WHAT IS A HERNIA?

A hernia is a lump that results from a part of the intestine (bowel) or fatty tissue slipping through a weakness in the abdominal wall. They are commonly of two types. Inguinal hernia and Ventral Hernia. The most common hernias are inguinal hernias (groin hernias). They are most often found in men.

WHAT IS INGUINAL HERNIA ?

Inguinal Hernias are of two types-

1. Indirect inguinal hernias - An indirect inguinal hernia is located in the inguinal canal, particularly in young males and adults. In males, this is the location of the spermatic cord. Typically, the hernia is discovered when it descends down towards the scrotum from the groin. The treatment for this type of hernia is surgical repair.
2. Direct inguinal hernias  - This type of hernia usually appears later in life in elderly males mostly. It is often found on both sides of the groin. Obesity and hard physical work can contribute to its development. Cigarette smoking, chronic constipation, prostate disease and chronic coughing can also contribute. Surgery is again the standard treatment for this type of hernia. When a very elderly person has a hernia, the doctors may decide not to operate if the hernia is unlikely to cause complications.

Less Common Hernias

Femoral hernias are rare, and mostly seen in middle-aged and older women who may have given birth several times. These hernias are present lower in the groin than an inguinal hernia.
Umbilical hernias – a hernia or weakness of the umbilicus (belly button).
Incisional hernias – a hernia or weakness usually in a previous abdominal scar.

WHAT ARE THE SYMPTOMS?

The most common symptom of a hernia is a lump in the groin. Sometimes the lump is painful, but a small hernia may not even be noticed and may only be found as part of a routine examination. The lump often disappears when the patient is lying down, and may not be obvious after a night’s sleep.

However, a hernia can be dangerous if its contents particularly the bowel gets trapped and twisted in the weak spot in the abdominal wall and becomes tender. This is known as a strangulated hernia. If the intestinal loop is damaged, its contents can leak out. Gangrene and peritonitis, which can be life-threatening, may occur as a result. Strangulation is an emergency requiring urgent surgery.

HOW IS IT DIAGNOSED?

A hernia is usually diagnosed through a simple physical examination. Sometimes an ultrasound examination of the groin in conjunction with this physical examination may help.

WHY SURGERY?

The majority of these hernias require surgical repair to alleviate symptoms and to prevent possible strangulation of the intestine. The most common form of repair is to insert an artificial mesh in the defect, sometimes under local anaesthetic.

General anaesthetic is used when planning for an Endoscopic (Laparoscopic or Key-hole surgery) Hernia repair, commonly called TEP or TAPP

WHAT KIND OF SURGERY IS USED TO REPAIR HERNIAS?

The operation for a groin hernia is one of the commonest surgical procedures.

The standard (open) operation involves a 10cm incision in the groin (or both groins if there are hernias present on both sides), finding the hernia and patching the defect with polypropylene mesh.

In endoscopic or keyhole surgery a 1.5cm (3/4 inch) incision is made just below the umbilicus (bellybutton) and two further tiny incisions are placed between the umbilicus and the pubic bone. The operation is performed with long instruments inserted through these incisions. A camera inserted through one of the small incisions lets the surgeon watch the operation on a TV screen linked to the camera inside the patient. No further incisions are required even if there are hernias in both groins. The hernia is identified and the defect repaired with mesh as in the open (non-keyhole) operation. It is usually carried out under general anaesthesia.

THE PROS AND CONS OF KEYHOLE HERNIA REPAIR

There are three main advantages of keyhole surgery:

• The small incisions result in less pain and earlier return to work, especially when hernias are present on both sides.
• The positioning of the mesh on the inside of the defect is mechanically better than when placed on the outside as in the non-keyhole operation. A larger mesh can be used than in Open repair.
• By positioning the mesh on the inside of the defect, the very sensitive nerves in the inguinal canal are not damaged or irritated by the mesh as can occur in the non-keyhole operation.
• Although exceptionally rare, mesh infection is even rarer than in open surgery where the mesh is on the outside of the muscles unlike TEP, where the mesh is deep inside.

For recurrent hernias, keyhole surgery is also useful. A surgeon using the open technique has to dissect through tissue that is very scarred from the first operation. This is much more difficult than a first-time operation and can lead to increased risks of complications. If the operation is done with the keyhole technique, the hernia is approached from the inside, where the tissue has not been affected by the first operation. This makes it much easier for the surgeon, and less painful for the patient.

Possible disadvantages of keyhole surgery:

• The operation can sometimes take longer. With experienced surgeons however there is very little difference in time taken between the keyhole and non-keyhole operation.
• Cost: Because the surgeon uses some disposable instruments during keyhole surgery, the cost is higher than open surgery.