Inguinal Hernia With M. Rosen
With Dr. Michael Rosen · hosted by Dr. Jeffrey Ponsky · Jeffrey Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For an 89-year-old with asymptomatic hernia, observation is appropriate because odds are in a couple years they might not develop symptoms, but in younger patients the odds are against them living the rest of their life without symptoms.
Inguinal hernias can be repaired under local anesthesia in high-risk patients with severe comorbidities (cardiac disease, ascites, coagulopathy).
The primary advantage of laparoscopic repair is placing mesh away from nerves, resulting in lower risk of chronic pain compared to open repair when done correctly.
Chronic pain incidence in open inguinal hernia repair varies depending on measurement method: very high if detailed surveys are used, lower if only counting patients who present with complaints.
Laparoscopic repair offers approximately one week to 10 days earlier recovery compared to open repair.
The disadvantage of laparoscopic repair is operating near intestines with risk of intestinal injury and major blood vessel injury, though this risk should be incredibly low with proper technique.
In elderly patients or those on anticoagulation requiring quick restart, open repair is preferred to avoid dissecting the retroperitoneal space.
In a 78-year-old with symptomatic hernia on one side and asymptomatic hernia discovered laparoscopically on the other side, repairing the asymptomatic side doubles anesthetic time and increases hematoma risk without clear benefit.
Previous lower abdominal surgery increases risk of enterotomy and OR time for laparoscopic repair; if patient has not had previous open inguinal hernia, open approach is preferred.
Previous prostate surgery creates unpredictable difficulty for laparoscopic repair, ranging from straightforward to brutal; currently managed with open repair.
The most important part of laparoscopic repair is parietalization of the cord (stripping peritoneum off cord inferiorly and posteriorly), a principle promoted by Rene Stoppa in open preperitoneal repairs.
The inferior dissection is the Achilles heel of laparoscopic repair because it is awkward to view, risky for creating peritoneal holes, and close to vessels.
For large direct hernias, heavier weight mesh material should be used.
Heavyweight mesh is approximately 90 grams per meter squared (Marlex or Prolene), midweight is 40-50 grams per meter squared, and lightweight (Ultrapro) is less than 30 grams per meter squared.
Lightweight mesh has less foreign body and may contract less due to better ingrowth, but has half the material and is at risk for fracturing, particularly in direct hernias where it bridges and muscles never come together.
Heavier weight mesh rarely breaks but can cause chronic pain if wrinkles or buckles are present in the groin.
Surgeons commonly downsize preformed meshes; for inguinal hernia repair, never use smaller than a large preformed mesh to cover the entire myopectineal orifice.
If struggling with mesh placement during laparoscopic repair, the problem is inadequate dissection of the space, not oversized mesh; the solution is to remove mesh and dissect more widely.
There is no evidence that absorbable fixation causes reduction in pain, provides better fixation, or improves long-term outcomes compared to permanent fixation.
If absorbable tack is placed through a nerve, it is the neuroma that causes the problem, not the tack itself.
Bassini or McVay tissue repairs remain appropriate operations for contaminated fields.
For incarcerated femoral hernia with bowel compromise, an infrainguinal vertical incision allows direct access to the hernia sac, bowel resection if needed, and reduction without dividing the inguinal ligament.
To facilitate reduction of incarcerated femoral hernia contents, the lacunar ligament (medial to femoral space) can be released with scissors or bovie to gain an extra centimeter, avoiding destruction of the inguinal ligament.
Reverse McVay repair for femoral hernia involves taking the inferior border of the inguinal ligament and sewing it down to Cooper's ligament from below, starting immediately lateral to the femoral vein to avoid impingement.
Mesh plugs in femoral hernia repair can cause DVT due to irritation of the femoral vein, particularly in thin women who typically present with femoral hernias.
For recurrent hernias, operate where no prior surgery has been performed; if both spaces have been operated, choose the approach where you have the most skill.
For bilateral hernias in a skilled laparoscopic surgeon, laparoscopy is the best approach, but surgeons learning laparoscopy should avoid bilateral and recurrent hernias as these are twice as hard despite potentially offering the most benefit.
Large inguinoscrotal hernias are managed with open operation; if truly incarcerated and cannot be reduced in office, open approach is used.
For difficult-to-reduce but not truly incarcerated hernias, patient can be put to sleep for reduction under anesthesia, then TAPP repair performed; the internal ring can be cut laparoscopically at the two o'clock position (avoiding epigastric vessels) to facilitate reduction.
If bowel holes are made during incarcerated hernia repair, the morbidity of the operation increases unacceptably high.
In the Fitzgibbons VA study of minimally symptomatic to asymptomatic hernias in patients in their 70s-80s, the risk of presenting with an emergency problem (incarceration/strangulation) requiring operation was less than 1% (actually one-third of 1%) over the initial study period.
In the Fitzgibbons study, almost one-third of observed patients developed symptoms requiring operation within two years, and by five years almost three-quarters developed symptoms.
Patients who developed symptoms during observation in the Fitzgibbons study did not do any worse with their eventual operation compared to immediate repair.
The learning curve for laparoscopic inguinal hernia repair is real, with some studies showing 200-250 cases required.
Inadequate inferior peritoneal dissection leads to use of smaller mesh, but Stoppa's original description for unilateral inguinal hernia specified never using less than 15×15 cm (6×6 inch) mesh, which is larger than most laparoscopic meshes being placed.
There is mounting evidence that medium-weight polypropylene mesh can be placed in contaminated fields, with several series in ventral hernias supporting this.