The Inguinal Hernia

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A hernia is when on organ or structures that are usually enclosed in an outer layer start to protrude through this. In the lower part of the abdomen (inguinal region), structures including blood vessels pass through an ‘inguinal ligament’ from the abdomen to the scrotum and testis in males. In females, nerves and ligaments pass through this ‘canal’. There are multiple layers of the abdominal wall these structures pass through and can result in a persistent defect allowing contents to pass through this ‘inguinal canal’ or allow for a weakness later in life that results in an inguinal hernia. In the case of an inguinal hernia, contents within the abdomen (fat, intestines/bowel etc) start to protrude and cause a lump in this region and can extend into the scrotum in males. 

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Hernias can cause pain, limit activities of daily living and over time a danger with not repairing hernias is that abdominal contents may get stuck in the neck of the hernia and require an emergency operation. Obstruction or strangulation of bowel with compromise to the blood supply can be a life threatening condition.

Surgery aims to repair the hernia, improve pain and avoid the complications above.

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Alternatives to Surgery

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A conservative approach is to use a truss which is a padded belt that is worn around the waist and hold the hernia in. This is normally used if one is too unwell for an operation under a general or local anaesthetic. These hernias can be left alone but will usually get bigger and is associated with risks as described above.

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Surgery is the only way to potentially prevent recurrent symptoms and complications associated with hernias. This operation can be carried out laparoscopically (keyhole surgery) or via an open operation. The laparoscopic approach is described elsewhere as there are different approaches that are individualised to each patient and so the surgeon will advise you.

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What does an operation involve?

 

The operation is aimed at bring the abdominal contents back into the abdomen, preserving all the normal structures and then reconstructing and re-enforcing the ‘inguinal canal’ with mesh to prevent recurrence.

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In a laparoscopic (keyhole) operation, once under anaesthesia and asleep, you will have a small 1cm cut in the umbilicus (belly button area) and two smaller 5mm cuts on either side to allow ports and instruments into the abdomen to carry out the procedure.  The abdomen is filled with gas (carbon dioxide) to allow for operating space to carry out the procedure. Abdominal contents are pulled back into the abdomen and a mesh is then placed to re-enforce the weakened area and reduce recurrence rates of the hernia. The skin will then be closed. The operation usually takes 30-45 minutes and may take longer if you require a repair of the other side (2 in 10 people have an hernia of the other side that does not given them any symptoms).

In around 1 in 100 people the operation cannot be carried out laparoscopically and will need to be converted to an open operation to repair the hernia.

 

Before the operation.

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Ensure you tell your specialist and anaesthetist about all medication you take. You will usually also have a pre-assessment appointment to ensure you are optimised before your surgery.

 

General recommendations for all operation are to reduce or stop smoking as this decreases complications of wound infections, breakdown, chest infections and longer term health problems. Regularly exercising even leading up to your operation has shown to improve on outcomes post-operatively by leading to better ‘pre-habilitation’. It is also recommended to not shave the week before surgery over the abdomen and is advisable to have a shower/bath the day before or morning of surgery to decrease infection risks.

 

On the day operation day. 

 

The procedure is usually done as a day case procedure and therefore be admitted and discharged from the hospital on the same day. After the anaesthetic, you will be given local anaesthetic to help with any pain post-operatively and may be given antibiotics.

 

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Potential Complications

 

Complications can be both general for any operation and specific for the particular procedure.

Your specialist will be able to go over specific ones with you.

 

 

General Complications of Laparoscopic Surgery:

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1. Pain (and local numbness): Local anaesthetics are given at the time of surgery and would be important to continue oral pain killers after the operation. Pain should be well controlled to enable you to take a deep breath in to expand the lungs and prevent chest infections from occurring. Shoulder tip pain (if this occurs from retained air after the operation) should settle within 24 hours.

2. Bleeding: Bleeding is rare but if occur may require a blood transfusion or re-operation.

3. Infections: This usually causes a high temperature, redness, swelling and increased pain at wound sites and can happen in around 3 in 100. Antibiotics are used to treat this. It is safe to shower after 2 days following the operation. If this does not settle within a few weeks to months then a further operation may be required. Antibiotics are used to treat this. It is safe to shower after 2 days following the operation. This this does not settle within a few weeks to months then a further operation may be required.

4. Blood clots in the legs or lungs: Keeping mobile is important to prevent this along with the use of TED stockings.

5. Damage to Other Structures: This is more with laparoscopic (keyhole) surgery and can occur rarely in less than 3 in 1000 people and is not obvious in one third of people. Previous surgery and scar tissue (adhesions) can increase the risk of this. Damage to bowel can happen in around 1 in 200 people which includes the risk of bowel getting stuck between the mesh and abdominal wall.

6. Hernias: Where cuts are made in the skin, there is a risk of 1 in 100 people of developing a hernia at these sites which can be repair at a later date if this does occur.

7. Scars around the operation site.

 

 

 

Specific Complications:

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1. Collections of fluid: Blood (haematoma) or fluid (seroma) can form where the hernia was under the wound (1 in 10 people). This usually settles spontaneously over a few weeks. Very rarely this needs to be drained. If there is a high risk of collections at the time of the operation then a drain may be left in place for a few days.

2. Bowel injury: This is very rare and may require another operation.

3. Damage to structures in the inguinal canal: Damage to the blood supply of the testis can occur in around 1 in 1000 people which can result in the testis on this side shrinking and stop functioning.

4. Mesh Infection: This can be treated with antibiotics and may require removal of the mesh through another operation.

5. Continued pain or discomfort can occur. This can occur over the mesh site and radiate down to the scrotum or groin on the side of the operation.

6. Recurrence: There is a risk of recurrence of any hernia (5 in 100 people). You can minimise this by avoiding any heavy lifting and straining for at least 6-8 weeks after the operation.

7. Difficulty passing urine that requires a temporary catheter can occur (1 in 1000 people).

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Recovery from the Operation

 

Following the operation, you will be wake up in recovery and usually go home the same day. You will require a responsible adult to be with you at home for the first 24 hours and have access to a telephone in case you help or advice is required. It is important to continue to take regular pain killers to avoid chest infections as mentioned above.

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You will need to seek medical advice if you develop worsening pain, high temperature, shortness of breath, abdominal swelling/distension or problems in passing urine or opening your bowel.

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Activities following surgery

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For the first 24 hours following a general anaesthetic or sedation, do not drive, operative machinery, carryout dangerous activities, drink alcohol or sign legal paperwork. You can usually start driving once you can control and make an emergency stop.  It is important to be mobile to avoid blood clots and may need to wear stockings to prevent these. Depending on the type of work you do, you can usually return within 2-4 weeks but should avoid heavy lifting for 6-8 weeks (or longer for lager hernias – your surgeon will advise you for your individual case).

 

You will usually have a follow-up after you operation between 4-12 weeks depending on the operation carried out.