors:

-Chronic constipation leading during bowel movements of urination.

-Heavy lifting.

-Excess weight.

-pregnancy chronic

-coughing chronic,sneezing

-family history of hernias and premature birth.

Preparation

Patients will have standard preoperative blood and urine tests, anelectrocardiogram, and a chest x ray to make sure that the heart, lungs, and major organ systems are functioning well. A week or so before surgery, medications may be discontinued, especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before surgery, patients must not eat or drink anything. Once in the hospital, a tube may be placed into a vein in

the arm (intravenous line) to deliver fluid and medication during surgery. A sedative may be given to relax the patient.

Management

Medical

The hernia truss is intended to contain a reducible inguinal hernia within the abdomen. This device fell out of favour with the advent of hernia surgery. It is not considered to provide a cure, and if the pads are hard and intrude into the hernia aperture they may cause scarring and enlargement of the aperture. In addition, most trusses with older designs are not able effectively to contain the hernia at all times, because their pads do not remain permanently in contact with the hernia. The more modern variety of truss (medicine) is made with non-intrusive flat pads and comes with a guarantee to hold the hernia securely during all activities. Although there is as yet no proof that such devices can prevent an inguinal hernia from progressing, they have been described by users as providing greater confidence and comfort when carrying out physically demanding tasksTheir popularity is likely to increase, as many individuals with small, painless hernias are now delaying hernia surgery due to recently published reports on the incidence of Post Herniorrhaphy Pain Syndrome.

Surgical

Herniorrhaphy

What to Expect After Surgery

For adults, open surgery for hernia repair usually involves a recovery period of up to 4 weeks before resuming normal strenuous activities. But this varies depending on the individual.

Aftercare

The hernia repair site must be kept clean and any sign of swelling or redness reported to the surgeon. Patients should also report a fever, and men should report any pain or swelling of the testicles. The surgeon may remove the outer sutures in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed and whether or not the surgery is the first hernia repair. To

allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for six to eight weeks after surgery. The postoperative activities of patients undergoing repeat procedures may be even more restricted.

Inguinal Hernia Repair - Series: Aftercare

Prevention

You can't prevent the congenital defect that may lead to an inguinal hernia, but the following steps can help reduce strain on your abdominal muscles and tissues:

Maintain a healthy weight. If you think you may be overweight, talk to your doctor about the best exercise and diet plan for you.

Emphasize high-fiber foods. Fresh fruits and veget ables and whole grains are good for your overall health. They're also packed with fiber that can help prevent constipation and straining.

Lift heavy objects carefully or avoid heavy lifting altogether. If you have to lift something heavy, always bend from your knees, not from your waist.

Stop smoking. In addition to increasing your risk of serious diseases such as cancer, emphysema and heart disease, smoking often causes a chronic cough that can lead to or aggravate an inguinal hernia.

Don't rely on a truss for support. Contrary to what you may have heard, wearing a truss isn't the best long-term solution for an inguinal hernia. A truss won't protect against complications or correct the underlying problem, although your doctor may recommend wearing one for a short time before surgery.

RisksHernia surgery is considered to be a relatively safe procedure, although complication

rates range from 1–26%, most in the 7–12% range. This means that about 10% of the 700,000 inguinal hernia repairs each year will have complications. Certain specialized clinics report markedly fewer complications, often related to whether open or laparoscopic technique is used. One of the greatest risks of inquinalhernia repair is that the hernia will recur. Unfortunately, 10–15% of hernias may develop again at the same site in adults, representing about 100,000 recurrences annually. The risk of recurrence in children is only about 1%. Recurrent hernias can present a serious problem because incarceration and strangulation are more likely and because additional surgical repair is more difficult than the first surgery. When the first hernia repair breaks down, the surgeon must work around scar tissue as well as the recurrent hernia. Incisional hernias, which are hernias that occur at the site of a prior surgery, present the same circumstance of combined scar tissue and hernia and even greater risk of recurrence. Each time a repair is performed, the surgery is less likely to be successful. Recurrence and infection rates for mesh repairs have been shown in some studies to be lower than with conventional surgeries.

Complications that can occur during surgery include injury to the spermatic cord structure; injuries to veins or arteries, causing hemorrhage; severing or entrapping nerves, which can cause paralysis; injuries to the bladder or bowel; reactions toanesthesia; and systemic complications such as cardiac arrythmias, cardiac arrest, or death. Postoperative complications include infection of the surgical incision (less in laparoscopy); the formation of blood clots at the site that can travel to other parts of the body; pulmonary (lung) problems; and urinary retention or urinary tract infection.

Healthy children who have a hernia repair have few risks. The surgery usually is done on an outpatient basis.

The surgeon may check to see whether a child younger than 1 year also has a hernia on the other side of the groin. If there is one, it may be repaired during the same surgery to avoid the risks of a second surgery. In males, this practice involves putting both testicles at risk at the same time.

Males with hydrocele and hernia may have both problems repaired at the same time to avoid the risks of a second surgery.

Premature babies are at risk for heart and lung complications during surgery.

Adults and children who have a hernia repair are at risk for:

Reaction to anesthesia (main risk). Infection and bleeding at the site.

Nerve damage, numbness of skin, loss of blood supply to scrotum or testicles resulting in testicular atrophy (all infrequent).

Damage to the cord that carries sperm from the testicles to the penis (vas deferens), resulting in an inability to father children.

Damage to the femoral artery or vein.

What To Think About

The following people need special preparation before surgery to reduce the risk of complications:

Those with a history of blood clots in large blood vessels (deep vein thrombosis) Smokers

Those taking large doses of aspirin

Those taking anticoagulation medicines (such as warfarin or heparin)

Most inguinal hernia repair surgery on adults of all ages and healthy children is done on an outpatient basis. This lowers costs (as much as 50% lower than inpatient surgery, which requires a stay in the hospital) and may reduce infection. Outpatient surgery takes about 1 hour.

Inpatient surgery is sometimes recommended for people who have:

Unusual, recurrent hernias. Very large hernias.

Hernias on both sides (bilateral hernias).

Severe illnesses (such as heart or lung disease), or who are taking anticoagulant medicines.

Infants with the following conditions may need to be hospitalized for hernia surgery:

Lung problems, such as bronchopulmonary dysplasia

Normal resultsInguinal hernia repair is usually effective, depending on the size of the hernia, how much

time has gone by between its first appearance and the corrective surgery, and the underlying condition of the patient. Most first-time hernia repair procedures will be one-day surgeries, in which the patient will go home the same day or in 24 hours. Only the most challenging cases will require an overnight stay. Recovery times will vary, depending on the type of surgery performed. Patients undergoing open surgery will experience little discomfort and will resume normal activities within one to two weeks. Laparoscopy patients will be able to enjoy normal activities within one or two days, returning to a normal work routine and lifestyle within four to seven days, with the exception of heavy lifting and contact sports.

How Well It Works

Open surgery for inguinal hernia repair is safe. The recurrence rate (hernias that require two or more repairs) is low when open hernia repair is done by experienced surgeons using mesh patches. Synthetic patches are now widely used for hernia repair in both open and laparoscopic surgery.

The chance of a hernia coming back after open surgery ranges from 1 to 10 out of every 100 open surgeries done.

Morbidity and mortality rates

Mortality related to inguinal hernia repair or postoperative complications is unlikely, but with advanced age or severe underlying conditions, deaths do occur. Recurrence is a notable complication and is associated with increased morbidity, with recurrence rates for indirect hernias from less than 1–7% and 4–10% for direct.

AlternativesIf a hernia is not surgically repaired, an incarcerated or strangulated hernia can result,

sometimes involving life-threatening bowel obstruction or ischemia.

Points to Remember

• An inguinal hernia is a condition in which intra-abdominal fat or part of the small intestine, also called the small bowel, bulges through a weak area in the lower abdominal muscles. An inguinal hernia occurs in the groin—the area between the abdomen and thigh.

• An inguinal hernia can occur any time from infancy to adulthood and is much more common in males than females.

• Direct and indirect hernias are the two types of inguinal hernia, and they have different causes.

• Symptoms of an inguinal hernia usually appear gradually and include a bulge in the groin, discomfort or sharp pain, a feeling of weakness or pressure in the groin, and a burning, gurgling, or aching feeling at the bulge.

• An incarcerated inguinal hernia is a hernia that becomes stuck in the groin or scrotum and cannot be massaged back into the abdomen.

• A strangulated hernia, in which the blood supply to the incarcerated small intestine is jeopardized, is a serious condition and requires immediate medical attention. Symptoms include extreme tenderness and redness in the area of the bulge, sudden pain that worsens quickly, fever, rapid heart rate, nausea, and vomiting.

• An inguinal hernia is diagnosed through a physical examination.

• Inguinal hernias may be repaired through surgery. Surgery is performed through one incision or with a laparoscope and several small incisions.

Surgery for inguinal hernia is usually done on an outpatient basis. Recovery time varies depending on the size of the hernia, the technique used, and the age and health of the patient.