Hernias

You may have noticed a lump on your abdomen or in your groin and been told by your doctor that this is a hernia. The abdominal cavity is basically an enclosed muscular compartment. If there is a tear in the muscles or they are damaged by surgery (incisional hernia) then a hernia can result. There are a few naturally weak areas, such as the groins, especially in men, that are classical sites for hernias after a muscle tear. The bulge is the abdominal contents pushing out through the muscular defect. These contents are usually intra-abdominal fat or bowel.

Hernias are named after their site or cause: inguinal and femoral in the groins; umbilical and para-umbilical at your belly button; epigastric above this; incisional through a previous operation site; ventral through the midline of the abdomen. You can also have hernias on both sides of your groins – ‘bilateral’ hernias and we also see ‘recurrent’ hernias when a hernia repair fails.

Most hernias are asymptomatic – causing no pain or discomfort and the first you know about it is when you feel or notice a lump. But sometimes they can cause discomfort or pain. The muscle cannot repair itself so the hernia can only get bigger over time and/or cause more issues. The most common symptom is mild discomfort. The lump may be more noticeable when you are standing up and reduce in size or even disappear when you lie flat. When a hernia does not do this we call it irreducible and this can lead to bowel becoming blocked when it is in the hernia or even leading to the blood supply to the bowel becoming strangulated. This is a surgical emergency but you would absolutely know that this had happened, it’s not a case of having just a little worse pain one day, so you would come immediately to the hospital. This would need urgent surgery before your bowel becomes permanently damaged. The risks of this happening are low and vary between hernia sites and sizes.

HERNIA TREATMENT IN JERSEY

Since the hernia will not repair itself, the only treatment for a hernia is an operation. Depending on the site and the size of the hernia, as well as your symptoms, there is often no urgency for surgery, only around 25% of hernias when left alone will cause problems within two years. However, by ten years almost all hernias will have need repair. Depending on the site there are various ways of fixing hernias. I can fix most hernias in Jersey using either a laparoscopic (keyhole) approach or open surgery. Naturally, you would think that a laparoscopic approach would be better but this is not always the case. I would discuss all this with you. Nearly always I use a reinforcing ‘mesh’ to repair your hernia. These are essentially made from synthetic material (like nylon) and last forever. The mesh forms an inert scaffold in your body that scar tissue grows into to strengthen the area in which it is placed. There have been scary stories about mesh but these are when this is placed around a human structure, in contrast hernia meshes are placed flat and do not cause these issues. The biggest risk is that it gets infected so we have to be very careful in keeping your operation sterile and give you a shot of antibiotics as you go to sleep.

An open inguinal, femoral, epigastric, spigelian or umbilical hernia repair operation is done under general anaesthesia as a ‘day case’ and takes about 30-45 minutes. A cut is made directly over the hernia. The hernia is dissected out and either excised or replaced back into your abdomen. If the defect/tear in the muscles is very small, it can be simply fixed with permanent sutures alone but in most cases a mesh is used to reinforce the muscles. The cut in the skin is closed with dissolvable sutures and if you recover well from the anaesthetic then you can go home a few hours after the operation, on the day of your surgery. If not then you can spend a night in the hospital and go home the next morning.

LAPAROSCOPIC HERNIA REPAIR IN JERSEY

Keyhole (laparoscopic) approaches to hernias are technically more difficult than open repairs. They are again done in Jersey under general anaesthesia as a ‘day case’ and take about 45 minutes. Usually three small cuts are made on your abdomen (one is around 12mm and two are 5mm in length). They are made a slight distance away from the hernia site to give me room for my instruments and camera. Again, the hernia is dissected out and either excised or replaced back into your abdomen. A mesh is always placed in these cases, this time underneath the muscle layer and fixed using glue or absorbable staples to reinforce the muscles. The cuts in the skin are closed with dissolvable sutures and if you recover well from the anaesthetic then you can go home a few hours after the operation, on the day of your surgery. If not then you can spend a night in the hospital and go home the next morning. There are actually two different laparoscopic approaches to inguinal hernias: TAPP (TransAbdominal PrePeritoneal) and TEP (Totally ExtraPeritoneal). In a TAPP repair, I go into your abdominal (peritoneal) cavity, essentially a true laparoscopy, and I open up the peritoneum over the hernia and place the mesh here. In a TEP repair the abdominal cavity is not entered and the mesh is sited from outside the peritoneum (which is the thin membrane covering the organs in the abdomen). This approach is considered to be technically more difficult than TAPP but has fewer and less dangerous associated complications. I prefer TEP as I find patients recover quicker and with less discomfort.

Most patients recover quickly from hernia repairs, it may mean taking painkillers regularly for a few days but you rapidly are able to resume your day-to-day activities within few days after surgery but it is best to avoid ‘strenuous physical activity’ for 4-6 weeks after surgery to allow the hernia site to repair fully and become strong. I advise not lifting more than 10kg but this is mostly common sense. If it’s sore, don’t do it! Otherwise there are no hard or fast rules and in some ways the quicker you return to exercise and mobility the better.

Like any operations, there are always risks with hernia repairs, although serious complications are rare. Bleeding, infection, scars, some skin numbness, chronic discomfort, recurrence of your hernia and injury to the underlying bowel are possible. I will discuss these with you in more detail as they vary with the approach. Recurrence runs at less than 5%, depending on the site and size of your hernia, how long it has been there, how old you are, whether you smoke or do a heavy job and whether this is a primary repair or for an already recurrent hernia. Sometimes fluid can collect in the space where the hernia was – this is called a seroma and can look like the hernia has come back. But over a few weeks this fluid is usually re-absorbed by the body.

Incisions through the muscles of the abdominal wall for other surgeries can lead to a weakness in this usually strong muscle layer. An incisional hernia is when one of these defects through your scar becomes a hole. Often this develops into a bulge or lump that comes and goes with abdominal contents, such as intra-abdominal fat or bowel, pushing out through the muscular defect. We sometimes also call these ‘ventral hernias’ and may require an ultrasound or CT scan to confirm the diagnosis or to get more information about the size of the defect, the surrounding muscle quality and the contents of the hernia. 

In similarity to groin and umbilical hernias, an incisional hernia will not repair itself so the only treatment for an incisional hernia is an operation and as with any abdominal wall hernia, there is always a risk of bowel obstruction or strangulation of the bowel. This risk varies greatly depending on many factors. This would always be discussed with you. I can fix most incisional hernias in Jersey using either a laparoscopic (keyhole) approach or open surgery. Naturally, a laparoscopic approach has many benefits over an open operation, but it can actually end up as more painful as this approach uses a lot of surgical staples or tacks into the muscle layer to hold the repairing mesh in place. So open surgery may be better if the hernia is either very large or very small. 

Incisional hernia repairs are performed under general anaesthesia and take varied amounts of time depending on the site and size of the hernia. The laparoscopic repair again usually utilises three keyhole cuts. It takes longer to repair these as there are usually some adhesions to deal with inside the abdominal cavity. A ‘composite’ mesh is used for the repair as it comes into contact with the bowel, so one side is placed up against the abdominal wall muscles and the other up against bowel with a special covering so it doesn’t ‘stick’ on this side. The mesh is fixed to the muscles using special absorbable tack or staples. The keyhole cuts are closed with dissolvable stitches. The length of hospital stay totally depends on the size of the hernia, the amount of dissection and the complexity of the operation. Sometimes this is as a daycase but usually patients to stay in hospital for a few nights.

Like the other hernia repairs there are risks of bleeding, infection, scars, and injury to the bowel during the dissection of adhesions as well as a seroma. Recurrence of a hernia after incisional hernia repair is more common at around 10%.

WHAT IF YOU HAVE PAIN IN YOUR GROIN BUT NO SWELLING? 

This is sometimes referred to as Gilmore's Groin or previously a Sportsman's hernia. The groin is a complicated area for muscles, so a small hernia may not be easily felt, equally there are many other conditions that can cause groin pain including a sprain. Sometimes a thorough examination of your groins by a specialist is enough and sometimes I need to order an ultrasound scan or even an MRI to determine the cause of your pain. This tends to be most difficult to determine in athletes or if you are an especially active sportsperson. Groin strains and sprains are really common with sports that involve rapid changes in direction or speed and kicking. If there is no hernia and no bone or joint problem then intensive physiotherapy and analgesia is the best option but sometimes we have no choice but to strengthen the groin with laparoscopic surgery.

Your six-pack is actually two strap muscles called rectus abdominis. These work like ‘braces’ and run either side of your umbilicus. They are strongly attached in the midline – the linea alba but sometimes this fibrous attachment can weaken, leading to separation of the muscles at relaxation. When these muscles are contracted they pull in and this increased pressure pushes the weak area to bulge outwards like the bow of a ship. Some patients describe this as a triangular shape when they sit up. This is called ‘divarication of the recti’. Although it looks unhealthy, it is not a hernia and it carries no risks of bowel obstruction or strangulation of the bowel. As such, surgery is only really cosmetic and is not very successful long term as the muscles tend to split away again over time. I therefore rarely advise that this is repaired.