The use of mesh in hernia repair, risk management and the advantages of day surgery

It is not always possible to distinguish clinically between a direct and indirect inguinal hernia.

Some guiding points are size:

1.                  It is uncommon for direct hernias to reach down into the scrotum, and they are generally smaller.

2.                  It is common for direct hernias to bulge forward. They are often bilateral in the older person.

3.                  The impulse as detected by palpation at the internal ring, is directly forward rather than oblique.

4.                  Pressure over the internal ring will prevent the descent of an indirect hernia but not a direct hernia.

While these are all practical points in differentiation there is a significant error rate. The basic need is to be able to decide which hernia should be operated on and which can be observed and reviewed.

Generally indirect herniae should be surgically repaired because they become larger, cause symptoms and may obstruct and strangulate.

In children this is especially so because strangulation is more prone to occur with little warning.

Direct herniae usually do not cause marked symptoms or become very large, nor do they obstruct or strangulate; surgery can usually be safely delayed.

Many other factors will decide whether surgery is carried out, but generally it is advised for either (ED. ?both type(s)) type. A truss is sometimes used to prevent the hernia protruding and to minimise the discomfort. A truss is often used when the patient declines or is considered unfit for surgery. A truss however, is not always effective and often only delays the issue.

THE SURGERY
Herniotomy
In children removal of the indirect sac is usually considered to be sufficient – herniotomy.

Hernioraphy
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 (Ed?) wall (ED?strengthened). using 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 on it is the suturing 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.  

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