How to treat. Abdominal wall hernias. inside Symptoms and signs of hernias. Get control Keep control. Pull-out section. Background

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1 How to treat Pull-out section Earn CPD points on page 36 Background Complete How to Treat quizzes online ( or in every issue. inside Symptoms and signs of hernias HERNIA repair is the most common general surgical procedure performed. The lifetime risk of a male developing an inguinal hernia is said to be one in four. It is estimated that about 4-5% of the population will have a hernia at any given time, so the total cost to the community, both in elective repair and work time lost, is enormous. The risks that a patient with a hernia will present with strangulation are greatly increased in communities where little elective surgery is performed. About 50% of all patients in Third World countries present with strangulation. Morbidity is greatly increased in patients with strangulation and there is a significant mortality risk. It is essential to be fully aware of the presentation, diagnosis and treatment of hernias to enable appropriate elective repair or urgent surgery if necessary. Aetiology A hernia by definition is a protrusion of abdominal contents through a weakened area of the abdominal wall. All hernias are now recognised as resulting from a pathological disease process causing the hernia in a particular weakened area. Pathological failure of obliteration of the embryological processus vaginalis at birth, or failure of obliteration of the umbilical defect, results in neonatal and infantile hernias of the inguinal and umbilical areas, respectively. Most adult hernias are related to a pathological change in collagen. A wide body of evidence continues to accumulate regarding defective collagen as the main factor. For example, examination of the muscle fascia (or skin) in the epigastric area in patients with inguinal hernias shows abnormalities in type I to type III collagen ratios and in histological, biochemical and electron microscopy studies. Similar changes occur in patients with congenital collagen diseases such as Ehlers-Danlos syndrome or cont d page 31 Abdominal wall hernias Surgical repair of inguinal hernias Instructions and recovery after hernia surgery Case studies The author DR DAVID J PHILLIPS, private surgeon working exclusively in hernia repair, Brisbane; member, European Hernia Society and American Hernia Society. Get control Keep control In clinical studies of healing 1 and maintenance 2 of erosive oesophagitis. Before prescribing, please review Product Information and PBS Information. Refer to primary advertisement elsewhere in this publication. 1. Richter J, et al. Am J Gastroenterol 2001;96(3): Johnson DA, et al. Am J Gastroenterol 2001;96(1): Trademarks herein are the property of the AstraZeneca Group. 07/04 AST1037a/CJB AstraZeneca Pty Ltd, ABN , Alma Road, North Ryde NSW esomeprazole 17 November 2006 Australian Doctor 29

2 from page 29 osteogenesis imperfecta. Similar collagen defects also occur in smokers, who have a high incidence of hernias, as well as vascular aneurysms. Relative frequency of types of hernias Inguinal hernias make up two-thirds of all hernias, with femoral hernias being much rarer, at about 2% of the total. The incidence of hernia type is: Inguinal hernias 66% of all hernias. Femoral hernias 2%. Umbilical hernias 15%. Incisional (postsurgical) hernias 10%. Others (epigastric, spigelian, obturator, lumbar, perineal) 7%. Groin hernias are much more common in men than in women: fewer than 6% of all groin hernias occur in women. One-third of groin hernias in women are femoral and two-thirds are inguinal. Women have an eightfold higher risk of presenting with a femoral hernia compared with men, and the risk of strangulation is much higher in women. However, because of the higher overall incidence of hernias in men, somewhat more femoral hernias present in men than women. Risk factors Risk factors for developing a hernia include: A strong family history of hernias. Previous repair of any hernia as an adult. Smoking. Increasing age the lifetime risk of a man aged 25 developing an inguinal hernia is one in five. At age 65 it is two in five. Systemic disease processes such as cirrhosis, renal failure, scurvy or malnutrition. Raised intra-abdominal pressure, such as occurs with pregnancy, ascites or obesity. Straining, such as chronic cough, prostatism or chronic constipation. Obesity is a major risk factor for umbilical, midline and incisional hernias, but not for inguinal hernias. Obese patients actually have statistically fewer inguinal hernias than expected. Previous hernia repair as an infant does not seem to add much to the risk of subsequent development of either an inguinal or an umbilical hernia. Twenty per cent of young adult males have some degree of patency of the processus vaginalis, but this does not commonly progress to a clinical inguinal hernia. The role of heavy work The role of repetitive heavy work is somewhat hard to establish, although by implication it is usually accepted as being a contributing factor in the development of a hernia. However, without the necessary underlying collagen problem a hernia will not develop. It is interesting to note that bodybuilders do not have a high incidence of hernias. A sudden jerking injury, such as when tripping while carrying a very heavy weight, can lead to the sudden appearance of a hernia in a susceptible individual. Localised severe blunt trauma to the abdominal wall can rarely result in a hernia. Risk factors for recurrent and/or incisional hernia after surgery All the previous factors are relevant to the development of a recurrent hernia after surgery (incisional hernia), but obesity is the most significant. Other risks include postoperative surgical problems such as ileus with abdominal distension and coughing, wound infection and poor choice of suture material. The type of repair or the surgical technique can sometimes be contributing factors. It is often quoted that about 11% of laparotomies will subsequently result in an incisional hernia. Presumably the total number of incisional hernias will reduce as more laparoscopic surgery is performed relative to open surgery. Symptoms and signs of hernias Anatomy of the groin REFRESHING your knowledge of groin anatomy helps to differentiate clinical findings (figure 1). The thin external oblique aponeurosis, with its lower border forming the inguinal ligament, forms the anterior wall of the inguinal canal. In men the spermatic cord, which contains testicular vessels and the vas as well as the remnant of the peritoneal processus vaginalis, enters the inguinal canal through the deep inguinal ring and exits medially through the superficial inguinal ring. The ileo-inguinal and ileohypogastric nerves and genital branch of the genito-femoral nerve also traverse the inguinal canal. An indirect inguinal hernial sac is one that extends through the deep ring, along the inguinal canal and often reaches the scrotum. A direct inguinal hernia protrudes through the weak fascia transversalis forming the posterior wall of the inguinal canal. The femoral canal lies medial to the femoral vein below the inguinal ligament. Its entrance, the femoral ring, is formed by very dense ligaments or pubic bone on three sides and the femoral vein laterally. Clinical signs of groin hernias The visible or palpable swelling present on standing and disappearing on lying flat and exhibiting a cough impulse is well known to all. With smaller inguinal hernias it is often much easier to demonstrate a cough impulse when the patient is lying flat. Bilateral inguinal hernias are extremely common, as is clinically evident connective tissue weakness in both groins. Any patient presenting with an inguinal hernia should have the contralateral groin examined when lying flat. A digit inserted through the superficial inguinal ring into the inguinal canal will often detect a Figure 1: Anatomy of the groin. 1. External oblique 2. Inguinal ligament 3. Superficial inguinal ring 4. Spermatic cord covered by cremaster 5. Femoral hernia 6. Femoral ring 7. Pubic tubercle cough impulse if one is not immediately apparent. The cough impulse is felt on the tip of the examining finger in an indirect inguinal hernia and on the side of the finger with a direct inguinal hernia. Obviously this examination is not possible in a woman. With the patient lying flat and the hernial contents reduced, external pressure on the deep inguinal ring prevents extrusion of the bowel when coughing if the patient has an indirect inguinal hernia. Distinguishing between a direct and an indirect inguinal hernia has no major benefits apart from strangulation risk: an indirect hernia is more likely to cause strangulation by a factor of four to one. Surgical repair is the same for both types of hernia. Femoral hernias are best demonstrated when the patient is standing. A round swelling, exhibiting a cough impulse, and arising below and lateral to the pubic tubercle is the distinguishing feature. Clinically it can be very difficult to distinguish between a larger tight or swollen femoral hernia and an inguinal hernia. Role of ultrasound in diagnosis Ultrasound examination of the groin is difficult, operator dependent and often results in false-positive reports. There is absolutely no value in performing an ultrasound examination on a clinically obvious inguinal hernia. Most surgeons will not operate on the basis of an ultrasound report alone without corroborating clinical features of a hernia, because of the possibility of the test being a false positive. 1. External oblique 2. Internal oblique 3. Spermatic cord covered by cremaster 4. Indirect sac emerges through the deep inguinal ring and runs with the spermatic cord 5. Direct sac protrudes through the posterior wall of the inguinal canal (transversalis fascia) 6. Femoral hernial sac protudes through the femoral ring into the thigh Ultrasound is sometimes useful in detecting tiny occult hernias in patients with painful incarcerated fat in small direct or indirect inguinal hernias, when a cough impulse will not be present. It is also of use in excluding recurrent hernial defects after previous surgery and in the diagnosis of femoral hernias. If the diagnosis of a groin swelling is truly in doubt, an ultrasound or CT scan can be of assistance. Ultrasounds are also very useful in searching for small epigastric or umbilical hernias in obese patients who complain of localised midline pain or pain in a previous surgical incision. Symptoms of uncomplicated hernia Most commonly the presenting complaint is a visible bulge or swelling with or without local discomfort. Some people let very large hernias slowly develop over many years, claiming minimal discomfort. Initially the contents usually reduce spontaneously when lying flat, but later the patient may spontaneously learn to reduce them when uncomfortable. With time, especially if minor compression episodes occur, the contents develop adhesions to the sac and may become irreducible, either partially or fully. If present, pain can be a localised dragging, pulling or tightness in the area. Inguinal hernias often cause pain radiating to the testis. Tiny tight hernias with protruding fat containing nervous tissue may be quite painful and tender to touch. This presentation is more common in small epigastric or umbilical hernias than in inguinal hernias. Very large inguinoscrotal or umbilical hernias in the obese can be totally plugged with irreducible omentum and cause little in the way of symptoms until finally large enough to cause dragging discomfort or cosmetic problems. If bowel is somewhat compressed at the narrow neck of the hernia and it becomes more swollen than normal there may be associated nausea and abdominal gut-type pain or cramps. Lying down often causes the symptoms to subside as the lump disappears, with or without manual reduction of the contents. These symptoms suggest a hernia with a high potential for strangulation. Strangulation Strangulation occurs when the hernial contents at the neck of the hernia are compressed. This causes oedema, which then increases the compressing pressure in a vicious cont d next page 17 November 2006 Australian Doctor 31

3 How to treat abdominal wall hernias from previous page cycle. If the contents are not speedily manually reduced, full bowel obstructive symptoms rapidly occur, with massive fluid losses into the proximal bowel lumen. By definition any hernial obstruction is a closed-loop obstruction with ischaemia of the affected bowel segment. Transudation and systemic absorption of endotoxic bacterial products results in septicaemia, circulatory effects, organ damage and failure. This occurs in a closed-loop obstruction before actual infarction and necrosis of the strangulated bowel segment. Symptoms The presenting symptoms are those of bowel obstruction, together with a tender palpable lump. Colicky abdominal pain, distension, vomiting and constipation the typical symptoms of bowel obstruction are present. Beware of the patient with a Richter s hernia: only one wall of the herniated bowel is ischaemic and the lumen only partially obstructed. Such patients will have colicky pain and diarrhoea, not constipation. Clinical signs As a rule, a tender swelling lying in a groin area or other potentially weak site of the abdominal wall is easy to find. Gut obstruction with a distended tympanitic abdomen, active tinkling bowel sounds and a succussion splash on auscultation complete the relatively easy diagnostic criteria of a bowel obstruction. All patients with gut obstructive symptoms, but particularly the elderly and frail, should have careful examination of the groins. Seventy per cent of patients presenting with obstructive hernias are aged over 70 and many may not have even been aware that they had a hernia. An obstructed femoral hernia presents with a round tender swelling extending well over the inguinal area. It is often clinically difficult to distinguish from an obstructed inguinal hernia. Risk of strangulation The risk of strangulation for different types of hernia is: Inguinal hernias 2% per annum. Femoral hernias 30-50% per annum. Umbilical hernias 15% per annum. Others (incisional, etc) 15% per annum. The risk of any individual hernia strangulating is related to the tightness of the neck and the ease with which the hernial contents usually reduce on lying. When the bowel contents are adherent within the hernial sac the risk of strangulation is much higher. Mortality rates for strangulated hernias vary between 4% and 40%, depending on the geographical area, the local facilities for intensive management and the time delay before presentation, as well as the age and fragility of patients. Some reports suggest that delay in diagnosis in up to onethird of patients occurs because of failure of the primary care physician to recognise the problem initially. Timing of referral in patients with hernias Urgent Patients need urgent referral if there is any suspicion of a bowel obstruction with a non-reducible painful hernia. Near future Refer as soon as practicable usually within a month, but sooner if symptomatic in all the following cases: A tight-necked hernia prompt referral is usually indicated if the primary care practitioner has had difficulty in reducing the contents of a tender hernia, with or without analgesics. Similarly, patients giving a history of gut-type pains while the hernia is swollen should be instructed to reduce the contents and seek early surgical intervention if pain is not relieved or the hernia not reduced. All femoral hernias at diagnosis, as one-third will develop strangulation. Infantile inguinal hernias, as these have a higher risk of strangulation than in adults up to 15% of infantile inguinal hernias present with strangulation, with some 30% risk in the first year of life. Incarcerated painful hernias containing fat only. Irreducible hernial contents. Routine Routine referral is adequate for most cases of reducible hernias and non-tender hernias. There are no controlled clinical trials to show that a policy of elective hernia repair reduces the risk of strangulation. In 1988 in the UK, because financial health system restraints, only onethird as many elective hernia repairs per head of population were performed compared with elective surgical repairs in the US. One-half of all hernias in the UK presented with obstruction, which was an uncommon complication in the US population. Urgent referral is required if there is any suspicion of a bowel obstruction with a non-reducible painful hernia. Surgical repair of inguinal hernias Infants and children SIMPLE ligation and excision of the sac at the deep inguinal ring is all that is required in children, as recurrence in adulthood is uncommon. There is some discussion as to whether the contralateral groin should be explored or examined laparoscopically at the same time, as in the first few months of life up to 40% of hernias are said to be bilateral. Twenty per cent of young adult males will have a patent processus vaginalis, but this does not commonly lead to development of an adult hernia. Adults Regardless or whether the hernia is direct or indirect, all hernia patients have a collagen disorder, so surgery must repair the posterior wall of the inguinal canal, as well as remove the hernial sac. Repair with sutures alone under some tension runs a high risk of recurrent hernia developing, sometimes many years later. In European countries where adequate statistics have been kept, all sutured repairs show about a 15% recurrence rate. The only sutured repair with good results is the Shouldice repair. However, this is a very meticulous operation requiring a very long learning curve and is rarely used in Australia. Open tensionless mesh repair The Lichtenstein repair was introduced in 1987 in the US and has become the gold standard of inguinal hernia repairs. It is not technically difficult to learn and has a reported recurrence rate of 1-2%. Most adults presenting without strangulation, should have mesh reinforcement of the inguinal canal. The technique involves dissection and reduction of the hernial sac after opening of the inguinal canal. A small flat sheet of mesh is then sutured to the posterior wall of the inguinal canal behind the cord, with a slit to enable tails of the mesh to surround the cord at the deep inguinal ring (figure 2). Complications after mesh hernia repair Complications include: A small risk of postsurgical haematoma, seroma and wound infection. Penile and scrotal oedema, especially if bilateral repairs are performed. Rare cases of damage to testicular vessels, with testicular atrophy (<0.5%, but much higher in surgery for Figure 2: The Lichtenstein inguinal hernia repair. Figure 3: Prolene hernia system design and function. The underlay patch reinforces all three aspects of the triangle of the groin. This system is used to repair (or prevent) direct, indirect and femoral hernias. a recurrent hernia). A few recorded cases of obstruction of the vas. Possible nerve compression by sutures or mesh contraction. Recent concerns have been raised about chronic pain, reported to occur to some extent in up to 8% of patients undergoing open mesh repairs. This may be due to an inflammatory reaction and fibrosis caused by mesh impinging on nerves or causing compression of the spermatic cord. Newer open mesh-repair techniques There are several alternative techniques for open hernia repair, which include the following. Plug and patch. A standard groin dissection is performed and the hernia reduced. One or more mesh plugs are inserted into the pre-peritoneal space and sutured to the edges of the hernial defect. A mesh patch encircling the spermatic cord is positioned and fixed. First introduced in 1990, some 30% of hernia repairs done in the US use this technique far more than in Australia. Prolene hernia system. A flat sheet of mesh is positioned in the pre-peritoneal space, attached to a mesh tube passing through the hernial defect. An anterior leaf of mesh, also attached to the mesh tube, lies in the inguinal canal, reinforcing the posterior wall (figure 3). In practice this technique has an extremely low recurrence rate and has the advantage of being technically easy to learn. It is slowly gaining in popularity. Kugel patch (figure 4). This is a pre-peritoneal repair. A very small transverse musclesplitting incision is performed above the inguinal canal and a pre-peritoneal dissection is performed to reduce the inguinal hernial sac. The operation is technically demanding, with a long learning curve. It is very good in expert hands but its use is unlikely to become widespread. There is probably not a great deal to choose between any of the methods of open mesh repair, although complications of some, and difficulty with others, will influence the surgeon s choice. Laparoscopic inguinal hernia repair First introduced in 1990, laparoscopic repairs initially had a poor reputation because of surgical difficulty, failure rate, complications because of general surgeons 32 Australian Doctor 17 November

4 poor knowledge of the anatomy when the region is viewed from within the abdomen, and the inadequate repair methods used in the early stages. Repair involves placing a large sheet of mesh to cover the posterior aspect of the inguinal and femoral regions, with or without tacking, glueing or stapling the mesh in position. In experienced hands recurrence rate is very low, and complications are few. Persistence has led to two modified techniques being used worldwide. Trans-abdominal pre-peritoneal repair (TAPP) A standard laparoscopy is performed to enter the peritoneal cavity and examine the groin for hernias. A transverse incision is made in the peritoneum above the inguinal canal, after which the peritoneum is dissected downwards to raise a flap of peritoneum. The hernial sac is then reduced. A sheet of mesh measuring about 10 15cm is positioned behind the femoral and inguinal regions and usually fixed. The peritoneum is then closed either by suturing or stapling and the laparoscope removed. Totally extra-peritoneal repair (TEPP) A small sub-umbilical incision is performed and a balloon on a stick is introduced behind the rectus muscle to lie anterior to the peritoneum in the lower abdomen. Inflation of the balloon pushes the peritoneum backwards creating a space behind the abdominal muscles into which a laparoscope and operating instruments are introduced. A large mesh sheet is inserted after hernia reduction and usually fixed. The peritoneal cavity is not entered. No exact figures are kept in Australia on any methods of repair. Perhaps 5-10% of inguinal hernias are repaired laparoscopically. Laparoscopic repair varies from <2% in the UK, <5% in the US to about 25% in Germany. Its use depends on the local costs and surgical training. The vast majority of laparoscopic repairs done in Australia are by the TEPP method. This is because of an early well-publicised case of adhesive small bowel obstruction when bowel had adhered to the peritoneal closure incision after a TAPP repair. The recovery advantages in repairing a unilateral inguinal hernia laparoscopically is not as great in 2006 as it was in 1990, purely because of evolution and Figure 4: A Kugel patch. Table 1: Laparoscopic surgery advantages and disadvantages and patient suitablility Advantages Quicker recovery time than open repair usually about half the time to activity. (The hospital stay may be a little longer for laparoscopic repairs, possibly overnight, as a general anaesthetic is always required. After the initial two days of postoperative discomfort, movement is easier. Return to sedentary work is possible within days and heavier work or exercise in 7-10 days.) Less postoperative pain has been shown in several series. Less chronic groin pain the surgery takes place behind the muscles, so no nerves are likely to be damaged. Less risk of damage to the testicular blood supply. Disadvantages Rarely, unrecognised bowel perforation caused by balloon inflation has occurred when dense adhesions after peritonitis have tethered the bowel. Future prostate cancer surgery is very difficult for the urologist, as the pre-peritoneal space anterior to the bladder is obliterated. A general anaesthetic is always required. More expensive than open repair. Suitable cases Recurrent inguinal hernias laparoscopic repair is ideal, as there is little pre-peritoneal scarring and hence less risk to testicular blood supply than after open surgery for recurrent hernia. Bilateral inguinal hernias. Patient requiring speedy return to work or exercise. Unsuitable cases Large inguinoscrotal herniae. Obese patients. Previous lower-abdominal surgery. Previous peritonitis or known adhesions. Patients at risk from general anaesthetic. When speedy return to work is not required. Possibility of prostate cancer surgery being required. improvement in open surgical techniques. Patient suitablility for, and advantages and disadvantages of, laparoscopic repair are listed in table 1. Femoral hernias As previously discussed, onethird of all groin hernias presenting in women are femoral hernias, whereas in men only about one in 50 groin hernias are femoral. In both sexes the risk of strangulation is very high and early surgery is always indicated. There is little advantage in laparoscopic repair, as a small incision in the groin, with no cutting of muscle or fascia, is all that is required. Most repairs involve placing a mesh plug in the inguinal canal. In emergency surgery a laparotomy is often required if the bowel viability is compromised. Umbilical hernias Infantile umbilical hernias These result from failed closure of the orifice through which the umbilical cord emerges. Most small umbilical infantile hernias close spontaneously and surgery is usually only required if a significant hernia is still present at school age. Adult umbilical hernias Only 10% of adults who present with an umbilical hernia had an umbilical hernia as an infant adult umbilical herniation is an acquired disease. The supra-umbilical midline fascia fibres decussate and are penetrated by fat globules or an incipient peritoneal bud to form a small funnel. Intra-abdominal pressure causes gradual enlargement of the defect over time. The defect can vary from a few millimetres to >20cm, and the hernial contents may be pre-peritoneal fat, omentum or any intra-abdominal viscus in larger hernias. Obese women over 40, especially those with type 2 diabetes, are particularly prone to umbilical hernias. Tiny fat-containing hernias may only be tender if prodded while the contents are being reduced. Small hernias containing only omentum may be associated with intermittent nausea and vomiting due to vagal stimulation. Persistent ischaemia of omentum may result in localised tenderness. If infarction of the omentum occurs, aseptic inflammation causes haemorrhagic fluid discoloration of the stretched umbilicus, with marked tenderness. No intestinal or systemic upset is present. Larger hernias containing bowel may present with incipient or full bowel obstruction. There is a high risk of strangulation of contents (15% per annum), particularly in the larger hernias, and elective surgery should be advised. This advice may be resisted, as the hernias often cause little in the way of symptoms for many years as they slowly enlarge. Most umbilical hernias are very obvious and no investigations are required. In the morbidly obese, large hernias may be impalpable and ultrasound and CT scan can be of diagnostic assistance if an umbilical hernia is suspected because of pain. The surgical repair of a small hernia is quite simple and may be performed under local anaesthetic alone, although usually sedation or general anaesthetic is administered. Day-case surgery is possible. A mesh patch or plug reinforcement is usually used, as suturing of anything other than the tiniest of defects will create tension on the repair and result in a recurrent herniation rate of at least 40%. Repair of larger umbilical hernias by conventional surgery usually requires excision of the umbilicus and an extensive operation with mesh reinforcement. This can be a formidable undertaking in an obese patient with diabetes, with a significant mortality if strangulation is present. Electively, such large hernias may be repaired by the laparoscopic approach, if available, which offers less morbidity. Epigastric hernias In epigastric hernias, small protrusions of fat pass through decussating fascial fibres, and this defect gradually enlarges. These hernias may be painful when small and often progressively enlarge to form a sac containing viscera. They are very often multiple ( Swiss cheese defects) and associated with umbilical hernias. The presentation and treatment are much like those for umbilical hernias. Repair of the tiniest can be done with simple sutures but most commonly a mesh reinforcement is required. Spigelian hernia These rare hernias are most common in people aged and pass below the lower margin of the posterior rectus sheath (linea semilunaris), situated half way between the umbilicus and pubis. The hernial sac passes through the fibres of the transversus abdominus and internal oblique muscles and presents in the lateral abdomen some distance from the origin of the sac. The external oblique muscle and aponeurosis remain intact. This condition should be suspected in a patient presenting with a painful palpable mass in the lateral abdomen, especially if the contents are reducible. CT scan confirms the diagnosis. Obturator hernia This rare hernia occurs through the obturator foramen, usually presenting with complete or partial bowel obstruction. It is a disease of thin elderly women and is often fatal because of delayed diagnosis. Pain caused by pressure on the obturator nerve may radiate down the inner thigh to the knee. Diagnosis is usually made at laparotomy or laparoscopy for intestinal obstruction. Preoperative CT scan demonstrates the hernia. Incisional hernias The incidence and causative risk factors for incisional hernias were discussed previously. The clinical presentation is very similar to that for umbilical hernias. Smaller hernias are often undetectable in obese patients and very large hernias can be difficult to detect clinically and carry a high risk of strangulation. Repair of major incisional hernias is a formidable undertaking because of the extensive dissection required, the associated comorbidities and, not infrequently, the respiratory compromise that occurs when protruding viscera are reduced. Potential complications include skin-flap ischaemia, seromas, haematomas and wound infections, which are most common in anterior onlay mesh procedures. Simple primary suture closure of even smaller fascial defects of up to 5cm leads to a recurrence rate of >50%. If relaxation incisions are employed, less tension on the repair leads to better results. In most incisional hernia repairs a sheet of mesh that widely overlaps the defect margins is necessary. In all cases the peritoneal sac contents must first be returned to the abdomen and very often extensive dissection is required. The mesh can be placed in a variety of anatomical positions, either anterior or posterior to the muscle layer or in an intraperitoneal position. The best of these is retro-muscular positioning, which has a reported recurrence rate of 10%. Laparoscopic incisional hernia repair is gaining in popularity, with many reports of good results (0-10% recurrence rate), at least in the short term. It has less morbidity due to local complications such as haematomas and wound infection, and much less pain, with quicker return to activity than after conventional mesh repairs. However, the technique requires a long learning curve. Dissection and freeing of adherent bowel within the hernial sac can be tedious, or impossible. In a cont d next page 17 November 2006 Australian Doctor 33

5 How to treat abdominal wall hernias from previous page few cases, unrecognised bowel damage occurs, with inevitable serious morbidity or mortality. Specialised hernia and laparoscopic centres have sufficient volume of cases to ensure training and practice in the techniques of laparoscopic repair, but as yet most incisional hernia repairs are carried out by other open mesh-replacement techniques. The Kugel Composix patch is used in open surgical repairs. It consists of bilayered mesh, with the deeper surface being nonadherent Teflon and with an external pocket and a spring-loaded ring at its edge. The intraperitoneal mesh Figure 5: Intra-abdominal ventral hernia repair using a Kugel Composix patch. A malleable or ribbon retractor may be used to facilitate placement of larger-sized patches, and to help flatten out the patch. is placed through the hernial defect via a conventional open technique. When the patch is sprung open it covers and protects the same areas as in a laparoscopic repair (figure 5). The recovery time is therefore similar. It is not a difficult surgical technique to learn and offers similar advantages to those of laparoscopic surgery in having less tissue dissection and disruption. Short-term results are promising but medium- and long-term results are unknown. It may well become a common surgical technique. Instructions and recovery after hernia surgery IN most patients there is little point in stopping physical activity before surgery. Often the hernia has been present for a prolonged period before the patient presents. Most patients can continue to work unless a lot of pain is experienced during heavier activities. Physical activity will not make the hernia significantly worse in the short preoperative waiting period. The length of hospital stay depends to some extent on theatre scheduling and the surgical technique used, as well as patient preferences, family support, etc. As a guide to hospital stays: Open inguinal hernia repair is performed as either a day case or an overnight stay. An overnight stay is often required for laparoscopic inguinal hernia surgery. Open incisional hernia techniques require a 1-5-day hospital stay, depending on the technique used. Patients undergoing laparoscopic incisional hernia repair can be discharged the next day. Recovery time after surgery depends to some extent on the surgical method employed, but more importantly on the patient s, and on cultural, expectations. Formerly it was usual for patients who have had a sutured inguinal hernia repair to take six weeks off work. However, this did not lead to a reduced hernia recurrence rate, which was up to 15%. With mesh hernia repair, recurrence rate is <1% even when heavy activities are resumed soon after surgery. In the US, where there are only two weeks of annual leave and daycase open inguinal hernia surgery is also the norm, most people are back at work, on lighter duties, in a week. With long-acting local anaesthetic instilled into the wound before or during surgery, often very little pain is experienced and early mobility and hence day-case surgery is feasible. Patients should be encouraged to resume activities as soon as they are comfortable to do so and to increase the level of straining as postsurgical discomfort lessens. No damage can be caused by physical activity. In general, office workers can return to work in 1-2 weeks, and manual workers a week or so later, on lighter duties. With laparoscopic repairs the work loss is about half that after open surgery. Take-home messages Ultrasound is not necessary or useful in assessing a clinically obvious groin hernia. Check both groins carefully, particularly in the elderly. Encourage early return to work as soon as the patient is comfortable. The best hernia repair is the one that a particular surgeon feels most comfortable with and which gives good results in their hands. Author s case study Severe abdominal pain with a soft mass in the right groin A FIT 84-year-old woman presented to her GP a few days after suffering griping severe mid-abdominal pain. Clinical examination revealed no abdominal abnormality or signs of intestinal obstruction. A soft palpable mass some 6cm in diameter was present in the right groin. An ultrasound report stated, There is a complicated mass in the right groin showing cystic and fluid components suggest a CT scan. The CT scan report stated, Small bowel and free fluid is seen, lying below the inguinal ligament and anterior to the pectineus muscle. This is a direct inguinal hernia containing bowel. On review by the surgeon the following week there had been no further abdominal pain. A soft non-tender swelling was obviously a large femoral hernia. Pressure for a few minutes caused reduction of the hernial contents, leaving a small non-tender fluctuant swelling about one-third of the original size. The patient was booked to have elective repair of a femoral hernia the following week, with instructions to notify immediately if she experienced pain in the meantime. She remained well and the hernia was unchanged at the time of operation. On opening the femoral hernial sac, clear fluid was present together with about 6cm of viable bowel. After reduction of the bowel and ligation of the sac, repair was carried out by suturing a shaped mesh plug to the deep aspect of the femoral ring. Surgery was carried out under neuroleptic local anaesthetic as a day case. Points to note This patient had not been aware of any lump in the groin, as is common in the elderly. Not many femoral hernias present in general practice, and diagnosis can be confused with inguinal hernias or lymphadenopathy. Ultrasounds are not much use in groin hernia diagnosis. The radiologist gave a perfect anatomical description of a femoral hernia then made an incorrect diagnosis. They felt (obviously incorrectly) that only a fluid filled sac remained after reduction of the hernial contents, hence the further delay in operating. Even when a fixed smallbowel segment was present in the hernia there were no symptoms. Any very-highrisk hernia should be operated on as soon as practicable. Any such patient should be instructed on how to practise reducing the hernial contents and to be sure to do so if there is any discomfort as well as notifying the doctor if there is significant pain. Online resources Australian web sites Brisbane Hernia Clinic: brisbane.com.au Melbourne Hernia Clinic: Sydney Hernia Clinic: International web sites British Hernia Centre: Hernia Care USA: Hernia Institute Florida: Prolene Hernia System: The Kugel Patch: 34 Australian Doctor 17 November

6 How to treat abdominal wall hernias GP s contribution DR MARCIA MANNING Greenwich, NSW Case study GERARD was a very active 78-year-old non-smoker who described an intermittent twitch on the right side of his abdomen. On examination I found bilateral direct inguinal hernias with no tenderness. The left hernia contained a large loop of bowel that was mostly reducible. Gerard had three comorbidities: Profound iron deficiency anaemia, due to silent bleeding from a large gastric ulcer. He had Helicobacter pylori infection on testing at endoscopy/ colonoscopy and he had just completed the triple therapy. Marfan s syndrome Gerard had already acquired porcine mitral and aortic valves in 1997 and He was taking aspirin alone as an anticoagulant. Severe chronic anxiety, which had recently led him into a depressive episode. How to Treat Quiz Abdominal wall hernias 17 November 2006 He was taking sertraline 50mg and having CBT with a local psychologist. Gerard underwent bilateral laparoscopic hernia repairs. The procedure was uneventful but two weeks later he represented saying the surgeon can t have been too good because one of his hernias had already recurred. In the left groin there was a soft-ish 4cm elongated lump. Ultrasound revealed an intact repair and a large seroma. He was returned to the surgeon who reassured him and drained some clear fluid to reduce pressure discomfort. This uncomfortable lump recurred and persisted for about four weeks. It took several visits before Gerard could be reassured that it would settle but eventually he returned to normal. Question for the author Was Gerard s Marfan s syndrome a significant risk factor in development of the hernias and the complication of a seroma? Yes. General questions for the author Are there enough laparoscopic surgeons outside the major cities doing hernia repairs, or do country folk still often end up with open repairs or delayed repair? Many surgeons in provincial areas perform laparoscopic repairs in large numbers, depending on their training. There is not a huge advantage of laparoscopic repair over open surgery for inguinal hernia, as there is for incisional hernia. What proportion of strangulated inguinal hernias give enough warning to be able to operate quickly enough? Do some of these creep up slowly and get missed until it has become too late to prevent gangrenous bowel? Usually gangrene of the bowel won t occur unless obstructed for eight hours or more. Patients especially the elderly or isolated often don t seek attention early. It is very easy to miss an obstructed hernia in the elderly, with vague complaints and vomiting. The patient is quite ill from obstruction, even if gangrene is not present. INSTRUCTIONS Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with an X on this form. Fill in your contact details and return to us by fax or free post. FAX BACK FREE POST ONLINE Photocopy form How to Treat quiz and fax to Reply Paid for immediate feedback (02) Chatswood DC NSW Which TWO statements about abdominal wall hernias are correct? a) Men have a 5% lifetime risk of developing an inguinal hernia b) About one in 25 people in the community have a hernia at any given time c) Most hernias in adults are directly related to pathological changes in tissue collagen d) Women have a similar incidence of hernia to that in men 2. Which ONE of the following is NOT a risk factor for the development of a hernia? a) A family history of hernias b) Smoking c) Obesity d) Having had a previous hernia repair as an infant 3. Jack, 78, presents with a soft left groin lump, which usually becomes smaller when lying down. Which THREE features on history and examination would suggest an indirect inguinal hernia as the likely cause? a) With Jack lying flat and the lump reduced, pressure over the deep inguinal ring prevents return of the lump on coughing b) On standing, a 4cm lump is visible below the inguinal ligament c) A cough impulse can be felt on the tip of an examining finger positioned through the superficial ring and into the inguinal canal d) Jack reports pain that radiates to his left testis 4. On examination Jack appears to have a left indirect inguinal hernia. To more fully assess Jack, which TWO actions would you take? a) Examine Jack for a cough impulse in his right groin as well as his left b) Check to see that the groin lump contents can be fully reduced manually c) Arrange an ultrasound of Jack s groin lump d) Arrange a CT scan of Jack s groin 5. You explain your clinical diagnosis to Jack. His non-tender hernia reduces easily and he does not want surgery. What advice should you give Jack (choose THREE)? a) He should be referred urgently to a surgeon because of the high risk of strangulation b) Inguinal hernias have a risk of strangulation of about 2% per year c) Older patients have a higher risk of developing an obstructed hernia d) He should promptly report any abdominal symptoms that develop when the hernia is swollen 6. Which ONE of the following is NOT a recognised symptom of a strangulated hernia? a) Abdominal distension b) Rectal bleeding c) Colicky abdominal pain d) Constipation 7. Terry, 56, is a self-employed builder. He has a right direct inguinal hernia that requires elective repair. What advice would you give Terry about the surgery (choose TWO)? a) Open tensionless mesh repair carries a 1-2% risk of recurrence b) Terry will need to take at least six weeks off work to recover properly c) To avoid making his hernia worse, he should stop physical activity while awaiting surgery d) Having a laparoscopic hernia repair will reduce his recovery time to about half that of open surgery 8. Terry would consider a laparoscopic hernia repair. Which TWO factors would make him an unsuitable candidate for this technique? a) A BMI of 32 b) A small hernia on the other side as well, which he would like fixed at the same time c) Surgery for a ruptured appendix 10 years ago d) Previous repair of a direct inguinal hernia at this site 9. Fran, 69, had a right hemicolectomy for bowel cancer 10 years ago. She now presents with an incisional hernia. What information can you give Fran about the development of incisional hernias (choose TWO)? a) After a laparotomy there is a 30% chance of developing an incisional hernia b) Development of an incisional hernia is not affected by weight gain c) Postoperative wound infections increase the risk of developing an incisional hernia d) The type of suture material used and the surgical technique are contributing factors 10. Angus, aged six weeks, is brought in by his mother. He has a swelling in his left groin, which on examination appears to be a reducible indirect inguinal hernia. What advice are you most likely to give Angus mother (choose TWO)? a) Angus needs to be seen soon by a paediatric surgeon for repair of this hernia b) He has up to a 40% chance of having a defect on the other side of his groin c) He will need an open tensionless mesh repair for his hernia d) Because his hernia is easily reduced Angus has a low risk of developing strangulation CONTACT DETAILS Dr: Phone: RACGP QA & CPD No: and /or ACRRM membership No: Address: Postcode: HOW TO TREAT Editor: Dr Marcela Cox Co-ordinator: Julian McAllan Quiz: Dr Marcela Cox The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October. NEXT WEEK Our understanding of nocturnal enuresis has advanced, with several different causes now recognised. It is imperative to identify the type of nocturnal enuresis a child is experiencing, as this provides a guide to the most appropriate therapy. Make sure you are in the loop with next week s How to Treat on nocturnal enuresis in children and adolescents. The authors are Denise Edgar, RGN, BN, manager/continence advisor, Continence Foundation of Australia in NSW, Silverwater, NSW; and Dr Patrina Caldwell, lecturer, discipline of paediatrics and child health, University of Sydney Centre for Kidney Research, and staff specialist, NHMRC Centre of Clinical Research Excellence in Renal Medicine, The Children s Hospital at Westmead, NSW. 36 Australian Doctor 17 November