Hernia is a protrusion of part of the abdominal organs or tissue through a defect in the muscular wall of the abdominal cavity. The defect occurs as a result of muscle weakness, it appears in the form of a lump that goes away usually when the patient lie down. Hernias are uncomfortable but can be painful if the contents get incarcerated. They are more common in men with a lifetime risk of one in twenty. Most of these hernias are in the groin (inguinal hernia and femoral hernia). Hernias usually increase in size with time. Hernia repair is one of the most common operations performed by a general surgeon.
Inguinal hernia is the most common groin hernia and it usually occurs in male patients due to the potential defect in the abdominal wall caused by migration of the testes during growth in utero. In the early stages the hernia is usually reducible but it can cause bowel obstruction if untreated.
Femoral hernia is rare. It most often happens in elderly female patients. Once discovered this hernia should be treated surgically due to the high rate of small bowel obstruction.
Paraumbilical hernias are very common due to the defect in the abdominal wall around the umbilical vessels. They are often precipitated by lifting a heavy object, strenuous exercise, and pregnancy. Usually it contains some abdominal fat but large hernias that are neglected can contain part of the bowel that may lead to bowel obstruction.
Epigastric hernia is a swelling that appears in the midline of the anterior abdominal wall, somewhere between the xiphisternum and the umbilicus. These tend to be painful and require surgical repair.
Ventral or incisional hernia
This type of hernia occur at the site of previous abdominal surgery and is usually caused by poor healing. They have several risk factors such as obesity, smoking, infection and abdominal distention. These hernias have higher risk of recurrence than other types of hernias.
Inguinal hernia can be precipitated in male patients by chronic cough due to smoking or urinary difficulty due to enlarged prostate. These issues will have to be dealt with prior to making a decision to operate.
Factors considered before surgery
- The risk of strangulation
- Bleeding tendency
- Suitability for anaesthesia, which can be either general or spinal
- Blood thinners used for medical problems that you will need to stop before surgery
- Any allergies
Most hernias will require a synthetic mesh made of plastic. It gets integrated with the body tissues, hence you will not be able to feel it. This is done to reduce recurrence of the hernia. Recurrence rate without a mesh is about 10%; while recurrence with a mesh repair is about 2%.
This occurs under anaesthesia. Most patients will need to stay overnight for observation and pain control. The operation choice is either laparoscopic or open surgery. Regardless of the approach a mesh will likely be used. Keyhole surgery helps the patients to recover faster and perhaps go back to work earlier. Pain is usually tolerable but you will need to have regular paracetamol for a few days. After surgery you should be able to resume your daily function within a week or so; you need to discuss with your surgeon what you can and can’t do after surgery for activities related to work, exercise and sports. Generally heavy lifting and strenuous exercise should be avoided for six weeks.
Complications of hernia repair:
1. Infection; generally this is controlled with antibiotics, occasionally the mesh may need to be removed
2. Bleeding and bruises; usually this does not need any specific treatment. Excessive bleeding, however, may need a trip back to theatre.
3. Scrotal swelling
4. Hernia recurrence; the rate of recurrence is relatively small but needs a second operation to fix
5. Chronic pain; this is not uncommon, particularly in groin hernia, a nerve can get entrapped by the fixation material or sutures. There are a variety of methods to treat that, which starts with medications usually. If this is not successful talk to your surgeon about other options.