Mending inguinal hernias
David W. Rattner
When the doctor found a small lump in Mark Wilson’s groin, the 47-year-old patient was surprised. At least 2% of adult men in the United States develop an inguinal hernia and, like Wilson, one third of them have no symptoms. An inguinal hernia is the protrusion of the intestine or fatty tissue into the groin through a weakness or tear in the abdominal wall. It is usually caused by a congenital defect and appears after lifting a heavy object, persistent coughing, or straining during urination or defecation. A person may be uncomfortable while standing or moving or may experience a heavy feeling in the groin. Often, the protruding lump can be felt and pushed back into the abdomen. This type of hernia is generally found on one side of the groin, but it can appear on both.
Inguinal hernias account for 75% of abdominal wall hernias. (The other common types are epigastric, umbilical, and femoral.) Men are far more vulnerable than women because they are sometimes born with a weakness in the inguinal canal, the passage through which the testis descends into the scrotum. Although some hernias can be managed by wearing a truss (a device that puts pressure on the hernia and holds it in), the only way to fix the problem is through surgery. Living with a hernia for any great length of time is risky because eventually it may become impossible to push the intestine back into place. This could lead to a bowel obstruction or strangulation.
Under the knife
Each year, more than half a million Americans undergo one of two types of hernia repair: open surgery or laparoscopy. Both are relatively safe, take about an hour, and enable a patient to go home the same day. But open repair requires a somewhat longer recovery time, primarily because an incision is made through groin muscle. When performed by a well-trained surgeon, the recurrence rate for both operations is less than 3%.
Open surgery accounts for about 95% of all inguinal hernia repairs. It’s usually done under local anesthesia and requires a 4-6-inch incision in the groin. The doctor then pushes the herniated tissue back into place and sutures the opening shut. Sometimes a small piece of synthetic material is placed over the gap to serve as scaffolding on which scar tissue will grow. This helps fortify the weakened muscle so the hernia won’t recur. The material causes no long-term complications. Although people are generally back on their feet in less than a week, it can take as long as 4-6 weeks for the groin to heal completely.
In the laparoscopic procedure, which has been in use since the early 1990s, the surgeon makes three small incisions (half an inch or less) in the abdomen, which is then inflated with carbon dioxide. Surgical instruments and a small video camera (the laparoscope) are inserted through the incisions. While watching a monitor, the surgeon pushes the distended organ back into place and staples a patch over the opening. The procedure requires general anesthesia because inflating the abdomen is painful.
On the other hand, postoperative pain is substantially reduced with laparoscopy because the small incisions cause little trauma to the groin muscles. A full recovery generally takes a week or less. The disadvantage of this approach is that it’s difficult to perform, and although uncommon, bowel or bladder perforations do occur. Because these complications are more likely to happen in the hands of a surgeon who is inexperienced in laparoscopy, it’s important to find a doctor who has performed many of these operations.
The latest laparoscopic technique is called the extraperitoneal or “balloon” approach. Preliminary data suggest that the procedure is safer than standard laparoscopy because the balloon creates an operative space between the muscles of the abdominal wall and the peritoneum, the lining of the abdominal cavity. This reduces the risk of injury to the bowel and blood vessels.
Like all surgical procedures, hernia repair can have complications. In one study of 686 patients conducted at Creighton University School of Medicine in Omaha, researchers reported a complication rate — due directly to laparoscopy — of 5.4%. These included mostly bleeding problems, but there was one bowel perforation and a bladder injury. Complication rates for open surgery are similar. Problems include bleeding, nerve injuries, and testicle damage.
Localized swelling, bleeding, and transient urinary retention are common following both operations. One in five people has leg or groin pain, bruising, or swelling that usually dissipates within two months.
If a surgeon finds no medical reason to select one operation over the other, people can weigh the non-medical factors. Laparoscopy patients tend to have less postoperative pain and smaller scars. They can usually return to desk work within a couple of days; some even go hiking or skiing the following week. People who have had open repair can get around, but with difficulty, the first few days and may be out of work for a week or two. It may take an additional month for a full recovery. Another consideration — which is generally of greater concern to insurers — is cost. Although people who have had laparoscopy are back at work sooner, the procedure can cost more than traditional surgery. For those who need to avoid general anesthesia or live in a part of the country where surgeons have little experience in laparoscopy, it probably makes sense to have open surgery.
Keeping hernias at bay
Unfortunately, there’s not much people can do to prevent hernias, but experts say a few things may help: keep your weight down, make sure abdominal muscles are in shape, and avoid lifting heavy objects or straining in the bathroom. Quitting smoking is also a good idea because the cough from smoker’s bronchitis may cause sufficient abdominal strain to induce a hernia.
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