Inguinal hernia repair
Inguinal hernia repair
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 a hernia can develop if there are any weak spots.
What is an inguinal hernia?
An inguinal (pronounced "ingwanal") hernia is the most common type of hernia. The hernia can appear as a swelling or lump in your groin, or as an enlarged scrotum (the pouch containing the testicles). The swelling may be painful.
The lump will often appear when you are lifting something and disappear when you lie down.
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 (the ligament surrounding the womb) passes in women.
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 (tummy) can become weaker.
Inguinal hernias can sometimes appear suddenly due to strain on the abdomen, such as straining on the toilet if you have constipation or carrying and pushing heavy loads. They have also been linked to having a persistent, heavy cough.
When is surgery needed?
Inguinal hernias can be repaired using surgery to push the bulge back into place and strengthen the weakness in the abdominal wall.
The operation will only usually be recommended if you have a hernia that causes severe or persistent symptoms, or if any serious complications develop.
Complications that can develop as a result of an inguinal hernia include:
obstruction – where a section of the bowel becomes stuck in the inguinal canal, causing nausea, vomiting and stomach pain, as well as a painful lump in the groin
strangulation – where a section of bowel becomes trapped and its blood supply is cut off; this requires emergency surgery within hours to release the trapped tissue and restore its blood supply so it does not die
Surgery will get rid of the hernia and prevent any serious complications, although there is a chance of it returning after the operation.
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 the surgeon to push the lump back into the abdomen
keyhole (laparoscopic) surgery – a less invasive but more difficult technique where several smaller cuts are made, allowing the surgeon to use various special instruments to repair the hernia
There are advantages and disadvantages to both methods. The type of surgery you have will depend on which method suits you and your surgeon’s experience.
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.
Most people make a full recovery from inguinal hernia repair within six weeks, although many people are able to return to driving, work and light activities within two weeks.
Are there any risks from the operation?
An inguinal hernia repair is a routine operation with very few risks. However, up to 1 in every 10 hernias will recur at some point after surgery, with around 1 in every 50 recurring within two years.
Other potential complications of inguinal hernia repair 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 or base of the penis in men
pain and numbness in the groin area caused by a nerve being damaged or trapped during surgery
Complications are more likely if you are over 50 or you have another illness, such as heart disease or breathing problems.
How inguinal hernia repair is carried out
There are two ways that an inguinal hernia repair can be carried out. These are open surgery or keyhole surgery (also calledlaparoscopic surgery).
The hospital will send you instructions about when you need to stop eating and drinking before the operation.
The operation usually takes about 30-45 minutes to complete and you will usually be able to go home on the same day. Some people stay in hospital overnight if they have other medical problems or if they live alone.
Open inguinal hernia repair is often carried out under a local anaesthetic or a regional anaesthetic injected into the spine, which means you will be awake during the procedure but the area being operated on will be numbed so you won't experience any pain.
In some cases, a general anaesthetic is used. This means you will be asleep during the procedure and won't feel any pain.
Once the anaesthetic has taken effect, the surgeon makes a single cut (incision) over the hernia. This incision is usually about 6-10cm long. The surgeon will then place the lump of fatty tissue or loop of bowel back into your abdomen (tummy).
A mesh is placed in the abdominal wall, at the weak spot where the hernia came through, to strengthen it.
When the repair is complete, your skin will be sealed with stitches. These are usually a type that dissolve on their own over the days following the operation.
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 4-5 days.
Keyhole (laparoscopic) surgery
General anaesthetic is used for keyhole inguinal hernia repair, so you will asleep during the operation.
During keyhole surgery, the surgeon usually makes three small incisions in your abdomen (instead of a single, larger incision).
A thin tube containing a light source and a camera (laparoscope) is inserted through one of these incisions so the surgeon can see inside your abdomen. Special surgical instruments are inserted through the other incisions so the surgeon can pull the hernia 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 or glued to the weakened area in your abdomen wall to strengthen it.
Totally extraperitoneal (TEP) – this is the newest keyhole technique. It involves repairing the hernia without entering the peritoneal cavity.
Once the repair is complete, the incisions in your skin are sealed with stitches or surgical glue.
Which technique is best?
The National Institute for Health and Care Excellence (NICE), says that both keyhole and open surgery for hernias are safe and work well.
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 tends to have a quicker recovery time in people who have been treated before and the hernia has come back (recurrent hernia) or people with hernias on both sides at the same time (bilateral hernias), although there is very little difference in recovery time in people who only have a hernia on one side that has not been treated before (single-sided, primary hernia).
However, the risks of serious complications, such as the surgeon accidentally damaging the bowel, are higher in keyhole surgery than open surgery.
The risk of your hernia returning is similar after both operations.
Discuss the advantages and disadvantages of keyhole and open surgery with your surgeon before deciding on the most appropriate treatment.
Deciding which technique to use
The choice of technique for inguinal hernia repair will largely depend on:
your general health - elderly people or people in bad health may be too weak or frail to safely have a general anaesthetic, so open surgery using local anaesthetic may be advised
the experience of your surgeon - open surgery is more common than keyhole surgery, so not all surgeons have enough experience in keyhole techniques
Recent guidance from the British Hernia Society advises that most primary, single-sided hernias are best repaired using the open technique. Laparoscopic techniques are usually only recommended for recurrent or bilateral hernias.
Keyhole surgery can also be useful if your surgeon is not sure exactly what type of hernia you have.
Inguinal hernia illustration
Recovering from inguinal hernia repair
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.
After the operation, your groin will feel sore and uncomfortable. 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 in case you experience any problems.
If you are still in pain after going home, continue taking painkillers as advised by the hospital.
Make sure you follow the instructions your nurse gave you about caring for your wound, hygiene and bathing before you left hospital.
Straining on the toilet because of constipation can cause pain around your wound. You can reduce your risk of constipation by drinking lots of fluids and eating plenty of vegetables, fruit and high-fibre foods such as brown rice, wholemeal bread and pasta. A mild, over-the-counter laxative may also help.
If the operation was carried out under a general anaesthetic (which puts you to sleep during your operation), your co-ordination and reasoning may be affected for a short time. You should avoid drinking alcohol, operating machinery or signing legal documents for at least 48 hours after any operation involving general anaesthetic.
Over time, you can gradually return to your normal activities as soon as you are able to do them without feeling any pain.
Most people are able to do light activities, such as shopping, after one or two weeks. You should also be able to return to work after one or two weeks, although you may need more time off if your job involves manual labour.
Gentle exercise, such as walking, can help the healing process, but you should avoid heavy lifting and strenuous activities for about 4-6 weeks.
You may find sex painful or uncomfortable at first, but it is usually fine to have sex when you feel like it.
Speak to the medical professional in charge of your care for advice about when you can drive. It is usually advisable to avoid driving until you are able to perform an emergency stop without feeling any pain or discomfort (you can practise this without starting your car).
It will usually be one or two weeks before you reach this point after having keyhole surgery, although it may take longer after open surgery.
It is usually recommended that you contact your car insurance company before starting driving again.
When to call a doctor
Call your surgeon if you develop any of the following symptoms:
persistent fever over 38°C (100.4°F)
increased swelling or pain in your abdomen
pain that is not relieved by painkillers
persistent nausea or vomiting
persistent coughing or shortness of breath
increasing redness surrounding your incisions
difficulty passing urine