What is a hernia?
A hernia is a defect in the abdominal wall allowing contents from inside the abdomen to protrude through.
Are their different types of hernias?
Yes there area number of different types of hernias of the abdominal wall. The commonest types are inguinal, umbilical, paraumbilical, femoral and incisional. There are other rarer types such a spigelian and lumbar. In addition there are hernias at other sites. The most common being a hiatus hernia in which the stomach slips up through the diaphragm into the chest. This can be associated with a number of problems the commonest of which is gastro-oesophageal reflux which we experience as heartburn.
Is a hernia dangerous?
The danger of a hernia lies in the fact that it is possible for the abdominal contents entering the hernia to become stuck. Should this occur the hernia becomes increasingly painful and cannot be pushed back.
If the hernia contains bowel then it will become blocked (intestinal obstruction}. This produces colicky abdominal pain in addition to the constant pain experienced within the hernia, abdominal distension, vomiting and a variable degree of constipation. Patients may hear a lot of gurgling coming from their abdomen as the bowel contracts vigorously in an attempt to overcome the blockage. With time, the blood supply to the bowel may be cut off leading to it rupturing and the development of peritonitis. This is a serious complication requiring emergency surgery. It is to avoid the possibility of this serious complication occurring, that doctors recommend the repair of the majority of hernias as a matter of routine.
So the answer is yes hernias can be dangerous, on occasions leading to the need for an emergency admission to hospital and an emergency surgery.
How can a hernia be repaired?
The way in which repair is performed depends on the type of hernia. The commonest type of hernia seen is inguinal which appears in the groin. The methods of repair can be divided into open operations and laparoscopic procedures.
In the open operation a cut approximately 8 cm long is made in the groin, the hernial sac is removed and the weakness, through which the hernia came, repaired. There are a number of possible ways of repairing the weakness although most surgeons now use a piece of plastic mesh. This is placed over the defect and stitched down. The mesh remains in place permanently.
The repair of an inguinal hernia using a laparoscopic approach is a modern innovation. Like the open technique it uses a mesh, but unlike the open technique the operation can be performed through three small cuts, the largest of which is 15mm in size.
There are two different laparoscopic approaches: transperitoneal and extraperitoneal. These names are often abbreviated to TAPP (trans abdominal preperitoneal approach) and TEP (total extraperitoneal approach). In the former the abdominal cavity is entered. In the latter the operation can be completed without the need to enter the abdominal cavity.
With all these different ways of repairing an inguinal hernia which one should I choose?
The open mesh repair and laparoscopic repairs have similar success rates and so from that point of view there is really nothing to choose between them. Equally, both can normally be performed as a day case (the patient goes home on the day of surgery). A laparoscopic repairs requires a general anaesthetic and relaxation of the abdominal wall in order to allow the space required to perform the operation to be created. So if you do not want to be put to sleep for your operation, or it is not thought safe to put you to sleep, then you cannot have a laparoscopic approach. You will have to have your hernia repaired under local or regional anaesthetic as an open procedure.
It is unlikely that the surgeon will offer a choice between TAPP and TEP laparoscopic operation. It may be that they have had experience at both techniques but likely that they will have chosen to offer one technique only. The technique employed is less important than the fact that the surgeon should be comfortable with the technique they choose and perform the operation effectively and safely.
What are the differences between open and laparoscopic repair of an inguinal hernia?
The major differences are in the amount of postoperative pain, the time to start walking and the time taken to return to work which have been shown to be less in patients undergoing laparoscopic repair (6 to 18 days less). Wound numbness is also less after laparoscopic hernia repair. One study showed a slightly increased quality of life after laparoscopic, as apposed to open, repair.