Hernia Repair

I have an interest in the repair of groin and abdominal wall hernias. I have a particular interest in the use of the mesh plug technique – which I use routinely for repair of femoral hernias, recurrent inguinal hernias and certain primary inguinal hernias.

I presented a study in mesh plug technique for hernia repair in the International Union of Ambulatory Surgery in Venice; the study was subsequently published in the Ambulatory Surgery Journal below.

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Abu-Own A, Onwudike M, Haque KA and Barker SG. Primary inguinal hernia repair utilizing the mesh ‘plug’ technique. Ambulatory Surgery 2000; 8: 31-35. Department of Surgery, University College London (UCL) Medical School, The Middlesex Hospital, London, UK.

This page has been designed to provide you with some background about groin hernias, the nature of the surgery, what to expect throughout the process and the potential risks. An aftercare page has also been included to provide more information about recovery and getting back to normal daily activities.

A hernia is a “bulge” in the groin or abdomen, which develops because of an abnormal protrusion through a weakness in the abdominal wall. They can occur at any age and in many different locations. The protrusion contains a cavity (the hernial sac) which can be empty or it can fill with abdominal contents (bowel or fat).

Typically, hernias are more obvious when standing or straining, such as when coughing, lifting heavy items or digging, as the increased pressure in the abdomen can force bowel into the sac.

Hernias usually develop over time for no obvious reason, although in some people there may be an inborn weakness in the abdominal wall. Occasionally, a strenuous activity will cause a lump to appear suddenly for the first time.

An inguinal hernia is the most common type, accounting for around 75% of all hernias. They may occur at any age and are more common in men. They produce a bulge in the groin due to a weakness in an area of the abdominal wall called the inguinal canal. The canal serves as a pathway for structures (such as the testes or 'testicles') to pass from the abdominal wall to the genitals during fetal development.

A femoral hernia also produces a similar bulge in the groin but it arises from a weakness in a different location, called the femoral canal. This type of hernia is much less common than inguinal hernias for both sexes, but those that get femoral hernias are more likely to be women. Femoral hernias are more troublesome as they have a higher risk of complications (below).

Hernias may simply appear as a painless bulge that enlarges when standing or coughing, but often they cause an aching discomfort or a dragging sensation. Over time, it may gradually become bigger and more uncomfortable.

Occasionally, the contents of the hernia may become trapped in the weak point in the abdominal wall. This can cause bowel obstruction with severe pain, nausea and vomiting (incarcerated hernia).

There is also a small chance that the hernia may strangulate. This means that the bowel becomes squeezed to the extent that it cuts off the blood supply to the portion of bowel in the hernia. This serious complication is very painful and requires emergency surgery.

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The risk of strangulation is greater with a femoral hernia than with an inguinal hernia. A small hernia is at least as risky as a big hernia to strangulate.

It is usually advised that provided you are fit for the operation, all hernias should be repaired to prevent the complications (above) from arising; even if it is not currently bothering you.

Femoral hernias in particular are considered more urgent cases for repair because of the increased risk of strangulation, although the treatment itself is very similar to that of inguinal hernias - all groin hernias can usually be repaired as a day case using local anaesthetic.

1. The standard hernia operation involves placing a mesh on the outside of the weak area in the groin through a 8-10cm cut overlying the hernia. It can be performed under local or general anaesthetic. Mr Abu-Own with discuss with you his preferred technique for this using the prolene 'mesh plug'.

2. The laparoscopic (keyhole) technique uses a mesh in a very similar way to the standard open operation, but instead of a cut in the groin you have three smaller wounds on the abdominal wall. This technique is always performed under general anaesthetic. Occasionally, conversion to the standard open repair is required, although this is a rare occurrence.

Mr Abu-Own will discuss the benefits and drawbacks of each technique with you and help you decide which is the best option for your individual case.

It is recommended that patients with two hernias (one in each groin) or those with recurrent hernias, should be considered for the laparoscopic technique.

For those with recurrent hernias, Mr Abu-Own considers the prolene mesh plug technique to be a safe and simple alternative to the laparoscopic technique. Whilst keeping dissection of tissue to a minimum, he is able to deal with the hernial sac and repair the defect using this technique. Mr Abu-Own uses the mesh plug technique as standard for patients referred to him with hernia recurrence, including those who have had a previous laparoscopic hernia repair.

Hernia repairs are generally very safe and serious complications are very rare.

Short term complications include:

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Bleeding or Wound haematoma: Bleeding under the skin can produce a firm swelling or blood clot (haematoma). This may simply disappear gradually or leak out through the wound. Rarely, it needs to be drained in theatre.

Infection: Hernia repair is classed as a clean operation. Therefore, wound infection is uncommon. It is Mr Abu-Own's policy to give one dose of antibiotic just prior to starting the operation to further reduce the risk of wound infection. You will be asked before the operation if you have any known allergies. If you are allergic to any antibiotics then it is important that you disclose this.

Seroma – a collection of clear fluid that sometimes occurs after surgery

Damage to surrounding structures: 1)Testicular vessels in men - inguinal hernias are very close to the spermatic cord which contains the blood supply to the testes. Damage to the blood supply can lead to swelling, pain and shrinkage of the testes. Problems with sterility (having children) in the future is extremely rare. 2) Surrounding nerves - several nerves cross the operative field in hernia surgery. It is usually possible to preserve them but some minor nerve injury, rather like a bruise, is common and usually returns to normal in time. Permanent numbness may occur. 3) In laparoscopic (keyhole) surgery, other structures within the abdomen are at very small risk of being damaged. These include the bowel and blood vessels.

Deep Vein Thrombosis (DVT): This is rare after this type of day surgery. You may be given a heparin injection (Enoxaparin) in recovery to reduce the risk further, depending on the results of your VTE risk assessment.

Medium to long term complications include:

Recurrence: There is never a guarantee that you will never develop another hernia in the same place after your operation. Fortunately, recurrence after hernia surgery is rare. For example, with good surgical technique using mesh, e.g. the prolene plug, the recurrence rate is about 1-3%.

Chronic pain: Some patients develop pain lasting for more than 3 months after hernia surgery. This is rare but can occur in up to 5% (1 in 20) groin hernia repairs. Young men are most at risk to develop this complication. The cause of this is not well understood and investigations often do not point to a cause. The pain does tend to settle gradually at a variable rate.

Mesh infection: this is very very rare (about 1 in 500 risk). The mesh can become infected – usually from bacteria on the patient’s skin. If this does occur the mesh will normally have to be removed with another operation and the hernia may come back (recur).

You will attend a pre-admission clinic where you will be seen by a Nurse Specialist for your pre-operative assessment.

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At this clinic, you will be asked about details of your medical history. Any investigations and tests required will be arranged. This is a good opportunity for you to ask any questions about your admission for the operation, but please feel free to discuss any concerns you have at any time.

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You will be asked if you are taking any tablets or other types of medication - these might be ones prescribed by a doctor or bought over the counter in a pharmacy. It helps us if you bring details, or the packaging, with you of anything you are taking.

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It is very important that you tell us if you are allergic to any medications or dressings/plasters.

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You will be admitted on the day of your operation. Hernia surgery is usually performed as a day case procedure, meaning that you will be able to go home on the same day. We might occasionally recommend that you stay in hospital overnight. This will be discussed with you when you are seen in clinic.

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General Anaesthesia:

If you are having a general anaesthetic, your anaesthetist will visit you on the ward. They will review your medical history. In particular, you will be asked about your medications and any health problems that you have. They will also ask you about previous anaesthetics you have had and whether you had any problems with these (for example, nausea). You will be asked if you are allergic to anything. They will also want to know about your teeth, whether you wear dentures, have caps (crowns) or a plate. Your anaesthetist may examine your heart and lungs.

You may be prescribed medication to take shortly before your operation. This is known as the 'pre-medication' or 'pre-med' - it relaxes you and may help send you to sleep.

A general anaesthetic is usually performed by giving you an injection of medication into a vein through a thin, plastic cannula (tube), usually placed in your arm or the back of your hand.

While you are unconscious and unaware, your anaesthetist remains with you at all times, monitoring your condition and controlling your anaesthetic. At the end of the operation, your anaesthetist will reverse the anaesthetic and you will regain awareness and consciousness in the recovery room, or as you leave the operating theatre.

Local Anaesthesia (LA):

When seen in the outpatient clinic, Mr Abu-Own will make an assessment and discuss with you whether to have a general or local anaesthetic for your operation. This will of course include a consideration of your preferences.

If you are having your operation under LA, Mr Abu-Own will see you in the anaesthetic room to give the local anaesthetic. Local anaesthetic is given by injection under the skin in the area of the incision. Mild sedation may also be given - injected through a vein using a cannula (tube), usually in the arm. A single dose of antibiotic is given using the same cannula.

Open repair: This involves an incision in the groin directly over the hernia. freeing up the hernia sac and replacing it inside the abdominal cavity. The abdominal muscles in the groin are strengthened with the aid of a sheet of Prolene mesh - which does not dissolve - directly behind the weak area in the groin. This prevents the bulge of the hernia from returning. Mr Abu-Own's preferred surgical technique for doing this is using the Prolene Mesh Plug.

The mesh is made of the same material as sutures (stitches) we commonly use in other operations and does not cause any reactions with your body (100% inert). You will not be aware that it is there.

The wound is closed with dissolving stitches under the skin. A number of different dressings may then be used.

Laparoscopic repair: This involves an incision near your navel and two or three further incisions. Each incision is about 1 cm long. Through these, the abdomen is inflated with carbon dioxide gas which is completely harmless. If a mesh is used, it is placed directly behind the weak area, as with the open repair.

At the end of the operation, before you wake up, the wounds in your abdomen will be treated with local anaesthetic so that when you first wake up there should be very little pain. Some patients have some discomfort in their shoulders, but this wears off quite quickly.

The cuts made will be covered with small waterproof dressings.

After your operation, you will wake up in the recovery room. You might have an oxygen mask on your face to help you breathe. You might also wake up feeling sleepy.

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You will have a thin, plastic tube in one of the veins in your arm, attached to a bag of fluid called a drip.

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Sometimes, people feel sick after an operation, especially after a general anaesthetic, and they may vomit. If you feel sick, please tell a nurse and you will be offered medicine to make you more comfortable.

Local anaesthetic is usually injected into the wound(s) to minimise pain immediately after surgery and this lasts for 4-6 hours. You will be given pain relief medication to take home for you to take if required. As the discomfort subsides you will need less pain relief but you may need to take the pain killers for 2-4 weeks.

If you have had a laparoscopic repair you may have some discomfort and a pulling sensation around the navel which will last 7-14 days.

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You will be able to drink immediately after the operation and if this is all right and you do not feel sick, you will be able to eat something.

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After your operation we will try to get you up and about as soon as you are comfortable. You will be allowed home when you are comfortable, have had something to drink and eat, and have passed urine.

Your stitches will not need to be removed as they are dissolvable.

You may have a shower after 48 hours. You may then have a bath but do not soak until the wound is healed.

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You should expect some numbness underneath the scar - this may be temporary or permanent.

Bruising around the wound or tracking down into the scrotum is sometimes seen - this may look dramatic but is harmless and will settle spontaneously.

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If you have had an open repair, it is safe to perform light exercise soon after your operation, but it is sensible to avoid anything strenuous for 4-6 weeks. However, the only thing to hold you back will be discomfort and, if the wound is not hurting, you should be able to do whatever you like.

You are not insured to drive unless you are confident that you can brake in an emergency, and turn to look backwards for reversing, without fear of pain in the wound. This takes about 10-14 days for most people. If in doubt you should check with your insurers. A good test is to sit in a stationary car and practise doing am emergency stop. If you are not inhibited because of any pain or discomfort, then you are probably safe to drive.

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You will be able to return to your normal daily activities gradually. You should be able to return to office work within two weeks and manual work within 4-6 weeks. You should avoid heavy lifting for at least 6 weeks. You will be given a certificate to cover the time off work that you require.

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The two pain relief medications most commonly prescribed after hernia surgery are paracetamol and codeine (or paracetamol and ibuprofen). You should be aware that codeine can commonly cause constipation and drowsiness. All medications are supplied with an information leaflet which lists possible side effects — please read this for more details.

Mr Abu-Own routinely sees his patients at least once following a hernia repair, around 2-4 weeks after the procedure. Your ward nurse will let you know. For self-funding patients, this is included in your pre-agreed all-inclusive procedure price.

In the period following your operation you should seek medical advice if you experience any of the following problems:

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• increasing pain, redness, swelling or discharge;

• severe bleeding;

• difficulty in passing urine;

• high temperature over 38°C or chills; or

• nausea or vomiting.