Herniorrhaphy

Aka: Herniorrhaphy, Hernioplasty, Hernia Repair, Bassini Technique, McVay Technique, Shouldice Technique, Iliopubic Tract Repair, Nyhus Technique, Lichenstein Technique, Rutkow Technique, Laparoscopic Hernia Repair

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II. Technique: Group 1 Open Anterior Repair

  1. Summary
    1. Inguinal Canal repaired without mesh prosthesis
  2. Procedure (under local, spinal, or general Anesthesia)
    1. Bassini Technique
    2. McVay Technique
    3. Shouldice Technique

III. Technique: Group 2 Open Posterior Repair

  1. Summary
    1. Inguinal Canal reconstruction from inside
    2. Avoids scar tissue from prior surgeries
  2. Procedure (under spinal or general Anesthesia)
    1. Iliopubic Tract Repair
    2. Nyhus Technique

IV. Technique: Group 3 Tension-Free Repair with Mesh

  1. Most common Hernia Repair procedure
    1. Preferred over laparoscopy for older, less healthy patients
  2. Summary
    1. Similar to Group 1 anterior repair
    2. Nonabsorbable synthetic mesh is used
    3. Allows for no pressure on surrounding fascia
    4. Recurrence rates <1% and good longterm safety data
      1. Recent study showed 4.9% recurrence
      2. Neumayer (2004) N Engl J Med 350:1819-27 [PubMed]
    5. No Sexual Dysfunction after repair
      1. Zieren (2001) Am J Surg 181:204-6 [PubMed]
  3. Procedure (under local, spinal, or general Anesthesia)
    1. Lichenstein Technique
    2. Rutkow Technique

V. Technique: Group 4 Laparoscopic Repair

  1. Accounts for only 10-20% of Hernia Repairs in United States
    1. Performed more often for recurrent or bilateral Hernia Repairs
  2. Summary
    1. Similar to Posterior approach and uses mesh repair
    2. Faster return to work (especially heavy labor)
    3. Allows bilateral Hernia Repair simultaneously
    4. Avoids scar tissue from prior surgeries
    5. More expensive than other procedures
    6. Less post-operative pain
    7. Higher risk of vascular, colonic or Bladder injury
    8. Higher recurrence rate than with open mesh repair
      1. Recurrence: 10.1% (twice the open mesh repair rate)
      2. Neumayer (2004) N Engl J Med 350:1819-27 [PubMed]
  3. Procedure (under general Anesthesia)
    1. Transabdominal Preperitoneal Approach (TAPP)
    2. Total Extraperitoneal Approach (TEP)
      1. Uses balloon to expand extraperitoneal space
      2. More technically challenging than TAPP

VI. Complications

  1. Complications of both Open and Laparoscopic Repair
    1. Hemorrhage or Hematoma (including Ecchymosis at Scrotum and penis)
    2. Bowel or Bladder injury
    3. Urinary Retention
    4. Nerve transection
    5. Nerve entrapment
      1. Ilioinguinal Nerve Entrapment
      2. Genital branch of Genitofemoral Nerve entrapment
    6. Wound Infection
    7. Chronic Pain (5-12%)
      1. Related to nerve entrapment (including scarring), mesh contraction, Osteitis Pubis
    8. Recurrence (See below)
  2. Complications specific to Open Repair
    1. Testicular atrophy
    2. Vas deferens transection
    3. Scotal Ecchymosis
    4. Hydrocele
  3. Complications specific to Laparoscopic Repair
    1. Major vessel injury
    2. Urinary Retention
    3. Trocar site Hernia
    4. Small Bowel Obstruction

VII. Efficacy: Recurrence

  1. Timing of recurrence: 5 to 25 years after repair
  2. Rate of recurrence
    1. Inguinal Hernia recurrence: 5-8%
      1. Direct slightly higher recurrence then indirect
      2. Lower recurrence rate with tension-free mesh
    2. Recurence after recurrent Hernia Repair: 30%
  3. Risks of recurrence
    1. Longstanding large Hernia (poor tissue quality)
    2. Overly rapid return to daily activity after repair
    3. Incomplete surgical dissection
    4. Comorbid condition
      1. Obesity
      2. Corticosteroid use
      3. Chronic Obstructive Lung Disease

VIII. Management: Return to work (approximate times)

  1. Light duty (desk work) by 10 days
  2. Heavier duty work by 4 weeks depending on procedure and per surgeon's discretion
  3. Laparoscopic repair may allow return to Physical Activity by 3-5 days after surgery

IX. References

  1. Bax (1999) Am Fam Physician 59:143-56 [PubMed]
  2. Flanagan (1984) Surg Clin North Am 64:257 [PubMed]
  3. LeBlanc (2013) Am Fam Physician 87(12): 844-8 [PubMed]
  4. Lichtenstein (1993) Surg Clin North Am 73:529-44 [PubMed]
  5. Liem (1997) N Engl J Med 336:1541 [PubMed]
  6. Schumpelick (1994) Lancet 344:375-9 [PubMed]
  7. Shakil (2020) Am Fam Physician 102(8): 487-92 [PubMed]

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