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 from the abdomen to the scrotum and testis through an ‘inguinal 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 through this canal that can extend into the scrotum.  

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.

 

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. This hernias can be left alone but will usually get bigger and is associated with risks as described above.

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.

 

What does an operation involve?

 

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

In an open operation, once under anaesthesia and asleep, you will have a cut in the lower abdomen made over the inguinal region.  Abdominal contents contained in a ‘hernia sac’ is freed from the normal structures that pass through this ‘inguinal canal’ and is placed back into the abdomen. A mesh is then placed between the layers of muscle to re-enforce the ‘canal’ and reduce recurrence rates of the hernia. The skin will then be closed. The operation usually takes up to 1 hour. Occasionally a drain is left in place to reduce the risk of fluid building up under the skin or into the scrotum that is normally removed within a few days.

 

Before the operation. 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.

 

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 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. Local anaesthetic in the inguinal region can cause temporary weakness of the thigh muscles (less than 1 in 20) that settles within 1 to 2 days.

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.

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

5. 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 nerves can lead to a numb area around the groin (less than 1 in 10 people) and blood supply to the testis (less than 1 in 100) can lead to shrinking and loss of function of the testis on that side.  

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 (mild in 1 in 4 people and severe in 3 in 100 people) can occur due to the mesh affecting the nerves in this area. If there is an identifiable risk of this, sometimes the nerve is cut to leave you with a numb patch that is better then chronic pain.

6. Recurrence: There is a risk of recurrence of any hernia (2 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 may require a catheter to help empty the bladder temporarily (1 in 100 people).

 

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.

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.

 

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.