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Understanding inguinal hernia and other abdominal wall hernias

It is not easy to understand what aninguinal hernia, and a hernia in general, is. It is useful for, that purpose, to clarify some concepts of abdominal wall anatomy.

Hernia consists of the leakage of part or all of the viscera from the cavity in which it is normally contained. The leakage, or herniation, occurs through an orifice that is naturally present or pathologically formed. The typical feature of a hernia is that the leaking viscera is covered by integument: normally, skin and subcutaneous tissue. Often, the lining of the cavity containing the viscera (in the case of the abdomen, the peritoneum) is added.

However, to simplify matters, understanding what a hernia is becomes easy by looking at the following photos:

inguinal hernia, hernia surgery, trabucco method, inguinal hernia, umbilical hernia, epigastric hernia, laparocele, laparoscopyThe first represents an intact tire: we imagine the tire to be the healthy abdominal wall. The inner tube, which we can imagine in close contact with the inner wall of the tire, is the peritoneum.

The second, again by analogy, we can imagine that it is a diseased abdominal wall from which a hernia is protruding.

inguinal hernia, hernia surgery, inguinal hernia trabucco method, umbilical hernia, epigastric hernia, laparocele, laparoscopyHernias are very frequent pathologies; in Europe they are diagnosed 70,000 new cases of inguinal hernia per year. They are benign pathologies, the treatment of which is solely surgical; surgery, when the hernia is diagnosed early after its onset, has been relatively simple and standardized for more than a century.
However, if the patient comes to the surgeon with an already "long-standing" hernia, the surgery can become very complex. This is the case with theincarcerated hernia o strangled, which require urgent and often demolition surgery. For this reason, we recommend our patients to Undergo surgical examination as soon as they suspect they may have a hernia.

inguinal hernia, abdominal hernia, abdominal wall hernia, epigastric hernia, umbilical hernia, Spiegel's hernia, laparocele, Petit's hernia, Grynfelt's herniaHernia typically is a swelling or a swelling which is located in some well-defined areas Of the abdominal wall. The most affected region is the inguinal with theinguinal hernia and thecrural hernia. Also thenavel with theumbilical hernia and the upper abdominal wall with theepigastric hernia hernial sites are common. More rare are the Spiegel's hernias and back ones (Petit's hernia and Grynfelt's hernia).

Peculiar, but very common, hernias are laparoceles, which consist of the appearance of swelling at a surgical wound. The mechanism that causes a laparocele is the opening, or dehiscence, of the wound itself at its innermost layers.

At the level of the herniated swelling, one may sometimes experience a feeling of weight, burning, or pain. This occurs especially after standing for a long time or performing physical activity (even simply walking). Typically, a hernia increases in size when the patient performs any activity, while it decreases when lying down. The sudden onset of intolerable pain at the level of the swelling, but radiating to the entire abdomen, is a typical sign of the onset of a hernia complication, and indicates that the patient should urgently seek the advice of his or her trusted surgeon.

As mentioned above, hernia is a purely surgical condition. There are no medicines or external devices (such as hernia belts) that can cure a hernia.

The surgery can be done either anteriorly, with a skin incision, or minimally invasive laparoscopically.

Anterior route surgery is performed by incising the layers of integument and fascia overlying the hernia until reaching the herniated sac (i.e., the peritoneal "bag" containing the herniated viscera) and the herniated defect (i.e., the "hole" in the abdominal wall from which the herniated sac escapes). The sac is isolated and placed back into the abdominal cavity, and the defect is repaired with a prosthesis of synthetic material. In many cases, and in particular in almost all cases of inguinal or crural hernia and umbilical hernia, the operation can be performed under local anesthesia, and the patient can go home a few hours after leaving the operating room. The operation usually takes 40 to 60 minutes. Our group's technique of choice for the treatment of inguinal hernia is the plastic with prosthesis according to Trabucco.
La chirurgia laparoscopica si effettua introducendo nella cavità addominale, precedentemente espansa tramite l’insufflazione di anidride carbonica per creare lo spazio necessario al chirurgo, tre piccoli tubicini (i trocars) attraverso i quali il chirurgo introduce una telecamera e visiona il difetto erniario “da dietro”, ovvero dalla superficie posteriore della parete addominale. Mediante gli stessi trocars, il chirurgo introduce altri strumenti lunghi e sottili che gli consentono di ridurre l’ernia, isolare il sacco e ricollocarlo in cavità addominale e collocare la protesi che rinforzerà la parete addominale. L’intervento in laparoscopia viene eseguito in anestesia generale, ed il paziente necessita, in genere, di una notte di ricovero. Quando viene eseguito per il trattamento delle ernie inguinali o crurali, è generalmente più lungo dell’intervento realizzato per via anteriore, soprattutto perché le indicazioni sono diverse: si operano in laparoscopia le ernie inguinali bilaterali (ossia che si manifestano ad entrambi gli inguini) e le ernie recidive, ossia che ricompaiono dopo un primo intervento.
Nel caso delle altre ernie addominali, l’intervento laparoscopico è più breve e più semplice. L’ernia inguinale, invece, dev’essere operata in laparoscopia solo da un chirurgo esperto e con adeguata formazione in chirurgia mininvasiva.
 

The importance of prostheses in the surgery of inguinal hernia and other wall hernias

The question of prostheses for use in hernial surgery is quite complex, because hundreds of them are available on the market, many of which are nothing more than copies or modest modifications of others.

La rete da usare dipende, prima di tutto, dall’intervento che si esegue.
La nostra équipe ha deciso da oltre un decennio, in caso di chirurgia aperta per ernia inguinale, di affidarsi alla tecnica di Trabucco. Il compianto Prof. Ermanno Trabucco, chirurgo italiano emigrato a New York, è stato una delle colonne portanti della chirurgia erniaria degli ultimi venticinque anni, ed è l’ideatore di una tecnica che ha tra le sue caratteristiche quella di essere semplice, riproducibile, e di non necessitare dell’apposizione di punti di sutura per fissare la rete. Ciò riduce il rischio di sanguinamento, e quindi di formazione di ematomi postoperatori, e di dolore, evitando l’intrappolamento dei piccoli rami nervosi di cui la regione inguinale è ricca (il cosiddetto fenomeno del “nerve entrapment”, che può provocare dolore cronico spesso intrattabile).

The prostheses we use are the same as those designed by Prof. Trabucco, and among them is one with great innovative content, the Hybridmesh by Herniamesh, which is partly reabsorbed by the body, so that after two years the amount of "foreign material" that remains integrated in the tissues is really very low. This is ideal for young individuals and athletes, who will be living with the prosthesis for a long time, with the need for it to "stay put."

For the laparoscopic surgery of inguinal hernia we use theTrans Abdominal Pre Peritoneal ( TAPP) technique, which involves the use of low-weight polypropylene mesh.

For the laparoscopic surgery of abdominal hernias we use another prosthesis developed by Prof. Trabucco's staff and studied experimentally at the University of Bologna Alma Mater Studiorum. It is the Relimesh by Herniamesh, a very thin and ductile prosthesis consisting of a layer of polypropylene and a layer of a material that ensures that the abdominal viscera do not "stick" to it, thus avoiding the occurrence of serious post-surgical complications such as intestinal occlusion or fistula.

Groin hernia: what about after surgery...?

After surgery there is an early return to normal daily activities. The only precaution is not to undergo intense physical exertion and not to perform sports activities for a month. This is in fact the time needed for the scars that will fix the mesh to form.

Our technique ensures the least amount of postoperative pain and the confidence of being able to return to normal daily life quickly.

 

Read more...
  • Inguinal hernia -Inguinal hernia information page from the Harvard Medical School on its Patient Education Center. In English, very clear and comprehensive, with some nice illustrations.
  • Hernia - Patient resource page on Medline Plus, a site specializing in professional information from the U.S. National Library of Medicine, the largest existing medical database. English.
  • Abdominal hernias - by Surgeons of Cuccomarino, MD the first brochure in Italian oninguinal hernia and other abdominal hernias