General Surgery - Hernia Repair

What is a hernia?

A hernia is a bulge or protrusion caused by weakness of a muscle in the abdominal wall or surrounding tissue wall. There are different types of hernia; femoral, incisional and inguinal being the most common. Another common type of hernia occurs around the belly button, called an umbilical hernia. Inguinal and femoral hernias usually present as a lump, which can limit day to day activities and the ability to work. Incisional hernias occur in any old surgical scar.

What are the alternatives?

Surgery is recommended as it is the only dependable way to cure the condition. You can sometimes control the hernia with a truss (padded support belt) or simply leave it alone. You may also find some relief by lying down as it will stop the hernia from bulging, but it will not go away without an operation.

Why do I need an operation?

Some patients have no symptoms. Some small hernias which are not causing any discomfort can be left alone. Others describe aching or dragging sensations. Some complain of pain or swelling in relation to certain activities (e.g. lifting).

Your consultant has decided to operate because you are in pain or because there is a risk of the hernia causing an obstruction or becoming strangulated. In very rare cases this could cause more severe problems. Sometimes, if it is left too long, it increases in size and it may become strangulated, that means the loop of the bowel inside the hernia may become twisted which requires an emergency operation. It is better to have an operation. Normally it is done as an elective operation.

What is the procedure?

Hernia operations can be performed under general anaesthetic or very rarely under spinal anaesthetic. The surgeon makes an incision, opens the muscle layer and the hernia is carefully put back in place and repair is made to strengthen the weakened area. This repair consists of two or more layers of stitches or by putting a mesh over the weakened area. The surgeon will decide what is required depending on what type of hernia they find.

Will my hernia be repaired by keyhole surgery?

This depends on what type of hernia you have, its size, and whether your surgeon is trained in keyhole (laparoscopic) surgery. Keyhole surgery is simply a method of repairing a hernia through several small cuts on the tummy, rather than a single larger one. Both keyhole and open surgery aim to close or patch the gap in the muscles that is the hernia. Your surgeon will discuss with you which type of surgery they are planning to perform.

• Keyhole surgery may not be an option for some hernias
• Keyhole surgery must be performed under a general anaesthetic
• Keyhole surgery always involves use of a mesh
• Keyhole surgery generally gives less pain and has a quicker post-operative recovery compared to the open surgery
• However, keyhole surgery has a slightly higher failure rate as compared to the open inguinal hernia repair

Your surgeon will be happy to discuss the option of keyhole surgery with you and advise you as to whether your particular hernia is suitable for that method of repair.
 
The National Institute for Health and Care Excellence (NICE) has assessed the benefits of keyhole versus open hernia repair only for inguinal hernias.

They concluded that inguinal hernias which have come back after a previous repair (recurrent inguinal hernias) and bilateral inguinal hernias (having a right and left sided hernia at the same time) should be mesh repaired laparoscopically.

They have also concluded that patients with a single inguinal hernia should be offered the choice of open or laparoscopic surgical mesh repair.

Possible risks

All operations carry a risk. There are general risks that are common to all operations. Some of these include:

Wound infection: The skin around the wound may go red and painful or the wound may leak pus. Around one in 20 patients will experience this complication usually after they are already at home. You should get your GP or practice nurse to check your wound if this occurs, as you may need antibiotics.

Bruising: It is quite normal to experience some bruising where your wound is, often this does not appear until after you have gone home from hospital. Occasionally a very large bruise may form which takes one or two weeks to go away. The wound may ooze a little bit of blood or clear fluid for the first 48 hours, requiring a change of wound dressing.

Haematoma: This means a collection of blood. In hernia operations, this usually occurs just beneath the wound, forming a lump. A large lump may take several weeks to disperse. As it disperses, bruising usually appears. With keyhole surgery of groin hernias, the haematoma may appear in the area where your hernia lump was, it is important not to mistake this haematoma for a recurrent hernia.
 
Chest infection: If you develop a cough or feel short of breath after your operation, you may have developed a chest infection. This is rare if you are fit and healthy. You are at high risk of this if you have a lung disease (such as chronic bronchitis, emphysema, severe asthma) and moderate risk if you are overweight or are a smoker.

Internal bleeding: This is rare (occurring in less than one in 1000 hernia operations) but may require you to have a blood transfusion or a second operation in order to stop the bleeding.

Allergic reactions to antibiotics or anaesthetics: This is also rare (occurring in less than one in 100 operations). If you have had a previous bad reaction to an anaesthetic or any medication, you must inform the surgeon or the anaesthetist before your operation.

Blood clots in the legs: This is also known as deep vein thrombosis (DVT). It carries the risk of the blood clot moving from the leg up to the lungs (pulmonary embolus), which can be a life-threatening condition. A fit healthy person has a very small risk of DVT. Your risk is higher if you are overweight, a smoker, in poor general health, have difficulty walking, or have had a previous DVT. To reduce your chance of developing a DVT you will be encouraged to get out of bed as soon as you are sufficiently recovered from the anaesthetic. You may also be given an injection of a medicine called heparin, which is proven to reduce your chance of developing a large pulmonary embolus. While you are on bed rest, you should exercise your calf muscles by moving your feet up and down.

Ischaemic orchitis: This is an extremely rare complication of inguinal hernia repairs in the male. Here, the blood supply to the testis gets affected causing the testis to become painful and small and thus becoming non-functional. This is more common in patients undergoing repair of their inguinal hernias for the second time (one in 50 as compared to one in 1000 for the first time goers).

Complications due to the mesh itself: All types of mesh used in the repair of hernias are made of synthetic material that is not absorbed by the body but remains permanently in place. This is why they are so successful in repairing hernias. Rarely, however, there can be problems related to the mesh itself.

Infection: All meshes are sterilised and free of germs when they are put in. However, everyone carries germs on their skin, so there is a small risk that one of your skin germs could get on the mesh at the time of surgery and cause an infection. To further safeguard against this, you will receive antibiotics during the anaesthetic, while you are having the operation. Mesh infection is a rare complication for hernia repairs performed as a planned operation. Less than one in two hundred patients having a hernia repaired will get a mesh infection. Once a mesh is infected, antibiotics may not get rid of the infection, and you may require having the mesh removed by further surgery. Having the mesh removed may result in the hernia coming back.

Chronic groin pain: Open inguinal mesh hernia repair can give rise to chronic pain in the groin. This can occur in up to one in 10 patients undergoing the operation. This is virtually unheard of in keyhole repair of inguinal hernias.

Can hernias come back?

Yes. The use of mesh has reduced the number of hernias that come back (called “recurrence” of a hernia). The risk of a hernia coming back is related to many factors:

• The type of hernia you have
• The size of hernia (larger ones are more difficult to patch successfully)
• The hernia is recurrent (it has been repaired before but has come back again)
• If you are diabetic, you heal less well
• If you have an emergency operation
• If you have a heavy physical job or routinely undertake extremely strenuous exercise
• If you are on medication which impairs healing for example steroids or cancer drugs
• If you have a chronic cough

What are the benefits of the operation?

By having this operation, it will relieve you from your present symptoms.

What happens before the operation?

• You will be asked to attend a pre-operative assessment clinic where we will ask you questions about yourself and discuss any worries or queries you may have
• Your operation will be explained, and you will be asked to sign a consent form
• Routine blood samples may be taken, and an ECG (heart tracing) and chest x-ray carried out
• Your temperature, pulse, respiration rate, blood pressure and weight will be recorded
• If you are having a general anaesthetic and are a smoker, we advise you to stop smoking at least 6 weeks before your operation
• Please leave jewellery and valuables at home. The hospital cannot accept responsibility for these
• Please do not wear makeup or nail varnish
• Take regular medication as normal, unless advised otherwise, and bring any inhalers and tablets with you
• If you are taking blood thinning tablets (anti-coagulants) such as Warfarin, Aspirin or Sinthrome, please contact your consultant for further advice
• If you are diabetic, please discuss this when you attend your pre-operative assessment appointment where the staff will be able to give you advice

What happens after your operation?

• You may be given oxygen via a face mask. This will be discontinued when you are fully awake
• You may eat and drink normally if you feel like doing so but do not worry if you are not hungry
• You may have an IV line (drip) in place. This will be removed when you are drinking normally
• When you return to the ward, you will have a small dressing over your wound
• Your pulse, respiration rate, and blood pressure will be monitored until you are fully awake
• When you wake up you should have no pain only mild discomfort as a local anaesthetic is usually used to numb the wound. For a period of 2 to 4 hours afterwards, you may notice some weakness in your legs, but this will wear off
• Following a short period of recovery, you will be able to get out of bed and move around gently
• You may have staples, stitches or clips in your wound site. If so, they may be dissolvable but if not, they will be taken out about 7 days after your operation by the district or practice nurse. Most surgeons nowadays use absorbable stitches

When you are ready for discharge

• The doctors or nursing staff will discuss with you when you are ready to go home
• Your length of stay in hospital can vary between 1 – 3 days following your surgery, or as your consultant advises. However, some patients are discharged on the same day as their surgery
• We advise that you have a supply of painkillers at home
• You may have been asked to stop taking some medicines before your operation. If so, please ask your hospital doctor about restarting these
• You will be referred to the district/practice nurse who will contact you to assess your needs, check your wound and remove any staples, stitches or clips
• If you are advised to return to work in 7 days, then you can cover your sickness absence with a self-certification form, available from the General Office on all hospital sites. The ward will issue you with a medical certificate to cover your anticipated sickness or until your follow-up appointment (where relevant). Please ask a member of staff for this certificate before you are discharged home
• A letter will either be sent to your GP or given to you on your discharge

Will I need to have somebody to look after me at home?

After day case surgery, you should have a responsible adult able to stay with you for 24 hours. Many people feel tired and woozy after a general anaesthetic, so having someone able to look after you by making hot drinks and light meals is helpful.

They can also phone the hospital on your behalf if you have an unexpected problem. After the first 24 hours, it is helpful to have someone able to do shopping or run errands for you, until you are fully mobile.

What should you remember at home?

It is normal to feel tired and a bit sore for several days. You should rest and eat only light meals for the first day or two and avoid any alcohol while taking painkillers stronger than paracetamol.

You may find your bowels tend to be constipated; this is as a result of missing normal meals around the time of your surgery and is also a side effect of many painkillers. It should settle by itself, but if not, you can use a gentle laxative that you can buy from any chemist.

You may not feel like leaving the house for the first couple of days, but make sure you walk about within the house or around the garden every couple of hours during waking hours to keep the blood circulating in the legs and reduce the chance of a blood clot forming in the legs.

If you feel quite sore you should take your painkillers regularly to enable you to move about. If you are still feeling sore and requiring painkillers after you have finished the supply provided by the hospital, contact your GP for a further supply (this is seldom necessary). Younger people will usually return to normal more rapidly than an older person.

Patients who have had a general anaesthetic and are discharged the same day

For 24 hours after your surgery:

• Do not drink alcohol
• Do not drive or operate machinery
• Do not go out unaccompanied
• Do not sign any important documents
• Take care with the cooker, boiling water, fires etc.

If you are worried or have problems after your discharge, contact your GP or telephone the ward for advice.

In an emergency, go to the nearest Accident & Emergency department.

What should I do with my wound(s)?

The nurses on the ward will explain this to you in detail before you leave the hospital. Most surgeons use skin stitches which go away by themselves, and your wound will be covered by a light dressing. After 48 hours wounds are usually sealed enough for you to have a shower and you may have a bath seven days after your surgery, provided your wound is clean and dry.

It is normal for the wound to feel hard and tender for several weeks. It is also quite normal for you to feel a lump under the wound, as this is the healing ridge of tissue. The actual scar itself will appear red and often remains red for many months. If the skin around the wound develops redness extending more than one inch (2cm) from the scar and this does not go away within 24 hours of you noticing it, you should contact your practice nurse, as you may be developing a wound infection.

When will I be able to go back to work?

This depends on your type of work and the type of hernia you have had operated on. A desk job can usually be returned to after a week or two. A heavy manual job will require longer off work, usually around four weeks.

When can I start to drive again?

You must not drive within 24 hours of a general anaesthetic. It is also recommended that you do not drive while on strong painkillers, as they may make you sleepy. Otherwise, once you can comfortably use all the controls in the car, it is safe to drive.

This means being able to perform an emergency stop and being able to turn round in your seat to safely reverse the car. Most people find they need a week to recover enough to drive safely. It is always best to check with your insurance company to see if they have any specific rules related to the type of operation you have had done. This is particularly important for professional drivers.

When can I start to exercise again?

Doctor’s opinions vary about this, because of a lack of any detailed study into this question. Your surgeon will be able to give you their opinion related to your specific type of hernia and the type of sport you have in mind.

Will I have a follow-up appointment?

This varies from surgeon to surgeon. Most surgeons do not routinely see the majority of patients after a hernia repair. The vast majority of patients make a straightforward recovery but if you have problems your GP can refer you back to see your surgeon if they have any concerns.

Is there anything I can do to improve my health before having surgery?

If you are a smoker, you should stop as far in advance (at least six weeks) of your surgery as possible (smoking increases the risk of a chest infection after an anaesthetic). If you are overweight, you should try and lose weight, to get down to your target weight for your height. Your GP may have a nurse in the practice that can help you with a weight reducing diet.

If you are diabetic, you need to keep your blood sugar levels in the correct range. If you have high blood pressure it needs to be well controlled before you can have surgery.

Any complaints, comments, concerns, or compliments:

If you have other concerns, please talk to your doctor or nurse.
Alternatively, please contact our Patient Advice and Liaison Service:

How to contact PALS:

Telephone Number: 0161 778 5665
Email: pals@nca.nhs.uk.

Alternatively, you can write to:

PALS Department
The Northern Care Alliance Foundation Trust
2nd Floor, Horton House
Hamilton Street Oldham
OL4 1DE