Hernia Repair

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Overview

Every year, more than half a million hernia repairs are performed in the United States. A hernia occurs when inner layers of abdominal muscle become weakened. The lining of the abdomen then bulges out into a small sac, and part of the intestine or abdominal tissue may enter the sac. Hernias occur most commonly in the groin (inguinal hernia), the navel (umbilical hernia), and at the incision site of a previous surgery.

A hiatal, or diaphragmatic, hernia occurs when the lower part of the esophagus and a portion of the stomach slide up through the esophageal hiatus, an opening in the diaphragm through which the esophagus passes before it reaches the stomach. In a small percentage of cases, the junction of the esophagus and stomach remains in place, but a portion of the stomach rolls up and through the esophageal hiatus alongside the esophagus.

Some people with hernias remain relatively free from symptoms. But a hernia can cause severe pain and other potentially serious problems (e.g., infection, bowel obstruction). Surgery is the only way to repair them, because they do not resolve on their own.

Surgical Procedures

Surgical methods currently employed to repair hernias include open surgery and laparoscopic surgery. A hiatal hernia is corrected by a surgical procedure called Nissen fundoplication.

Open Surgery

The type of anesthesia utilized depends on the patient's and the physician's preference, as well as the health of the patient. Choice of anesthesia includes general, which renders the patient unconscious and prevents memory of the surgery; epidural or spinal, which numbs a large area of the body; and local, which numbs the immediate area around the hernia. Local and spinal anesthetics are often used with sedation, which induces drowsiness.

Once the anesthesia has taken effect, the area around the hernia is cleaned thoroughly with an antiseptic solution to prevent postoperative infection. The surgeon makes an incision near the location of the hernia. For an inguinal hernia, the incision is made just above the crease where the abdomen meets the thigh. To repair an umbilical hernia, it is made close to the navel. If the hernia has occurred at the site of a previous operation, the incision from that surgery is reopened.

Surgery proceeds in much the same way, regardless of where the incision is made. The hernia sac is carefully opened and the intestine or other tissue is placed back inside the abdomen. The weakened area is repaired and reinforced with a synthetic mesh or a suture that pulls the abdominal muscle tissue back together. The entire procedure takes about 1 hour in adults and 30 minutes in children.

Laparoscopic Surgery

Laparoscopic surgery can be used for hernia repair. Instead of one long incision, four or five tiny incisions are made in the area around the hernia. A device called a laparoscope, which is a miniature scope attached to a video camera, is inserted into one of the incisions. The surgeon is able to see the hernia and the surrounding tissue and organs on a video screen.

Instruments used to repair the hernia are inserted through the other incisions and the operation proceeds in much the same way as open surgery. Advantages of this technique include shorter recovery time and less postoperative pain. A major disadvantage is that it must be performed under general anesthesia, which carries far more risks than local or epidural anesthesia. Laparoscopic hernia repair has only been used for a few years, and while research shows it to be safe and effective, long-term results are unavailable.

Eligibility for laparoscopic surgery depends on a number of factors. The surgeon must be able to see the interior of the abdomen clearly, and sometimes obesity or large amounts of scar tissue make that difficult. Also, the patient may not be a good candidate because other health problems prohibit the use of general anesthesia. The choice of surgical procedure is based on patient safety.

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