Hernia repair is one of the most commonly performed surgical procedures in Australia. One in every 20 men will develop a hernia sometime in their life.
A hernia is the protrusion of tissue, most commonly intestines or fat, through an abnormal opening in the abdominal wall. Think of an old-fashioned rubber tire with an inner tube. When the tire wall weakens and separates, the inner tube can push through the opening.
Similarly, a hernia occurs when tissue protrudes through an opening or separation of muscular layers in the abdominal wall. As the hernia enlarges a bulge appears which is most often visible when standing. Lying down allows the tissue to return to its proper position and the bulge temporarily disappears.
While hernias can occur anywhere on the abdominal wall the greatest number occur in the groin (inguinal hernia), umbilicus (umbilical hernia) or at a previous abdominal scar (incisional hernia).
How Do I Get a Hernia?
Hernias can be present at birth or occur over time due to stress and strain on the abdominal wall. Most hernias develop later in life. It develops in a weakened spot or tear of the abdominal wall, such as at the umbilicus or groin. Some of the common precipitating factors for hernias are chronic cough, constipation, urinary retention, heavy lifting, obesity and previous abdominal surgery. Hernias are also more common in male and those with a family history.
What are the Symptoms?
Frequently hernias do not cause any symptoms and found incidentally on clinical examination or imaging tests for other reasons. When symptoms are present they commonly present with a lump most prominent with straining or standing. Patients may develop pain particularly with straining or complain of a dragging sensation. Occasionally patients present with a complication such as incarceration or strangulation described below.
What are the complications of Hernias?
The body cannot repair a hernia and over time they tend to get bigger as the defect in the muscle stretches to allow more abdominal contents to slip in and out. Hernias are prone to serious complications such as incarceration, obstruction and strangulation.
Incarcerated hernia present as an irreducible and painful hernia. The hernia contents have come out and are unable to be pushed back in. These hernias are at great risk of progressing to strangulation and require urgent surgical repair.
Obstructed hernias typically involve a segment of bowel that has become incarcerated and blocked. There is usually pain involved and the patient cannot pass any bowel motion or even flatus. This is an emergency and warrants immediate admission to hospital and repair of the hernia.
Strangulated hernias are when the blood supply to the contents of hernia (eg. bowel or fat) are blocked and become starved of blood. The hernia contents are in the process of dying and this also is a medical emergency. Patients present with severe pain and an irreducible hernia. This is an emergency and warrants immediate admission to hospital and repair of the hernia.
What Are My Options?
Without surgery, you simply tolerate the hernia. Wearing a truss or binder may temporarily control the bulge from increasing in size, but it will not permanently cure the hernia. Only surgery can permanently correct the hernia defect. he principle of hernia repair is to reduce the contents back into the abdominal cavity and close muscle.
Traditional or more old-fashioned hernia repair techniques involve suturing the separated abdominal wall muscles and ligaments together. Since muscles are soft and movable while ligaments remain rigid and stationary, these structures can re-separate over time or the sutures can tear through the tissue, causing the hernia to reform.
Modern hernia repairs involve placement of a plastic mesh over the hernia defect. The advantage of mesh that a large area is covered, and there is no tension on the repair that would encourage stitches to pull through and lead to a recurrence. The mesh gets incorporated and strengthens the tissue surrounding the hernia and closes off the separation so that tissues can no longer push their way through.
Other predisposing factors (eg. obesity, constipation, urinary retention) need to be investigated and treated. Overweight patients should try to lose weight before surgery as it will reduce change of recurrence or other complications.
Can I have a laparoscopic (keyhole) hernia repair?
Most inguinal and incisional hernias can be repaired laparoscopically, however it may not suitable for everyone. The advantage of laparoscopic repair is that there is less pain and therefore a quicker return to normal and sporting activities.
What Preparation Is Required?
The following includes typical events that may occur prior to laparoscopic surgery; however, since each patient is unique, what will actually occur may be different:
Preoperative preparation includes blood tests, medical evaluation, chest x-ray and an ECG depending on your age, medical condition and anaesthetic recommendation.
After Dr Noushi discusses the surgery including the potential risks and benefits of the operation, you will need to provide a written consent.
It is recommended that you shower the night before or morning of the operation.
You should have nothing to eat or drink for 6 hours prior to your procedure.
Dr Noushi and the hospital will be more specific about the time to begin fasting depending on the time of day that your procedure is scheduled. However you are allowed to have medications that Dr Noushi or his anaesthetist has told you are permissible to take with a sip of water prior to surgery.
Medication may need to be adjusted or avoided. It is best to inform Dr Noushi and his anaesthetist of ALL your current medications as well as allergies to medications prior to the examination.
Most medications can be continued as usual. Medication use such as aspirin, non-steroidal anti-inflammatories (arthritis medication), blood thinners (eg. Warfarin, clopidegral etc), antidiabetic medication (insulin), Vitamin E, St John’s wart and any dietary drugs should be discussed with Dr Noushi and his anaesthetist prior to the procedure.
Blood thinners may need to be ceased for your procedure and this may require consultation with your other specialists.
It is also essential that you alert Dr Noushi and his anaesthetist if you require antibiotics prior to undergoing dental procedures, since you may also require antibiotics prior to this procedure (eg for patients with artificial heart valves).
Quit smoking and arrange for any help you may need at home.
What happens after surgery?
Most patients make a full recovery in 4-6 weeks after surgery. Hernia surgery is a major abdominal operation and a certain amount of postoperative pain occurs. Nausea and vomiting is also common. Most patients who have a laparoscopic hernia surgery go home from the hospital the day after surgery.
The recovery from surgery is different for each person and it also depends on the type of hernia. Most patients stay 1-2 nights in hospital. The sutures are dissolving and the dressings remain on for 7 days after which they can be removed and the wound left open.
Activity is dependent on how the patient feels. Walking is encouraged and patients will probably be able to return to normal activities within 2 week’s time which including driving, walking up stairs, light lifting and working. In general, recovery should be progressive, once the patient is at home.
Patients should not drive for 1 week after surgery and may return to work in 1-4 weeks depending on the nature of their job. Patients with administrative or desk jobs usually return in 1-2 weeks while those involved in manual labour or heavy lifting may require 3-4 weeks.
Heavy lifting and vigorous sports should be avoided for 6 weeks after the surgery.
Make an appointment with Dr Noushi within 2 weeks following your operation.
What are the possible complications from hernia surgery?
As with all surgical procedures hernia surgery does have some risk. Serious complications after hernia surgery are rare. It is not usual to outline every possible and rare complication from an operation, however it is important that you have enough information to weigh up the benefits, risks and limitations of surgery.
Complications from hernia surgery include (but not limited to) the following:
- Wound infection, keloid/hypertrophic scar and wound pain.
- Hernia recurrence. No matter what method of repair is used there is a small lifetime risk of the hernia recurring. If a hernia recurs then a repair of the recurrence is advised.
- Post operative pain and nerve injury. Applies particularly for open inguinal hernia repair, as it is not so common in laparoscopic inguinal or other hernia repairs. Patients may complain of pain or numbness near the scrotum and inner thigh and occasionally chronic pain (rare) in the groin or running down the thigh. Occasionally staples used for laparoscopic hernia repairs can also cause pain in the muscle where it is fixed. Most post-operative pain usually settles in time with the assistance of inguinal massage therapy.
- Uninteded injury to internal organs near the hernia site such as intestine, bladder and blood vessels.
- Injury to the testicular artery. This is only relevant to inguinal hernia surgery as the artery supplying the testicle runs within the inguinal canal and is rarely injured during the repair. It would tend to present as a swollen painful testicle that would gradually shrink to less than its normal size. It would not usually require further surgery.
- Other general surgical and anaesthetic complications include nausea, bleeding, blood clots, chest infections, deep vein thrombosis, allergic reactions and heart troubles. Difficulty urinating after surgery is not unusual and may require a temporary tube into the urinary bladder for as long as one week.
When should I be concerned and call Dr Noushi after surgery?
Be sure to call Dr Noushi or the hospital if you develop any of the following:
- Persistent fever over 38 C
- Increasing abdominal or groin swelling
- Pain that is not relieved by your medications
- Persistent nausea or vomiting
- Inability to urinate
- Persistent cough or shortness of breath
- Purulent drainage (pus) from any incision
- Redness surrounding any of your incisions that is worsening or getting bigger
- You are unable to eat or drink liquids