Hernia Surgery

Learn more about hernias and their treatment
What is a hernia?

A hernia occurs when the layers of muscle of the tummy wall split apart, leaving a gap through which the contents of the abdominal cavity protrude. This is what the lump or bulge is, at the site of your hernia.

What is a hernia repair?

To repair a hernia, the split in the muscle layer that has produced the gap needs to be closed with either strong permanent internal stitches, and/ or by reinforcing it with a permanent artificial material known as mesh.

What sort of trouble can hernias cause?
A hernia may cause no pain or discomfort at all, and you may simply notice that there is a lump present.

Often the lump disappears when you lie down. Some people experience discomfort, aching, or an actual pain at the area where the lump appears. This is often worse towards the end of the day, when you have been on your feet a lot. You may notice that this discomfort can be reduced/stopped by lying down and pushing and massaging the lump away (the contents of the hernia go back in to the abdominal cavity where they belong).

Do all hernias need to be operated on?
No. Some small hernias, which are not causing discomfort, can be left alone.

If a small hernia grows, it may reach a size where it causes discomfort or is large enough to cause doctors concern that it may develop complications. If you have a small hernia which has grown significantly larger, contact your general practitioner who will send you to see a surgeon who will assess it.

Can hernias develop complications?

Yes, but fortunately most hernias do not develop complications, but remain simply a lump, which may only cause minor discomfort.

Possible complications include:
Irreducible

This means that the hernia lump never goes away. Hernias may originally have gone away by themselves when you lay down or pushed on them, but by having grown larger, have stopped going away. This is commonest with femoral and inguinal types of hernias. If you have a hernia which does not go away, you should have it looked at by a doctor, and particularly if the hernia lump also becomes painful you need to be seen by a doctor as an emergency as it may mean that you have developed an obstructed or strangulated hernia.

Obstructed

This means that part of the bowel has become stuck within the hernia, blocking the bowel from passing food and fluid along. This will result in colicky pains in the tummy (like trapped wind), followed by vomiting. You will also notice that you have stopped passing wind from the back passage, and your hernia lump is hard, often painful, and it has become irreducible. If this happens you must seek immediate attention from your general practitioner or hospital Emergency Department.

Strangulated

This is the most severe complication. It means that the bowel in the hernia has had its blood supply cut off. This process can occur in just a few hours, which is why it is called a surgical emergency. In a strangulated hernia there is severe pain at the site of the lump, and several hours later the skin over the lump turns red. Vomiting and a stoppage of all bowel activity may later develop. If this happens you must seek immediate medical attention from your hospital Emergency Department.

Can there be complications of an operation to fix my hernia?
Yes. All operations carry a risk.
  • Wound infection: May occur in 1 in 20 patients, usually after they are already at home. You should get your doctor or practice nurse to check your wound if this occurs, as you may need a short course of antibiotics.
  • Haematoma: this means a collection of blood which usually occurs just beneath the wound, forming a lump. A large lump may take several weeks to disperse. As it disperses, bruising usually appears. With keyhole surgery of groin hernias, the haematoma may appear in the area where your hernia lump was, it is important not to mistake this haematoma for a recurrent hernia.
  • Internal bleeding: this is rare (occurring in less than 1 in 1000 hernia operations).
Complications due to the mesh itself

The mesh used to repair hernias is made of a synthetic material (commonly a type of nylon) that remains permanently in place, acting as a scaffolding for natural scar tissue produced by the body.

Rarely, however, there can be problems related to the mesh itself:

  • Infection: Mesh infection is a rare complication for hernia repairs performed as a planned operation, occurring in less than 0.5% of patients having a hernia repaired.
  • Bowel obstruction/bowel fistula: this is an extremely rare complication. It occurs if the bowel in contact with the mesh becomes inflamed and scarred. Major surgery is required to deal with this problem.
Will I have a mesh hernia repair?
The majority of hernias are now repaired with mesh.

 The mesh is usually placed deeply within the layers of muscle, so that you are unaware of its presence.
The modern use of mesh has reduced the number of hernias that come back (called “recurrence” of a hernia).

So can hernias come back?
Yes. The risk of a hernia coming back is related to many factors:
  • the type of hernia you have
  • the size of hernia (larger ones often have large gaps in the muscle which are more difficult to patch successfully)
  • if you are overweight, particularly if you are carrying a lot of weight on your tummy
  • the hernia is recurrent (it has been repaired before, but has come back again)
  • if you are diabetic (you heal less well)
  • if you have an emergency operation
  • if you have a heavy physical job or routinely undertake extremely strenuous exercise
  • if you are on medication which impairs healing e.g. steroids, immunosuppressive medication
  • if you have a chronic cough
Will my hernia be repaired by keyhole surgery?

This depends on the type of hernia you have, and it’s size. Keyhole surgery is simply a method of repairing a hernia through several small cuts on the tummy, rather than a single larger one.

Your surgeon will discuss with you which type of surgery they are planning to perform.

  • Keyhole surgery may not be an option for some hernias.
  • Keyhole surgery has to be performed under a general anaesthetic.
  • Keyhole surgery always involves use of a mesh.

Your surgeon will be happy to discuss the option of keyhole surgery with you and advise you as to whether your particular hernia is suitable for that method of repair.

The National Institute for Clinical Excellence (NICE) has assessed the benefits of keyhole versus open hernia repair only for inguinal hernias.

  • They concluded that recurrent inguinal hernias, and bilateral inguinal hernias (having a right and left sided hernia at the same time) should be mesh repaired laparoscopically.
  • They have also concluded that patients with a single inguinal hernia should be offered the choice of open or laparoscopic surgical mesh repair.
Are there any advantages specific to keyhole surgery?

Keyhole surgery of inguinal and femoral hernias causes less pain than open surgery in the first few days after surgery. It is also associated with fewer wound infections. There is also evidence to support that patients have an earlier return to normal activities and less prolonged groin pain after keyhole surgery.

Are there any disadvantages specific to Laparoscopic surgery?

Yes, rarely the laparoscopic instruments or ports may unintentionally puncture the bowel or bladder. This injury is usually identified at the time or surgery and repaired. It may prevent your intended operation from being completed.

Types of hernias
1. Inguinal hernia

this type of hernia occurs in the groin, immediately above the crease at the top of the leg. It is much more common in men than women. It is virtually always repaired with a mesh. If you have a single hernia there is a 10-30% chance you will develop a hernia on the opposite side at some time in your life.

Risks Specific to Inguinal Hernia Repair
  • Numbness in the groin and/or upper scrotum.
    It is common to experience reduced sensation in those areas for several weeks/months after surgery. This is not painful, and it usually gets better with time. This is more common after open surgery, and rarer after keyhole surgery.
  • Chronic pain.
    Several nerves that supply the skin of the groin, thigh and scrotum/labia travel in close proximity to the hernia. Unfortunately, around 10% of patients get long-term groin pain due to nerve irritation, which can last for months or years after the operation.
  • Damage to the testicle.
    This is a very rare complication. The blood supply to the testicle is very close to the hernia, if the blood supply is damaged the testicle will shrink over the weeks/months after the operation, and it will no longer function. This complication is usually only encountered in an operation for recurrent inguinal hernia.
  • Mesh sensation
    Some patients describe feeling a slight stiffness where their hernia used to be. This is likely to be the scar tissue on the mesh, giving a good strong repair. Patients who describe this are not usually troubled by it.
2. Femoral hernia

This is another type of groin hernia, occurring immediately below the groin crease at the top of the leg. This type is more common in women than men. It may be repaired by open surgery or keyhole surgery. In open surgery your hernia may be repaired with a mesh, or by stitches; if done by keyhole surgery a mesh will be used.

3. Umbilical hernia or paraumbilical hernia

This type of hernia occurs at, or beside, the tummy button. Most of these hernias are small (less than 2cm across), and many people are unaware of them. It is perfectly safe to have a small umbilical hernia. These hernias are more common if you are overweight, and you are advised to lose weight prior to any surgery.

Uncommonly, these hernias can enlarge and then the skin may become very thin, or the hernia may become strangulated.

Small umbilical hernias can be repaired without a mesh, usually by open  surgery. Larger umbilical hernias usually require a mesh.

4. Epigastric hernia or ventral hernia

this type of hernia occurs anywhere in a line between the bottom of the breastbone and the tummy button. Despite their small size, these hernias can often be quite tender.

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