How Are Hernias Repaired?
The type of hernia repair performed by your surgeon will depend on the size and location of the hernia, anaesthesia risk, strength of the surrounding tissue and the expertise of the Surgeon.
Hernias can be repaired in one of the following two ways:
1. Using your Natural Tissue without the use of surgical mesh. These repairs are often called “anatomical” repairs as they use your own tissue to repair the hernia defect.
Natural tissue repairs are always performed using an “open anterior” surgical procedure which entails making an open incision over the hernia site, in contrast to laparoscopic procedures as outlined below.
Groin hernias make up over 80% of all abdominal wall hernias, and over the past 100 years, many natural tissue repairs have been developed with the Bassini, McVay and Shouldice methods being the most recognized. Although all these methods differ in their approach to reconstructing the abdominal wall, they are all similar in that they use the body’s natural tissue instead of mesh, and use permanent sutures to approximate the surrounding tissue around the hernia defect and repair the posterior wall of the inguinal canal.
Natural tissue repairs can be used to successfully repair virtually all direct and in-direct inguinal hernias and many ventral hernias. Mesh is most often required when the surrounding natural tissue is inadequate, or of poor quality, to allow for a strong anatomical repair – this is most often seen when repairing femoral, large incisional and recurrent hernias. Shouldice Hospital uses natural tissue repair whenever possible, or in over 98% of all its hernia cases.
Natural tissue repairs can safely be done using local and conscious IV sedation which avoids the complications of general anaesthesia.
2. Using Synthetic Mesh to either “patch” or “plug” the hernia defect instead of your natural tissue. Hernia repair using mesh can be done by using either the “open anterior” surgical technique or using a Laparoscopic approach.
a) Open anterior mesh repairs use the same initial approach as natural tissue repairs, however, instead of suturing the fascial tissue and muscle layers together to repair the hernia defect, synthetic mesh is used. There are many types of mesh repair techniques but the most recognized is the Lichtenstein patch technique (75% of all cases), plus numerous others which includes Plugs, Plugs and Patches and other hybrid systems.
In the patch method (Lichtenstien) the hernia defect is overlaid with synthetic mesh which is then secured using either sutures or with a range of other methods including tacks, staples or glues.
In the plug method (Rutkow), a mesh plug is used to fill the hernia defect like a cork stoppering a bottle. The plug is then secured by a variety of methods.
In plug and patch systems, an overlay mesh patch is anchored over the plug. In other hybrid techniques an underlaid patch is added to the overlaid patch and plug to form a once piece plug with top and bottom mesh patches. The underlaid patch is “splayed” and left unsecured while the overlaid patch is anchored.
What is common in all these techniques is the anchoring of the mesh, which puts tension on the surrounding tissues, particularly over time as the mesh shrinks and hardens.
Some of these methods often claim they are not anchored (tension free, at least initially) but this in itself creates issues when the mesh moves or “migrates”. These are more fully outlined in the section natural tissue vs. mesh in hernia repair.
b) Laparoscopic repairs are always performed under General Anaesthetic and always use mesh, as it is very difficult to do a true anatomical or natural tissue repair laparoscopically.
In this approach, three 1 cm punctures are made in the abdominal wall, one to allow a surgical scope to be inserted, along with two additional narrow tubes (trocars) to allow placement of the surgical instruments. The abdomen is inflated with carbon dioxide to create a positive pressure in the abdominal cavity that allows the bowel to fall away from the operative site, thus identifying the hernia. The hernia is then repaired by stapling, tacking or glueing a mesh patch over the defect from behind (“posterior”).