NIS

Hernia Repair

Hernias explained

  • Indirect Inguinal Hernia

  • Direct Inguinal Hernia

  • Femoral Hernia

  • Umbilical Hernia

  • Epigastric Hernia

  • Incisional 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.

Hernia 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?

Take 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.

The most 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 their 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.