Diagnosis, treatment and aftercare by renowned vascular surgeon Mr Michael Gaunt MD (Dist), MA Cantab, FRCS
Abdominal wall hernias
Hernias represent a tear in the muscles of the abdominal wall through which the abdominal contents e.g. bowel, omentum, may protrude and come to lie underneath the skin. Certain parts of the abdominal wall are weak spots and hernias are more common at these sites – the commonest being the groin, especially in men.
The groin is a particular weak spot in men because this represents a natural gap where the blood vessels and spermatic cord penetrate the muscles to reach the testicles. Straining associated with coughing and lifting may stretch this natural gap enough to form a hernia – an inguinal hernia. This is also a weak spot in women because a structure known as the round ligament passes through the gap instead of the spermatic cord.
Where else can hernias occur other than the groin?
Other weak spots include around the umbilicus (umbilical hernia), inside of the top of the thigh (femoral hernia) and any point along the middle of the abdomen (epigastric or ventral hernia). Hernias in other sites can also occur.
In the early stages, there may be no lump to feel but people describe pain or a sense of weakness especially if lifting or straining. As the hernia enlarges, a lump becomes obvious which appears on standing but either disappears on lying down or can be ”pushed back’ inside – this is known as a reducible hernia. Typically the lump appears on coughing. Later the hernia may become larger and is present most of the time. It may become more difficult to ‘reduce’ i.e. push back inside.
Once a hernia is present it is unlikely to get better on its own and will usually enlarge. However the main risk with hernias is strangulation. Strangulation occurs when a loop of bowel or other abdominal organ enters a hernia and becomes stuck. This may occur suddenly during a period of exertion or straining. Within a few hours the bowel within the hernia begins to swell and eventually the blood supply to the bowel is cut off and the bowel dies and perforates resulting in peritonitis. This represents a surgical emergency and requires an urgent, life-saving operation. It is impossible to predict with any certainty which hernias will strangulate so, for safety, most hernias are repaired sooner rather than later.
Treatment for Hernias
Because of the risk of strangulation most hernias are treated surgically. For inguinal hernias an alternative treatment is a truss. To use a truss the hernia is pushed back inside, a pressure device is applied over the weak spot preventing the hernia from reappearing, and the pressure device is kept in place by a tight fitting garment or belt. It is possible to control hernias in this way but many people find a truss cumbersome and uncomfortable and their use is mainly reserved for patients unfit for surgery.
The essential elements of a surgical repair consist of dissecting the hernia, reducing the contents, removing the coverings of the hernia (the sac), and closing the defect in the muscles. In the last few years surgeons have used a plastic mesh to close the defect as this avoids the tension suturing which caused most of the pain associated with traditional hernia repairs. This is a simple technique which can be performed under local anaesthetic.
Hernias can also be repaired using the keyhole method, repairing the hernia from inside the abdomen, however this is a more complicated method which is requires a general anaesthetic and is still under evaluation.
Admission – depending on arrangements you will either be admitted to your room the day before surgery or the morning of surgery. The ward nursing staff will show you to your room and help you to settle in. They will explain the preparations for theatre and show you where everything is. You should not have anything to eat or drink for six hours prior to the time surgery is due to start. Mr Gaunt will visit you prior to your surgery to explain the procedure again and answer any last minute questions. The site and side of the hernia will be marked using a highlighter pen.
Anaesthesia – hernia surgery is usually performed with you asleep under general anaesthetic although it can be performed under local or regional anaesthetic. Discuss which method you prefer with your surgeon and anaesthetist. Your anaesthetist will discuss the anaesthetic technique with you before the operation.
Surgery – an incision will be made over the point of the hernia and the defect in the muscles of the abdominal wall identified. The contents of the hernia will be returned to the abdominal cavity, the coverings of the hernia removed and the defect in the muscles repaired using a plastic mesh. The wounds are closed using self-dissolving sutures inserted underneath the skin so they cannot be seen. The operation usually takes about 30-60 minutes but you may be away from the ward longer because all patients spend a minimum of half an hour in the recovery room waking up from the anaesthetic.
After the operation – when you return to the ward you may feel drowsy, but you should not feel any pain or sickness. If you do, tell the nurse who is looking after you and they will give you a painkiller or something for sickness. You should remain in bed for the first 4-6 hours, if you require anything use the nurse call button. Later, when the nursing staff are happy with your observations, you may sit up and later still get out of bed under supervision. Once you have woken sufficiently you can start drinking again and have something light to eat.
Discharge from hospital – the operation may be performed as a day-case or as an overnight stay. You will be allowed home once the effects of the anaesthetic have subsided, your pain is well controlled, you are eating and drinking and able to walk around safely. You should also have been able to pass urine normally.
Once at home – you will probably need 7-14 days off work, returning when you feel comfortable. Avoid driving until you are pain-free and in full control of the vehicle (usually about seven days). Walk as much as possible to keep the blood circulating in the legs and to avoid the hernia wound stiffening-up. You may shower after three days and bathe after seven days but avoid soaking the wound. You may resume sex when it is comfortable at about two weeks.
Complications – potential risks and complications specific to hernia surgery include but are not limited to the following:
- Bruising around the wound may develop in the first 1-3 days after the operation and in men this may track down to involve the scrotum and penis. This is not unusual and is nothing to worry about as long as the development of bruising is not associated with increasing pain or swelling. Increasing pain and swelling may indicated the formation of blood clot within the wound known as a haematoma which may require surgical removal. A rare complication can occur when the blood supply to the testicle is impaired by the hernia repair which can result in atrophy – this occurs in less than 1% of operations.
- Some patients, usually older men, have difficulty passing urine in the first few hours after groin hernia surgery especially after simultaneous surgery in both groins. If this occurs a temporary catheter is inserted into the bladder via the penis and left for 12-24 hours to drain the urine and removed before discharge home.
- All surgical wounds, but especially those in the groin, can become infected. If the wound becomes painful and red this may indicate infection which can usually be treated by a course of antibiotics. Occasionally, wound infection fails to respond to antibiotics and indicates deeper infection which may require intravenous antibiotics and/or removal of the plastic mesh.
- Small nerves next to the hernia can be disturbed during the surgery leading to patches of pain and/or numbness in about 10-20% of patients. These usually resolve over the first year after surgery but occasionally the numbness is permanent. Persistent pain in the region of one of these nerves is known as neuralgia and occurs in small number of patients. Treatment usually consists of a permanent nerve block.
- A thrombosis can occur in the deeper veins of the leg (DVT). This occurs in less than 1% of patients.
Recurrence of hernias
Sometimes a hernia at one site may indicate a generalised weakness of the abdominal wall. Therefore, repairing a hernia at one site increases intra-abdominal pressure at another weak spot, either producing or exacerbating another hernia. This may be close to the site of the original repair. With the mesh technique, recurrence of the original hernia is unusual because the mesh is permanently left in position – however it can occur in 1-5% of cases and further surgery to repair this recurrent hernia may be indicated.