The groin is a weak point of the abdominal wall, due to the passage of blood vessels from the abdomen to the thigh and the spermatic cord joining the testicle to the prostate. There are two types of groin hernias, inguinal and femoral.
Inguinal hernia protrudes through the area weakened by the passageway of the spermatic cord. For this reason it is very common in males; it is by far the most frequent hernia.
Femoral hernia is exteriorized through the femoral orifice, the passageway of femoral vessels.
Since this orifice is very small, this type of hernia is less frequent and it more commonly occurs in females.
The diagnosis of hernia is essentially based on physical examination.
In most cases an experienced surgeon doesn’t need any complementary exam.
The protrusion forms a bulge in the groin that can be reduced by simple manual pressure.
The treatment of hernia consists of closing the abdominal wall defect. This sounds very simple, but it is not, due to the complexity of the groin anatomy and especially to the passage of the spermatic cord that must be preserved. For this reason, surgeons have conceived many different techniques, based on suturing or patch reinforcement. Suturing methods were of course the first used, especially the Bassini and Shouldice techniques. They consist of approximating the hernia edges by sutures, what results in tension on those structures. Tension induces severe postoperative pain, long time off work and the increased risk of recurrence due to tearing. For those reasons, suturing techniques are less and less commonly used in adults.
Placement of a patch to close the hole and reinforce the wall can avoid the drawbacks of suturing, because the method is tension-free. Consequently, postoperative pain is reduced, as well as the risk of recurrence that switched from 8-10% with suture to 1-2% with patch techniques.
The patch can be placed onlay or sublay. The patch placed on the superficial aspect of the muscular wall (Lichtenstein technique) tends to be separated from the wall by intra- abdominal pressure. Therefore, it must be fixed by sutures that can trap tiny nervous endings, which can result in chronic pain lasting for months or years.
On the contrary, the patch placed sublay in the preperitoneal space, at the deep surface of the abdominal wall, is applied to the wall by intra-abdominal pressure and doesn’t require fixation or minimal. Thus, there is no risk of nerve entrapment and no risk of nerve irritation by the patch, because it doesn’t contact he nerves running in the inguinal canal. Many studies showed that the preperitoneal patch induces less postoperative and chronic pain and better quality of life.
Placement of the patch in the preperitoneal space can be achieved by laparoscopy, through small holes and a camera, what results in minimal damage to the abdominal wall and quite invisible scars.
The technique called TIPP (Trans Inguinal Pre Peritoneal) consists of placing the patch in the preperitoneal space by a short minimally invasive incision. It can be performed in general anesthesia or in local anesthesia as well.
Methods used at the Hernia InstituteParis
We put a patch in the preperitoneal space (sublay) in any case.
In most cases we use the laparoscopic techniques TEP (Total Extra-Peritoneal) or TAPP (Trans-Abdomino-Pre-Peritoneal).
We also practice the TIPP technique (Trans-Inguinal PrePeritoneal), which consists of deploying a patch endowed with memory of shape in the preperitoneal space, by a short minimally invasive incision, through the hernia orifice. This technique can be performed in light general anesthesia or even in local anesthesia with sedation or hypnosis.
In both cases, surgery is carried out in day-case surgery.