Dr. R.K. Mishra
- What is hernia?
- What is inguinal hernia?
- What are the methods of hernia repair?
- What is the principle of laparoscopic repair of hernia?
- Why do you approach the hernia from inside?
- What are the advantages of laparoscopic hernia repair?
- What are the methods of laparoscopic repair of hernia?
- What are the chances of the hernia coming back?
- Is it more risky for patients with other medical problems?
- How safe is it to leave a mesh inside the body?
- Is this all very expensive? How can one justify the cost of the equipment and surgery?
What is hernia
Hernia result from a hole or defect in the layers of abdominal wall, through which the peritoneum protrudes, forming the sac.
The content of intestine can pulled inside the sac and sometime give rise to serious problems, like, strangulation, obstruction.
What is inguinal hernia
This is the commonest type of hernia resulting from a hole or defect in the muscles of inguinal region, through which the peritoneum protrudes, forming the sac. Inguinal hernia's sac some time communicate with the scrotum and gives a passage to the intestinal content or omentum.
What are the methods of hernia repair
The hernia can be repaired by either conventional or laparoscopic methods. Inguinal Herniorrhaphy is one of the most common operations that general surgeons perform. Laparoscopic Herniorrhaphy is being done at a time when Laparoscopic Cholecystectomy has shown definite benefits over the open technique.
What is the principle of laparoscopic repair of hernia
We can Imagine a bathtub. When we 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.
Why do you approach the hernia from inside?
The hernia is protrusion of the body contents through the weakness in the muscle. It is logical that something coming from inside is best dealt from inside. Also this way one does not cut and weaken the already weak muscle at the hernia site.
What are the advantages of laparoscopic hernia repair
Laparoscopic approach has several advantages:
1. Tension free repair that reinforces the entire myo-pectineal orifice
2. Less tissue dissection and disruption of tissue planes
3. Less pain postoperatively
4. Low intra-operative and postoperative complications.
5. Early return to work.
What are the methods of laparoscopic repair of hernia
There is two types of laparoscopic Hernia repair:
(1) The Transabdominal Preperitoneal repair (TAPP) and
(2) The Totally extraperitoneal (TEP) repair
In the transabdominal preperitoneal (TAPP) repair, the peritoneal cavity is entered, the peritoneum is dissected from the myopectineal orifice, mesh prosthesis is secured, and the peritoneal defect is closed. This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction.
The totally extraperitoneal (TEP) repair maintains peritoneal integrity, theoretically eliminating these risks while allowing direct visualization of the groin anatomy, which is critical for a successful repair. The TEP hernioplasty follows the basic principles of the open preperitoneal giant mesh repair, as first described by Stoppa in 1975 for the repair of bilateral hernias.
What are the chances of the hernia coming back?
Almost nil if the operation has been done properly as has been shown in numerous studies abroad.
Is it more risky for patients with other medical problems?
The general anaesthesia and the pneumoperitoneum required as part of the laparoscopic procedure do increase the risk in certain groups of patients. Most surgeons would not recommend laparoscopic hernia repair in those with pre-existing disease conditions. Patients with Cardiac diseases and COPD should not be considered a good candidate for laparoscopy. The laparoscopic hernia repair may also be more difficult in patients who have had previous lower abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum.
How safe is it to leave a mesh inside the body?
The mesh used is the same as the one used for open operations over last 30 years. Its safety and efficacy is beyond doubt as proved by the numerous trials all over the world.
Is this all very expensive? How can one justify the cost of the equipment and surgery?
The cost of laparoscopic equipment and instrument that is used to fix the mesh inside increases the cost of surgery. Unfortunately these are still imported and will remain expensive till they are locally produced. However, 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. The hidden lowering of cost is due to less leave, early return to normal activity and work, and also from the greatly reduced disruption of the family routine.