For Hernias, a Decision About the Incision
Most people would assume that an operation performed with smaller incisions is a good thing, but surgeons aren’t so sure--at least when it comes to hernia repair. As for patients, many don’t understand what a hernia is.
The term “hernia” is used to describe a weakness or abnormal opening in a body structure that permits another organ to protrude through. Perhaps the most familiar types of hernias are those that occur in an anatomically weak spot in the abdominal wall, such as around the bellybutton (umbilical hernia) or in the groin (inguinal hernia), and those that develop where the abdominal wall has become weakened, such as at the site of a surgical incision (incisional hernia).
Typically, abdominal hernias appear as round bulges in the abdominal wall when a person is straining (for example, when lifting a heavy object), and disappear when the muscles are relaxed. In some cases, however, the bulging--caused by intestines pushing through the weakened area in the abdominal wall--persists. Many people with hernias have no symptoms; others experience discomfort or mild pain.
With inguinal hernias, the bulging occurs in the groin area. This type of hernia affects men much more commonly than women, because men have an intrinsic weakness where the testes descend into the scrotum during fetal development. As a result, an inguinal hernia in men can produce swelling of the scrotum if a loop of intestine follows that same path through the weakened (and now enlarged) opening.
For decades, people with hernias were advised to use “hernia supports,” trusses that minimize the bulging by applying pressure over the weakened area. However, the only true cure for a hernia is an operation that closes up the opening and strengthens the weakened area around it.
Surgery may not be necessary in all cases of umbilical or incisional hernias, especially if no symptoms are present and the bulging disappears whenever the stomach is relaxed. But most surgeons agree that almost all groin hernias should be repaired surgically, because serious--even life-threatening--complications can develop when they are left untreated. With this type of hernia, the intestines and any other tissue that protrudes through the weakness can become trapped and its blood supply cut off.
Traditionally, hernias have been repaired using “open” surgery, with a very high rate of success. With this technique, an incision is made in the skin directly over the hernia, and the weakness is identified and repaired. Sometimes the edges of the defect are simply pulled together (much like sewing a hole together in a piece of cloth). More frequently, a small piece of synthetic mesh is used to bridge the defect. (The mesh is sutured to the edges of the opening, and serves as a “patch” over the weakened area.)
About 10 years ago, some surgeons began to repair hernias using a laparoscope. With this technique, the entire procedure is done through very small incisions in the abdominal wall. The surgical instruments are inserted through these incisions, along with a miniature camera that enables the surgeon to see the area being repaired. Unlike open hernia surgery, all laparoscopic repairs utilize mesh to cover the weakened area.
Advocates of the laparoscopic procedure point out that patients treated this way have less postoperative pain and return to normal activities more quickly. They say this approach may be better for patients with recurrent hernias, because laparoscopy avoids the old scar tissue. The open procedure, on the other hand, cuts through it.
Critics counter that the procedure presents an increased risk of rare--but serious--complications, such as injuries to the bladder and bowel. And, unlike open surgery, which can often be performed using only local anesthetic, the laparoscopic procedure requires general anesthesia, which means it may not be advisable for people with serious cardiac or respiratory problems. (They also point out that the laparoscopic procedure is more expensive and longer.)
Perhaps the biggest question surrounding laparoscopic hernia repairs relates to its long-term success rate: How does this procedure compare to the traditional open procedure for preventing another hernia from recurring at the same site? The laparoscopic procedure is so new that no one--including the doctors who have been performing it--could answer definitively.
A recently published study, however, offers some preliminary results. Researchers in the United Kingdom reported on a group of almost 400 men and women who underwent hernia repair; slightly more than half had an open procedure, and the others had their hernias repaired laparoscopically. Five years after surgery, the recurrence rate of hernias in the two groups was almost identical.
So what’s a person with a hernia to do? Most experts agree that the single most important step is to find a surgeon who has extensive experience with hernia operations. As with almost all surgical procedures, experience counts, and practice makes (almost) perfect. If there is any question about the necessity for surgery or about which procedure (open or laparoscopic) is better, get a second opinion--preferably from a surgeon who has extensive experience with both procedures.
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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. Their column appears the second and fourth Mondays of the month. Send questions by e-mail to our [email protected]. They cannot respond to every query.
