Surgery
for hernias
A hernia is caused by a defect or weakness
in the abdominal wall muscles. It results in a bulge in the
groin (inguinal and femoral hernias) or elsewhere, e.g the
tummy button (umbilical hernia) or following previous
surgery (incisional hernia). The first symptom is often
discomfort in the area affected although a painless
swelling may also be the first indication of a hernia. If a
swelling is present the diagnosis is usually obvious to
your doctor whilst discomfort in the absence of a lump may
cause difficulty in diagnosis. When you are examined your
doctor will at some stage ask you to cough as this raises
the pressure within your abdomen and makes the hernia
appear.
With certain types of painless hernias you may not require
any treatment at all. In most cases however an operation is
advisable. This is either because of discomfort or because
of the risk of strangulation of the hernia. The swelling
consists of what is called a hernia sac and its contents.
The sac can be likened to a small balloon and is part of
the lining of the abdominal cavity. Inside there may be
just abdominal fat or more often bowel. Strangulation of a
hernia occurs when the bowel inside the sac gets stuck in
the abdominal wall defect. The bowel can then lose its
blood supply and become gangrenous which is a very serious
situation requiring emergency surgery.
All operations to repair a hernia seek to achieve the same
aim, i.e removal of the swelling and closure of the
abdominal wall defect. In most cases these days a piece of
artificial material will be used to close the defect. This
is referred to as a mesh repair. The operation can be
performed using open or keyhole techniques.
The open operation (Lichtenstein repair) has been in use
for many years and is a very effective way of dealing with
a hernia. It does have some drawbacks however. It involves
a painful cut in the groin and there is a 1 in 10 chance of
chronic long-term discomfort following the operation. In
addition there is a significant incidence of numbness below
the scar. Other complications can include wound infection
and very occasionally the mesh may need to be removed
because of infection. The recurrence rate (chance of the
hernia coming back again) is very low at approximately 1in
200 people.
The keyhole operation was first performed in the late
1980's and has proved to be a very effective procedure with
a recurrence rate similar to the open mesh operation. The
procedure is performed using three very small cuts in the
abdomen, two of which are only 5 mm in length and the third
1cm long. One of the major advantages of this technique is
that if a second hernia is present on the opposite side
this can be repaired at the same time using the same
incisions. An occult (not detected before the operation)
hernia on the opposite side occurs in up to 30 percent of
patients. The other major advantage of this procedure is
that the incidence of chronic discomfort and numbness is
extremely low in comparison to the open mesh operation.
Wound and mesh infections are extremely rare.
The National Institute for Clinical Excellence (NICE) is a
body set up by the Department of Health to assess new
treatments and operations. This body has recently reviewed
operations for hernia groin hernia and has concluded that
the keyhole operation is a safe, effective and in many
cases the preferred technique. It can be used for all types
of groin hernia including recurrent (where the hernia has
been repaired in the past and the repair has given way) and
bilateral (both sides of the groin) as well as one-sided
first time hernias which of course constitute the majority
of cases.
Incisional hernias are a common complication of any
abdominal operation and the chance of developing one
increases with time. They result in an unsightly bulge in
the abdomen underneath the scar and may be uncomfortable or
even painful. Traditionally incisional hernias have been,
and still are, repaired by reopening the old incision and
most commonly inserting an artificial mesh to repair the
defect in the abdominal wall. They can now be repaired
using keyhole techniques where a piece of artificial
material is placed inside the abdomen to repair the defect.
The advantages of the keyhole approach are very similar to
those seen with groin hernias,i.e. less discomfort, more
rapid recovery and less complications. The operation can
however sometimes be difficult or even impossible because
of adhesions within the abdominal cavity as a result of the
previous surgery. Your surgeon should be able to advise you
as to whether a keyhole approach would be suitable in your
particular circumstances. Note however that laparoscopic
incisional hernia repair is an advanced procedure and
should only be undertaken by surgeons with considerable
experience of keyhole techniques.
For more
information please visit our 'Patient Information' page where
you can download information sheets relating to the
specific operations.