An inguinal hernia is a weakness or a defect in the inguinal canal. Anatomically we have a natural orifice in the inguinal canal where the round ligament (in females) and the spermatic cord (in males) passes from the abdomen to the groin area. If the inguinal canal enlarges the person will develop an inguinal hernia.
Multiple factors can contribute to inguinal hernia formation.
Many patients with an inguinal hernia have no symptoms. This is particularly true for small hernias. Hernias tend to enlarge over time and symptoms can develop. The most common symptom associated with an inguinal hernia is groin pain.
Symptoms can be more pronounced during certain activities. Most patients complain of pain during lifting, coughing, jumping, reaching or standing/walking for long periods of time. The pain is usually described as a burning sensation that goes down into the scrotum or the medial aspect of the upper thigh.
If a hernia becomes strangulated the pain can get severe. The patient can also develop abdominal pain, abdominal distention, nausea and/or vomiting. Lack of flatus or bowel movements can also be present if a portion of the bowel is incarcerated or strangulated. If any of these symptoms develop rapid medical attention is needed.
The diagnosis of an inguinal hernia is usually very straight forward. A good history and physical exam is normally the only thing needed to make an accurate diagnosis.
In more complex cases radiologic evaluation might be needed. A CT scan is the test of choice for most surgeons. CT scans are very sensitive at diagnosing hernias but unfortunately, very small hernias are difficult to visualize.
An MRI can also be useful, especially in the diagnosis of sports hernias. Sports hernias have different pathophysiology and we will discuss them in another section.
Many physicians will obtain an ultrasound as the first test but the sensitivity is low and is highly dependent on the sonographic technologists.
Many years ago the recommendation was that every hernia had to be repaired. In more recent years that has changed. Currently, the decision to repair an inguinal hernia is base on the symptoms. For a completely asymptomatic hernia that doesn’t limit the patients daily activities, watchful waiting is not unreasonable.
For an inguinal hernia that is enlarging, causing pain or limiting the patients daily activities, elective surgical repair is routinely recommended.
For hernias that are incarcerated and/or strangulated that are causing significant pain, surgical repair is usually mandatory and sometimes an immediate repair is warranted.
Below we will discuss the three main approaches to repair an inguinal hernia. We will also discuss a very common question that patients have nowadays. Do I need mesh?
An open inguinal hernia repair is done through a 6-7 cm incision in the groin above the hernia. The defect in the abdominal wall is identified and using a combination of sutures and mesh the defect is repaired. The surgery time is approximately 30-45 minutes and the surgery is an ambulatory procedure.
The decision to go with an open approach is made base on the hernia size and/or the patient’s medical condition. An open inguinal hernia repair can be done with minimal intravenous anesthesia and local anesthesia. An 85 years old patient with multiple medical problems is better suited for an open repair with minimal anesthesia, this will limit the possibility of having complications from general anesthesia.
A giant incarcerated inguinal hernia is also better suited for an open approach were reducing the intestine back into the abdominal cavity can be a significant challenge.
Previous surgical history can also be a factor in determining the surgical approach. Patients with a previous radical prostatectomy can be better treated with an open approach to prevent injuries due to scar tissue from prostate surgery.
The laparoscopic approach is done with three small incisions just below the umbilicus. The surgical time is approximately 30-60 minutes and is an ambulatory surgery. A laparoscopic inguinal hernia repair has to be done under general anesthesia.
There are two different approaches to a laparoscopic inguinal hernia repair. An extraperitoneal approach (TEP) where the hernia is repaired through the layers of the abdominal wall or the intraperitoneal approach (TAPP) where the hernia is repaired from inside the abdominal cavity. The end result is relatively the same and the technique utilized is mainly surgeons preference. Dr. Caban preference is to do the extraperitoneal approach when feasible.
Not every surgeon has adequate skills to perform inguinal hernia repairs laparoscopically. Every patient should do their research regarding their surgeon. Dr. Angel Caban has done hundreds if not thousands of these procedures laparoscopically. If you are looking for a surgeon to get your hernia repaired laparoscopically, look no further.
Robotic inguinal hernia repairs have become more popular in recent years. The hernia is repaired similarly to a transabdominal laparoscopic repair. The biggest difference is the set of tools. Robotic surgery fans advocate that the DaVinci system give the surgeon more accuracy and better visualization when dealing with delicate tissues.
The decision to go with a robotic approach is mainly surgeons preference. Patients that had prior lower abdominal surgery are better candidates for a robotic approach than a laparoscopic approach. One example can be a female patient after a C section or a hysterectomy. Many times a laparoscopic extraperitoneal approach is not an option but a robotic transabdominal approach is a feasible option.
Dr. Angel Caban is highly trained in minimally invasive techniques including the DaVinci Robotic System. In North Central Florida no other surgeon can perform this procedure better than Dr. Caban.
Dr. Caban has taught other surgeons in national meetings on how to perform these procedures safely and effectively.
If you watch any television most likely you have seen a commercial about mesh recall or mesh complications. The truth is that these commercials are not new. Mesh complications, recalls, and infections have affected patients for decades. Mesh is like any other medical device, they can be defective or they can cause issues in certain patients.
Many clinical trials have looked into these issues and the conclusion is always very similar. The best way to fix a hernia is with mesh. Mesh placement has proven to decrease the recurrence rate by reinforcing the tissues and by creating tension-free repairs. Some patients complain of chronic pain due to the “mesh”, but the chronic pain can also develop in patients with a non-mesh repair. The incidence of chronic pain after a hernia repair is around 2-5% for all hernias.
There are many types of mesh, permanent mesh, absorbable mesh, and hybrid meshes. Also inside these three broad catergories, you can find different materials made by different manufacturers. Selection of the type of mesh is usually determined by the surgeon and many times the surgeon is limited to whatever product is available at the institution where he or she operates.
If you have concerns about the mesh product that will be used in your surgery you should ask your surgeon. Dr. Caban is an advocate of mesh placement in most hernia repairs, but he is also opened to discussions with the patients regarding what product will be used and what the outcomes data is for that product.
So to answer the question of mesh or no mesh. The short answer is that most hernias are better repaired with mesh.
An inguinal hernia repair is an ambulatory surgery in most instances. The surgery takes between 30 – 60 minutes. After surgery, the patients will go to the recovery room for approximately 1-2 hours. You will be given a prescription for pain medications and other instructions will be given prior to going home.
You will follow up with Dr. Caban in 2-3 weeks and then on as needed basis.
Most patients that have office type job can expect to return to work after several days. For those of you that have a heavy job were heavy lifting more than 15-20 pounds is necessary, you should account for 4-6 weeks out of work or sooner if light duty is an option.
Other activities like playing golf, pickleball, bowling or any other sports were using the core muscles is necessary should be postponed for 4-6 weeks. Swimming should be limited until the incisions are completely healed.
“Dr. Angel Caban performed my surgery almost 5 years ago on 6/2/2014. He is a kind doctor and always treated me fairly. I always felt welcome in his office. I recommended him to many over the past 5 years”.
Gina
“Me encanta no lo cambio. Exelente el doctor caban y su personal. Muy buen grupo”.
Johanna
“Dr. Caban did my colon resection and did an outstanding job all the way across the board. I highly recommend him as well”.
Dan
“I have the privilege of working with Angel M Caban in the hospital environment. I also have had him be the surgeon to one of my family members. I would like everyone to know that he is a great surgeon. We are fortunate to have him here in Ocala. He is personable, easy to talk too and has excellent bedside manners”.
Karen
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