An inguinal hernia, also known as an inguinal hernia, is the most common type of hernia: it accounts for around 75 to 80 percent of all hernias. Inguinal hernia surgery is therefore the most common hernia operation.
An inguinal hernia (also known as an inguinal hernia) is ahernia in the area of the inguinal canal.
The inguinal canal, which runs diagonally through the abdominal wall and is formed by the abdominal muscles, is where the spermatic cord from the testicles and its accompanying blood vessels and nerves pass through in men. In women, a thin ligament of the uterus runs through the inguinal canal.
If the abdominal muscles weaken, the inguinal canal widens and a hernia occurs in the abdominal wall. Parts of the abdominal organs, for example parts of the intestine, can protrude from the abdominal cavity through this hernia gap and become palpable and visible as a protrusion.
This can be accompanied by pain in the groin area, especially during physical exertion, and, in the worst case, by an incarceration of the abdominal viscera, for example the intestine, in the inguinal canal. Men are much more frequently affected by an inguinal hernia than women.
In most cases, an inguinal hernia is harmless and often causes no or only mild discomfort.
However, as the hernia gap in an inguinal hernia will never close on its own, but rather becomes larger and larger over time, and there is also a risk of the intestine being trapped in the inguinal canal and cut off from the blood supply, an inguinal hernia should usually be treated with an operation.
Nowadays, there are many different surgical procedures available for the surgical treatment of an inguinal hernia, in which the hernia surgeon moves the hernia contents back into the abdominal cavity, closes the hernia gap in the abdominal wall and stabilizes the tissue.
Which procedure is used for an inguinal hernia operation must be decided individually by the doctor and patient and depends on various factors. For example, the surgical procedure to be used for an inguinal hernia operation depends on
The hernia gap in the abdominal wall can be closed as part of an inguinal hernia operation either
be closed.
This can be done either conventionally as part of an open operation or minimally invasively using an endoscopic or laparoscopic procedure. In the meantime, most inguinal hernia operations worldwide are performed with plastic mesh implants.
Based on these different surgical options, three different surgical procedures can therefore be used in principle for inguinal hernia surgery, namely
This method of inguinal hernia surgery was developed in 1944 by the Canadian surgeon Edward Earle Shouldice and was considered the gold standard in hernia surgery until the introduction of surgical procedures in which a synthetic mesh is implanted.
Shouldice hernia surgery is a conventional, i.e. non-minimally invasive surgical method in which the hernia gap is closed with the body's own tissue.
The Shouldice procedure is as follows: The surgeon makes a transverse incision of approximately 5 to 8 centimeters above the inguinal ligament and from this approach exposes the hernia sac that has formed as a result of the hernia.
The surgeon then opens the hernia sac, checks the intestines inside in order to treat them if necessary and moves them back into their original positions in the abdominal cavity. The hernia sac is then removed and the peritoneum is closed with a suture.
The transverse fascia is then opened transversely and mobilized.
In order to additionally stabilize and reinforce the posterior wall of the inguinal canal and the inguinal region, the surgeon sutures the inguinal ligament to the so-called transverse fascia transversalis, i.e. the adjacent connective tissue that lines the inside of the abdominal wall. This suture is performed in several rows for safety.
Shouldice inguinal hernia surgery is considered the best suturing procedure and has a comparatively low recurrence rate of recurrent hernias after surgery. This type of surgery is mainly used for smaller inguinal hernias and for young patients without a significant risk profile.
Shouldice inguinal hernia surgery is usually performed under general anesthesia. However, one of the advantages of this surgical method is that the procedure can also be performed under spinal anesthesia or local anesthesia. In addition, no artificial material is required for this hernia operation.
However, patients must take it easy for a long time after this open inguinal hernia operation. It takes around two months before they are allowed to resume physical activity or sports.
This method of inguinal hernia surgery was developed in 1984 by the American surgeon Irving Lester Lichtenstein and is now one of the most commonly used inguinal hernia surgery procedures. Inguinal hernia surgery according to Lichtenstein, like inguinal hernia surgery according to Shouldice, is an open, i.e. non-minimally invasive, surgical procedure.
However, unlike Shouldice inguinal hernia surgery, the Lichtenstein method does not close the hernia gap with the body's own tissue, but with a special plastic mesh.
The Lichtenstein inguinal hernia operation is initially performed in the same way as the Shouldice method: The surgeon makes a transverse skin incision of around 5 to 8 centimeters above the inguinal ligament, then exposes the hernia sac and opens it.
The contents of the hernia sac are pushed back into the abdominal cavity, the hernia sac is removed and the peritoneum is closed with a suture.
In the next step, unlike the shouldice method, the surgeon covers the hernial orifice with a thin plastic mesh made of polypropylene and sutures this to the abdominal wall muscles and the inguinal ligament.
The Lichtenstein inguinal hernia operation is particularly suitable for older people and for patients with a medium or large inguinal hernia. This surgical method is also used for patients who have had a recurrent inguinal hernia(recurrent hernia).
One advantage of the Lichtenstein method is that the procedure can also be performed under spinal or local anesthesia and does not necessarily require general anesthesia. The risk of a new hernia occurring after the operation is low.
In addition, patients can resume weight-bearing earlier after Lichtenstein inguinal hernia surgery and are fit again more quickly than after Shouldice surgery.
In contrast to the Shouldice and Lichtenstein open procedures, minimally invasive inguinal hernia surgery is not performed with a large incision in the groin region, but by means of small abdominal incisions below the navel, through which an endoscope and the necessary surgical instruments are inserted and advanced to the inguinal hernia. Minimally invasive surgical procedures are therefore also referred to as keyhole surgery.
With TAPP (transabdominal preperitoneal hernioplasty) and TEP (total extraperitoneal hernioplasty), two different types of minimally invasive inguinal hernia surgery are available. Both procedures work with large plastic meshes that are inserted from the back of the abdominal wall and are always performed under general anesthesia.
One of the advantages of minimally invasive inguinal hernia surgery is that the patient can resume physical activity just a few days after the operation. In addition, the plastic mesh is placed loosely over the inguinal hernia without it having to be sutured closed under tension. This means that the patient generally does not feel any pulling pain after the operation and is able to move again more quickly.
In principle, minimally invasive techniques can be used for all patients who have no contraindications. They are also used for repeat operations where external access is made more difficult by a previous hernia operation.
Minimally invasive inguinal hernia surgery using TAPP is performed as follows: The surgeon makes small incisions in the skin around the navel and on the mid-abdomen. He then inserts a special needle through which he fills the abdomen with carbon dioxide and inflates it. This serves to push back the bowel and give the surgeon a good view of the hernia to be operated on.
In the next step, the surgeon inserts the endoscope with the camera and the surgical instruments through the incisions in the skin.
The peritoneum is now incised, the hernia sac is carefully released from the hernial orifice and the hernia contents are pushed back into the abdominal cavity.
A sufficiently large plastic mesh is advanced from the abdominal cavity (transabdominally) to the hernia and placed in front of the peritoneum (preperitoneally) over the hernial orifice.
The plastic mesh is usually at least 15 x 10 centimeters in size and is fixed in place with the help of adhesives or holds without fixation. The peritoneal opening is closed again with a suture to prevent the plastic mesh from coming into direct contact with the intestinal loops.
In the case of a double-sided inguinal hernia, TAPP can be used to treat both hernias in one operation. TAPP is therefore used in particular for bilateral inguinal hernias. It is also frequently performed for repeated inguinal hernias (recurrent hernias) that have already been treated in a previous open operation.
The abdominal cavity is not opened during inguinal hernia surgery using TEP. The operation is performed in the so-called preperitoneal space in front of the abdominal wall. The risk of damaging internal organs such as the intestine is therefore even lower.
The procedure for minimally invasive inguinal hernia surgery using TEP is as follows: The surgeon makes a small incision in the skin below the navel, through which he inserts a balloon filled with air between the abdominal wall and the peritoneum.
This serves to separate the abdominal wall and the peritoneum. Carbon dioxide is blown into the balloon to widen the resulting gap between these two layers. The surgeon now has a good view of the area to be operated on.
The surgical instruments and the endoscope with the camera are inserted through two further small incisions in the skin.
The hernia sac is now carefully exposed and the hernia contents are moved back into the abdominal cavity.
A plastic mesh is then placed over the hernial orifice, between the layers of the abdominal wall, i.e. behind the muscles and on the peritoneum. This mesh usually fixes itself by the natural internal abdominal pressure and the counter-pressure of the abdominal muscles.
Further fixation with a tissue adhesive is therefore usually not necessary, but can still be carried out if necessary.
Hernia surgery is a branch of visceral surgery. Certified hernia centers have particularly extensive experience and expertise in the treatment of hernias. Clinics or departments receive certification if they meet certain requirements.
