Hernia Surgery

A hernia develops when the outer layers of the abdominal wall weaken, bulge, or actually rip. The hole in this outer layer allows the inner lining of the cavity to protrude and to form a sac. 

Types of Hernia
Inguinal Hernia (Groin Hernia) 
Umbilical Hernia
Epigastric Hernia
Incisional Hernia              

Any part of the abdominal wall can develop a hernia.

However, the most common site is the groin. A hernia in the groin area is called an inguinal hernia (inguinal is another word for groin). Inguinal hernias account for 80 percent of all hernias. In an inguinal hernia, the sac protrudes into the groin towards and sometimes into the scrotum. Although most common in men, groin hernias can also occur in women.

Another type of hernia develops through the navel, and it is called an umbilical hernia.

A hernia that pushes through past a surgical incision or operation site is called an incisional hernia.

Epigastric hernias occur between the lower part of the breastbone and the naval and is caused by a weakness or opening in the fibrous tissue of the abdomen. This type of hernia usually consists of fatty tissue and rarely contains intestinal tissue. Although generally small in size (no bigger than a golf ball), epigastric hernias can easily become pinched in their small area, sometimes causing a great deal of pain.

What is an inguinal hernia?

A hernia is a lump that results from a part of the intestine (bowel) slipping through a weakness in the abdominal wall. The most common hernias are inguinal hernias (groin hernias).

There are three types of inguinal hernia:

• indirect inguinal hernia which is common in children - they may be present at birth - and young people. They are mostly seen in males but can also occur in females.
• direct inguinal hernias mostly afflict adults especially middle-aged and elderly men.
• femoral hernia is rarer than the other types and mainly affects women.

The opinion of a specialist doctor is usually necessary to determine which type of hernia is present.

How does a hernia develop and is it dangerous?

The inguinal ligament is a tight band located between the thigh and the stomach and there are several weak spots along it.

Obesity, pregnancy, heavy lifting, chronic coughing, constipation and straining to pass stools can cause the intestine to push against the abdominal wall, and a part of intestine may slip through a weak spot, creating a lump. However, in a large number of patient there may be no cause and hernia simply occurs because there is a week area in the groin.

A hernia consists of a sac - the peritoneum - which may contain a piece of intestine (an intestinal loop). It is often able to move inside your body, meaning that it disappears when you lie down, and reappears when you stand up or are straining to pass a stool. The hernia itself is harmless.

However, a hernia can be dangerous if it gets trapped in the weak spot in the abdominal wall and becomes tender. This is known as a strangulated hernia. If the intestinal loop is damaged, its contents can leak out. Gangrene and peritonitis, which can be life-threatening, may occur as a result. Strangulation is an emergency requiring urgent surgery.

Indirect inguinal hernias

An indirect inguinal hernia is located in the inguinal canal. In males, this is the location of the spermatic cord.

• Typically, the hernia is discovered when it descends into the scrotum.
• The hernia may be present at birth.
• The treatment for this type of hernia is removal through surgery. Although this can be performed immediately after birth, some surgeons prefer to wait until the child has reached the age of two. Surgery is also the standard treatment for older children and adults.

Direct inguinal hernias

This type of hernia appears later in life.

• It is often two-sided.
• Obesity and hard physical work can contribute to its development.
• It can be seen and felt towards the middle of the inguinal ligament.
• Surgery is again the standard treatment for this type of hernia. Unfortunately, in many cases the hernia recurs and the surgery has to be repeated.
• When a very elderly person has a hernia, the doctors may decide not to operate if the hernia is unlikely to cause complications.

Femoral hernias

Femoral hernias are similar to inguinal hernias. The femoral hernia occurs when abdominal contents are forced through the "femoral canal". Typically this type of hernia forms near the crease of leg in the abdominal region, but in an area relatively lower than the more common inguinal hernia. The two types of hernias are often too difficult to tell apart in diagnosis, which is why a hernia specialist is often required to confirm diagnosis. Femoral hernias are more likely to become incarcerated or strangulated because of their location, which is why repair is strongly advised upon diagnosis of this type of hernia.
Femoral hernias are rare, and mostly seen in middle-aged and elderly obese women who have given birth several times.

• The hernia is seen as a lump below the inguinal ligament.
• The treatment is surgery.

Treatment Options

There is no acceptable non-surgical medical treatment for a hernia. The use of a truss (hernia belt) can help keep the hernia from bulging but eventually will fail. The truss also causes the formation of scar tissue around the hernia making the repair more difficult. If you suspect you have a hernia, consult with your GP promptly. Delayed hernia repair can result in intestinal incarceration (intestine is trapped inside the hernia sac) or strangulation (intestine is trapped and develops gangrene). The latter is a surgical emergency.

The hernia will not go away without treatment; it will only get bigger. The bigger the defect the bigger the operation required to fix it.

Under certain circumstances the hernia may be watched and followed closely by a physician. These situations are unique to those individuals who are at high operative risks (i.e. those with severe heart or lung disease, or bleeding problems). Of course, even in the high risk person, if the symptoms become severe or if strangulation occurs, then an operation must be performed.

Laparoscopic Inguinal Hernia Repair

In laparoscopic hernia surgery, a telescope attached to a camera is inserted through a small incision that is made under the patient's belly button. Two other small cuts are made (each no larger than the diameter of pencil) in the lower abdomen. The hernia defect is reinforced with a 'mesh' (synthetic material made from the same material that stitches are made from) and secured in position with titanium tacks.

How do open and laparoscopic hernia repairs compare?

Both the laparoscopic and the standard open inguinal hernia repair (known as the Lichenstein repair) use a synthetic mesh which stimulates the formation of scar tissue, strengthens the area and reduces recurrence rates.

Type of Anaestheric: Inguinal hernias can be repaired by either the open or laparoscopic approach under general anaesthetic (GA). If a patient is not fit to have a GA then it can be repaired by the open method under local anaesthetic.

Post-operative pain: Patients experience significantly less pain, or require fewer painkillers, immediately after a laparoscopic hernia repair compared to an open procedure.

Return to work: After laparoscopic hernia repair motivated patients will be able to return to work after 2 or 3 days. For an open procedure fitness to return to work will take considerably longer.

Long term pain or numbness: A recent study showed that five years after open hernia repair 10% of patients still experienced groin pain and 22% reported parasthesia (numbness) in the groin. This compares with significantly less patients who experienced these symptoms following laparoscopic repair (2% and 2.5% respectively)

The difference between the two types of procedure is most likely due to the close proximity of nerves in the operating field during open hernia repairs. These nerves are further away from the area being operated upon in laparoscopic surgery.

Recurrence rate : Both open and laparoscopic hernia repairs have very low chances of recurrence, with no difference between the procedures.