(Hernia Repair using Keyhole Surgery Techniques)

The traditional approach to repairing abdominal wall hernias has been to make an incision over the defect (lump). This incision has to be wide enough and deep enough to allow access to the abdominal wall defect. It also requires the exposure of enough normal tissue around the defect to enable an adequate repair to be performed. Consequently, there may have to be a considerable amount of dissection and disruption of normal tissues including muscles, nerves and blood vessels. Once the defect is adequately exposed, a tension-free repair is performed, and in most cases a prosthetic mesh is secured in place. This then allows ingrowth of cells called fibroblasts which lay down permanent scar tissue to strengthen the defect.

Open hernia of this kind is offered in most general surgical centres and a variety of clinics. It is usually very safe and successful and for straightforward cases can be offered as a day-case surgery.

Rather than repairing the defect from the “outside”, keyhole surgery aims to repair the defect from the “inside”. This involves the making of small (less than 1cm) incision on the abdominal wall, usually at some distance away from the hernia rather than directly over it. This incisions allow the insertion of special instrumentation, which are then used to expose the defect from the inside the abdomen. No cutting or dissection of muscles, nerves or blood vessels is necessary as the hernia is approached in the reverse way to open surgery. A mesh is then placed over the defect and secured in place. The two main techniques of laparoscopic hernia surgery are known as trans-abdominal pre-peritoneal repair (TAPP) and the totally extra-peritoneal repair(TEP). The mesh itself is usually covered with peritoneum (the inner lining of the abdominal wall), which prevents bowel sticking to the mesh. In the cases of laparoscopic incisional hernia repair, it may not be possible to cover the defect with peritoneum because this is usually disrupted from previous surgery. However, in these cases, a dual-layer mesh may be employed which has a special lining designed to prevent bowel sticking on to it, as well as the normal synthetic layer that repairs the defect.

• Less Pain and Quicker Recovery . Because much smaller incisions are being used, the immediate post-operative pain is considerably less, and therefore getting up and about immediately after surgery is much easier. This in itself has obvious advantages, but means that virtually all laparoscopic hernia surgery can be performed as a day-case. Although this is also true for single, uncomplicated open hernia surgery, it is not possible when hernias on both sides (bilateral) are being repaired at the same time, or in the case of incisional hernia, which usually require an extensive dissection and the placement of suction drains in the tissues following surgery for a few days. Return to normal activities, work or recreation is much faster.
• Less Chronic Groin Pain . A proportion of patients who have had open hernia surgery will suffer from chronic pain or abnormal sensation in the area of the operation. This is mainly the case for inguinal hernia. The reason for this is the cutting and dissection of normal muscles and nerves. These structures can then undergo scarring, and in some cases this can cause considerable discomfort, requiring further medical or even surgical intervention. Since there is minimal dissection of the abdominal wall required in laparoscopic hernia surgery, this debilitating late and chronic complication of open hernia surgery is very rarely seen. Again in the case of open inguinal hernia surgery, in men there may be disruption of the blood supply to the testicle caused by dissection in the inguinal canal (even more so the case if it is a recurrent hernia), and in rare cases can cause testicular atrophy. This problem is avoided in laparoscopic surgery.

The main potential risk of laparoscopic hernia surgery is accidental damage to the bowels or internal blood vessels during surgery. This is exceedingly rare, and is indeed common to all forms of keyhole and laparoscopic surgery. Care is always taken when making the small incisions to gain entry into the abdomen to avoid this from happening. A general anaesthetic is always required. Most open hernia operations also require a general anaesthetic, but some are suitable for treatment using local anaesthetic.

The two main reasons why laparoscopic hernia surgery is not as widely available as traditional open surgery is firstly because by using special (disposable) instruments it becomes more expensive for hospitals and trusts to provide this service, and secondly because not many general surgeon who usually perform hernia repair have had training in keyhole surgery.

Laparoscopic hernia surgery has been a controversial and hotly debated issue for the last five or more years. Established surgeons and hospital trusts initially found it difficult to justify providing this surgery because of the need to take special training and the cost issue, with only the patient being the potential recipient of any benefit. The National Institute for Clinical Excellence (NICE) has been, and continues to appraise and monitor developments. Initially they passed guidelines that recommended that laparoscopic hernia repair should only be offered to patients with bilateral, recurrent or incisional hernias. In these cases, the additional cost of the laparoscopic procedure is offset by the reduction in hospital in-patient stay and bed-usage, and the benefit received by the patient is also translated to an overall cost saving for the hospital or trust. NICE also recommends that only surgeons trained in the technique perform laparoscopic surgery.

Recently, NICE has revised its guidelines, now stating that laparoscopic hernia surgery can be offered to patients with unilateral hernias as well. However, not all NHS trusts have agreed to provide this service just yet unless the extra cost of the procedure can be justified. This is hopefully likely to happen in the near future, with the combined benefit of less medical intervention of for chronic pain, and the return of patients back to normal work impacting on the health economics of hernia surgery.