What is a hernia?
A hernia is a protrusion of something, either bowel or fat, from inside the abdomen through a weakness or hole in the abdominal wall.
What are the symptoms of a hernia?
A patient usually feels a lump in the abdominal wall, either in the groin, the belly button or in the upper part of the abdomen. There may be pain associated with the lump but some patients may not have any pain at all. A small number of patients only experience pain and do not feel a lump and this requires further investigations to see if the pain is due to a hernia.
Do all hernias need surgery?
Hernias are usually repaired with an operation to avoid the possible uncommon risks of obstruction and strangulation, which occurs when a part of the bowel becomes trapped in the hernia. If this did happen, an emergency operation would be necessary. Another reason for repair is to relieve the pain associated with some hernias and to allow patients to be able to do lifting or manual labour without any risks to the hernia.
What are the different types of abdominal wall hernias?
There are several types of hernias through the muscle of the abdominal wall. Common ones are umbilical, groin hernias such as inguinal and femoral, epigastric and incisional. A less common hernia is a Spigelian hernia.
This is a hernia through the belly button. This is a very common hernia in babies and the majority settle spontaneously by the age of five years without surgery. However, if the hernia persists, it can be repaired on cosmetic grounds.
Umbilical hernias are also common during and after pregnancy due to stretching of the abdominal wall. This hernia can also be repaired on cosmetic grounds, but this hernia may not need surgery as the risks associated with this hernia are very small.
Umbilical hernias can also occur in women and men and can be associated with being overweight, due to weakness of the muscles of the abdominal wall. If the hernia is causing discomfort or pain, it should be repaired. Another reason for repair is if the hernia is enlarging.
Repair of an umbilical hernia is usually performed under general anaesthesia, but in some cases, this can be undertaken under local anaesthesia. Surgery involves only half a day in hospital in most cases.
In most patients, the hernia is small and the incision to repair such a hernia would also be relatively small. However, in large hernias, it may be advantageous to undergo laparoscopic (keyhole surgery) to reduce the pain and discomfort associated with repair of a large hernia. In cases where the hernia has come back (recurrent hernia), a laparoscopic approach may also be advised.
During surgery, a mesh may be placed around the hernia defect in order to reinforce the repair. The mesh is a non-absorbable material which is permanent. It acts by allowing the body to form scar tissue over it, so strengthening the surgical repair. However, not all hernias require a mesh. If used the mesh is either placed on top of or under the muscle and it is unlikely that you will be able to feel it after the surgery.
Some hernias occur either above, below or to the side of the belly button. These are called paraumbilical hernias. These are repaired in the same way as umbilical hernias.
The most common groin hernia is an inguinal hernia. This appears as a lump in the groin. Sometimes, this hernia develops in babies and children and should be repaired. Surgery is performed to avoid the possible risks of bowel becoming trapped in the hernia. Surgery for children is undertaken at a hospital where paediatric anaesthetists and paediatric nurses are available.
In adults, this hernia should also be repaired. Surgery is undertaken either under local anaesthesia with sedation (awake and mildly sedated), under general anaesthesia (asleep), or under spinal anaesthesia (where the lower abdomen is made pain free by an injection in the spine). Elderly patients may decide to undergo surgery under local anaesthesia to avoid any risks associated with general anaesthesia. The majority of patients will stay for half a day in hospital after the operation before being discharged home. However, in certain circumstances, it may be appropriate for the patient to stay in hospital overnight.
Groin hernias may be repaired either as an open technique (the traditional method), involving approximately a 5 cm to 8 cm length incision in the groin. Groin hernias may also be repaired by the laparoscopic (keyhole surgery) method. This involves three small incisions in the skin ranging from half a centimetre to one centimetre in length. The laparoscopic method offers a quicker return to normal activities and less pain after surgery when compared with the open technique. It has particular advantages when the patient has a hernia in both groins, or when there is a recurrent hernia (the hernia has returned after it has previously been repaired). When utilising the laparoscopic method, patients will undergo general anaesthesia.
Inguinal hernias are repaired with a mesh, a non-absorbable permanent material similar to nylon. The meshes are used in both the open and laparoscopic techniques and are inserted either over the muscle (open method) or underneath the muscle (laparoscopic method) of the abdominal wall.
Are there any risks with hernia surgery?
There are risks specific to hernia surgery. The risk of a wound infection is less than 1% (1 in every 100 patients). The signs of infection include redness around the wound and sometimes a discharge from the wound. If this happens, your doctor should be consulted and a course of antibiotics may be prescribed.
There is usually swelling around the wound following surgery, but a few patients may experience bruising, or even swelling of the scrotum (in males) which usually indicates a haematoma. Although this may look unsightly and sometimes uncomfortable, this usually settles completely after a few weeks without any treatment. However, if you are concerned, you should consult your doctor.
Discomfort is common after hernia surgery. This is reduced in laparoscopic surgery when compared with the open method of hernia repair. You will be prescribed painkillers for at least two weeks which you should take until the pain becomes much easier. A small number of patients (approximately 5% of patients undergoing hernia repairs) experience long term groin pain which is usually due to nerve pain. If this occurs, it can be treated with tablets and if it persists, patients can receive a course of injections of steroids and local anaesthetic. Long term pain is less common with the laparoscopic method.
The chance of a hernia returning after surgery is very small, less than 1% ( 1 in every 100) with the traditional hernia repair, approximately 3% (3 in every 100) with the laparoscopic repairs. If you are concerned that your hernia has come back following surgery, you should consult your doctor.
Numbness over the scar is common after inguinal hernia repair and more common with the open method of repair. It is associated with cutting of nerves which supply the skin in the area of the operation. The numbness may settle after several months, but some patients experience numbness permanently.
What precautions should I take after surgery?
Following surgery, you should refrain from driving for one week, and from heavy lifting for two weeks. Generally, I would advise refraining from work for one week after the operation. Immediately after surgery, you will have dressings on your wounds. If these are waterproof, you will be able to shower immediately. However, the dressings should be changed every two to three days. After one week, you will not need to have any wound dressings.
A less common groin hernia is a femoral hernia, which occurs more commonly in women. It is nearly always associated with a lump near the groin crease and is due to a weakness in the muscles of the groin. As it is associated more commonly with obstruction and strangulation, it should be repaired soon after it is diagnosed. It can be repaired either by the open method of surgery (under local or general anaesthesia) or by the laparoscopic method (keyhole surgery).
This is a hernia situated above the belly button and most commonly in the midline of the body. It is associated with a lump. This hernia can be repaired either by the open or laparoscopic (keyhole surgery) methods.
This is a hernia associated with a previous operation, either abdominal or pelvic surgery. The main symptom is a lump overlying the scar from previous surgery. Although the muscles of the abdominal wall are closed successfully after abdominal or pelvic surgery, the muscles may become weaker in time and a hernia develops. This hernia may become quite large. It is associated with a bulge whenever you cough or strain. However, some hernias are quite obvious on standing.
If you develop an incisional hernia, please consult your doctor. Not all incisional hernias require surgery. However, if surgery is advised, an open or laparoscopic (keyhole surgery) method of repair may be used. In nearly all cases, a mesh is stitched underneath the muscle weakness to reinforce the repair and prevent the hernia from coming back.
This hernia is quite uncommon. It occurs due to a weakness where the muscles of the side of the abdominal wall (oblique muscles) meet the muscles along the front of the abdomen (rectus muscle).
It is usually associated with a lump, but sometimes an abdominal scan is necessary to make the diagnosis.
These hernias are usually repaired to avoid any risks associated with obstruction or strangulation.
Some patients describe pain in the groin but have not felt a lump. The pain can be quite severe and can prevent them from doing exercise. The diagnosis may be either a small hernia where a lump cannot be felt, or may be due to a groin strain (involving ligaments, muscles or tendons).
Firstly, a clinical examination is performed with the patient standing. The patient is asked to cough to increase the pressure inside the abdomen and to allow a hernia to push out through a weakness in the groin. If a hernia is not felt, an ultrasound scan may be arranged to look for a small hernia. An MRI scan may also be arranged to look at the muscles, tendons, ligaments and bones of the pelvis and joints.
If a hernia is found, this can be repaired. If a hernia is not found and an abnormality is found on MRI scan, treatment under a sports physiotherapist is advised.