Hernia Repair, Inguinal

Introduction

A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.

Your muscles are usually strong and tight enough to keep your intestines and organs in place, but sometimes they are not, which causes a hernia.

What is an inguinal hernia?

An inguinal (pronounced “ingwanal”) hernia is the most common type of hernia. The hernia can appear as a swelling in your groin or as an enlarged scrotum (the pouch containing the testicles), which may be painful. The swelling will often appear when you are lifting something and disappear when you lie down.

There are two types of inguinal hernia:

An indirect inguinal hernia is the most common type of hernia, which can occur at any age and is more likely to cause pain in the scrotum.
A direct inguinal hernia is more common in older men and rare in children.

What causes an inguinal hernia?

An inguinal hernia usually occurs when fatty tissue or a part of your bowel, such as the intestine, pokes through into your groin at the top of your inner thigh.

It pushes through a weak spot in the surrounding muscle wall (the abdominal wall) into the inguinal canal. The inguinal canal is a channel through which blood vessels to the testicles pass in men and through which the round ligament passes in women.

Straining, for example on the toilet, increases pressure inside the abdomen and can trigger a hernia. Other triggers include:

Obesity
A smoker’s cough
Constipation
Carrying or pushing heavy loads

Inguinal hernias occur mainly in men. Most are thought to be due to ageing. This is because as you get older, the muscles surrounding your abdomen can become weaker.

Why is surgery needed?

An inguinal hernia repair is an operation to push the bulge back into place and to strengthen the abdominal wall. The operation is necessary as an inguinal hernia is a potentially dangerous condition. The section of bowel can become:

Stuck in the inguinal canal, causing an obstruction – this causes nausea, vomiting and stomach pain, as well as a painful lump in the groin
Trapped and have its blood supply cut off (known as a strangulated hernia) – emergency surgery within hours is essential to release the trapped tissue and restore its blood supply so it does not die

Surgery will get rid of the hernia and prevent you from having any serious complications that a hernia can cause.

What happens during surgery?

There are two ways that an inguinal hernia repair can be performed:

Open surgery – where one cut is made to allow Dr. B C Shah to push the lump back into the abdomen
Keyhole surgery – a less invasive but more difficult technique where several smaller cuts are made, allowing Dr. B C Shah to use various instruments

There are advantages and disadvantages to both methods. The type of surgery you have will depend on which method suits you.

When recovering from an inguinal hernia repair, you should be able to go home the same day or the day after surgery. It’s important to follow the hospital’s instructions on how to look after yourself. This includes eating a good diet to avoid constipation, caring for the wound and not straining yourself too soon.

Are there any risks from the operation?

An inguinal hernia repair is a routine operation with very few risks. However, around 1% of inguinal hernias will return after the operation.

Although complications due to an inguinal hernia repair are rare, they can include:

Blood or fluid building up in the space left by the hernia (this will usually get better without treatment)
Painful swelling and bruising of the testicles
Pain and numbness in the groin area caused by damage of a nerve during surgery
Stitches trapping a nerve, mesh applied too tightly, or scar tissue forming (this is more common after open surgery)

Complications are more likely if you are over 50 or you have another illness, such as heart disease or breathing problems.

For information on other types of hernia see:

femoral hernia
hiatus hernia
umbilical hernia

How it is performed

There are two ways that an inguinal hernia repair can be carried out. These are open surgery or keyhole surgery (also called laparoscopic surgery).

The hernia repair should take about 45 minutes. The hospital will send you instructions about when you need to stop eating and drinking before the operation.

You will usually be able to go home on the same day, but some people stay in hospital overnight if they have other medical problems or if they live alone.

Open surgery

Dr. B C Shah makes a 6cm cut in your lower abdomen or over the hernia.
The inguinal canal (the channel near your bowel) is opened to return the fatty lump or loop of bowel to your abdomen, where it should be.
Stitches are used to repair the weak spot that let the hernia through.
The wall of your abdomen may be strengthened by fixing a patch of composite mesh to it.
If the hernia has become trapped (strangulated) and part of the bowel damaged, the affected segment may need to be removed and the two ends of healthy bowel rejoined. This is a bigger operation and you may need to stay in hospital for four to five days.

Keyhole (laparoscopic) surgery

With keyhole surgery, Dr. B C Shah will make three very small cuts in your abdomen (a large cut is not needed) and inserts special instruments to pull the loop of bowel back into place.

There are two types of keyhole surgery:

Transabdominal preperitoneal (TAPP) – instruments are inserted through the muscle wall of your abdomen and through the lining covering your organs (the peritoneum). A flap of the peritoneum is peeled back over the hernia and a piece of mesh is stapled to the weakened area in your abdomen wall, to strengthen it.
Totally extraperitoneal (TEP) – this is the newest keyhole technique, also known as Desarda technique. The hernia is repaired without entering the peritoneal cavity.

Open or keyhole?

With keyhole surgery, there is usually less pain after the operation because the cuts are smaller. There is also less muscle damage and the small cuts can be closed with glue. Keyhole surgery also tends to have a quicker recovery time and you can get back to work quicker.

However, the risks of serious complications, such as the damage of the bowel, are also higher in keyhole surgery.

The risk of your hernia returning is similar after both operations. Discuss the advantages and disadvantages of keyhole and open surgery with Dr. B C Shah before deciding on the most appropriate treatment.

How is the decision made?

Your choice will depend on:

Whether you can have a general anaesthetic. Elderly people or people in bad health may be too weak or frail to safely have a general anaesthetic. Therefore, they may be advised to have open surgery, which can be done under local anaesthetic, where the area is numbed.
Open surgery is more common than keyhole surgery.

It is recommended that keyhole surgery should always be considered if the hernia has been repaired previously and comes back. This is known as a recurrent hernia.

Keyhole surgery is especially useful if Dr. B C Shah is not sure what type of hernia you have.

Recovering from surgery

You should be able to go home on the day of or the day after your operation. Get an adult to take you home in a car or taxi and follow any instructions you are given by the hospital.

You will not feel any pain while your hernia is being repaired, but your groin will feel sore and uncomfortable afterwards. You will be given painkillers to help relieve this discomfort.

Looking after yourself

An adult must stay with you for the first 24 hours after your operation.

Follow these tips to ensure your recovery is as quick as possible:

Follow the instructions your nurse gave you about caring for your wound, hygiene and bathing.
If you are still in pain, continue taking painkillers as advised by the hospital.
Eat plenty of vegetables, fruit and high-fibre foods such as brown rice, wholemeal bread and pasta. This helps to avoid constipation, which may cause pain in your wounds from straining.
You can return to normal activities if you are not in too much pain, but avoid lifting.

Activities

A general anaesthetic (which puts you to sleep during your operation) can affect your coordination and reasoning skills. Therefore, avoid drinking alcohol, operating machinery or signing legal documents for at least 48 hours.

Speak to the medical professional who is in charge of your care for advice about when you can drive. It will usually be at least one to two weeks before you can drive after having keyhole surgery and two to six weeks after having open surgery. You must not drive before you are free of pain.

It usually takes 10–15 days to get back to activities such as shopping. You may recover faster if you have had keyhole surgery.

You should be able to return to work after two to four weeks, depending on the extent of surgery and your type of work.

Gentle exercise can help the healing process, but avoid heavy lifting and anything that is too strenuous.

You may find sex painful or uncomfortable at first, but it is fine to have sex when you feel like it.