Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (19 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Complications of herniorrhaphy include recurrence, urinary retention, ischaemic orchitis and testicular atrophy, wound infection and nerve injuries (neuromas of the ilioinguinal or genitofemoral nerves). A wide variation in recurrence rates is reported in the literature, depending on both the surgical technique employed and the method and length of follow-up (questionnaire, physical examination, etc.). In general, papers comparing mesh to suture repair note lower recurrence rates in the mesh group.
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Nevertheless, the percentage of recurrent to primary hernia repair has remained largely constant in Lothian, Scotland over the past 30 years at around 10%. Perhaps the only role for suture repair remains in the adolescent age group, where perhaps a herniotomy alone is insufficient and the risks of mesh insertion not merited. There has been a suggestion that mesh repairs in the groin can affect fertility in males.
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This is a very controversial area, as the occurrence of a hernia per se in the young is associated with reduced fertility. There is no convincing evidence to support the view that a mesh repair affects fertility except when there is obviously direct trauma to the vas or vessels to the testicle.
The complication that is becoming the benchmark for comparing hernia repairs is the incidence of chronic pain, rather than recurrence rate. Risk factors for chronic pain include nerve damage, preoperative pain in the hernia, young age, pain at other sites of the body, postoperative complications and psychosocial features.
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Pain response to a standardised heat stimulus appears to be a useful tool in assessing risk of postoperative chronic pain.
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The Shouldice technique using suture repair rather than mesh is still carried out in many centres worldwide and numerous publications have reported recurrence rates of 1–2%.
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To date, the Lichtenstein tension-free repair has the largest number of published repairs with the lowest recurrence rates. Lichtenstein and colleagues published a multicentre series of 22 300 hernioplasties performed by this technique, with a recurrence rate of 0.77%.
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The 2004 NICE report commented on 37 randomised controlled trials that compared laparoscopic with open mesh repair of inguinal hernias in a total of 5560 participants.
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The report summarised these results, stating that the laparoscopic repair as compared to an open repair was associated with less acute pain and thus a quicker return to daily activites and work, fewer wound complications such as haematoma, seroma and infection, and less risk of chronic pain. There was a similar recurrence rate and a similar risk of major vessel, bowel or bladder injury (except for a slightly higher risk for the TAPP repair). However, the laparoscopic repair took longer to perform and was a more expensive option. The cost of open surgery has to be set against the price of open surgery for the patient and society, namely more acute and chronic pain, more time off work and more wound complications. This is borne out by a cost–benefit analysis using the same data as the 2004 NICE report.
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Unilateral hernia open flat mesh repair was the least costly option, but it provided fewer quality-adjusted life-years compared to both TAPP and TEP. Also, laparoscopic repair for bilateral hernias reduces both operating times and convalescence period, equating to greater cost-effectiveness. In addition, repair of an occult hernia on the other side may also be performed, enhancing the benefit of the laparoscopic procedure.
Mesh repair using the Lichtenstein technique has the lowest worldwide recurrence rate for primary inguinal hernias. The laparoscopic repair is associated with less early and late pain, earlier return to normal activities and work, but is more expensive. It is, however, the preferred technique for the repair of recurrent and bilateral hernias.
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Recent publications now demonstrate that laparoscopic repairs, whether unilateral or bilateral, can be performed more quickly than open repair.
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The only downside to laparoscopic hernia surgery is the need for general anaesthesia. While small numbers have been done under local or regional techniques, these have been confined to young fit patients, for whom avoidance of a general anaesthetic is not necessary. Nevertheless, in many Western countries open inguinal hernias are still predominantly repaired under general anaesthetic.
Inguinal hernia arises as a design fault, both anatomically and at the level of collagen metabolism, so there is every reason why it should be a bilateral disease. Furthermore, clinical assessment of bilateral or unilateral hernia has a false positive and negative rate of around 10%. The rate of development of a contralateral inguinal hernia following open repair is around 25% at 10 years.
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The Edinburgh experience is that time from first repair to contralateral repair in the laparoscopic era is about half the time compared to open hernia repair. It could be argued that the larger mesh inserted laparoscopically places more strain on the contralateral side. An alternative hypothesis is that following laparoscopic repair, patients are more likely to volunteer for repair of the contralateral side as the operation is less painful. It is thus the author's practice to offer the majority of patients a bilateral laparoscopic repair, unless the laparoscopic approach is contraindicated and the patient unfit or elderly.
The repair of recurrent inguinal hernia remains a common operation and there is now some evidence to suggest that the increasing use of mesh may be having a small effect in reducing the number of recurrent hernia repairs
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(see section on prophylactic hernia repair at the end of this chapter). As a result there is little role now for suture repair of recurrent inguinal hernias, and a re-recurrence rate of 30% for the Bassini technique has been reported.
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The McVay procedure and transversalis repair are not commonly employed and the results are probably of historic interest only. In centres where alloplastic material is unavailable or too expensive for routine use, the Shouldice technique is probably the technique of choice.
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The Lichtenstein repair remains the commonest operation for recurrent inguinal hernias. Rate of re-recurrence depends to an extent on the length of follow-up, but is typically under 10%. Since its introduction, excellent results have been reported with the mesh plug method.
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The transinguinal pre-peritoneal prosthetic repair/Rives procedure tends to be reserved for selected cases and is not indicated for the majority of recurrent inguinal hernias.
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When an open pre-peritoneal approach is used with pre-peritoneal mesh implantation, the re-recurrence rate ranges between 0.5% and 25% after an observation period of up to 10 years, suggesting that this technique may require a degree of surgical experience for success.
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Divergent results are also reported for the Stoppa technique, with re-recurrence rates varying between 1% and 12%.
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The most likely explanation for this wide variation is that the size and type of recurrence probably varied between the reporting centres, and there is variation in the length and the quality of the follow-up.
The 2004 NICE
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report acknowledges that after a previous open repair, laparoscopic repair is the preferred technique. The advantages of the laparoscopic approach include: elimination of one of the commonest causes of recurrence, the missed hernia; allowing the surgeon to identify those patients with complex hernias; and covering the entire myopectineal orifice, buttressing the intrinsic collagen deficit, thereby overcoming one of the causes of late recurrence. The complication rate is low, and the majority of such repairs are as easy as primary laparoscopic repair. The data from the Swedish Hernia Registry would support the benefit of a pre-peritoneal repair (open or laparoscopic) for recurrent inguinal hernia following a previous open non-peritoneal repair.
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The type of surgery following recurrence after a previous laparoscopic repair is less well defined, and is more governed by surgeon preference and expertise. It is the author's opinion that an open mesh repair is the best option following a failed TAPP repair, and a TAPP repair for a failed TEP repair. The TAPP approach allows assessment as to why the TEP repair failed, and maintains the speedier recovery of the laparoscopic approach over open repair. However, the significant adhesions following a TAPP make a redo TAPP much more difficult, but still possible in experienced hands.
Traditional teaching used to suggest that once an inguinal hernia was detected, it merited repair to prevent hernia-related complications unless the patient was not fit for such surgery. However, increasing awareness of complications following hernia repair, particularly chronic pain, has questioned this approach. Two randomised trials have reported similar results but come to different conclusions.
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In essence, chronic pain on follow-up is similar between the operation group and the watchful waiting group. However, significant numbers in the watchful waiting group crossed over to the surgery arm because of increasing symptoms, but it is likely that such patients would tolerate complications of surgery better than if they were asymptomatic at the time of the surgery. Also, the risk of incarceration or strangulation is much lower than previously thought. Thus, following informed consent, surgery or watchful waiting for an asymptomatic hernia is appropriate. The younger the patient, or less fit the patient on presentation, then perhaps the earlier surgery should be offered, with suitable informed consent of the risks, benefits and alternatives to the proposed surgery.
Repair of an asymptomatic hernia does not increase the incidence of chronic pain as compared to a wait and see policy. Either treatment option is acceptable with appropriate informed consent.
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The majority of wait and see patients will cross over to surgery with time as their hernia increases in size and/or becomes more symptomatic.
Femoral hernia represents the third commonest type of primary hernia. It accounts for approximately 20% of hernias in women and 5% in men, strangulation being the initial presentation in 40%.
The femoral canal occupies the most medial compartment of the femoral sheath, extending from the femoral ring above to the saphenous opening below. It contains fat, lymphatic vessels and the lymph node of Cloquet. It is closed above by the septum crurale, a condensation of extraperitoneal tissue pierced by lymphatic vessels, and below by the cribriform fascia. The femoral ring is bounded anteriorly by the inguinal ligament and posteriorly by the iliopectineal (Cooper) ligament, the pubic bone and the fascia over the pectineus muscle. Medially, the boundary is the edge of the lacunar ligament, while laterally it is separated from the femoral vein by a thin septum (
Fig. 4.4
).
Femoral hernias are considered to be acquired, possibly as a result of increased abdominal pressure on the background of disturbed collagen metabolism. A postulated mechanism is the insinuation of fat into the femoral ring secondary to raised intra-abdominal pressure. This bolus of fat drags along pelvic peritoneum to develop a peritoneal sac. Once the peritoneal sac has moved the short distance down the canal and out of the femoral orifice, the sac becomes apparent. The hernia not only becomes visible and palpable, but the contents of the sac become at risk of incarceration and strangulation. The incidence of femoral herniation increases with age, and a potential mechanism for this involves the muscle bulk adjacent to the distal femoral canal. Normally, the iliopsoas and pectineus muscle bundles encroach on the canal and thus act as a barrier to the development of a femoral hernia. With the natural atrophy of muscle tissue that occurs with senescence, the actual volume of muscle within the canal decreases, allowing positive intra-abdominal pressure to push the peritoneum into the canal. This would explain the high rate of femoral hernia among elderly women as well as men. In women of all ages, the muscle mass is not as great as in men. Consequently, women are predisposed to femoral hernias with any condition that increases intra-abdominal pressure, such as pregnancy or obesity.
The treatment of femoral hernia is surgical repair due to the invariable presence of incarceration and the associated risk of strangulation. Several operative approaches have been described: the low approach (Lockwood), the high approach (McEvedy) and the inguinal approach (Lothiessen). To these can now be added the laparoscopic approach.
The low approach (Lockwood):
The low approach is based on a groin-crease incision and dissection of the femoral hernia sac below the inguinal ligament. The anatomical layers covering the sac should be peeled away and the sac opened to inspect its contents. Once empty, the neck of the sac is pulled down, ligated as high as possible and redundant sac excised. The neck then retracts through the femoral canal and the canal is closed with a plug or cylinder of polypropylene mesh, anchored to the inguinal ligament and iliopectineal ligament with non-absorbable sutures. Suturing of the iliopectineal ligament to the inguinal ligament may result in tension due to the rigidity of these structures and may predispose to recurrence.
Transinguinal approach (Lothiessen):
Techniques of femoral repair that open the posterior inguinal wall for exposure and repair (the inguinal approaches of Lothiessen, Bassini, Shouldice, McVay–Cooper, Halsted and Andrews) should rarely be used. This technique usually involves ligation and division of the inferior epigastric vessels at the medial border of the internal inguinal ring followed by incision of the transversalis fascia to expose the extraperitoneal space and the femoral hernia sac. This is reduced and the defect closed by either suture (as in the original description) or, increasingly, mesh. However, the need to incise the natural fascial barrier in Hasselbach's triangle for exposure results in this technique being inferior to either the low or high approach, both of which leave the inguinal floor intact.
High approach (McEvedy):
The high approach was classically based on a vertical incision made over the femoral canal and continued upwards above the inguinal ligament. This has now been replaced with a transverse ‘unilateral’ Pfannenstiel incision, which can be extended to form a complete Pfannenstiel incision if a formal laparotomy is required. The dissection is continued through the subcutaneous tissue to the anterior rectus sheath. This can either be divided transversely or longitudinally, following which transversalis fascia is incised, the rectus muscle retracted medially and the pre-peritoneal space entered. The femoral hernia sac is identified medial to the iliac vessels and reduced by traction. If the hernia is incarcerated, the sac may be released by incising the insertion of the iliopubic tract into Cooper's ligament at the medial margin of the femoral ring. The sac is then opened, the contents dealt with appropriately and the sac ligated at its neck. The hernioplasty may then be completed by either suturing the iliopubic tract to the posterior margin of Cooper's ligament or by insertion of a prosthetic mesh, either as a sheet covering the whole of the myopectineal opening or as a mesh plug. The wound is closed in layers. This technique is particularly useful in the presence of strangulated femoral hernias as it is easy to convert to laparotomy for bowel resection.
Laparoscopic approach:
The laparoscopic approach is the same as for inguinal hernias and may employ the TAPP or TEP technique. The femoral ring is easily seen during either of these approaches and, indeed, visualisation of the whole of the myopectineal opening is frequently quoted as one of the advantages of laparoscopic herniorrhaphy. Small series of laparoscopic femoral hernia surgery have been reported with excellent results on short-term follow-up.
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