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What is an inguinal hernia?

An inguinal hernia is one of the commonest causes of a lump in the groin. It sometimes causes pain with or without a lump being present. Hernia is protrusion of an abdominal content out of its cavity.

How does a hernia occur?

Hernias can occur from a defect at birth or from gradual weakening of the muscles. The abdominal wall muscles surround the stomach, intestines, and other organs. There is an opening in the muscles to the groin on each side called the inguinal canal.

In women, the inguinal canal contains a ligament that supports the uterus. In men, it holds an artery that supplies blood to the testicles and the vas deferens (a tube through which semen flows from the testes to the penis).

Weak spots can develop in the muscle layer, causing the contents of the abdomen to push through the abdominal wall.

The weakness can develop later in life; it is then due to excessively straining the muscles of the groin region. This may happen as a result of a chronic cough. Some people tend to be constipated and therefore have to strain to have their bowels open, or they may strain to pass urine because of a prostate gland enlargement. The weakness may also occur as a result of excessive straining while lifting heavy objects or playing sport. However, usually a hernia is something that just happens. A hernia in the groin area causes a bulge, often the size of an egg and can lead to a lump, pain and discomfort.

What might I Notice?

Inguinal hernias occur in the groin either on the left or the right side and, in about 10 in 100, occur on both sides- these are known as Bilateral Hernias.

At the start of your trouble you may have noticed a sudden pain in the groin. This is followed by a swelling, either immediately or a few weeks later. Sometimes this swelling may slide back on lying down, or may be pushed back. The hernia is called reducible when this happens, but if it cannot be pushed back it is irreducible. The hernia can enlarge and extend down into the groin or scrotum. It can lead to a lump, pain and discomfort.

How is the diagnosis made?

Usually it is a clinical decision made after examination by a doctor. Sometimes the diagnosis may require special x-rays and /or scan (herniogram, ultrasound, CT or MR scans).

Are there any alternatives to surgery?

A hernia will not go away without an operation. Surgery is, therefore, usually recommended, as it is the only dependable way to cure the condition. You can sometimes control the hernia with a truss (padded support belt) or simply leave it alone.

What may happen if I decide not to have the operation?

A Hernia is not dangerous in itself. However, very occasionally they can be dangerous when the intestines or other structures within the abdomen get trapped and have their blood supply cut off. This can cause a serious complication (Strangulated hernia) which, if left untreated, will need a bigger and more risky operation to correct. Hernias causing no symptoms especially in a person who is unfit for an operation can be left alone and watched. If it’s untreated, a hernia is likely to get larger and become more uncomfortable. Therefore, in most cases, a hernia repair operation is recommended. If the hernia becomes irreducible, it cannot be pushed back. It is usually painful, tender and may be associated with redness of the overlying skin. Blockage of the bowel may result; this leads to bowel obstruction which causes vomiting, severe constipation and abdominal pain (Strangulated hernia). In this case you must seek medical help immediately.

What to watch out for with a Truss?

However, because of age or other medical reasons, it may be decided that your hernia is unsuitable for surgery. Provided the contents of the pouch can be reduced (returned into the abdominal cavity), a truss may then be worn. This is a pad over the site of the weakness in the muscle wall and should be worn when you are walking around. This then prevents the pouch from protruding through the weakness.

Using a truss should always be discussed with your Doctor and should be fitted by a surgical appliance fitter.

If the truss being worn is not holding back the swelling, you should either not wear it or have it changed to a more effective one. Damage to the bowel inside the pouch may otherwise occur.

What does the operation involve?

Inguinal hernias can be repaired using the laparoscopic (‘keyhole’) technique or by an open cut in the groin. 

Laparoscopic repair (Keyhole) is a relatively new technique although tens of thousands of patients have had a laparoscopic repair already. The operation will be carried out under a general anaesthetic and takes about 30 - 60 minutes. The operation involves a 1cm cut at the belly button and two 5mm cuts, one on either side at the level of the belly button. The wounds are placed here to allow long instruments to be used to perform the operation. The hernia is pulled back through the gap in the muscles into its proper place inside the abdomen by a special instrument. A mesh is inserted over the gap in order to reinforce the wall of the abdomen. The mesh is simply placed over the hole or weakness (A bit like repairing a puncture on a tyre). The mesh is left in the body and acts as a permanent barrier to prevent the hernia from recurring.

This mesh, although it remains forever, causes few, if any, problems. The mesh is stitched in place and the skin then closed with stitches or skin glue. You will be told if these need to be removed.

The wounds will be closed with dissolvable sutures, the wound will have sealed within 48 hours after which time you may remove the dressings and take a bath or shower.

Occasionally (1 in 500 cases) it may not prove possible to proceed with the laparoscopic method, in these circumstances an open procedure will be carried out.

Your Anaesthesia

All patients will require general anaesthesia. Laparoscopic hernia repairs can not be performed under spinal or local anaesthetic.

Patients who are unfit for (or choose not have) a general anaesthetic can still often have a hernia repair under local anaesthetic but it will have to be an open repair with a 10cm cut in the groin.

Who shouldn’t have this type of surgery?

If you had surgery in the area of your hernia before, if you tend to bleed a lot, or if you have any problem that would make it hard for our doctor to see your hernia, an open surgery may be better for you. Your doctor will decide which type of surgery is appropriate for you.

What can I do to help make the operation a success?

Lifestyle changes

If you smoke, try to stop smoking now. There is strong evidence that stopping smoking several weeks or more before you feel comfortable to do so, usually after about one week. You do not need to avoid lifting but you may find it uncomfortable if you lift heavy weights within the first two to four weeks.

What to watch out for after treatment?

There will be some discomfort and tenderness where the keyhole incision was made.

If the wounds become reddened, painful or throbbing or a firm swelling appears then make an appointment to see your doctor to have the wound(s) checked.

It is important that you try to walk normally from the first possible opportunity, and overcome the stoop, which comes rather naturally from having had an operation in that region of your body. Simple pain killing tablets will relieve most of the discomfort. It is usually advisable not to put excessive stress on the operated are for 2 to 3 weeks after the operation.

Work

If your work is sedentary and does not involve heavy lifting or strenuous exercise, then a return to work could be as soon as 5-14 days. If it does involve heavy lifting or strenuous exercise, then it is safer to wait for a further 2 to 3 weeks.

Driving

You are not insured to drive unless you are confident that you can brake in an emergency and turn to look backwards for reversing without fear of pain in the wound. It is wise not to drive for 2-4 weeks, once you can get in and out of the bath unaided.

Exercise

If is safe to perform light duties immediately after the operation, but sensible to avoid heavy work for 2-3 weeks. By 3 weeks you should be able to do any activity you wish. Plenty of activity will aid healing and your recovery. You may resume sexual activity as soon as you are comfortable.

When should I call the doctor ?

Call the doctor immediately if:

-You develop a fever.

-You have severe abdominal or chest pain that doesn’t go away.

-You cannot urinate.

-Your wound becomes red, swollen, or drains fluid.

-You can’t control your pain or get severe abdominal pain.

The future

Most patients make a full recovery and can return to normal activities in a short period of time.

Summary

Hernias are a common condition best treated by surgery. If left untreated, they can occasionally cause serious complications.

Surgery is very safe and effective. However, risks and complications can occur. You need to know them to help you make an informed decision about surgery. Knowing about them will also help with early detection and treatment.

Complications with Laparoscopy