Hernia Repair

What is a hernia?

A hernia occurs when part of the bowel sticks out through a weak area in the muscles of your abdomen, causing a bulge or soft lump under the skin. A hernia is sometimes described as a rupture. A hernia can be uncomfortable and feel tender, especially when bending or lifting. It may make it difficult for you to do normal activities. Some people can push their hernia back in, but it’s likely to come out again. Surgery is the only way to repair a hernia.

What causes a hernia?

• Congenital weakness – present at birth
• Age-related weakness in the abdominal wall
• Strenuous activity or excessive strain from heavy lifting
• Pregnancy
• Previous surgery involving the abdominal wall
• Hernias are very common, approximately 120,000 per year in the United Kingdom, and occur in people with both active and inactive lifestyles.

What are the different types of hernia?

Inguinal hernia – This is the most common type of hernia – affecting approximately 2-3% of the population. It is much more common in men than women. The hernia is seen as a lump in the groin which may disappear on lying fl at or which may be pushed back, only to reappear with standing, coughing or straining. It usually causes discomfort and tends to increase in size with time. Occasionally the hernia can get stuck, or be very painful – when urgent surgery might be necessary. This is sometimes called a strangulated hernia.

Femoral hernia – This is more common in women than men. It is usually seen as a lump lower in the groin, near the skin crease towards the top of the thigh. It is more likely to become stuck than an inguinal hernia and should be repaired promptly by surgery.

Epigastric hernia – This is caused by weakening of the muscles in the central, upper abdomen, causing a lump or bulge to appear anywhere between the breastbone and the navel. The lump can be quite small or extremely large and tends to be more common in middle age. It is best repaired by surgery.

Umbilical hernia – This occurs at, or near the navel. It is very common in children. In adults it is more common in women, often in those who have had children. Incisional hernia – This may occur at any site where an operation has been performed previously. The scar represents a weakened area, which, over time, may allow the intestines underneath to bulge through. Surgical repair is often necessary.

Strangulated hernia – Sometimes a hernia can become strangulated trapped in the gap it has come through. This can cut off the blood supply to this part of the intestine, which causes an acute blockage. This may lead to perforation of the bowel, which then allows bacteria to escape into the abdomen and cause a serious infection or infl ammation called peritonitis. This is a potentially life-threatening condition that requires emergency surgery. The main symptom is usually severe pain over the hernia bulge, often with reddening of the overlying skin.

What is the treatment for hernia?

Generally, a hernia that can be pushed back easily, or flattened, is not an immediate danger to your health, although it can be uncomfortable. An untreated hernia will not get better on its own. If left untreated, it is likely to continue to increase in size over time and become more painful. Surgery is the only way to repair a hernia.

What is involved in hernia repair surgery?

The operation will either be open or keyhole surgery. A hernia repair is usually carried out as a day case that means you don’t need to stay in hospital overnight.

Open surgery – This approach is performed by making a cut and is undertaken for most hernias on the abdomen. For inguinal and femoral hernia repairs the laparoscopic approach is preferred. Open inguinal hernias involve making a 10 cm (4’’) long cut in the groin. The hernia is pushed back through the gap into its proper place inside the abdomen. The weakness is usually covered by a piece of sterile synthetic mesh that is stitched in place. The abdomen is then closed with further stitches or staples.

Laparoscopic surgery (keyhole) – Laparoscopic surgery is mainly used for inguinal or femoral hernias where the surgeon makes several small cuts near the belly button and inserts the camera into the abdominal cavity to repair the weakness from inside. A synthetic mesh is stitched in place over the defect to reinforce the area. The advantage of this type of surgery is significantly less post-operative pain and faster recovery, but a slightly increased risk of the hernia coming back.

What happens to the mesh in a mesh repair?

The mesh is surgically stitched in place and as the stitches dissolve, tissue grows into and around the mesh to keep it in place. The mesh does not dissolve. There is very small risk, 1 in 2,000 – 3,000 people, of the body rejecting the mesh – it would then need to be removed.

What are the risks?

Although uncommon, complications and side effects can occur. The medical team or nurse specialist will be able to explain how the following risks apply to you.

• Temporary bruising, swelling or scarring at the site of surgery. This is very common and will only last a few days. Although the scarring will fade an incision line will always remain.
• In men, swollen testicles and bruising are common for a few days after the operation.
• Temporary difficulty in passing urine that can last for 12 – 24 hours, but it is uncommon.
• Side effects of the anaesthetic such as feeling sick. Serious problems are rare.
• Infection deep inside your groin or in the wound on your skin, but this is very rare.
• Bleeding under the skin after the operation. If blood builds up and clots, your groin will swell and feel tender, this will give you a big bruise called a haematoma. Sometimes it will stop by itself, but sometimes an operation is needed.
• Damage to blood vessels or other organs, such as the bowel, this is rare.
• Damage to nerves causing numbness in the groin area. Feeling may come back, but it can last for months or years. About 11 in 100 people have numbness in their groin area a year after the operation although the risk is less with keyhole surgery.
• Risk of the hernia reoccurring between 3 and 9 hernias in 100 come back.

What happens before the operation?

Prior to admission you will need to have a pre-operative assessment. This is an assessment of your health to make sure you are fully prepared for your operation. The pre-operative assessment nurses will help you with any worries or concerns that you have and will give you advice on any preparation needed for your surgery.

Before your date of admission to hospital, please read very closely the instructions given to you. You will be given specific instructions about when to stop eating and drinking, please follow these carefully as otherwise this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming to hospital.

What happens on admission?

On admission a member of the nursing staff will welcome you. The nurses will look after you and answer any questions you may have. You will be asked to change into a theatre gown. The surgeon, specialist nurse and anaesthetist will visit you and answer any questions that you have. You will be asked to sign a consent form. A nurse will go with you to the anaesthetic room and stay with you until you are asleep. A cuff will be put on your arm, some leads placed on your chest, and a clip attached to your finger. This will allow the Anaesthetist to check your heart rate, blood pressure and oxygen levels during the operation. A small plastic tube will be put in the back of your hand using a needle. This will be used to give you the medication to send you off to sleep.

Preventing Deep Vein Thrombosis (DVT)

• Your risk for DVT will be assessed on the day of your operation and you may require an injection of medicine to prevent blood clots. In addition you may be asked to wear anti-embolic stockings that should ideally be worn until you are back to your usual level of activity, usually 24 hours. If you need to wear them for longer than 24 hours, you should remove them for 30 minutes each day.
• If possible, avoid long periods of immobility, if you feel more tired than usual is it still important that you try to mobilise to promote circulation. For instance mobilising around the house or going out for short walks.

What happens after the operation?

• Your blood pressure, pulse and wounds will be monitored closely over the first few hours. You will normally be able to start drinking shortly after the operation and can start eating as soon as you are hungry. You will normally be able to get out of bed as soon as you feel well enough to although the nurses may assist you the first time.
• You may experience some pain from your wounds. If you do, the nurses will give you painkillers. Before your discharge you will be given a supply of painkillers, dressings and post-operative instructions. Your GP will be notified of your discharge. A hospital follow-up appointment will be arranged for you usually within 6-8 weeks.

How long will it take to recover from the anaesthetic?

Whilst most of the effects of anaesthesia wear off in a few hours, it is common to have poor concentration and memory for the first day or so. It is important therefore that you do not make important decisions, sign legal documents or operate machinery or equipment for at least 24 hours after the anaesthetic. Muscle aches or headaches may also be experienced over the first few days.

Will I feel sick after surgery?

Nausea and vomiting not unusual after surgery, we endeavour to keep this at a minimum. Medication can be used during the anaesthetic and after to control this. Take extra rest and try to drink something regularly. If you can tolerate food, take small frequent snacks.

How much pain should I expect?

It is normal normal to have wound pain after surgery and your tummy or groin may feel quite tender. This should start to subside after a few days. After about 10 days most of the soreness should disappear. You may also notice that you have a slightly sore throat. This is due to the breathing tube placed in your throat during surgery and should get better in a day or so. To minimise discomfort, you should take the painkillers that you have been given, regularly over the first few days. Make sure that you do not exceed the dose prescribed. After your discharge, if you have any queries or problems with your painkillers you can seek advice from your local GP or chemist.

When can I resume daily activities?

You can return to normal physical and sexual activities within a few weeks. It is normal to feel tired after your operation, so take some rest, two or three times a day, and try to get a good night’s sleep. After a week or so, you should be able to resume most of your normal daily activities. You should avoid heavy lifting and vigorous exercise for at least six weeks. You should not drive for at least one week. Before driving you should make sure that you can perform a full emergency stop. That you have the strength and capability to control the car and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance.

When can I return to work?

You can return to work as soon as you feel well enough. This will depend on how you are feeling and the type of work that you do. If you have a desk job you may feel ready to return in a week or so. If you are involved in manual labour or heavy lifting you may require a bit more time. Typically, you will need between two and three weeks off work.

What can I eat?

There are no dietary restrictions after hernia repair however for the first week or so, we would encourage eating a healthy well balanced diet at all times. It may take a few days before your appetite returns. When you feel hungry start with light frequent meals and then increase at your own pace.

How do I care for my wounds?

• If there are any dressings in place, you can remove them 24-48 hours after your operation. Initially it is preferable that you take a shower, if you do not have a shower a short bath would be better to prevent the wounds becoming ‘soggy’. There is no need to apply further plasters unless you feel it would be more comfortable to do so.
• The incisions will usually be closed with staples. The ward nurses will arrange for you to go to the Practice nurse at your GP surgery to remove them. The incisions will probably be red and uncomfortable for one-two weeks and some bruising and swelling is common. After the incisions have healed there will be a small scar. These scars first appear pink, but over the next few months they will become less and less noticeable. There may be some persistent bumpiness and bruising around the wounds, but these will gradually improve. You may also notice numb patches in the skin around the incisions. Whilst in most cases sensation will gradually return, occasionally the numbness may be permanent.
• Occasional aches and twinges in the wounds can persist for several months. Rarely, a wound infection may develop during the fi rst few weeks after surgery. Symptoms include increasing tenderness, pus like discharge, swelling and redness of the wounds. If this occurs, visit your GP as you may need some antibiotics to resolve the infection and discomfort.

Who can I contact if I am concerned after discharge?

If you have any concerns or experience any of the following symptoms, please contact the Acute Surgical Assessment Unit on 01274 383205 to speak with a member of the medical team who will offer advice:

• If you have a discharge of blood or pus coming from your wounds.
• If you develop fever or vomiting symptoms for several days.
• Inability to have a bowel movement after four days.
• Persistent pain not relieved with your prescribed painkillers.
• Persistent bloating of your tummy.
• Increasing pain or swelling around your wounds.

The Acute Surgical Assessment Unit is open 24 hours a day.