Hernia Surgery

A hernia is simply a lump in the abdominal wall caused by a weakness in the muscle with fat or sometimes gut as its contents. Medically we define a hernia as a protrusion of an organ or the tissues that surround it through the wall of the cavity that normally contains it. This is a medical definition; with time the weakness in body wall that appears as a bulge initially will gradually enlarge as the contents of the hernia begin to protrude more. Most commonly these are inguinal hernias.

Why do hernias occur?

In the abdomen they develop when there is a tear or weak spot in the muscle, this may be associated with a rise in pressure in the compartment of the residing organ. Because of this weakness an organ such as the intestine can push through surrounded by the peritoneum (abdominal lining). There are therefore many types of hernias depending on the site. In the abdomen these include inguinal (groin), incisional (through the wound of a previous operation); umbilical (through or next to the umbilicus, “belly button”) and hiatal hernia or hiatus hernia (where the stomach protrudes into the chest through the opening in the diaphragm for the oesophagus).

Types of hernia

Hernias can be classified according to their site (as alluded to previously). Most of this section refers to adult type hernia as those in children often have a different aetiology or causation.
Abodominal hernias:
  • Inguinal (direct and indirect
  • Femoral
  • Incisional and parastomal
  • Umbilical
  • Para-umbilical
  • Epigastric/ventral
  • Hiatal
  • Obturator
  • Spigelian
  • Lumbar (known as Bleichner’s hernia; these are subdivided into Petit’s hernia and Grynfeltt’s hernia)
  • Sciatic
  • Internal hernias (Supravesical, Transmesenteric, Foramen of Winslow, Sigmoid mesocolon, paraduodenal). These are all rare hernias and the diagnosis is often only made at the time of abdominal surgery. They will not be discussed further.
Other hernias:
  • Intracranial (head)
  • Hernias of the nucleus pulposus of the intervertebral discs these are commonly known as slipped discs
How are hernias classified?
  • Hernias may be classified by their site as above or by their properties:
  • Reducible-the contents are easily returned to the abdomen
  • Irreducible-contents can not be reduced
  • Obstructed-the bowel in the hernia is blocked, but the blood supply to the bowel is good
  • Strangulated- the blood supply to the bowel in the hernia is lost. This is a life threatening problem and requires immediate surgery
  • Inflamed-the contents of the hernia have become inflamed
Why do we worry about hernias?

We worry about hernias’ because of the risk of “strangulation”-this means the hernia contents lose their blood supply and die. This is obviously dangerous; for some types of hernia this risk is low; whilst for others much higher. Overall about 5% of hernias require emergency surgery.

An irreducible hernia where the contents can not be returned to the abdomen is at risk of strangulation at any time. An obstructed hernia normally goes on to strangulation; a strangulated hernia can lead to gangrene within 6 hours. These conditions require urgent surgery.

How is a hernia diagnosed

By visiting your family doctor or your specialist they will be able to perform a simple clinical exam to confirm the hernia. Sometimes an ultrasound scan is necessary. Up to a quarter of patients with inguinal hernias will go on to develop hernias on the other side. Sometimes for very complicated hernia a CT or MRI scan is necessary.

Inguinal hernias

These are what are termed indirect and direct. They are managed surgically by the same operation as they occur in close proximity; indeed they may co-exist. The terminology direct or indirect relates to the anatomy of the hernia; technically an indirect hernia travels a region known as the inguinal canal; whereas a direct hernia comes out through the posterior wall of this canal.

Indirect hernia. This is the most common of all hernia, occurring in all ages. In adult males 65% of inguinal hernias are indirect and 55% are on the right. 12% are bilateral. They are 20 times more common in men than women.

Direct Inguinal hernia. These hernias make up 35% of inguinal hernias and are always acquired. Risk factors for direct hernias include smoking and chronic cough as well as occupations where there is much heavy lifting. These hernias often have a wide neck and are therefore less prone to strangulation.

What are the symptoms caused by hernias?

Hernias normally present as a lump. Sometimes pain may be the only symptom, especially in a small hernia. Small hernias can be difficult to find and an ultrasound scan may be necessary. Clinical examination is enough in many patients to confirm a hernia. Typically the lump will disappear when lying down.

We worry about hernias’ because of the risk of “strangulation”-this means the hernia contents lose their blood supply and die. This is obviously dangerous; for some types of hernia this risk is low; whilst for others much higher.

An irreducible hernia where the contents can not be returned to the abdomen is at risk of strangulation at any time. An obstructed hernia normally goes on to strangulation; a strangulated hernia can lead to gangrene within 6 hours. These conditions require urgent surgery.

Surgery for Inguinal hernias

Surgery is the treatment of choice; this is the most common general surgical operation and all general surgeons offer experience for the repair of inguinal hernias. In adults this is normally achieved by either an open approach or via a laparoscopic approach (keyhole). By both methods the hernia is repaired and normally reinforced with a “mesh”. This mesh is a man made material that is normally permanent and allows a “tension free” repair with a much lower incidence of recurrence of the hernia. For children and young adults a mesh is not necessary.

Open vs Laparoscopic hernia repair

This is an important consideration to be discussed with your surgeon. The open repair method using a synthetic mesh has been the gold standard technique in the past. However laparoscopic surgery offers many advantages in terms of early mobilisation and pain relief requirements. The Cochrane database lists one meta-analysis of open versus laparoscopic repair. (This is a large medical database created to look at medical trials). There were 41 randomised trials of open versus laparoscopic repair (involving over 7000 patients). The laparoscopic techniques were of 2 types: Transabdominal preperitoneal (TAPP) and Totally extraperitoneal repair (TEP). In the TAPP repair the surgeon enters the abdomen and peels back the peritoneum (lining of the cavity) to reveal the hernia and surrounding structures before undertaking the repair and placement of the mesh. In the TEP repair the abdominal cavity is not entered and the hernia is reduced in the space between the muscles and peritoneum with a consequent placement of mesh in this space. The authors concluded that either laparoscopic techniques took longer than the open method and had a more serious complication rate but there were undoubted benefits in the laparoscopic group with respect to pain, numbness and return to normal activities.

All these issues should be discussed with you as a part of the consent process for surgery so that you can make an informed decision regarding your surgery.

Femoral hernia

These are more rare and prone to complication. Typically they are found in middle aged and older women. The lump is lower than that seen in an inguinal hernia and an experienced clinician can normally discriminate. They require repair.

Ventral hernia

Umbilical hernias, paraumbilical hernias and epigastric hernias are all hernias in the midline of the abdomen occurring between the xiphoid process (bottom of the midline of the rib cage) and the umbilicus (belly button). Their name describes their position.

Epigastric hernias: These are usually small defects in the linea alba (the midline of the muscular wall of the abdomen). These probably occur as a result of a weakness in the fibres in this area. Normally they are too small to allow bowel to enter and only contain fatty tissue.

Umbilical hernia: These usually occur in children through a weak umbilicus (belly button). In children under 2 they are usually managed expectantly. After the age of 2 surgery is usually offered.

Paraumbilical hernia: In adults the hernia does not occur through the umbilical scar but rather through a small defect just above or below umbilicus. These can become very large; however the neck of the hernia may often remain small. These occur far more frequently in women for a number of factors. They are often accompanied by symptoms of the gastrointestinal tract.

Surgery for these cases is most often indicated. This may be via an open approach or a laparoscopic approach. A mesh is often needed especially if recurrent.

Frequently Asked Questions

Does it require surgery?

Most doctors believe hernias need intervention; normally by surgery. However there is limited evidence (www.clinicalevidence.bmj.com) for hernias that have none or limited symptoms may be managed by watchful waiting. However if these hernias become symptomatic they should be repaired.

For most groin hernias surgery is the treatment of choice; this is the most common general surgical operation and all general surgeons offer experience for the repair of inguinal hernias. In adults this is normally achieved by either an open approach or via a laparoscopic approach (keyhole). By both methods the hernia is repaired and normally reinforced with a “mesh”. This mesh is a man made material that is normally permanent and allows a “tension free” repair with a much lower incidence of recurrence of the hernia.

About 5% of hernias require emergency surgery because they become irreducible or become strangulated. This means the contents of the hernia lose their blood supply; this is very dangerous.

How is the surgery performed?

Surgery is the treatment of choice; this is the most common general surgical operation and all general surgeons offer experience for the repair of inguinal hernias. In adults this is normally achieved by either an open approach or via a laparoscopic approach (keyhole). By both methods the hernia is repaired and normally reinforced with a “mesh”. This mesh is a man made material that is normally permanent and allows a “tension free” repair with a much lower incidence of recurrence of the hernia. For children and young adults a mesh is not necessary.

What are the benefits of surgery?

Once hernia surgery is performed the bulge should go. Once you’ve healed after the surgery; the pain or discomfort should also go.

The advantages of keyhole surgery are that there is less pain and a lower chance of numbness. The pain after should also last for a shorter time. But about 10% of patients still have some pain at 1 year after keyhole surgery; for open surgery this is 20%. Keyhole surgery means smaller scars also and a quicker time to return to normal activity.

What are the risks of surgery?

All operations carry risks; these should be discussed with you as a part of informed consent.

Nausea and feeling sick can happen after anaesthesia. Serious complications from anaesthesia are rare.

Bleeding and bruising after hernia surgery occurs in about 10% of patients. This can lead to a large bruise called a haematoma. Sometimes there is a build up of fluid under the skin called a seroma (about 5%).

Accidental damage to other organs such as the bladder is rare in open surgery but is recognised in some forms of keyhole repair. This may require further surgery to correct this.

Recurrence is a long term rick but rates for this are low. There is a very small risk to the blood supply of the testicle and the tube that carries the sperm in men (vas deferens). Nerve entrapment (groin pain) is a significant but again uncommon complication; this will normally settle with simple pain relief.

Keyhole versus open surgery

Keyhole Surgery has many advantages over open surgery:

  • Because of the smaller cuts there is less pain and earlier return to normal. If there are hernias on both sides this is especially so.
  • The mesh is placed deep to all the layers this is mechanically in a better position than when placed via the open route.
  • There is a lower risk of damage and irritation of the nerves in the groin compared to open.
What are the disadvantages of keyhole surgery?

The operation can take longer. Cost: because of the additional often disposable equipment the cost can be higher than open.In the rare circumstance of a mesh infection it can be more difficult because of the placement to remove the mesh.

Do hernias come back?

With all hernia repairs there is a risk of the hernia recurring. Rates of recurrence of up to 6% are recognised. If there is recurrence after an open operation normally it is better to repair it keyhole.

Is keyhole surgery for all?

There are a number of reasons when keyhole surgery is not recommended. Keyhole surgery requires a general anaesthetic. Very large hernias are not suitable for keyhole repair. Some patients who have had extensive lower midline surgery may not be suitable.

What happens after surgery?

Most people are able to go home the day of surgery. Painkillers should be taken regularly for the first couple of days. Some pain killers cause constipation so please drink plenty of fluid and sometimes a stool softener such as lactulose will help.

Depending on the type of surgery the need and frequency for pain relief will change from this time. After open surgery pain relief may be needed for longer.

Wearing supportive underwear such as Y fronts is recommended; this should be more comfortable.

For the first few days there is to be no heavy lifting but move around the house normally. You should be comfortable at rest.

By a week most daily activities should be comfortable.

If there is redness or weeping of the wound you should contact your own doctor or the specialist immediately in order to get some antibiotics. This should sort out this issue for most people.

The stitched do not normally need removal as they will dissolve with time. The waterproof dressings may be removed after a week; the other dressings may stay until clinic follow up at the 2 week stage.

Driving a car should not happen for 1 week after a keyhole repair and 2 weeks after open.

Follow up after surgery is normally at about 2 weeks.

WHEN DO I GET BACK TO NORMAL?

After keyhole surgery

Return to normal activities should be guided by common sense and pain. It is normally fairly rapid. By the 2 week mark there is little limit to activities.

After open surgery

Return to normal activity takes longer by a week or two than keyhole surgery.

Hiatus hernia

This is the stomach sliding up into the chest. It may be associated with gastro-oesophageal reflux disease. It is a common condition; most do not require surgery. When there is a giant hiatus hernia or a rolling component of the hiatus hernia this will often require a surgical opinion from an upper GI (gastrointestinal) surgeon.

Surgery for other forms of hernia

Umbilical/Paraumbilical

An umbilical hernia is a sac (pouch) formed from the inner lining of your belly (abdominal cavity) that pushes through a hole in the abdominal wall at the belly button. They are very commom and can occur in women after pregnancy or in those who are overweight. They are often small and may go unnoticed. There is a small risk of strangulation as for inguinal hernias.

These can be repaired via an open or laparoscopic approach. The approach determines the type of anaesthetic. A simple suture repair may suffice in selected patients; however a mesh provides reinforcement that is necessary in certain cases. The risks of suture repair include recurrence in the long term of about 10%.

The risk of recurrence is much lower with mesh but here there is a risk of infection (1%) and seroma (fluid formation). The laparoscopic approach is newer and carries certain benefits and risks.

Epigastric/Ventral

This is a type of hernia that occurs in the upper abdomen (epigastrum). They occur in adults and frequently trap fat causing symptoms. Simple suture repair is normally adequate.

Incisional

Incisional hernias occur at the site of previous surgery. They tend to occur where healing has been suboptimal especially where there has been infection or haematoma (a large bruise). They may also be associated where there is raised pressure in the abdomen from conditions such as chronic cough; constipation or pregnancy. Poor surgical technique may also play a part.

These need to be discussed with your specialist as to the preferred technique for repair. Simple suture repairs have a higher failure rate. Meshes may be placed to decrease the risk of recurrence; but bring the risk of infection. For larger hernias large wounds may need to be made causing pain. But for many the laparoscopic approach avoids re-entry through the original operative site and this can be discussed.

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