Laparoscopic (keyhole) inguinal hernia repair
Ten years ago, a member of my close family had an inguinal hernia and needed surgery. At the time, most surgeons were repairing hernias using traditional ‘open’ surgery but there was a relatively new approach known as ‘keyhole’ or laparoscopic hernia repair.
I deliberated for quite some time about which type of surgery I thought they should have based upon the available evidence. Once I had concluded that laparoscopic surgery would be the best operation, I recall thinking, if that's what I'd like my own family to have, I should probably start offering it to my patients. Since then I have carried out hundreds of laparoscopic hernia repairs and have seen the benefits of this surgery time after time.
People normally come and see me complaining of a bulge that is making them feel uncomfortable. A hernia is only rarely painful, which does cause some issues when someone is trying to get treatment. A big problem is that the government recommendations for GPs to be able to refer people for hernia repair surgery largely relate to pain. This means, unfortunately, that a lot of people aren't able to get a hernia repaired for reasons other than pain.
The consequence of this is that people have to carry on with their daily activities, aggravating any unpleasant sensations they may have from their hernia and potentially making it worse. More people are being admitted for urgent hernia repair, which is far riskier than a planned procedure. Emergency hernia repair can involve having to remove some of the bowel and having a longer recovery. It can also sometimes affect the quality of repair that can actually be done and usually means that keyhole surgery cannot be performed.
There are two standard ways of inguinal hernia repair; open and keyhole. Both options involve placing a mesh in the weak point of the abdominal wall to strengthen it, but the way they achieve this is different.
Open surgery involves cutting into the skin and abdominal wall muscles over the hernia, pushing the hernia back in and then putting the mesh in place. The cut is usually around 6-8cm long, so not an insignificant size and it will often leave a noticeable scar.
There are two types of keyhole hernia repair known either as: 'totally extraperitoneal repair' (TEP) or 'transabdominal pre-peritoneal repair' (TAPP). My preferred approach is the extraperitoneal repair (TEP) but both are less invasive than the open approach although they do always require general anaesthetic. I only need to make small cuts in the skin, through which I place special instruments that help me reach the hernia, carefully pull it back inside the abdomen and then position the mesh.
One way of explaining the difference between open and laparoscopic surgery is to use the analogy of making a sandwich. Let’s say you've just made a ham sandwich but then decide that you want to add some lettuce to it; open surgery would be like cutting a hole in the bread to put the lettuce in while laparoscopic surgery would be more like lifting one edge of the bread and carefully sliding the lettuce in.
I offer keyhole hernia repair because, on average, it reduces the amount of pain somebody feels after surgery, in both the short term and the long term and especially for younger patients. The particular approach I use minimises the need for fixation of the mesh by using shaped meshes, which itself lowers the likelihood of pain even further. My particular version of the keyhole hernia operation, totally extraperitoneal repair (TEP), also minimises risk to the bowel because it doesn’t involve entering the abdomen, as happens with a transabdominal (TAPP) repair.
Keyhole repair does require a general anaesthetic and therefore may not be suitable for elderly and infirm patients who can still have open repair under local anaesthetic. I am also very comfortable performing open repair when it is appropriate and will discuss that with you.
The keyhole technique is less invasive surgery, meaning recovery time is reduced. I usually encourage people to do gentle activity and walking straight afterwards, although they should avoid excessive or intense exercise for a week or two. After two weeks, most people can return to normal activities, including work and sports, without any concern.
I believe in patient-led care. When I first meet somebody for a consultation, I will spend time talking with them, explaining exactly what a hernia is, what may have caused it and what surgery would be helpful for them, balancing the potential benefits with any potential pain. I will reassure you if you do not need an operation.
Although a hernia isn't normally a serious health risk, it can be uncomfortable to live with. If you have a hernia and would appreciate expert help and guidance, it is very easy to book a consultation with me. Please contact my private secretary who will be delighted to schedule things for a time that is most convenient for you.
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