Herniorrhaphy (Hernia Repair Surgery)

Note on terminology: The user asked about "herniactomy" - the correct surgical term is herniotomy (sac excision alone) or herniorrhaphy (repair including wall reconstruction). Both are explained below.

What Is a Hernia?

A hernia occurs when an organ or tissue (most commonly bowel or omentum) pushes through a defect or weakness in the surrounding muscle or fascial wall. The most common type is the inguinal hernia - accounting for the vast majority of hernia repairs worldwide.

Terminology Clarified

Term	Meaning
Herniotomy	Simple excision (cutting away) of the hernia sac alone - no wall repair
Herniorrhaphy	Sac removal + surgical repair/strengthening of the abdominal wall
Hernioplasty	Repair using a prosthetic mesh to reinforce the defect

In children, herniotomy alone is sufficient because the inguinal canal musculature is still developing. In adults, herniotomy alone has a high recurrence rate and some form of muscle-strengthening repair (herniorrhaphy) is mandatory. - Bailey and Love's Short Practice of Surgery, 28th Ed.

Indications for Surgery

Symptomatic inguinal hernia (pain, dragging discomfort)
Increasing hernia size
Irreducible (incarcerated) hernia
Strangulated hernia (emergency - ~5% of cases) - time-critical due to risk of bowel infarction
Asymptomatic small direct hernias in elderly patients may be managed conservatively; surgical trusses are not recommended

Surgical Approaches

1. Herniotomy (Children)

In children with a lateral (indirect) hernia due to a patent processus vaginalis, it is sufficient to simply excise and close the hernia sac. The steps are:

Incision over the inguinal canal, Scarpa's fascia opened
External oblique aponeurosis incised
Cremaster opened to identify the sac
Sac mobilised from the testicular vessels and vas deferens
Sac divided, twisted to reduce any contents, and transfixed/ligated at the internal ring
Wound closed in layers

2. Open Suture Repair (Herniorrhaphy)

Bassini Repair (1890) - the historical gold standard:

The inguinal canal is entered by opening the external oblique aponeurosis
Spermatic cord is dissected free
For lateral hernias: sac is separated from cord, opened, contents reduced, sac closed at its neck and excised
For medial hernias: sac is inverted and the transversalis fascia is suture plicated
Sutures are placed between the conjoint tendon (above) and inguinal ligament (below) from pubic tubercle to deep inguinal ring - strengthening the posterior wall

Shouldice Repair - the best suture-only technique:

The transversalis fascia is opened centrally and then closed to create a two-layered (double-breasted) posterior wall
Expert centres report lifetime failure rates of less than 2%, but it is technically demanding
Most surgeons achieve similar results to Bassini

Maloney Darn - uses continuous non-absorbable nylon or polypropylene suture darned between the conjoint tendon and inguinal ligament; gives excellent results and is the most common operation in countries where mesh is too expensive.

Desarda Repair - a 1-2 cm strip of external oblique aponeurosis is isolated and sutured to reinforce the posterior wall; considered equivalent to Shouldice repair. - Bailey and Love's, 28th Ed.

3. Open Mesh Repair (Hernioplasty) - Most Common Today

Lichtenstein Tension-Free Repair (since 1980s) - the most common operation for inguinal hernia in resource-rich countries:

Initial dissection identical to Bassini
Hernia sac removed; medial defect closed if present
A flat polypropylene mesh (8 x 15 cm) is placed over the posterior wall, behind the spermatic cord
The mesh is slit to wrap around the spermatic cord at the deep inguinal ring
Loose sutures fix the mesh to the inguinal ligament and conjoint tendon

Lichtenstein's tension-free mesh repair showing the mesh sutured over the posterior wall of the inguinal canal

Figure: Lichtenstein's repair - Bailey and Love's, 28th Ed.

Two key advantages: lower recurrence rates and faster postoperative recovery. However, chronic pain is the most reported complication, with rates as high as 20%. - Bailey and Love's, 28th Ed.

4. Laparoscopic Repair

Two main techniques:

Technique	Full Name	Description
TEP	Totally Extraperitoneal	Mesh placed in the preperitoneal space without entering the peritoneal cavity
TAPP	Transabdominal Preperitoneal	Peritoneal cavity entered, mesh placed behind the peritoneum

Both approaches require general anaesthesia and place a large mesh in the preperitoneal space. Advantages include:

Less postoperative pain (particularly for bilateral or recurrent hernias)
Faster return to normal activities
Lower rates of chronic pain vs. Lichtenstein

Robot-assisted laparoscopic repair is increasingly used; the enhanced surgical view and ergonomic comfort for the surgeon are recognised benefits, though little additional patient benefit has been demonstrated and the cost is hard to justify for simple inguinal repair.

Mesh Materials

Three main classes of synthetic mesh are used:

Material	Properties
Polypropylene	Inert, hydrophobic monofilament; resists bacterial ingrowth; most commonly used
Polyester	Hydrophilic; encourages microvascular ingrowth
PTFE (polytetrafluoroethylene)	Flat sheets; very inert; resists both tissue ingrowth and adhesion formation

Mesh can be used to: bridge a defect (patch over), plug a defect (pushed into the defect - largely abandoned due to "meshoma" formation), or augment a primary suture repair. Inlay (edge-to-edge suturing into the defect with no overlap) is not recommended. - Bailey and Love's, 28th Ed.

Emergency Hernia Surgery

About 5% of inguinal hernias present as an irreducible, painful lump that may progress to strangulation and bowel infarction. Key points:

Time is critical in the presence of ischaemic bowel
~20% of emergency cases require bowel resection
May require conversion to midline laparotomy
Synthetic mesh is acceptable unless there is significant contamination (with appropriate antibiotics)

Complications

Category	Complications
Immediate	Haematoma (subcutaneous vessels; rarely inferior epigastric/iliac vessels), urinary retention, femoral nerve blockade from local anaesthetic
Short-term	Wound infection (<5% in groin herniorrhaphy), seroma, testicular swelling
Long-term	Chronic groin pain (most common overall - up to 20% with mesh), hernia recurrence, injury to vas deferens causing infertility (mesh can obstruct vas in inguinal canal), nerve injury (ilio-inguinal, iliohypogastric, genitofemoral nerves)
Rare	Enterocutaneous fistula (2-5% of all ECF cases involve prior herniorrhaphy)

Anaesthesia

Herniorrhaphy can be performed under local, regional, or general anaesthesia with minimal risk even in high-risk patients. Postoperative pain is managed by iliohypogastric and ilio-inguinal nerve blocks using bupivacaine 0.5% (10 mL each) injected 2 cm medial to the anterior superior iliac spine, providing relief for up to 6 hours. - Pye's Surgical Handicraft, 22nd Ed.

Choosing the Right Operation

No single operation suits all hernias. Factors to consider:

Surgeon's skills and available equipment
Patient type (age, fitness, bilateral vs. unilateral, recurrent vs. primary)
Hernia characteristics (direct vs. indirect, size of defect)

In summary, the Lichtenstein open mesh repair is the dominant operation in resource-rich settings; laparoscopic TEP/TAPP is preferred for bilateral or recurrent hernias; and suture-only repairs (Shouldice, Maloney, Desarda) remain the standard where mesh is unavailable. - Bailey and Love's, 28th Ed.

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