Inguinal hernia

An inguinal hernia is the most common type of hernia which presents with an intermittent or permanent lump in the groin. This is sometimes associated with pain. Your surgeon would recommend an operation to repair this hernia. This operation can either be done by an open or laparoscopic technique. There is no medical treatment for this condition. Surgery is the only option available for a definite of cure from hernia.

​

Your tummy cavity contains intestines and other structures. These are protected by your tummy wall which is made up of many layers. The inner most layer is a membrane. The second layer is a layer made of muscle. Superficial to these are the third layer, composed of fat and the fourth layer, which is the skin. Weak spots can develop in the muscle resulting in the content of your tummy along with the inner most thin layer pushing through the tummy wall and producing a lump below the outer layers. This is condition results into a hernia.

Inguinal canal is a narrow passage through your tummy wall. In men this canal consists of blood vessels to the testicle and testicular or spermatic cord. In females, this Canal contains the round ligament which has no clinical significance. Inguinal hernia forms when contents from inside the tummy come out through the inguinal canal.

There is no medical treatment for an inguinal hernia. Without surgery it will not get any better. You can sometimes control the hernia with a truss or padded support belt. However, if you leave it alone there are possibilities of the hernia getting bigger and serious complications like strangulation of hernia. Strangulation is a condition where the blood supply of the content of the hernia is lost at a point where the hernia passes through the muscle layer, called the neck of the hernia. If the hernia contain bowel, this can result into dead bowel and lead to peritonitis and sepsis. If a hernia causes pain, it is advisable that it is surgically repaired in every eligible patient, laparoscopically or by open technique.

The options available are

1. open repair of inguinal hernia. This involves a scar in the groin and repair of the hernia by use of a mesh which is a synthetic material used to reinforce the weakness in the muscle.

2. laparoscopic repair of inguinal hernia, which can either be Total extra peritoneal repair (TEP) or Trans abdominal pre peritoneal repair (TAPP) techniques.

The laparoscopic or keyhole surgery involves three tiny scars in the tummy and repair of the groin hernia on one side or both sides to the same three scars with use of a mesh.

Both laparoscopic and open hernia repairs are recommended by NICE guidelines with similar chances of recurrence after repair (2-3 in every 100 patients).

As compared to open technique laparoscopic surgery is associated with reduced numbness and pain at the operation site and shorter time taken by patients to return to usual activities. Although laparoscopic repair was associated with fewer complications like bleeding and infection of the wound, some rare complications like injury to bowel and major blood vessel injury were slightly higher as compared to open technique.

On balance both laparoscopic and open operations are safe and feasible options.

Patients presenting with recurrence after open repair is traditionally offered laparoscopic repair and vice versa unless there are any associated contraindications as explained by your surgeon.

The decision of anaesthesia is made after mutual agreement between the anaesthetist and the patient. With a general anaesthesia, both open and laparoscopic repairs can be performed. Patients undergoing open repair only, can have a spinal anaesthesia (numbness from below the level of mid tummy) and can stay awake during the operation.

There is a technique called Shouldice technique which involves non-mesh repair of inguinal hernia. This is performed by some specialists. However, when no mesh is used, chances of the hernia coming back is much higher as compared to the technique involving mesh. Moreover, the risk of having chronic pain in the two techniques (mesh versus no-mesh) are comparable. If you wish to have a repair of inguinal hernia without mesh, we can refer you to a suitable specialist.

Inspite of our best efforts, a hernia can come back after repair due to a number of reasons. These may be related to operative technique, increased strain on the wound after surgery, poor quality of tissue around the hernia site and healing power of the wound. Smoking, increasing body weight, return to strenuous activities early after the operation can all contribute to high chances of recurrence of hernia. It is advisable that one should not lift heavy weights or strain for 4 to 6 weeks after a hernia repair to reduce risks of it coming back.

The main complications involved with this operation are bleeding, infection involving the mesh or the wound, chronic pain, numbness, clots in the legs, clots in the lungs, chest infection, complications related to general anaesthesia, chances of hernia coming back in 2 to 3 patients per hundred cases and chances of repeat operations or procedures if necessary. Specifically in male patients, there is a risk to the testicle on the side of the hernia repair which might undergo shrinking and in rare cases ischaemia and loss of the affected testicle. Specifically for laparoscopic repair there is a risk of injury to bowel, urinary bladder and intra-abdominal organs along with risk of injury to the major blood vessels in the groin. A standard low risk of death (< 0.01%) related to surgery or anaesthetic complication is also quoted routinely with this operation.

Generally, most inguinal hernia surgeries can be performed in any hospital with a safe infrastructure. Prior to booking patients for any surgery, surgeons and anesthetists routinely take multiple clinical factors into account. Depending on their assessment, some patients are better suited for an NHS hospital with adequate intensive care facilities. Although this assessment is best done through a detailed consultation with your specialist(s), some of these factors are as follows, but are not limited to:

1. Patients with a higher body weight (BMI more than 40).

2. Patients with significant pre-existing medical conditions, especially related to heart and lungs.

3. Patients who had previous hernia operation on the same side may have higher risk of having complications. Patients with previous operation scars below the level of bellybutton may have intra-abdominal adhesions and may not be suitable for key-hole repair of groin hernia.