Indirect Inguinal Hernia
Direct Inguinal Hernia
On this page you will learn the basics of hernias and hernia
surgery. I will also give you a framework within which you can
understand the controversies in hernia surgery so that you can make
the best choice for yourself. You do have choices.
repair is very frequently the first operation that a surgeon is
taught to do. This is not because it is easy to do. It is partly
because it is the most common surgery done world wide. The
surgeon in training first learns to cut,
sew and tie. Later comes mastery. Hernia repair is nuanced.
If you have a hernia and you are doing your due diligence you will
very quickly see that there is controversy and patients are being
seriously injured. You will need to come to terms with the
controversy in your own way. The issues that you need to sort out
include 1) Risk of chronic pain, 2) Long term comfort 3) Risk of
hernia recurrence 4) Ease of treatment of complications 5)
Speed of recovery 6) Cosmetic appearance of wound in order of
importance by my judgment. Of course you have to decide for yourself
what is important. There is one point that I would like to stress. A
hernia recurrence is not the most important complication of hernia
surgery. Chronic pain is.
These six considerations can be
distilled down to two choices. 1) mesh or no mesh? 2) conventional
open surgery or high tech minimally invasive surgery?
question number 2 first. Minimally invasive surgery has a
small entrance wound(like a bullet) and therefore has the best
cosmetic results and has a lower risk of wound complications. But
wound complications are not a common problem of conventional
surgery. Aside from the small entrance wound the amount of trauma
inside the abdomen is the same for minimally invasive as it is for
conventional. In fact I have seen many patients who had worse post
op pain than my conventional surgery. Lastly, if you choose
minimally invasive surgery then you choose mesh. It may be possible
but nobody is doing minimally invasive without mesh.
important choice you will make, in my professional opinion, is mesh
or no mesh. You will not find a consensus on the risk of chronic
pain in the medical literature. Reports of the risk of chronic pain
caused by hernia mesh range from 0% to 60%. I quote to patients a
20% risk of chronic pain caused by hernia mesh. There are authurs
who say that the risk for chronic pain is the same with or without
mesh. I quote to patients a risk of less than 1% for chronic pain
caused by non mesh hernia repair based on my own experience.
Chronic pain is a very serious complication of hernia surgery. It
can and has ruined lives
If you have a hernia you are not alone. A hernia repair is the most
common operation that is preformed world wide. One in three men will
get a hernia repair some time in their life. One in ten women will
get a hernia repair.
A hernia is a defect in the strength
layer of our abdominal wall which contains our bowels. The main
danger is blockage of our bowels caused by a hernia strangulation. A
hernia strangulation can be life threatening.
All abdominal hernias
need to be repaired because they do not get better by themselves. It
is best to repair a hernia when it is small and it is best to repair
it before a serious complication like a strangulation occurs.
Strangulations are unpredictable and therefor the risk cannot be
managed. If you have a hernia, get it fixed.
There many types
of hernias and there are many types of repair. Broadly there are
pure tissue repairs and mesh repairs. There are open repairs and
laparoscopic repairs. I liken a hernia repair technique to a writing
instrument. The quality of the writing comes from the hands of the
writer. The quality of a repair comes from the hands of the surgeon.
Minimally invasive is a misleading moniker for laparoscopic
surgery. Laparoscopic surgery is not safer than open surgery. The
entrance wound is small but the trauma inside the abdomen is no less
than an open procedure.
A very important consideration for a
patient with a hernia is the issue of mesh complications. For
decades we have known that hernia mesh causes severe chronic pain in
a significant number of patients. But these issues have been
dismissed for the sake of the lowest recurrence rates among hernia
repair techniques. Unfortunately this dismissal of pain
complications has become militant and is approaching institutional
denial. Even worse is the fact that when mesh causes chronic pain
clinicians are slow to recognize it and have little to offer in the
way of effective treatment.
In most cases hernias may be
repaired without mesh and with an acceptably low risk of recurrence.