Hernia: it is the clinical name of a wall defect that is filled with content (for example, intestine, omentum or any other organ).
Thus, when operating, a doctor will see a hernia as a defect with a peritoneal sac and content.
Our pancreas is the only organ that can’t be a content of a hernia as it is retroperitoneal.
Hernias are diagnosed when they are located in a susceptible anatomical site, becomes swollen after coughing, and it is reduced when lying down or by pressure with the fingers.
An abdominal wall hernia does not necessarily require repair unless complicated or when it is likely to complicate.
For example, femoral hernia is at high risk to complicate. Thus, it is advisable to be repaired. In young age patients, hernias are more often repaired as complications are more likely to occur on the long run.
Also it is recommended to repair a hernia when it is associated with pain, tenderness or irreducibility, either partial or complete. In these cases, it should be repaired to prevent strangulation, infarction and gangrene which may lead to toxemia, septicemia and death.
Indications of hernia surgery
- Cosmetic concerns: A hernia may cause some problems to patients, especially for girls wearing bikinis or top-crop shirts, so they actively look for surgery.
- A hernia may be complicated if left untreated. Signs of these complications that the patients must be aware of are tenderness, pain, irreducibility or obstruction (which will lead to intestinal obstruction, constipation, vomiting and may even cause gangrene).
- Conservative: In this case, no active treatment may be recommended. This is the management in cases of early asymptomatic hernias or old age patients not seeking any type of surgical intervention.A surgical truss can be used for those refusing surgery but with a high failure rate.
A truss is a kind of surgical appliance or a belt used for hernia to maintain the herniated area in position; it is meant to be worn right before leaving the bed.
- Surgery: There are three main procedures available for surgery which include the following:
- Herniotomy: An excision of the hernial sac from its neck with reduction of its contents.
Indications: it is preferred to be used in children and adolescents as their muscles become stronger as they grow up.
Disadvantage: it may be associated with high recurrence rate, especially if used in old age people.
- Herniorrhaphy: which means excision of the hernial sac from its neck and reduction of its contents with repair of the hernia defect either by narrowing of the hernia orifice or reinforcement of the posterior abdominal wall.
- Hernioplasty: It features an excision of the hernial sac from its neck and reduction of its contents with a complete repair of the defect either by mesh repair or graft which has 2 types;
- 1st Natural: Skin can be used to close the defect. Also, fascia lata – the deep fascia of the thigh- can be used. But this type of repair has the disadvantage of leaving another wounded or weak area elsewhere.
- 2nd Synthetic: The sutures used in this case must retain their strength for long enough to maintain tissue opposition, which will reduce the recurrence rate. Thus, non-absorbable or very slowly absorbable suture material must be used in these cases. Prolene or PTFE (Polytetrafluoroethylene) are commonly employed with the risk of sepsis, tissue reaction or sinus formation.
Prolene is the suture material of choice.
- Herniotomy: An excision of the hernial sac from its neck with reduction of its contents.
Management according to anatomical types of hernia
1) Epigastric hernia
An epigastric hernia is very likely to present symptoms because its opening is narrow in the linea alba (which represents the midline of abdomen), and this anatomical site predisposes for strangulation. Epigastric hernia must be confirmed by full investigations to prevent misdiagnosing with other intra-abdominal conditions including a peptic ulcer, which may have similar symptoms.
General anesthesia is usually performed, but local anesthesia with lignocaine can be satisfactory as well.
The patient must be positioned flat on the back; the area is exposed, and the drapes that expose the abdomen are placed from the costal margin above to the umbilicus below.
The incision: the abdomen is incised vertically through the linea alba, an anatomical place that has little blood supply and does not have nerves.
After that, the fatty hernia is seen enclosed in its capsule. Dissection should be performed not to injure adjacent structures. The first thing to do is widening the defect in the linea alba to facilitate visualizing the hernia and relief the obstruction. Then, the hernia capsule is incised vertically, and its contents are reduced. This is followed by ligation and excision of the hernia neck. Logically, to complete the surgery, the incision is closed in an opposite direction, so we start by closing the linea alba followed by the subcutaneous fat, and then the skin using prolene sutures, which can be either simple sutures, mattress sutures or subcuticular sutures (the best one, cosmetically speaking).
2) Umbilical hernia
It is common in infants, but we usually don’t intervene unless complicated as it resolves spontaneously.
Umbilical hernia in adults:
Irreducibility here is not an absolute indication for surgery as it may have adhesions that interfere with its reducibility. In large hernias, the skin overlying may ulcerate, which requires intervention, but antiseptic measures should be established to prevent infection.
It’s performed under general anesthesia.
The patient is laid on his back, and sterilization is done. After that, the drapes are put to guarantee good exposure of the hernia, including part of the abdomen in case we needed to extend the incision.
The incisions are two semilunar incisions around the umbilicus joined at their margins, and the skin is removed along with the umbilical scar. Also, any redundant skin is excised but being careful not to over-excise to prevent putting the skin under tension. After that, we cut through the subcutaneous fat until we see the aponeurosis of the muscles.
N.B. Any bleeding must be ligated or stopped using the diathermy to achieve hemostasis (to prevent losing a lot of blood, especially if we want to avoid blood transfusion and its hazardous complications).
Now, we are searching for the neck of hernia, so we have to widen our field by retractors to push back the remaining skin and subcutaneous fat to facilitate seeing the neck. Once we see it, we have to widen the defect horizontally to reduce its contents quickly; then, the sac is opened from the fundus ( the upper part of the sac), and the contents are reduced if they are viable or resected if they are dead or doubtfully viable. Lastly, the sac is ligated and removed from its neck.
The remaining part of the operation is to restore the normal anatomy. First, we close the defect by what’s called Mayo’s repair, in which we suture one flap over the other to strengthen the abdominal wall and prevent the recurrence. A suction drain is placed in the area, and the subcutaneous fat is sutured. Finally, the skin is closed either with sutures or clips, but most surgeons prefer clips as sutures may become weak, get infected, and cause sepsis.
♦ Post-operative care:
Nasogastric tube and parenteral nutrition may be needed if the content of the hernia was not viable and needed to be resected.
Also, analgesics may be used to reduce the pain after surgery.
3) Inguinal hernia
It’s recommended to be done in adolescents and patients under retirement period. It is likely to be avoided in old age, especially if reducible to prevent anesthesia complications.
The surgery that is commonly performed is named Shouldice operation.
Local or General anesthesia can be used.
The patient is laid in a flat position on the table, and the head of the table is tilted down by about 15 degrees to reach the full extension of the body.
The incision is made over the medial 2\3 of the inguinal ligament, 1 inch above the mid inguinal point (The inguinal ligament lies between the anterior superior iliac spine and pubic tubercle). This is followed by performing an opening through the subcutaneous fat until reaching the muscles of the anterior abdominal wall (the external oblique aponeurosis).
Proper exposure is needed here and is maintained by using retractors. In addition to proper exposure, retractors have a role in hemostasis by causing tension on the skin and stopping small sources of bleeding immediately.
Then, the aponeurosis is cut to reach the spermatic cord below.
Hemostasis is a must in this stage.
The following step depends on whether it’s a direct or indirect hernia.
In the case of direct hernia (which means that the defect is in the posterior abdominal wall), invagination of the sac and hernioplasty is done.
If it’s indirect (which means that the sac becomes one of the contents of the spermatic cord), the spermatic cord is opened and the sac is dissected from the other contents, reduced, and only then hernioplasty is done.