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Hernias > The Surgery for Inguinal Hernias

In children removal of the indirect sac is usually considered to be sufficient - herniotomy.

However, in adults there is a mechanical defect in the structure of the internal ring which if not repaired will result in recurrence of the hernia. The internal ring must be narrowed and the posterior wall strengthened by either suturing or reinforcing the transversalis fascia, the arching muscular and aponeurotic fibers of the internal oblique and transversus muscles. Thus recurrence of an indirect inguinal hernia is prevented and the development of a direct inguinal hernia at a later stage is averted.

The aim is for a combination of early and long lasting strength using a suture which holds its ties well and does not have the propensity to develop chronic infection with subsequent sinus formation.

Early strength is obtained by the suturing but within a period of two to three months which entirely holds the repair together, but within a period of two to three months the wound has reached its maximum strength and the suturing plays a lesser role.

With a DIRECT HERNIA, the bulge can be reduced by imbrication of the thin tissue of the posterior wall. Imbricate means to turn in on itself. This reduces the hernia without exerting tension on the surrounding muscle and inguinal ligament. However it is generally considered that this is not sufficient to repair a direct inguinal hernia, and once the posterior wall has been reconstituted in this manner, additional measures are necessary.

This involves suturing muscular and preferably aponeurotic tissue of the arch down to the inguinal ligament. This is difficult to achieve without tension as the tissues are usually weak over a fairly wide area. In order to narrow this gap, a relieving incision is made in the anterior layer of the rectus sheath - sometimes termed Tanner's slide. Nevertheless it is thought to be the excessive tension on this suturing which is the main cause of recurrence of direct inguinal herniae. Generally it is believed that direct inguinal hernia recur following repair more frequently than indirect herniae.

Over the years many additional methods have been used to reinforce this repair with different types of grafts and implants. This process is termed hernioplasty.

An example of hernioplasty is the placement of non-absorbable synthetic mesh such as polypropylene mesh over the posterior wall. This acts as a buttress and a trellis into which fibrous and scar tissue grows.

Prosthetics, i.e. the addition to the body of some artificially prepared material are commonly used in surgery now. They have many desirable features but limitations as well. For herniae they must be strong and durable and pliable and should not cause a prolonged or excessive inflammatory response. They should be inert and not rejected. The mesh may be sutured in place with similar materials so friction and tension are reduced. Metallic staples are now commonly used. There has been a move to avoid suturing and staples all together.

With a mesh there is immediate strength and with time a strong wall is formed. The repair is reinforced without having to pull muscle and aponeurotic tissue tightly down onto the inguinal ligament.

Chronic infection and sinus formation can occur but fortunately are rare with the modern materials used.

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