Hernia
What is Hernia
A hernia is a weakness or opening in the abdominal wall, that often results in bulging out of fat or an organ such as intestine, which then occupies space under the skin.
The opening in the abdominal wall through which the fat or organs protrude is called the Hernia defect.
Hernia can affect anybody – going by statistics one-in-ten of us will have hernia at some point in our lives. It is found in both sexes, can occur at any age and sometimes infants may be born with it.
Surgery for hernia is one of the most commonly performed operations worldwide with millions of cases being treated every year.
Symptoms of Hernia
- A hernia may first appear as a new lump or bulge in the groin or in the abdominal area. There may be an associated dull ache but usually it is not painful on touch. The lump increases in size on standing, coughing and may be pushed back/disappear on lying down.
- A small painless hernia if left untreated, usually increases in size.
- Occasionally, the hernia may become irreducible i.e. it cannot return to the abdominal cavity on lying down or with manual pushing. At this stage it also becomes painful.
- Sometimes the loop of bowel that has herniated becomes obstructed. This can cause extreme pain, nausea, vomiting, constipation and needs immediate treatment.
- At times the hernia becomes ‘strangulated’ ( explained further below ) in which the person appears ill with/without fever, nausea, vomiting and extreme pain even to touch. This condition is life threatening and thus a surgical emergency.
Why do Hernias occur?
- Any condition that increases the pressure of the abdominal cavity over a prolonged period of time may become a cause for hernia eg. Obesity, chronic cough, heavy lifting, chronic constipation leading to straining during bowel movement.
- Family history of hernia makes one more likely to get it.
- Some hernias may be present at birth
- Idiopathic, which means the cause is not known.
Diagnosis of Hernia
The diagnosis of hernia is usually a clinical one, which means that your doctor will go through a history of your symptoms followed by a brief physical examination. During this check up she/he may feel the area of bulge by raising your abdominal pressure ( this is done by making you stand/cough ), as this manoeuvre makes the hernia more obvious. In case you have an inguinal hernia, the doctor will feel for the potential pathway by examining along your scrotum.To summarise, in vast majority of cases where there is an obvious swelling in the groin/abdominal area, which increases in size on standing, straining or coughing, a clinical diagnosis of hernia is made and NO TESTS are needed. More challenging diagnoses are best performed by hernia specialists.
About Hernia Treatment
Understanding the basics of a Hernia Surgery
The goal of a hernia surgery is to repair the weak tissue in the abdominal wall and seal the defect so that fat or intestines cannot push through it again.
Depending upon the surgical approach used, there are two types of repairs; Open repair and Laparoscopic ( keyhole ) repair. In an Open surgery, a single long incision ( cut ) is made in the area of the hernia. The herniated organs are pushed back in place and the area is then sutured back with/without placing a mesh to strengthen the weak area of the abdomen.
The basic principles of a Laparoscopic repair remain the same, the only significant difference being that instead of a single long cut, several small ( 3-5 ) nicks are made each being about a centimetre long. A laparoscopic repair is done under general anaesthesia and carries more benefits like a quicker recovery, lesser post-operative pain and lower infection rate. However, a laparoscopic repair may not be possible if you have a large hernia or you can’t receive general anaesthesia.
It is best to leave the decision to your doctor who will be in a better position to decide which approach would benefit you more depending upon various factors like location/type/severity of hernia as well as your medical history.
I. INGUINAL HERNIA REPAIR SURGERY
- Primary Muscular Repair aka Shouldice’s Repair
This method involves pushing back the herniated organs and sewing the abdominal wall tissues back together with the help of sutures. However, the abdominal muscles are constantly under tension after the suturing and hence may potentially give way once again in the future. Hence, this procedure has a high recurrence rate. - Simple Prolene Mesh Repair aka Leichenstein’s Repair
In this ‘tension-free’ repair, a Polypropylene mesh is used to seal the defect so that the tension that the muscles are under in a Shouldice’s repair is avoided. The procedure is usually done under local anaesthesia and needs 24-48 hour hospitalisation. Although the procedure is time tested, safe and economical, there are chances of post-operative groin pain ( Inguinodynia ) due to nerve entrapment. - Laparoscopic Repair ( TEP and TAPP Repair )
In these procedures done under general anaesthesia, a Polypropylene mesh is placed on the inner side of the abdominal wall ( posterior compartment ). However, these are technically much more difficult procedures with a recurrence rate of 8-15%. Hospitalisation time needed is 24-48 hours. - 3-D Mesh Hernia Repair
This is the most advanced and preferred technique for inguinal hernia repair. It is a simple and promising method which covers the hernia defect from 3 sides- above, below and centre. It is a tension-free repair in which a Polypropylene mesh is used.
Advantages:
- Negligible recurrence rate
- No risk of chronic groin pain as no stitches are taken to fix the mesh.
- It is a very short procedure requiring about 15-20 minutes
- Day care procedure with a short hospital stay of about 12 hours.
II. FEMORAL HERNIA REPAIR SURGERY
A Femoral hernia repair surgery can be done either as an open surgery or a laparoscopic ( keyhole ) surgery. In the open surgery a single long incision/cut is made whereas in a laparoscopic surgery about 3 small nicks are made. In either of the surgeries, the surgeon reduces the hernia by pushing the fatty tissues/loop of bowel back into the abdomen. This is followed by securing the femoral canal with a mesh to repair the weak spot which let the hernia through.
Both open and keyhole surgeries are safe and effective, although there is lesser pain and a faster recovery after a keyhole surgery. The choice of which technique to use depends upon your general health and the expertise of the operating surgeon.
III. UMBILICAL HERNIA REPAIR SURGERY
Umbilical hernia in adults is becoming fairly common due to increasing incidence of obesity and laparoscopy ( Port-site hernia ). A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. Although quite popular because of less post-operative pain and early recovery, the cosmetic outcome of this procedure is not good as some amount of bulge remains post-operatively. - 3-D Mesh repair
Most of the above methods involve removing the umbilicus, but at Healing Hands Clinic we ensure that umbilicus is preserved by adopting a modified 3-D umbilical hernia repair. In this procedure, the defect is closed from the anterior as well as posterior aspect. The umbilicus is repositioned to achieve an excellent cosmetic outcome. It is a day care procedure which means you will be discharged from the hospital the same day. The recurrence rate is almost negligible.
IV. EPIGASTRIC AND INCISIONAL HERNIA REPAIR
A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. - Octomesh Repair
In this innovative method, a specially designed Polypropylene mesh implant called Octomesh is used. As the name suggests, the Octomesh has 8 integrated radiating arms ( tentacles ) which are simply tunnelled through the muscles of the abdominal wall. These arms are held securely in place by friction. The most striking advantage of an Octomesh repair is that it is a sutureless ( no internal stitching ) with negligible recurrence rate. The absence of sutures also reduces the post-operative pain and chances of pus collection.
A hernia is a weakness or opening in the abdominal wall, that often results in bulging out of fat or an organ such as intestine, which then occupies space under the skin.
The opening in the abdominal wall through which the fat or organs protrude is called the Hernia defect.
Hernia can affect anybody – going by statistics one-in-ten of us will have hernia at some point in our lives. It is found in both sexes, can occur at any age and sometimes infants may be born with it.
Surgery for hernia is one of the most commonly performed operations worldwide with millions of cases being treated every year.
- A hernia may first appear as a new lump or bulge in the groin or in the abdominal area. There may be an associated dull ache but usually it is not painful on touch. The lump increases in size on standing, coughing and may be pushed back/disappear on lying down.
- A small painless hernia if left untreated, usually increases in size.
- Occasionally, the hernia may become irreducible i.e. it cannot return to the abdominal cavity on lying down or with manual pushing. At this stage it also becomes painful.
- Sometimes the loop of bowel that has herniated becomes obstructed. This can cause extreme pain, nausea, vomiting, constipation and needs immediate treatment.
- At times the hernia becomes ‘strangulated’ ( explained further below ) in which the person appears ill with/without fever, nausea, vomiting and extreme pain even to touch. This condition is life threatening and thus a surgical emergency.
- Any condition that increases the pressure of the abdominal cavity over a prolonged period of time may become a cause for hernia eg. Obesity, chronic cough, heavy lifting, chronic constipation leading to straining during bowel movement.
- Family history of hernia makes one more likely to get it.
- Some hernias may be present at birth
- Idiopathic, which means the cause is not known.
The diagnosis of hernia is usually a clinical one, which means that your doctor will go through a history of your symptoms followed by a brief physical examination. During this check up she/he may feel the area of bulge by raising your abdominal pressure ( this is done by making you stand/cough ), as this manoeuvre makes the hernia more obvious. In case you have an inguinal hernia, the doctor will feel for the potential pathway by examining along your scrotum.To summarise, in vast majority of cases where there is an obvious swelling in the groin/abdominal area, which increases in size on standing, straining or coughing, a clinical diagnosis of hernia is made and NO TESTS are needed. More challenging diagnoses are best performed by hernia specialists.
Understanding the basics of a Hernia Surgery
The goal of a hernia surgery is to repair the weak tissue in the abdominal wall and seal the defect so that fat or intestines cannot push through it again.
Depending upon the surgical approach used, there are two types of repairs; Open repair and Laparoscopic ( keyhole ) repair. In an Open surgery, a single long incision ( cut ) is made in the area of the hernia. The herniated organs are pushed back in place and the area is then sutured back with/without placing a mesh to strengthen the weak area of the abdomen.
The basic principles of a Laparoscopic repair remain the same, the only significant difference being that instead of a single long cut, several small ( 3-5 ) nicks are made each being about a centimetre long. A laparoscopic repair is done under general anaesthesia and carries more benefits like a quicker recovery, lesser post-operative pain and lower infection rate. However, a laparoscopic repair may not be possible if you have a large hernia or you can’t receive general anaesthesia.
It is best to leave the decision to your doctor who will be in a better position to decide which approach would benefit you more depending upon various factors like location/type/severity of hernia as well as your medical history.
I. INGUINAL HERNIA REPAIR SURGERY
- Primary Muscular Repair aka Shouldice’s Repair
This method involves pushing back the herniated organs and sewing the abdominal wall tissues back together with the help of sutures. However, the abdominal muscles are constantly under tension after the suturing and hence may potentially give way once again in the future. Hence, this procedure has a high recurrence rate. - Simple Prolene Mesh Repair aka Leichenstein’s Repair
In this ‘tension-free’ repair, a Polypropylene mesh is used to seal the defect so that the tension that the muscles are under in a Shouldice’s repair is avoided. The procedure is usually done under local anaesthesia and needs 24-48 hour hospitalisation. Although the procedure is time tested, safe and economical, there are chances of post-operative groin pain ( Inguinodynia ) due to nerve entrapment. - Laparoscopic Repair ( TEP and TAPP Repair )
In these procedures done under general anaesthesia, a Polypropylene mesh is placed on the inner side of the abdominal wall ( posterior compartment ). However, these are technically much more difficult procedures with a recurrence rate of 8-15%. Hospitalisation time needed is 24-48 hours. - 3-D Mesh Hernia Repair
This is the most advanced and preferred technique for inguinal hernia repair. It is a simple and promising method which covers the hernia defect from 3 sides- above, below and centre. It is a tension-free repair in which a Polypropylene mesh is used.
Advantages:
- Negligible recurrence rate
- No risk of chronic groin pain as no stitches are taken to fix the mesh.
- It is a very short procedure requiring about 15-20 minutes
- Day care procedure with a short hospital stay of about 12 hours.
II. FEMORAL HERNIA REPAIR SURGERY
A Femoral hernia repair surgery can be done either as an open surgery or a laparoscopic ( keyhole ) surgery. In the open surgery a single long incision/cut is made whereas in a laparoscopic surgery about 3 small nicks are made. In either of the surgeries, the surgeon reduces the hernia by pushing the fatty tissues/loop of bowel back into the abdomen. This is followed by securing the femoral canal with a mesh to repair the weak spot which let the hernia through.
Both open and keyhole surgeries are safe and effective, although there is lesser pain and a faster recovery after a keyhole surgery. The choice of which technique to use depends upon your general health and the expertise of the operating surgeon.
III. UMBILICAL HERNIA REPAIR SURGERY
Umbilical hernia in adults is becoming fairly common due to increasing incidence of obesity and laparoscopy ( Port-site hernia ). A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. Although quite popular because of less post-operative pain and early recovery, the cosmetic outcome of this procedure is not good as some amount of bulge remains post-operatively. - 3-D Mesh repair
Most of the above methods involve removing the umbilicus, but at Healing Hands Clinic we ensure that umbilicus is preserved by adopting a modified 3-D umbilical hernia repair. In this procedure, the defect is closed from the anterior as well as posterior aspect. The umbilicus is repositioned to achieve an excellent cosmetic outcome. It is a day care procedure which means you will be discharged from the hospital the same day. The recurrence rate is almost negligible.
IV. EPIGASTRIC AND INCISIONAL HERNIA REPAIR
A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. - Octomesh Repair
In this innovative method, a specially designed Polypropylene mesh implant called Octomesh is used. As the name suggests, the Octomesh has 8 integrated radiating arms ( tentacles ) which are simply tunnelled through the muscles of the abdominal wall. These arms are held securely in place by friction. The most striking advantage of an Octomesh repair is that it is a sutureless ( no internal stitching ) with negligible recurrence rate. The absence of sutures also reduces the post-operative pain and chances of pus collection.
DR VINCENZO DI DONNA
SPECIALIST VASCULAR SURGEON
Frequently Asked Questions
Smoking can lead to chronic cough by irritating your lungs. As discussed earlier, longstanding cough can cause hernia. It can also cause the hernia to recur after a surgery. Another factor is the nicotine in the tobacco that causes weakness of the abdominal wall, thus contributing to development of a hernia.
Any surgery carries with it some risks. The most common ones are bleeding and infection . These risks are higher in those with certain medical conditions like diabetes, in smokers, alcoholics and in old age . The chances of bleeding are almost negligible in the hands of a specialist and infection is avoided by judicious use of antibiotics.
Another problem with hernia is that it can come back after a surgery. This is called a Recurrent hernia. However, understanding your condition, ensuring any causative factors are eliminated and a repair using the most advanced techniques can significantly bring down the rate of recurrence.
It’s like taking a small nap! All you will feel is a small needle prick during your preparation for the procedure. The surgery usually takes about 20 minutes.
Occasionally, only the the area with the hernia is anaesthetised and you will be awake and probably having a chat with your doctor!
Anaesthesia will wear off within 2-3 hours after surgery, following which you will gradually be able to move your limbs. Do not take anything by mouth for 4-6 hours after surgery. You can then start with sips of water followed an hour later by a regular full diet, unless advised otherwise ( In a few cases you may need to wait for a day before you resume your regular diet ).As anaesthesia wears off, there may be difficulty in passing urine for the first time. However, this returns to normal and you will be able to pass urine as usual. Mild pain is expected after the surgery which is easily managed with pain-killers.
If your operation is planned as a day care procedure you can go home as soon as the effect of the aneasthetic has worn off, you have passed urine and you are comfortable, eating and drinking. Since a general anaesthetic is used frequently used, it is advisable that a responsible adult take you home and stay with you for 24 hours.
At times you may be given a discharge after 24 hours in which case you may need to stay in the hospital for a night.
Before you are discharged you will be advised about post-operative care, painkillers and antibiotics.
This time frame cannot be generalised, as the recovery depends on various factors like the type of hernia you have, the extent of the hernia, your general health and medical condition, type of surgery and expertise of the operating surgeon. As you may have earlier read, in most of the surgeries you will be discharged from the hospital on the same day or within 24 hours. In the beginning there may be discomfort during walking, climbing up and down a staircase and during movement. However, this is easily controlled with painkillers and you should be pain-free within a couple of days.
In most of the cases the answer would be ‘as soon as you feel you can’. How soon you can also depends on the type of work you do and your normal level of activity. Typically one can return sooner to a sedentary job ( 3-5days ) than one that involves strenuous physical activity or lifting weights ( 4-6weeks ). This question is best discussed with your operating surgeon.
- Fever > 101 degree F
- Pain not relieved by prescribed medicines
- Unusual bleeding
- Persistent nausea or vomiting
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