Contents

• Introduction

• LapSurgery Australia Hernia Service

• What is a hernia?

• How do I know if I have a groin hernia?

• What tests are available to diagnose a hernia?

• What is the difference between an inguinal and femoral hernia?

• What causes a hernia?

• Why can't I just wear a truss?

• What is keyhole surgery for a hernia?

• How is the mesh held in place?

• What are the advantages of keyhole surgery for hernia?

• When can I return to normal activities?

• Can the hernia come back (recur)?

• What if I have already had a hernia repaired the old way and it has come back?

• Should everyone have a keyhole operation for hernia?

• Are there any disadvantages of keyhole surgery for hernia?

• My surgeon wants to perform a non-keyhole operation!

• How do I make an appointment to discuss surgery for my hernia?

• Why choose LapSurgery Australia for your keyhole hernia operation?

• What hospitals do LapSurgery Australia surgeons use?

• Costs

• Links

/\  Introduction

Inguinal and femoral hernias, referred to as groin hernias, are very common. Approximately 16,000 hernia operations are performed in Victoria each year. Inguinal hernias occur in up to 10 percent of males but are much less common in females. Femoral hernias are more common in women than men but are much less common than inguinal hernias. The most serious complication of groin hernias is strangulation. This occurs when a segment of the bowel is caught in the hernia and becomes obstructed or even gangrenous – medical attention must be sought immediately. This complication is more common in femoral hernias. Hernias never cure themselves and almost always require surgery for repair.

/\  LapSurgery Australia Hernia Service

LapSurgery Australia offers a complete service for all hernias including groin hernias, umbilical and incisional hernias using both kehyhole and non-keyhole techniques. As we can perform both keyhole and non-keyhole procedures equally well, you can be assured that you will receive appropriate advice and skilled surgery specific to your condition and circumstances. The merits of keyhole v. non keyhole surgery will be discussed with you carefully before surgery is undertaken.

/\  What is a hernia?

A hernia is a protrusion of an organ or body part through the wall of a cavity in which it is normally enclosed. What this means, in the case of groin hernia, is that part of the abdominal contents, either bowel or fatty tissue, protrudes through the abdominal wall at the inguinal or femoral canal and comes out just below the skin. In males, a large hernia can descend into the scrotum. The inguinal canal is an oblique passage through the abdominal wall which, in the male, transmits the artery and vein to the testicle and the vas deferens. In the female, only the round ligament of the uterus goes through the inguinal canal and this is perhaps why inguinal hernia is less common in women. The inguinal canal is one of several weak spots in the abdominal wall where a hernia can occur.

/\  How do I know if I have a groin hernia?

The commonest symptom of a hernia is the presence of a lump in the groin. Sometimes hernias can be painful, but small hernias may not be noticed initially by the patient and are sometimes found unexpectedly at a routine examination. Often the lump is more prominent at the end of the day, disappears when lying down and may not be apparent after a night's sleep.
In rare instances, the first presentation of a hernia is a very painful lump in the groin which does not go away when lying down and may be associated with generalised pain across the abdomen and vomiting. This is caused by strangulation and should this happen it is an extreme emergency and immediate medical attention must be sought.

/\  What tests are available to diagnose a hernia?

For the vast majority of patients, a hernia is diagnosed by a simple physical examination from your general practitioner or specialist. In some cases ultrasound examination of the groin is used but most surgeons are sceptical of the accuracy of ultrasound examination for hernia. The results of ultrasound examination must be interpreted in conjunction with a physical examination by your general practitioner or specialist surgeon.

/\  What is the difference between an
    inguinal and femoral hernia?

It can sometimes be difficult for even an experienced specialist to tell the difference by physical examination. At operation the difference is easily seen. An inguinal hernia comes out through the inguinal canal above the inguinal ligament. A femoral hernia comes out below the inguinal ligament, just above the pubic bone. A femoral hernia is more liable to strangulation.

/\  What causes a hernia?

Hernias which occur in childhood or adolescence are probably congenital. In adults a hernia is usually acquired. Although not well proven, it is thought that occupations involving heavy lifting or manual work increase the chance of developing a hernia. Cigarette smoking, chronic constipation, obesity, prostate disease and chronic coughing are also thought to predispose to hernia formation. In many patients none of these factors is present and the development of a hernia is thought to be related to the fact that the inguinal and femoral canals are natural areas of weakness in the body wall.

/\  Why can't I just wear a truss?

A truss is a type of belt with padding which goes over the inguinal canal to keep the hernia from coming out during normal activity. They are generally uncomfortable, will not cure the hernia and do not prevent strangulation. We strongly recommend against the use of a truss except in those very rare people who are too sick to undergo operative repair of the hernia. A truss must NEVER be used on a femoral hernia.

/\  What is keyhole surgery for hernia?

Laparoscopic or keyhole surgery for hernias has evolved over the last 10 years. There have been several different ways of performing keyhole surgery for hernia, but the worldwide trend is toward the totally extra peritoneal (TEP) repair which is what we at LapSurgery Australia perform. The advantage of this method is that the peritoneum (the cavity containing the bowels) is not entered. A space is made by inflating a balloon between the lining of the peritoneal cavity and the groin muscles and inflating the space with CO2 gas to create a working space.

The standard (non-keyhole) operation involves a large incision in the groin (or both groins if there are hernias present on both sides), finding the hernia and patching the defect with polypropylene mesh.
In the keyhole operation a 1.5 cm (3/4 inch) incision is made just below the umbilicus (bellybutton) and two further tiny incisions are placed between the umbilicus and the pubis. No further incisions are required even if there are hernias in both groins. The hernia is identified and the defect repaired with mesh as in the open (non-keyhole) operation.

/\  How is the mesh held in place?

Currently we use tiny titanium staples to hold the mesh in place while healing takes place. These are spiral shaped to avoid any damage to nerves and stay in place permanently. Titanium staples are widely used in many keyhole and non-keyhole operations. They are inert and have no known long term effects. Being non-magnetic they do not affect MRI scans. Tissue glues are currently being developed to secure the mesh and may replace staples in the future.

/\  What are the advantages of keyhole surgery for a hernia?

There are three main advantages:

1. The small incisions result in less pain and earlier return to work, especially when hernias are present on both sides.

2. The positioning of the mesh on the inside of the defect is mechanically better than when placed on the outside as in the non-keyhole operation.
3. By positioning the mesh on the inside of the defect, the very sensitive nerves in the inguinal canal are not damaged or irritated by the mesh as can occur in the non-keyhole operation.

/\  When can I return to normal activities?

From the time you awake from the anaesthetic the repaired hernia is already stronger than a normal groin! Naturally you will be a little tender for the first few days but there are NO LIMITATIONS on activities other than common sense regarding any discomfort from the tiny wounds.

/\  Can the hernia come back (recur)?

Recurrence rates for modern mesh hernia repairs (keyhole or non-keyhole) are very low, of the order of 1-2%. LapSurgery Australia considers that the recurrence rates of keyhole hernia surgery are at least as low as with the non-keyhole operation and probably lower. The keyhole operation for inguinal hernia also prevents the future development of a femoral hernia which is a well recognised occurrence after the non-keyhole operation.
It is important to note that there is no evidence linking recurrence of a mesh hernia repair with physical activity either immediately after the operation or later.

/\  What if I have already had a hernia repaired the old way and it has come back?

You are in luck! The keyhole operation is vastly superior to the non-keyhole operation for recurrent hernia. Results of keyhole surgery for recurrent hernia are just as good as if there had never been a previous operation.
Non-keyhole surgery for recurrent hernias has a significant failure rate and significant risks including damage to the nerves in the inguinal canal and damage to the artery to the testicle which can even cause the testicle to die!

/\  Should everyone have a keyhole operation for hernia?

No. There are a number of reasons why an individual may be better off with the non-keyhole operation:

1. Very large hernias may not be suitable for keyhole repair.
2. Patients with previous lower abdominal surgery may not be suitable.
3. Patients unable to tolerate a general anaesthetic are not suitable.
4. Patients who do not have a need for quick recovery may be better off with the less complex non-keyhole operation.
5. Patients without private health cover may find the extra hospital costs of the keyhole operation are not justified.

/\  Are there any disadvantages of keyhole surgery for hernia?

A number of factors have been proposed as being disadvantages of the keyhole operation.

1. The operation takes longer. This is certainly true when a surgeon is learning how to do this quite complex procedure, but the experience of surgeons at LapSurgery Australia shows that once the keyhole technique is mastered, there is very little difference in time taken between the keyhole and non-keyhole operation.
2. There is a higher incidence of serious complications. This is true if the raw data published in the medical literature is examined. However, the same can be said of a number of new operations introduced over the last few years such as keyhole gallbladder surgery. As experience with these new techniques is gained, the complication rate declines to minimal levels. LapSurgery Australia surgeons have encountered no major complications specific to the keyhole operation.
3. In the exceptionally rare situation of a complication of the mesh such as infection or mesh rejection, the mesh is more difficult to remove than when it is on the outside of the muscles as with the non-keyhole operation. LapSurgery Australia accepts that this may be a disadvantage of the keyhole operation, but removal of mesh from any part of the body at any time can be extremely difficult and result in complications. Estimates of the chance of mesh infection or rejection range from 1 per thousand cases to 1 per 3000 cases.

LapSurgery Australia considers that the advantages of keyhole surgery for hernia greatly exceed any disadvantages.

/\  My surgeon wants to perform a non-keyhole operation!

The question to ask any surgeon who proposes a non-keyhole operation on your hernia is whether he/she is able to perform the keyhole operation.
As of the beginning of 2003, only a very small number of surgeons in Victoria have any significant experience in performing keyhole surgery for hernia.
If your surgeon is unwilling or unable to perform keyhole surgery for other than the reasons specified earlier on this page, you may choose to seek a second opinion. This is your prerogative.

/\  How do I make an appointment to discuss surgery for my hernia?

To see one of our surgeons you will need a referral from your family doctor. Under no circumstances can we see you without an appropriate referral. You might like to print out this page and take it to your family doctor when asking for a referral.

/\  Why choose LapSurgery Australia for your keyhole hernia operation?

LapSurgery Australia surgeons have performed over 800* keyhole hernia operations. They have the experience and skills necessary to perform this complex surgery which minimises discomfort and facilitates your early return to normal activities.

*Correct as of July 2003

/\  What hospitals do LapSurgery Australia surgeons attend?

Keyhole hernia surgery can be performed at:

• The Valley Private, Mulgrave
• Knox Private, Wantirna
• South Eastern Private, Noble Park
• Waverley Private, Waverley
• St John of God Berwick, Berwick

/\  Costs

Costs vary depending on your health insurance. The funding provided by Medicare and Health Funds for this revolutionary operation is no higher than for the old non-keyhole method. Consequently there will be out of pocket costs involved and the following information explains what to expect.

The Surgeon - LapSurgery Australia surgeons charge through the “Known Gap” scheme for a majority of Health Funds. This means that you pay a co-payment to the surgeon before the operation and the balance of the surgeon’s account is sent directly to the Health Fund. If you are with one of the few Health Funds that do not allow co-payments, your out of pocket costs will be higher. If so we suggest changing your Health Fund. If you have no private insurance the cost will be substantial and is estimated in the table below.

Assistant Surgeon & Anaesthetist - There will be charges from both the Assistant Surgeon and Anaesthetist. Accounts for these services vary and are independent of LapSurgery Australia. We are able to advise you of the individuals providing these services once a date has been scheduled for your surgery.

The Hospital – Out of pocket costs for the Hospital vary depending on your Health Fund, level of cover, excess etc. For an accurate cost, please refer to your Health Fund or the Hospital.
The Medicare item number you will need to quote is 30609.
It is YOUR RESPONSIBILITY to check that your health insurance is up to date and whether there will be any excess charges. LapSurgery Australia cannot check this for you.

Other costs – The normal services required for your operation are listed above. Occasionally patients require additional medical care and may incur charges for pathology, radiology and other specialists.

Estimate - The table listed below gives a “ball park” estimate of out of pocket costs – a detailed estimate will be provided prior to your operation. There are no out of pocket costs for patients with approved WorkCover claims. Bona fide old age pensioners will receive a significant discount to reduce or eliminate extra costs. No other discounts apply.

** Finance is available through Health Assist. LapSurgery Australia has no direct or indirect association with Health Assist, receives no commission and makes no warranty as to the suitability of this option for individual patients.

/\  Links

US National Library of Medicine – Femoral and Inguinal Hernia

Tyco Web Site (Manufacturers of Keyhole Surgery Equipment)

Laparoscopy.com - Pictures of Keyhole Hernia Repair
Under “Abdomen” choose “Extraperitoneal Hernia” from the drop list then click “Go”

Norman Swan, ABC Health Report on Keyhole Hernia Surgery