Hernia Repair Surgery
On February 17, 2013
Watch as Lee J. Skandalakis, M.D., F.A.C.S. performs Hernia Repair Surgery
Dr. Skandalakis is a general surgeon who has an interest in hernias and has published numerous books and journal articles on hernias, including the anatomy and repair of them. He has helped many patients get back to their normal active lives through simple and quick surgical procedures that require very little downtime. For more information on hernias and hernia surgery, please contact us.
Lee J. Skandalakis, M.D., F.A.C.S. is a graduate of Emory University School of Medicine and is Board Certified in General Surgery. Dr. Skandalakis has been in practice at Piedmont Hospital since 1986. He has also co-authored a number of books and journal articles on the subject of hernia repair and anatomy.
Definition—a hernia occurs when there is a tear or opening in the muscles of the abdominal wall. A small sac containing fat or intra-abdominal contents such as intestines protrudes through that opening. The repair of a hernia is called a herniorrhaphy. There are acquired hernias which are caused by straining over the years and congenital hernias which have resulted from a weakness in the abdominal wall present since birth. A hernia that cannot be reduced is incarcerated. If the blood supply of the hernia contents is compromised this is called a strangulated hernia. A hernia that develops at the belly button is called an umbilical hernia. Inguinal hernias develop in the groin. There are two basic types of inguinal hernias: direct and indirect. An indirect hernia follows the spermatic cord or round ligament where as a direct hernia protrudes directly through the muscles of the groin. Femoral hernias protrude through the femoral canal. A hernia that develops at an incision is called an incisional hernia. A ventral hernia can occur anywhere in the abdominal wall where there is a weakness. A hiatal hernia occurs when the stomach slides through the diaphragm into the chest.
A hernia can develop in anyone. Young, old, healthy or not, it makes no difference. Males are approximately five times more likely to develop groin or inguinal hernias. Femoral hernias are more common in females. The over all incidence of hernias in the adult male population is approximately five percent.
As a matter of fact there are. Lifting heavy objects, muscle strains, massive weight gains, chronic constipation, repeated attacks of coughing or chronic coughing and straining to urinate are just a few of the risk factors.
Generally a hernia can occur anywhere in the abdominal wall. If there is a weakness or defect in the abdominal wall a hernia can occur. The most common sight of a hernia is in the groin. Inguinal or groin hernias comprise 80 percent of all hernias. Hernias can also occur at previous abdominal incisions.
Frequently there are no symptoms. A hernia can be a fortuitous finding on a routine physical examination. More often however the hernias are symptomatic. The symptoms can include a bulge where the hernia is, pain in the area, a feeling of pressure or weakness in the area, a burning sensation, and a gurgling or squishy feeling in the area. A hernia can also present acutely. For instance heavy lifting in the yard or garden accompanied by sudden pain in the area of the inguinal or umbilical region could mean a hernia. Individuals who know they have a hernia should be aware of an incarceration. That means that the hernia cannot be pushed back can. Often incarceration can lead to strangulation. This is when the blood supply of what ever is in the hernia sac becomes compromised. This can be a life threatening condition that requires immediate medical attention.
There are many ways to repair a hernia. The conventional method: the hernia sac and defect are dissected out and the sac is either removed or reduced. Next using suture material, the muscle tissue surrounding the hernia defect is reapproximated. Tension free repair using mesh: This is our procedure of choice. Once again the hernia defect and sac is dissected out and the sac either removed or reduced. The mesh is then inserted and covers the abdominal wall defect. Since the hernia is repaired without tension and minimal suturing used, there is a less pain. The mesh is a synthetic substance that has been around for years and is well tested. It is well accepted by the body’s natural tissues which grow into the mesh. Recovery is rapid and the likelihood of a recurrence is low. The laparoscopic method: this is a similar to the tension free repair. A laparoscope which is a camera and light source is inserted in the vicinity of the hernia. The surgeon can then visualize the procedure on a television monitor. Surgical instruments are then inserted through separate incisions. The hernia defect and sac are dissected out and the hernia sac and its contents reduced back through the defect. Mesh is then used to cover the defect and is held in place with surgical staples.
Repairs are judged as good or bad depending on their recurrence rates. Obviously every surgeon strives to have a recurrence rate as close to 0% as possible. In reality however there is no such thing as a hernia repair that has a 0% recurrence rate. A tension free repair has a recurrence rate of approximately one half to 1%. A conventional repair, that is using suture material to close the hernia, can be associated with a recurrence rate as high as 10%. Recent studies have shown that a tension free repair using mesh as well as a laparoscopic repair have similar outcomes in terms of recurrence rates and complication rates. There are some patients that may be candidates for a laparoscopic repair depending on the type of work they do and their body habitus. Every patient is different and we try to tailor our recommendations based on the individual.
Most hernias do not reoccur. However, when they do, repair is usually done in the same manner as a primary hernia. Usually a synthetic mesh is used and is tacked or sutured in place. Some times a laparoscopic approach is used. It just depends on the patient and how many repairs they have had in the past.
Component separation technique is used for complex recurrent hernias when using mesh is not possible. This is usually the case when infected mesh is removed. Synthetic mesh cannot be replaced in an infected field so component separation is used to close the abdomen by advancing muscle tissue. Sometimes a porcine or bovine or cadaver mesh is used to augment this repair.
If you have pain and a bulge in any of the highlighted areas you may have a hernia. Please see a Specialist.
On February 17, 2013
Watch as Lee J. Skandalakis, M.D., F.A.C.S. performs Hernia Repair Surgery
How is it possible that there are records that go back thousands of years documenting hernias in human beings? We are in luck because most hernias when left unattended become very large and obvious and can lead to complications many of which can be fatal. If an important individual of that time was afflicted with a hernia it was memorialized in some way. Because of the obviousness of very large hernias even unimportant individuals would have been noticed by observant scholars of the time and their hernia chronicled in someway.
One of the first images of an individual with a hernia is seen in the picture to the left Phoenician terra-cotta figure showing an umbilical hernia in a woman in the fifth or fourth century BC.
In the sixth dynasty of Ptah-hotep, the relief picture to the left shows workers in the field with umbilical hernias.
The shown at the left is of the Ankhmahor tomb at Saqqara at 2500 BC shows a relief showing reduction of an inguinal hernia.
The mummy of Pharaoh Meneptah who rain around 1215 BC shows complete absence of the scrotum but not the penis. It is surmised that an Egyptian surgeon attempted cure for a hernia. The mummified remains of Ramses V, 1157 BC, shows a massive inguinal hernia.
The earliest written reference to hernias appears in the Egyptian papyrus of Ebers circa 1500 BC.
In 300 BC in the corpus Hippocraticum hernias are mentioned as well as a few varieties and correlates them to certain occupations.
Praxagorus of Cos at around the fourth century BC is reputed to have attempted reduction of a strangulated hernia. Two others of that same time Herophilus of Chalcedon and Erasistratus of Keos are reputed to have performed hernia surgery.
Celsus lived in Rome in the first century A.D. He came from a wealthy family and wrote on many subjects including philosophy, warfare, agriculture and medicine. He gives an excellent description of the clinical signs of strangulation and the symptoms that can occur. He described the first surgical technique for hernias. Heliodorus or (sun's gift) during the rein of Trajan describes a method of surgery for inguinal hernia. Claudius Galenus (shown on the left) who lived from 129 to 201 A.D. was a practitioner of medicine in the gladiator school. He was a prolific writer and published more than 100 books. He was a keen observer and commented that there was a deficiency in the two external abdominal muscles, which led to hernias.
Aretaios of Cappadocia lived sometime in the first century after Christ. He wrote a detailed description of a complication of a strangulation hernia. Aetius around 500 A.D. was a court physician to a Byzantine Emperor Giustiniano. He described a detailed surgical technique and also advocated that surgery was dangerous and should be avoided at all costs. In lieu of surgery he recommended prayers. Paul of Aegina from around 650 A.D. lived in Alexandria Egypt. He is responsible for a comprehensive surgical text describing scrotal and non-scrotal hernias. He suggested routine orchiectomy.
Albucasis was a Moorish surgeon circa 1000 A.D. he wrote a book which concentrated on procedures and instruments and was striving to revive the art of surgery as taught by the ancients. The picture on the left is an illustration from his book.
Avicenna from around 1000 A.D. was an Arabian physician who used auscultation to distinguish between hernia and hydrocoel. William of Salicet who lived around 1250 A.D. advocated preserving the testicle. Mondino de Luzzi was a professor of medicine in Bologna, around 1300 A.D. He revived the study of anatomy and came up for a radical cure for hernia. Guido Lafranchi from Paris, around 1350 A.D. advocated conservative treatment and was inspired by God to save the testicle! Roland of Parma from around 1383 A.D. treated hernias with with a position called Trendelenburg.
The image to the right shows an illustration from his book where the patient is positioned head down on a steep incline and uses gravity to help an incarcerated hernia reduce.
Guy de Chauliac (pictured to the left) lived in France in the 1300s. He wrote a magnificent book, Chirugia Magna. He was the first to note the difference between an inguinal and a femoral hernia. He also believed in manual reduction by Trendelenburg.
Pierre Franco was one of the more excellent surgeons of his time. He was the first to describe operation on a strangulation hernia. Ambrose Pare was a surgeon to Henry III (pictured above). He advocated trusses for treatment of inguinal hernias. He came up with many innovative instruments, which many of which are used today.
Casper Stromayr of Germany around 1560 AD differentiated direct, indirect and femoral hernias. The following is an illustration from his book. This shows a female with a femoral hernia.
Gabriel Fallopius (pictured above) was a professor anatomy, surgery and botany and Padula around 1570 A.D. He studied with the famous Vesalius. He noted a high incidence of hernias in singers and monks.
Fabricius Aquapendente (pictured above) in the late 16th century debated the merits of medicine versus surgery and he preferred trusses to surgery. If that failed his second choice was Ferrum Candens!
Lorenz Heister of Amsterdam first recorded description of a direct inguinal hernia. Pieter Camper of Leyden around 1750 AD described the surgical anatomy of the inguinal hernia and described the fascia named after him. Franz Hesselbach described the ligament that now bears his name and also the triangle that is the home of direct inguinal hernias. Antonio de Gimbernat (pictured below) described in enlarging the femoral ring by dividing the lacunar ligament as a treatment for incarcerated femoral hernia.
Sir Astley Pastan Cooper (pictured above) gives an excellent description of the anatomy and described new surgical techniques in his book published in 1802.
Henry O Marcy was a American general surgeon from Boston who practiced in the early 20th century. He performed high ligation of the hernia sac as well as closure of the internal ring to repair indirect hernias. This is a procedure that is still used widely today especially in pediatric patients.
Edoardo Bassini was an Italian surgeon from the early 20th century. Everyone considers him the father of modern herniorrhaphy. The procedure that he described is still in wide use throughout the world.
William Stuart Halsted was a prolific surgeon from Johns Hopkins in the early 20th century. He modified the Bassini procedure. He is also well known for championing aseptic technique and surgical education.
In the late 40s Chester McVay popularized the use of the Cooper's ligament for repair of inguinal hernias.
In the 1950s French surgeon and anatomist Henri Fruchaud clarified the preperitoneal anatomy. Based on his work prepare Preperitoneal approaches and laparoscopic approaches were realized.
In the early 50s Edward Shouldice, Nicholas Obney and Ernest Ryan were performing a multiple layer repair of the posterior inguinal wall.
One of the first synthetic meshes used was Marlex. This was a poly propylene substance which revolutionized hernia repairs. This ushered in the era of tension free repairs. In 1965 Dr. Rives developed a hernia repair placing mesh in the pre-peritoneal space. He felt that all patients did not need this type of repair and consequently was very selective about using it. In 1984 Dr. Renè Stoppa used a large dacron prosthesis to reinforce transversalis fascia for complex hernias in patients who were deemed at high risk for recurrences. In the 1970's Lloyd Nyhus, my chief and mentor (pictured to the left) from the University of Illinois and Cook County Hospital in Chicago and Robert Condon from the University of Wisconsin in Madison popularized the pre-peritoneal approach for repair of all inguinal and femoral hernias.
In 1986 Dr. Lichtenstein introduced his tension free repair. He placed his mesh on top of the inguinal canal as opposed to underneath the inguinal canal as is done in a pre-peritoneal repair. In 1991 Dr. Gilbert described a sutureless version of the list Lichtenstein repair. In 1994 Dr. Kugel performed a preperitoneal repair with a mesh he specifically designed for this occasion.
In 1982 Dr. Ralph Ger performed the first Laparoscopic inguinal herniorrhaphy. A few years later Dr. Fitzgibbons would add mesh to the laparoscopic approach. This is but a brief review of the history of hernias based on the definitive text on this subject titled Hernia Healers by Rene Stoppa, George Wantz, Gabriele Munegato and Alfonso Pluchinotta, published by Arnette 1998.
Lee J. Skandalakis, MD, FACS
Piedmont Surgical Associates, LLC
95 Collier Road, Suite 6015
Atlanta, Georgia 30309
phone: (404) 351-5959
fax: (404) 355-1113
Georgia Institute of Technology
(1972-1976) B.S., Applied Physics
Emory University School of Medicine
University of Illinois School of Medicine and Cook County Hospital
(1980-1985) General Surgery
General Surgery (December 18, 1986)
Recertification (May, 1998)
Advanced Trauma Life Support Instructors Course
Fort Gordon, Georgia
(February 14-16, 1986)
Annual CME credits
SESAP all editions