• Antecedents:
  • Your risk of developing a hernia is greater if you have a family history of inguinal hernias.
• Hernia personal history:
  • If you have already had a hernia, you have an increased risk of having one on the other side.
• Chronic coughing:
  • Smoking, chronic bronchitis.
• Chronic constipation.
• Excess weight/obesity.
• Physical work
• Pregnancy.

An Inguinal Hernia may be asymptomatic and only discovered during a routine medical check-up.

Often the presence of a hernia  makes you uncomfortable, or you experience a painful sensation when you cough, strain, lift, or stand for a long time.

• A bulge (protrusion) in the groin, or in the scrotum in a male.
• Feelings of discomfort or pain with physical effort, walking or even coughing.
• Heaviness, or burning in the groin.
• Pain in the scrotum (for men when the intestinal hernia moves into the scrotum).

A hernia increases in size and can become uncomfortable and/or painful if not treated in a timely manner.

A hernia is supposedly reducible when it can be reduced (put back in place) manually or when you are lying down.

Incarcerated hernia.

Is a hernia which is not reducible, the intestine (colon/small intestine) is blocked outside of the abdomen without any vascular sufferance.

Indications for surgery exist.

A strangulated hernia

The intestine remains not only blocked but risks being perforated as blood circulation is diminished.

To avoid necrosis of the intestine and the consequent peritonitis, surgery must take place immediately.

Please Note : A strangled hernia requires emergency surgery!

Post-operative complications after surgical treatment for groin hernias

For all techniques used, there are very few complications.

1. THROMBOSIS OF THE SPERMATIC CORD with inflammation of the testicles. Risk 8 times higher with a scrotal inguinal hernia (which is very large and descends into the scrotum).
2. HEMATOMA
3. SUPERFICIAL INFECTION rare when using keyhole surgery or a laparoscopic camera.
4. DEEP INFECTION which concerns the piece of mesh is ‘exceptional’. This complication leads to a second surgical intervention to drain the abscess and for the removal of the infected prosthesis (< 0.5% for patients who have no risk factors – diabetes, taking Non-Vitamin K Antagonist Oral Anticoagulants, immunodepression)
5. SECONDARY COMPLICATIONS following a general anaesthetic.
6. RECURRENCE rate < 1% with  the insertion of a piece of mesh to close the abdominal wall.
7. POST-OPERATIVE PAIN : SOMETIMES POSSIBLY PROLONGED The incidence of post-operative chronic pain is less high with patients operated using  keyhole surgery (Eklund A, Montgomery A, Bergkvist L, Rudberg C. Chronic pain 5 years after randomised comparison of laparoscopic/keyhole surgery and Lichtenstein inguinal hernia repair. Br J Surg 2010;97:600-8).

You must prepare for your consultation with your surgeon if you have a problem of an inguinal or parietal hernia.

Note down all the symptoms and any recent changes in habitude, at work, your physical activities, as well as any other prescription medicines  (antiplatelet agents or anticoagulants), medicine allergies.

Write down all the questions you want to ask your surgeon.

• Are there any other reasons/causes which could explain these symptoms?
• What examinations/x-ray/scan must I have to make the diagnosis precise?
• What happens in the operation? Is it really necessary?
• If you recommend that I wait and see, how do I control the evolution of my hernia?
• If you recommend that I have surgery, what type of surgical procedure is best for my case?
• Would it be an operation that you and your team do regularly? Are the results made available?
• What is the risk of complications for this particular surgery?
• What is the risk that the symptoms linked to the hernia reappear?
• What is the risk that it reoccurs?
• Are there any brochures that I could take home with me afterwards to help me understand better? 
• What website would you recommend that I look at to find the information you are giving me?
• Could I get in touch with you again for further information, if I feel it is necessary?

There are two types of surgery.

Treating  an Inguinal Hernia with conventional open surgery by inserting a mesh from the outside.

• ‘Lichtenstein, Rutkov and Robbins’ surgery techniques: Concerning the techniques which insert a mesh from the outside, tension free (Lichtenstein and similar), a 5 to 8cm incision is made in the inguinal region. The dissection of the hernia and its sac is made through the nerve network of the inguinal canal. Then the mesh is put in place under the fascia of the abdominal external oblique muscle without opening the transverse fascia.
• ‘Rives’ surgery technique: With the Rives technique, the Inguinal region also has an incision made from the outside. But the surgical procedure is more delicate as the dissection is deeper, but philosophically more interesting. The mesh is placed in the  preperitoneal space (under the transversalis fascia) to cover all the possible zones of weakness.

Treating an Inguinal Hernia from underneath, minimally invasive, by keyhole surgery.

• TAPP : TransAbdominal PrePeritoneal The TAPP technique consists of first of all entering the abdominal cavity, then dissecting the inguinal region. It can be used to treat all types of hernia.
• TEP: Totally ExtraPeritoneal With the TEP technique we directly use the preperitoneal space. The operation takes place in the space between the muscles and the peritoneum, without entering the abdominal cavity.

Keyhole surgery  is nothing more than realising the Rives concept by new, minimally invasive technologies. The mesh is put in place from underneath in the preperitoneal space (under the transversalis fascia) in order to cover all the possible zones of weakness.

A fibre optic cable with a camera is introduced through a one centimetre incision, the working surgical instruments are introduced through two other incisions of 5-10mm.

The main interest is not to traverse the nerve network of the inguinal canal, which can generate chronic pain and sexual problems.

• Infection complications: infection of the mesh. Cases of infection of the mesh seem to be less with  keyhole surgery than with open surgery.
• Chronic post-operative groin pain, inguinodynia.  Less with  keyhole surgery at 9% versus 30%.
• Testicular atrophy.
• Visceral/vascular lesions. More frequent in keyhole surgery if the surgeon has not completed their learning curve.

Recurrent inguinal hernia after surgery

The use of a mesh prosthesis has reduced the rate of recurrence, which was previously unacceptably high.

Whatever technique is used, there is always a risk of recurrence. However, the rate has decreased from the 10-15%  in the ’80s to 1-5% currently.

Such a problem may occur a long time after the surgery, but may occur early on if the mesh moves slightly.

This movement, or sliding, may be provoked by physical activity or intense efforts being carried out too early, or by unfavourable local conditions.

Traditional techniques for treating hernia compared with keyhole surgery.

‘Lichtenstein’ traditional technique for treating a hernia.

• Open surgery techniques group together a number of simple advantages: easy to learn, carried out using a local anaesthetic, provided on an ambulatory basis, with a recurrence rate of 1 to 1.5% in the hands of surgeons who are not experts.
• The results of a five year random multi-centre study  comparing the two approaches shows that recurrence is significantly less frequent after Lichtenstein (1.2%) than after TEP (2.4%).
• However, they incontestably generate chronic pain (30% in an historic cohort study of 351 patients followed over 1 year).

Minimally invasive TEP keyhole surgery for a hernia

The keyhole surgery technique requires a much longer learning curve and should only be carried out by surgeons expert in the matter.

• The recurrence rate after keyhole surgery for a hernia is shown by studies to be 2.4% (Eklund AS, Montgomery AKetude randomised Low recurrence rate after keyhole (TEP) surgery and open (Lichtenstein) inguinal hernia repair. Ann Surg 2009; 249:33-8)
• This rate of 2.4% is operator-dependant for TEP. In our experience, this rate is comparable with that of the Lichtenstein technique.
• The operating time, particularly in the case of bilateral inguinal hernia, is much shorter than that of the classic technique.
• Keyhole surgery generates globally less occasions of chronic pain. The choice of fixation or non-fixation of the mesh also plays a role in reducing postoperative pain in the long term.
• The prevalence of chronic pain after keyhole surgery to treat a hernia totally extraperitoneal was only 9.2% in one Hong Kong study.

The advantages of treatment  by keyhole surgery include aesthetic benefits, a more rapid return to normal life, work, and physical activity, and less occasions of chronic pain in the long term.