Inguinal

Treatment

Once you have a hernia it will not get better by itself. Some patients use a 'truss' to stop the hernia bulging out - this does not get rid of the hernia, simply controls it.

The only way to get rid of the hernia sac is to operate on it.

The surgery can be carried out under local, spinal/epidural or general anaesthetic (see patient information leaflet - 'In the anaesthetic room'). I give all of my patients a dose of antibiotics during the operation to lower the risk of infection.

Almost all hernia repairs are done using some form of mesh. The advantage of these mesh repairs over the older techniques using stitches alone is the lack of tension on the tissues. This makes the operation more comfortable with more rapid recovery and lowers the recurrence rates.

A number of different techniques are available:

Perfix plug

The operation involves a cut in the groin, dissecting down to the external oblique muscle (shiny white on video) and opening this. The cord is exposed and the hernia sac can then be isolated. In the video you will see the sac and some fat - this is the normal fat that is present beneath the abdominal muscles. The sac and the fat are reduced (pushed back into the correct place) and I then use a piece of permanent mesh in the shape of a shuttle-cock to plug the hole. The plug is held in place with permanent stitches. This technique also has an 'on-lay' mesh to help strengthen the back wall of the inguinal canal. The on-lay mesh is placed under the external oblique muscle and around the cord. The tissues are then closed and dissolving stitches used for the skin.

The figure below shows the plug and on-lay mesh. The video shows an edited operation highlighting the points mentioned above.

To see a video of the operation using a perfix plug, click here

Occasionally both a direct and an indirect hernia may be present on one side. In these cases, if the back wall of the inguinal canal is strong enough, I use 2 plugs.

I prefer not to use this technique anymore because some patients can feel the plug and a few of my patients have complained of long term pain with the plug - such that the plug had to be removed.

Lichtenstein repair

If the whole of the back wall is weak, instead of using the plug technique I use a large sheet of mesh to reinforce the whole of the back wall. This is called the 'Lichtenstein repair'. I prefer not to use this technique as it involves a fair amount of dissection and can cause more discomfort. I prefer the prolene hernia system (see below).

Laparoscopic surgery

Some hernias may be suitable for repair using key-hole (laparoscopic) surgery. In this case the mesh is inserted behind the abdominal muscles. This position for the mesh can also be achieved by an 'open' operation - see bilateral inguinal hernia repair.

This is a picture of the abdominal wall from the inside (keyhole surgery). The hernia opening can be easily seen at the deep ring. This lies to the lateral side of the epigastric vessels - making this an indirect hernia.

The video shows repair of an indirect hernia on the left and a direct on on the right. The right sided one is repaired first. The peritoneum (inner lining of the abdominal wall) is mobilised taking care to protect the vas and the blood vessels to the testicle. A vypro II mesh is used - this is a light weight mesh in that part of it will dissolve in time. It is held in place with small metal tacks. The peritoneum is closed before repairing the other side.

To see a video of laparoscopic hernia repair, click here

Prolene Hernia System

From December 2002 I started to use a new mesh - the prolene hernia system. This consists of 2 flat sheets of mesh (one circular and one oval) attached in the middle by a collar. The circular part sits beneath the abdominal wall (like the laparoscopic repair) and the oval component sits within the abdominal wall (like the Lichtenstein repair). This mesh combines the advantages of a preperitoneal mesh and a Lichtenstein mesh repair without the possibility of the two meshes moving apart as they are joined in the middle:

Prolene Hernia System

The video of the operation shows an operation carried out under local anaesthetic - injected at various points during the procedure. The hernia sac is identified and reduced (returned to the abdominal cavity). The mesh is then placed and the oval part sutured into place.

To see a video of inguinal hernia repair using the prolene hernia system, click here.