What is a hernia?

A hernia is a weakness in an anatomical structure which allows something inside, such as a segment of bowel, to protrude. The most common hernias are found in the abdomen and the diagram below shows the common varieties of abdominal hernia.

What causes hernias?

Hernias occur secondary to weakness in the supporting tissue against which an organ rests, for example the abdominal wall. The weakness may be congenital, developmental, or simply a result of wear and tear associated with daily activities. Stress on the abdominal wall or pressure within the abdomen may contribute. Being overweight, having to strain to urinate or open the bowels, or chronic coughing may all play a part.

What are the characteristics and complications of hernias?

Hernias may develop gradually over months or years, or appear suddenly. Once present they do not disappear without treatment. Some hernias cause pain or discomfort and some have a very noticeable bulge. Others are only detectable on examination. Most hernias disappear when lying; those that do not and which can not be massaged back into the abdomen are said to be incarcerated.

A potentially serious complication of hernias is strangulation. The blood supply to the tissue in the hernia is lost and the tissue becomes gangrenous. If the trapped organ is a segment of intestine bowel obstruction may occur with abdominal pain and vomiting. Strangulation is uncommon, but is a surgical emergency and can be life threatening.

Should my hernia be repaired?

It is recommended that all hernias be repaired if the patient is otherwise physically fit enough for an operation. The principal reasons for this are that the hernia will probably continue to enlarge, may be causing significant symptoms and may strangulate. Some hernias however, particularly those in the elderly, may not require surgery.

The common hernias:

Inguinal hernias

These occur in the groin and account for 80% of all hernias. They are more common in men than women. They may contain bowel, fat from inside the abdomen or fluid. There are two types. A direct hernia occurs as a result of a weak spot in the abdominal wall following wear and tear. An indirect hernia is due to a weakness in the channel through which the testicles pass to the scrotum. The hernia can hence pass down into the scrotum which may enlarge considerably.

Femoral hernias

These occur via the channel which allows blood vessels and nerves to pass from the abdomen to the thighs. A bulge is usually found just below the groin. These hernias are more common in women than men and have a significant risk of strangulation.

Umbilical/paraumbilical hernias

Umbilical hernias are usually found in babies and children. Paraumbilical hernias occur at the same site around the umbilicus but exploit the weakness left behind by the development of the umbilicus and usually present in adult life.

Incisional hernias

Previous surgery to the abdomen leaves a scar which is a potential source of weakness in the abdominal wall. With time this weakness may develop into a hernia. Incisional hernias commonly occur in midline scars and caesarean scars.

How will my hernia be repaired?

Repair may be under local, general or spinal anaesthetic. Wherever your hernia is, the principles of repair remain the same. An incision is made over the hernia – about 7-8 cm in the case of inguinal hernias – and the edges of the abdominal wall defect are defined. The contents of the hernia are then returned to the abdomen and the defect in the abdominal wall repaired. This is achieved through a variety of techniques using sutures. In the case of most inguinal hernias and many other large hernias a mesh may be sutured to the area to re-enforce it.

Why use a mesh?

Mesh repairs have a number of advantages over older types of repair:

  • The chance of recurrent herniation is much reduced.
  • The operation to repair the hernia is often technically easier with a mesh. This is particularly true if your hernia is recurrent.
  • The mesh can not be felt once implanted

What should I expect after my operation?

  • In most cases the stitches used to repair the skin are dissolving and are buried beneath the skin. They do not need to be removed
  • You will have a dressing in place. This will usually be waterproof but you should take care not to get the wound wet for 72 hours after the operation. After this you may soak the dressing off.
  • Most hernias can be repaired on a day case basis. Difficult repairs, recurrent repairs or repairs on both sides at the same time will usually require an overnight stay.
  • On discharge you will be given painkillers.

What should I do at home?

  • Once at home you should take gentle exercise, for example walking, and gradually increase this as pain allows.
  • You will be able to resume normal activities about 10 days after surgery, but it is important that heavy lifting (e.g. anything heavier than a bag of shopping) is avoided for six weeks.
  • You may not drive until you are confident in your ability to perform an emergency stop. This period varies, but for most will be around 10days.
  • Your return to work will depend upon the nature of your job. Most will need about two weeks off.

What are the complications and side effects of hernia repair?

Hernia repair is very safe and effective. As with all operations however there are some potential complications:

  • Bruising is common and may last several weeks. Following inguinal hernia repair in men bruising may occur in the scrotum.
  • Swelling of the area is common but rarely marked and resolves quickly
  • You may notice a firmness or ridge where the hernia was. This is due to the technique used to repair the hernia and lessens with time.
  • Redness and tenderness around the scar may indicate infection in the wound. This is rare and is usually treated with simple antibiotics.
  • Where a mesh has been used there is a small risk of infection in the mesh. This often means removal of the mesh. The risk in inguinal hernia repair is said to be about 1%; in my experience the risk is less than 0.1%
  • A small proportion of patients develop long term discomfort or pain following hernia repair, and in a very small number this may require further treatment. Whilst rare, this problem is more common following repair of an inguinal hernia.
  • Nerve damage during inguinal hernia repair may lead to some numbness around the wound and down into the scrotum. This may be permanent.
  • The hernia may recur. This is much less common with modern techniques; for example following mesh repair of an inguinal hernia the recurrence rate is about 1%.

What if I have concerns following my repair?

You will routinely be offered an appointment for a check-up six weeks or so after your operation. If you have any concerns in the meantime you should contact your GP or my private secretary at 24 West Street, Chichester, on 01243 789630.

Mr D K Beattie

January 2013