Inguinal hernia

Definition

An Inguinal hernia is a protrusion in the lower abdomen or groin area. It often presents predominantly with a bulge in the groin area but can also present with pain and sometimes a burning sensation.

Who commonly presents with it?

Anyone can present with an inguinal hernia, but they are more common in men and are associated with:

  1. Heavy lifting
  2. Persistent coughing or straining (constipation, difficulty in passing urine)
  3. Increasing weight (mild to moderate obesity)
  4. Pregnancy
  5. Keen sportsman, weight-lifting & cycling

How does it present?

An inguinal hernia usually presents with a lump or pain in the groin area.  Exercise, coughing or sneezing can aggravate the hernial lump and some inguinal hernia can also protrude down into the scrotum (men). Small inguinal hernias usually disappear on lying flat. Inguinal hernia are usually reducible by simple pressure but can on rare occasions become very painful and irreducible (incarcerated or strangulated). Usually the hernia will contain a sac, which may have small or large bowel contents.

What can be done?

An inguinal hernia is often painful and due to the risk of possible incarceration and/ or strangulation surgical repair is recommended. Surgery is performed as a day case for the large majority of patients requiring no overnight stay and can be performed by the following techniques:

1) Open surgery under Local or General anaesthetic (it can also be performed with epidural anaesthesia, where you are awake but numb below your waist due to a simple anaesthetic given by a needle in your back)

2) Keyhole 'laparoscopic' surgery - This involves a General anaesthetic and predominantly the use of the totally extra-pre-peritoneal repair (TEP) please see below. This repair technique can also be combined with the Trans-abdominal (TAPP) approach for very large groin hernias. 

3) TEP (totally extra-peritoneal repair) - This type of repair involves the creation of a space within the layers of your abdominal wall muscles and so does not involve going into the abdominal cavity and allows fixation of the hernia with placement of a mesh in this space once the hernia has been reduced.

The keyhole technique is not possible in a very small number of patients as there is no space present between the abdominal wall muscles/fascia. This can be seen in patients that have undergone previous surgery with an incision in the lower part of the abdomen due to a major abdominal operation, a caesarean incision and those with an open appendicectomy incision in the right lower part of the abdomen.

Professor Sheen will discuss all the options with you and together a decision will be made on which type of hernia repair will suit you best.

Professor Sheen utilises a specialised technique of fixation by the use of tissue glue to try and reduce the potential risk of long term groin pain and numbness (2% for all groin hernia repair), for more information on this technique click here.

How long will your recovery take?

Recovery is very quick, with most patients being discharged home the same day. Patients that undergo inguinal hernia repair on both sides (bilateral) may require hospital stay overnight especially if they are older (>70). Patients are encouraged to start mobilising immediately after surgery and refrain from lifting heavy objects for at least one month as well as heavy duty activity for a possible further month. A return to full regular activities is expected within 2 weeks for keyhole surgery and up to one month for open groin hernia surgery. A patient information leaflet will be provided which details what possible wound problems can arise after surgery as well as a rehabilitation programme.

What are the main risks of surgery?

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of bleeding in the abdominal wall and/ or groin, very rarely bleeding requires any intervention such as surgery. Older patients and those with large hernias may find more ?swelling? in the area previously occupied by the hernia known as ?dead space? (artificial space created by the hernia protrusion), which can be in the groin as well as the scrotum (in men). The ?dead space? fills with fluid especially in the scrotum, and requires support with ?tight? undergarments but not too ?tight?! This swelling is called a seroma and settles in most patients in 1-3 months with some persisting longer. Occasionally a small bleed into a seroma presents with a haematoma or bruise, this again settles in time but can be unsightly for at least the first 4-6 weeks after surgery especially if in the scrotum, therefore, supportive undergarments are again suggested. 

Another complication includes wound infection and a 1-2% risk of recurrence of the hernia. Specifically for inguinal hernia surgery the risk of groin pain and numbness is quoted as a long term risk seen in up to 2-6% of patients.

Men of increasing age can in some cases have difficulty in passing urine especially after keyhole hernia repair, this is because the prostate gland can swell. Some patients require a catheter passed into the bladder and may also need some medication, but this is temporary and in most patients the catheter can be removed after 24-48 hours. Very rarely a specialist in urology will be needed for advice.

The risks of underlying bowel complications are rare and are mainly associated with the keyhole (laparoscopic) technique and if they occur, are commoner with the TAPP over the TEP method.

Other very rare complications that have been described in the literature include injury to major blood vessels and the bladder but these again are predominantly associated with the keyhole (laparoscopic) technique.