HERNIA

WHAT IS A HERNIA ?

A hernia (rupture) is usually noticed as a lump, commonly in the groin or the umbilical region. It appears when a portion of the tissue which lines the abdominal cavity (peritoneum) breaks through a weakened area of the abdominal wall. This can give rise to discomfort as the hernia enlarges and can sometimes be dangerous if a piece of intestine becomes trapped ('strangulated') inside.

HERNIA TYPES

Causes, incidence, and risk factors

Usually, there is no obvious cause of a hernia, although they are sometimes associated with heavy lifting.
Hernias can be seen in infants and children. This can happen when the lining around the abdominal organs does not close properly before birth. About 5 out of 100 children have inguinal hernias (more boys than girls). Some may not have symptoms until adulthood.

If you have any of the following, you are more likely to develop a hernia:

• - Family history of hernias
  - Cystic fibrosis
  - Undescended testicles
  - Extra weight
  - Chronic cough
  - Chronic constipation from straining to have bowel movements
  - Enlarged prostate from straining to urinate

Symptoms

1. > Groin discomfort or groin pain aggravated by bending or lifting
   > A tender groin lump or scrotum lump
   > A non-tender bulge or lump in children

Signs and tests

A doctor can confirm the presence of a hernia during a physical exam. The mass may increase in size when coughing, bending, lifting, or straining. The hernia (bulge) may not be obvious in infants and children, except when the child is crying or coughing.

WHAT ARE THE TREATMENT OPTIONS?

Surgical procedures are now done in one of two fashions. I. The first, or traditional approach, is done from the outside through an incision in the groin or the area of the hernia. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole. This technique is usually done with a local anesthetic and sedation but may be performed using a spinal or general anesthetic. II. The second approach is a laparoscopic hernia repair. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a canula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.

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LAPAROSCOPIC HERNIA REPAIR

THE PRINCIPLE OF LAPAROSCOPIC HERNIA REPAIR

Imagine a bathtub. When you put the rubber stopper at the outlet and fill it with water, the water pressure pushes the stopper in place and keeps it fixed there. The more the water, the firmer is the stopper. Now, if we were to put the stopper from the outside. Then the water pressure in the tub is going to push the stopper out as the pressure increases. This is Pascal's law.

The same scenario can be imagined with placing a mesh on the hole where the hernia is. Is it going to be better fixed from outside or inside? Open surgery places it from outside and laparoscopic surgery places it from inside.

During laparoscopic surgery, we make a small ½ inch cut in the skin at the belly button. Then a cannula (thin tube) is introduced in between the muscle fibres without cutting any of the muscle. Through the cannula, the laparoscope is inserted into the patient's body. It is equipped with a tiny camera and light source that allows it to send images through a fibre-optic cord to a television monitor. The television monitor shows a high resolution magnified image. Watching the monitor, the surgeon can perform the procedure. While looking inside the patient, further two ½" diameter cannulas are put in. This way, the already weak muscles are not disturbed and the net is placed through the half inch holes that are away from the hernia. Thus there is minimal disturbance to the normal body physiology and as a result the pain is minimal and very little rest is required. Also the hernia that is going out from the tummy is pulled back in rather than pushed in from outside as is done in an 'open' operation. There are more and more reports now from the USA and Europe showing the success of this technique in reducing post operative pain, rest and recurrence rates.

The greatest advantage of laparoscopic surgery for hernias is in patients of recurrent hernias where the anatomy has already been disturbed and also in patients of hernias on both sides, as they can be repaired through the same three holes avoiding any further pain or trauma.

The two real problems of the laparoscopic hernia repair are the cost of the operation, which is almost twice the cost of an ordinary operation due to the expensive imported instruments that are needed ; and the necessity for general anaesthesia. The increased cost should be compared with the gain associated by a quicker and more productive return to work by the majority of the patients. Laparoscopic hernia is an efficient technique that compares favourably to current open surgical techniques.

Patients are relatively pain free following this procedure and can return to work and normal activities much quicker than following conventional hernia repairs. Recent reports from the USA show that these patients took an average of 9 days off work compared to 48 days after an open operation.

WHAT ARE THE COMPLICATIONS OF LAPAROSCOPIC HERNIA REPAIR?

1. Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair. 2. There is a slight risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle. 3. Difficulty urinating after surgery is not unusual and may require a temporary tube into the urinary bladder. 4. Any time a hernia is repaired it can come back. This long-term recurrence rate is not yet known. Your surgeon will help you decide if the risks of laparoscopic hernia repair are less than the risks of leaving the condition untreated.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED BY THE LAPAROSCOPIC METHOD?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that may increase the possibility of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety