Inguinal Hernia
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 sometimes they are not, which causes a hernia.
Schematic diagram showing the usual site of an inguinal hernia.
What is an inguinal hernia?
An inguinal
(pronounced "ingwanal") hernia is the most common type of hernia. The
hernia can appear as a swelling in your groin or as an enlarged scrotum (the
pouch containing the testicles), which may be painful. The swelling will often
appear when you are lifting something and disappear when you lie down. There are two types
of inguinal hernia:
- An indirect inguinal hernia is
the most common type of hernia, which can occur at any age and is more
likely to cause pain in the scrotum.
- A direct inguinal
hernia is more common in older men and rare in
children.
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 passes in
women. Straining, for
example on the toilet, increases pressure inside the abdomen and can trigger a
hernia. Other triggers include:
- obesity
- a smoker’s cough
- constipation
- carrying or pushing heavy
loads.
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 can become weaker.
An inguinal hernia
repair is an operation to push the bulge back into place and to strengthen the
abdominal wall. The operation may be recommended if symptoms are
severe, last for a long time, or if there are complications. The section of bowel
can become:
- stuck in the inguinal canal,
causing an obstruction – this causes nausea, vomiting and stomach
pain, as well as a painful lump in the groin
- trapped and have its blood
supply cut off (known as a strangulated hernia) – emergency surgery
within hours is essential 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.
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 surgery –
a less invasive but more difficult technique where several smaller cuts
are made, allowing the surgeon to use various instruments.
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. When recovering from an inguinal hernia
repair, 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.
Schematic diagram showing the usual places of incisions for TEPP laparoscopic inguinal hernia repair.
An inguinal hernia
repair is a routine operation with very few risks. However, around 1%
of inguinal hernias will return after the operation. Although
complications due to an inguinal hernia repair are rare, they can 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
- pain and numbness in the
groin area caused by damage of a nerve during surgery
- stitches trapping a nerve,
mesh applied too tightly, or scar tissue forming (this is more
common after open surgery).
Complications are
more likely if you are over 50 or you have another illness, such as heart
disease or breathing problems.
Surgical Repair of Inguinal Hernia
There are two ways
that an inguinal hernia repair can be carried out. These are open surgery or
keyhole surgery (also called laparoscopic surgery). The hernia repair
should take about 45 minutes. The hospital will send you instructions
about when you need to stop eating and drinking before the operation.
You will usually be
able to go home on the same day, but some people stay in hospital
overnight if they have other medical problems or if they live alone.
Open surgery
- The surgeon makes a 6cm cut
in your lower abdomen or over the hernia.
- The inguinal canal (the
channel near your bowel) is opened to return the fatty lump or loop of
bowel to your abdomen, where it should be.
- Stitches are used to repair
the weak spot that let the hernia through.
- The wall of your abdomen may
be strengthened by fixing a patch of composite mesh to it.
- 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 four to five
days.
Schematic diagram showing an open mesh inguinal hernia repair.
With keyhole surgery,
your surgeon makes three very small cuts in your abdomen (a large cut is not
needed) and inserts special instruments to pull the loop of bowel 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 to the weakened area in your
abdomen wall, to strengthen it.
- Totally extraperitoneal
(TEP) – this is the newest keyhole technique, also known as Desarda
technique. The hernia is repaired without entering the peritoneal cavity.
Schematic diagram showing a laparoscopic inguinal hernia repair being performed.
The National
Institute for Health and Clinical Excellence (NICE), which assesses medical
treatments for the NHS, 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 also tends to have a quicker recovery time and you can
get back to work quicker.
However, the risks of
serious complications, such as the surgeon accidentally damaging the bowel, are
also higher in keyhole 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.
Your choice will
depend on:
- Whether you can have a general
anaesthetic. Elderly people or people in bad health may
be too weak or frail to safely have a general
anaesthetic. Therefore, they may be advised to have open
surgery, which can be done under local anaesthetic, where the area is
numbed.
- The experience of your
surgeon. Open surgery is more common than keyhole
surgery, partly because not all surgeons have enough experience in keyhole
techniques. According to NICE, a surgeon is inexperienced if they have
done the operation fewer than 20 times.
NICE recommends that
keyhole surgery should always be considered if the hernia has been repaired
previously and comes back. This is known as a recurrent hernia. Keyhole surgery is
especially useful if your surgeon is not sure what type of hernia you have.
Recovering from Inguinal Hernia Surgery
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. You will not feel any
pain while your hernia is being repaired, but your groin will feel sore and
uncomfortable afterwards. You will be given painkillers to help relieve this
discomfort.
An adult must stay
with you for the first 24 hours after your operation. Follow these tips to
ensure your recovery is as quick as possible:
- Follow the instructions your
nurse gave you about caring for your wound, hygiene and bathing.
- If you are still in pain,
continue taking painkillers as advised by the hospital.
- Eat plenty of vegetables,
fruit and high-fibre foods such as brown rice, wholemeal bread and pasta.
This helps to avoid constipation, which may cause pain in your wounds from
straining.
- You can return to normal
activities if you are not in too much pain, but avoid lifting.
A general
anaesthetic (which puts you to sleep during your operation) can affect your
coordination and reasoning skills. Therefore, avoid drinking alcohol, operating
machinery or signing legal documents for at least 48 hours. Speak to the medical
professional who is in charge of your care for advice about when you can drive.
It will usually be at least one to two weeks before you can drive after having
keyhole surgery and two to six weeks after having open surgery. You must not drive
before you are free of pain. You may want to contact your car insurance company
before starting driving again.
It usually takes
10–15 days to get back to activities such as shopping. You may recover faster
if you have had keyhole surgery. You should be able to
return to work after two to four weeks, depending on the extent of surgery and
your type of work.
Gentle exercise can
help the healing process, but avoid heavy lifting and anything that is too
strenuous. You may find sex
painful or uncomfortable at first, but it is fine to have sex when you feel
like it.
Source: NHS Choices.
Source: NHS Choices.
