This is information about hernia (rupture). How does it occur? How to repair it? If you still have questions, ask your doctor for more information.

What are they?

A hernia is a weakness or defect in the abdominal wall. It may be present from birth, or develop over a period. If the defect is large enough, abdominal contents such as the bowels may protrude through the defect causing a lump or bulge felt by the patient.

 What types of hernia are there?

The most common type is the groin or inguinal hernia. Herniae may also occur through the umbilicus (umbilical hernia), through old abdominal scars (incisional hernia), through the muscles in the upper abdomen (ventral hernia) or alongside blood vessels running into the thigh (femoral hernia). There is also Hiatus hernia, which is often associated with Gastro-esophageal reflux disease. Laparoscopic repair is mainly used for hiatus, inguinal, ventral & incisional hernia repairs.

The abdominal wall is made up of 3 interwoven sheets of muscle. Although very strong, points of weakness do exist, especially in the groin and around the umbilicus (belly button), and along previous surgical incisions.
If stressed, these weak points may allow a sac of the abdominal lining (the peritoneum) to push through the defect. The hernial sac may be empty or may contain part of the abdominal contents, commonly intestine.

 Inguinal hernia:

There are two types on inguinal hernia. The direct type is more common and usually occurs because of a weak spot in the abdominal muscles leading to a visible bulge in the groin area. The second type is the indirect type, which goes down the inguinal canal into the scrotum.

Who develops a hernia?

Hernias are very common. Men, women and children experience hernias. Men are ten times more likely to have them than women, because of a residual weakness along the path (inguinal canal) where the testicles descended into the scrotum prior to birth. They occur in two ways: First, by wear and tear over time. Second, from a weakness in the abdominal wall that is present at birth as in children and young adults. The development of a hernia is promoted by stressing the abdominal wall, as in heavy lifting, straining in the toilet or coughing.

What are the symptoms of hernia?

Typically, an ache or discomfort is noticed when the hernia first appears, followed by the appearance of a swelling which can be less apparent first thing in the morning but becomes more obvious during the day or when you strain. The pain can be sharp and immediate, while other times it can be dull ache. Some times you might feel a vague sensation of fullness, nausea or constipation.

Are hernias dangerous?

What are Recurrent Hernias?

Three patients in 100, even after treatment return back with recurrent hernia.This doesn’t necessarily indicate your surgeon’s ability, but a poor tissue healing or trauma to the site of the repair.

Once a hernia has developed, it tends to enlarge and cause discomfort. As mentioned above, if a loop of bowel gets caught in the hernia, it may become obstructed or its blood supply may be cut off leading to strangulation. This could then become a life-threatening situation. Since hernias can be repaired effectively and with minimal risk, most surgeons therefore advise that hernias be repaired when diagnosed, unless there is serious medical problem, which makes it too risky.

What is an abdominal wall hernia?

Abdominal wall hernia is a weakness or defect in the abdominal muscle wall through which abdominal contents protrude causing a bulge. The protruding contents push out a pouch of the abdominal lining or peritoneum through the weakness forming the “sac of the hernia”. The areas in which hernias most commonly develop in addition to the groin are the umbilicus and at the site of previous abdominal incision. Usually, there is an opening in the muscle layer at the umbilicus that may have been present since birth. This can enlarge due to raised abdominal pressure, with muscular strain or pregnancy and force through it, abdominal contents resulting in the development of an Umbilical hernia.

Other causes include incisions from
old operations which may weaken the abdominal wall, if they do not heal properly after surgery or are weakened by infection. Muscle wall deterioration with age, inactivity or strain which may allow the muscle wall to tear or bulge, resulting in the development of various forms of hernias.

Why should it be repaired?

1. To avoid the possibility of intestines being caught in the hernial sac causing bowel obstruction. Without urgent surgical intervention this may lead onto strangulation, cutting off the blood supply to the bowel, with resultant death of the loop of bowel. This in turn causes peritonitis. This is a life threatening situation.
2. To reduce pain or discomfort at the hernia site.
3. To minimize the possibility of progressive enlargement of the size of the hernia with increasing likelihood of the above complications and increasing difficulty with repair.
4. To alleviate any anxiety and embarrassment caused by the size of the hernia which can be visible.

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Should my groin hernia be repaired?

In addition to causing discomfort at work, it can lead to loss of earning in those who work. And for those who are retired it can spoil their recreational activities. Once a hernia has appeared, it will ultimately increase in size because of the abdominal pressure. For this reason, together with the risk of strangulation, hernias should be repaired unless there is a serious medical condition preventing surgery. In general, the more uncomfortable the hernia, the sooner it should be repaired.

What are the options for treatment?

While many people live comfortably with hernias for years, without treatment, hernias cannot and will not disappear. Non-surgical treatments and lifestyle changes are usually only temporary solutions. Surgery is advisable and the aim is to reduce the intestines back into their normal position, and repair the torn or weakened tissues. For inguinal hernias, an incision is made in the groin and a repair of the muscle defect in carried out with the insertion of a plastic mesh to strengthen the area. The operation usually lasts less than an hour, and your recovery will take about 4 to 5 weeks. The hernia can also be repaired using minimally invasive laparoscopic techniques. Laparoscopic techniques of hernia repair are especially attractive when patients are dealing with recurrent hernias or bilateral inguinal hernias.

General precautions before surgery:

• Stop smoking
• Discuss your medications with your doctor.
• Avoid Heavy Lifting.

What happens when I get home?

Your recovery should be fairly rapid from Inguinal Surgery. You can take a shower or bath the day following surgery. You may feel some soreness around your incision for two or three days and notice a possible bruise around the area, which will disappear in several days. The discomfort in the area tends to ease as the days go by, however it can last for up to 2 weeks.

Are there any Precautions to take?

To Ensure a Smooth and Quick Recovery Following Surgery, you should pay attention to:

Lifting: Avoid heavy lifting for 6-8 weeks. After the first week, lift only light objects that you can manage easily, keeping your back straight.

Sex: You will probably be able to resume sexual relations as soon as it feels comfortable for you. Usually after 10 days.

Medications: You will be given pain killers to use during your first few days to ease any pain.

Driving: You should be able to drive after 10 days or when you are comfortable to do the emergency stop without getting pain.

Exercise: Gentle walking and moderate exercise helps improving your circulation.

Diet: You may fel bloated or constipated for a few days. Resume a healthy, high fibre diet. Try not strain when having a bowel movement. Drink lots of fluids; eat fruits and vegetables.

Work: You will be able to return to work,usually within two weeks. Do not be surprised if you can return sooner than you expected!

When to call the doctor?

If you experience any of the following:

• Fever
• Increasing swelling or pain
• Redness
• Bleeding
• Nausea or vomiting
• Inability to urinate.

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Depending on the type of your hernia, a laparoscopic repair might well be the best option for you. With Laparoscopy there is possibly less pain than with the conventional repair. It allows for shorter hospitalisation and you will able to resume normal activities at an earlier stage, than with traditional repairs. The disadvantages are that the procedure requires a general anaesthetic and that there are more equipment expenses namely; the laparoscopic ports, the mesh and the hernia tacker, which is used to fix the mesh in place. There are 2 methods of laparoscopic repair using either the Transabdominal preperitoneal (TAPP) approach or the total extraperitoneal (TEP) approach. The TAPP approach involves placing laparoscopic trocars in the abdominal cavity and approaching the inguinal region from the inside. This allows the mesh to be placed and then covered with peritoneum. While the TAPP approach is a straightforward laparoscopic procedure, it requires entrance into the peritoneal cavity for dissection. Consequently, the bowel or vascular structures may be injured during the procedure. In the TEP approach, the extraperitoneal space of the inguinal region is developed, sometimes with the use of an inflatable balloon. For most surgeons, the TEP approach to hernia repair is more technically demanding than the TAPP approach.

In both the TAPP and TEP approaches, the hernial sac is reduced, and a large piece of mesh is placed to cover the indirect, direct and femoral areas of the inguinal region. The mesh is held in place by metal staples.

Most of the inguinal herniae especially recurrent ones are suitable for laparoscopic repairs. However, previous Pelvic or lower abdominal surgery, such as radical prostatectomy or aorto-femoral grafts, would prevent the peritoneum separating from the muscle and render the laparoscopic procedure unsuitable.

The outcome is more or less the same for both the open and laparoscopic repair. You can discuss this with your surgeon.

How is it done?

The operation is performed through three very small incisions under a general anaesthetic, and involves the insertion of a mesh to completely reinforce the groin or the defect in case of the abdominal wall hernia. It might be performed as a day case, depending on the type and size of the hernia. It usually leads to a rapid return to normal activity and shorter hospital stay. The technique is appropriate for new hernias, and is also the best way to treat recurrent and bilateral hernias.

Laparoscopic Inguinal Hernia Mesh Repair

This description refers to the extra-peritoneal laparoscopic (TEP) repair for an inguinal or femoral hernia.

Under a general anaesthetic, three small incisions are made in the abdominal wall. The largest of these is 1.5-2cm just below the umbilicus. An incision in the superficial sheath of the rectus abdominis muscle, the space between the abdominal muscles and the lining of the abdomen (the peritoneum) is developed, sometimes with a balloon device which is then withdrawn after deflation and the space is maintained by the continuous inflation of CO2. The abdominal cavity is not entered during this procedure, therefore greatly reducing the likelihood of damage to the abdominal organs or production of adhesions. A telescope inserted into the space.Two further 0.5 cm incisions are made and 2 fine 0.5 cm diameter ports will be inserted to accommodate operating instruments. The peritoneum is then gently pushed away from the muscle layer until a sizeable space is created and the muscle defect is revealed. The sac of the hernia is pulled back into this space. A piece of flexible polypropylene mesh measuring 12 X 15cm in diameter is then rolled like a cigar through the large port and fixed so as to cover the defect in the muscle and also all other potential weak areas where hernias can occur. The mesh is held in place with approximately 3-4 tiny spiral tacking devices. The space is deflated after withdrawal of the ports and removal of the CO2.

The positive pressure in the abdominal cavity pushes the peritoneum onto the mesh. Any increase in the abdominal pressure, as in straining, simply pushes the mesh firmly against the abdominal wall. Straining therefore, does not have the effect of pulling apart the repair as it does in sutured repairs. This contributes enormously to the strength and durability of the repair. Skin wounds are closed with dissolvable stitches.

What is the best way to repair an inguinal hernia?

Randomised controlled trials have shown that laparoscopic inguinal repair has significant benefits compared with open repair which involves a large cut under general or local anaesthetic, with less pain and a quicker recovery, and yet has as good better long-term results. The National Institute of Health and Clinical Excellence (NICE), the NHS advisory body, has endorsed the laparoscopic repair of both primary and recurrent unilateral and bilateral hernias.

How long am I in hospital?

Day surgery is possible although I usually advise an overnight stay.

How long is the convalescence?

Sedentary workers may resume duties in a few days. Manual labourers can resume duties in 4-6 weeks. I advise no strenuous exercise such as tennis or golf for 4 weeks.

What are the side effects?

The Local discomfort and stiffness at the site of the operation usually diminishes over 2 weeks. Twinges of pain after the procedure can occur on exertion, and sometimes, albeit rarely for up to four months. This is not severe and tends to ease steadily. Bruising can appear in the genital area. This is not painful and disappears over 1-2 weeks. Swelling in the groin, at the site of the hernia, may occur due to serum collecting in the cavity left by reducing the hernial sac. This can alarm patients who think that the hernia is still present but it rapidly absorbs or may be aspirated if it is large. In men, there can be some swelling and tenderness in the scrotum and involving the testes. This also resolves over a few weeks.

What are the potential complications of Hernia Repair?

This is by no means a complete list all of the complications that can occur in this, and indeed in any other operation. It is merely an attempt to cover the most serious, specific complications that could potentially occur in this procedure. Again I would like to emphasise that the incidence of complications to date, is very low indeed. I have no hesitation in recommending the procedure in appropriate cases.

1. Anaesthetic problems, these can vary from anaphylactic shock, cardiac irregularities or cardiac arrest, causing death.
2. Damage to major vessels or to the intestine.
3. Recurrence of the hernia.
4. Infection of the mesh. This would require removal of the mesh and is the reason antibiotics are given at the time of surgery.
5. Nerve injury. Some of the nerves supplying the skin of the upper thigh. Temporary pain radiating down the outer part of the thigh can be a potential complication albeit rare.
6. Haematoma formation. Scrotal haematomas can occur with very large hernias extending into the scrotum especially when these are long standing.
7. Bowel obstruction rarely occurs if the small bowel became trapped in an accidental tear in the deep muscle under the uppermost incision when performing a laparoscopic repair.
8. Pneumonia and other lung complications.
9. Thrombosis and lung embolism. With the use calf compressors during surgery and advising early mobilization, these are rare complications.
10. Bowel Trauma if it was trapped in the sac of a hernia, especially if it is a recurrent hernia.

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This is a newer technique and has become available largely because of new development of special meshes which have two sides, one that adheres to the muscle layer and the other, which is exposed to the intestines, is smooth and non-adherent to avoid bowel sticking to it. Briefly, the procedure is performed by inflating the abdomen with CO2 gas and placing 3-4 laparoscopic ports to one side of the abdominal wall. The hernial contents will be reduced back into the abdominal cavity. In case of adhesions or if the contents are stuck, these will be dissected away from the hernial sac prior to repairing the defect. If for any reason, the above was not possible, then the procedure may have to be converted to an open conventional repair.

   
   
Once the defect is fully exposed, a piece of mesh is placed in the abdomen. This is rolled up initially like a Cigar after marking it according to the size and shape of the defect. A number of pre-tied sutures can be placed around its edges to facilitate accurate positioning of the mesh. Once inside the abdomen, it is unrolled and the pre-tied sutures will be picked up and the mesh tied up to the abdominal wall. This covers the hernial defect. Further fixation with metal tacks is used to keep the mesh in position. The laparoscopic ports are removed, after a thorough inspection for any bleeding or any bowel injury. The wounds are closed with absorbable sutures. The mesh is usually incorporated within the abdominal wall over the next six weeks, thus repairing the hernia.

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