A hernia occurs when internal tissue pushes through a weakness in the abdominal wall, often appearing as a lump or bulge, and can be effectively managed with surgical repair if needed.
A hernia is a defect (weakness) in the abdominal wall muscles through which the abdominal contents (usually fat, but sometimes intestines or other abdominal structures) can bulge. These occur at natural points of weakness in the body wall, usually in the groin, or belly button, region. In the groin they are typically inguinal (common), or femoral (less common), and occasionally other rare areas of the lower abdominal wall. They can occur on one side, or both. Higher up they can be peri-umbilical, epigastric or ventral and here at one, or more than one, site. Hernias can also happen at the site of previous surgery, related to healing issues.
Most occur later in adult life (I do not treat childhood hernias). They happen at points of natural weakness in the abdominal wall, as a result of many factors combined: genetic factors that lead to weaker connective tissues, smoking, or some drugs, which weaken body tissues, previous surgery or scars that can disrupt the normal body anatomy, and things which increase pressure in the belly like obesity, repeated heavy lifting, constipation or straining, or coughing.
A) Groin hernia
• Inguinal – 2 types
• Femoral – more common in women
B) Paraumbilical (belly button)
C) Ventral (other sites on the front of the belly)
D) Rarer sites:
• Spigelian
• Lumbar
• Obturator
E) Incisional – At the site of a surgical wound / scar
F) Para-stomal (at the site of a stoma or -ostomy)
G) Diastasis Rectii -is not a true hernia, but a larger symptomatic diastasis can be treated by hernia surgery techniques.
Most patients notice a lump or a bulge, where something can protrude through the hole in the wall, but the hole itself is not painful. The hernia can, but not always, cause discomfort—but not severe pain—when it protrudes out, when you are standing, straining, or coughing. When lying down, or on gentle pressure, the protruding contents usually disappear, unless in some longstanding hernias the contents are stuck out. Acute hernias are those that are newly stuck out, cause you to vomit, or are excruciatingly painful (or red), and these should be treated by an emergency service, and not in a hernia clinic.
Most hernias are diagnosed by a history and examination alone. Occasionally, if the diagnosis is unclear or if pain is the predominant symptom, but there is no obvious lump, a specialist ultrasound scan or MRI scan may be required. Scans are not usually required and can ‘over diagnose’ hernias. An examination by an experienced surgeon is usually what is required.
This will be discussed in detail in the clinic with Mr Hopkins. There are usually more than one option and the exact approach will depend on the type of hernia, your symptoms, your risks, and of course your own choice.
This always requires a full general anaesthetic, but if this is possible for you as a specialist laparoscopic surgeon I always offer patients the benefits of this technique. Keyhole surgery can have the advantages of reducing immediate and long-term post-operative pain, with quicker recovery. It is definitely recommended if you have bilateral groin hernias (i.e., both sides) and want both repaired at the same time. It is also recommended for a recurrent hernia that has previously been fixed by a non-keyhole approach. Also, if there is doubt over the hernia type (difficult recurrent or some female groin hernias) or if you are at a particular risk of chronic pain, the keyhole approach may be recommended.
There are in fact two laparoscopic methods, and most surgeons choose one to become expert in. I use the TAPP (Trans-Abdominal Pre-Peritoneal) operation where the telescope is placed into the abdominal cavity. There are advantages and disadvantages to both, but I choose TAPP, over TEP (Totally extra-peritoneal, where the abdominal cavity is not entered), for the benefits of assessing everything to do with the hernia and the contents and the flexibility to fix any hernia type by one adaptable approach. In expert hands, both methods give the same good results, but the best operation for you is the one your surgeon is most comfortable with. All keyhole operations take between 60 and 120 minutes of operating time.
In some cases the keyhole approach cannot be used due to previous abdominal operation, so often for incisional hernias, or because the size of the hernia is too large, or if you cannot have a full general anaesthetic, which I will discuss with you in the clinic, open surgery will be offered. The long-term outcomes of open surgery (fixing the hernia and preventing it coming back) are the same as keyhole surgery (or better for larger hernias), but initial recovery is likely to be slower. Open operations can take the same 60 minutes for small hernias, but for larger or more complex hernias, and for component separations, can take hours of operating time, which I will always estimate for you in advance.
For simple groin or small belly button hernias, open repair can be carried out under local anaesthetic, particularly if the anaesthetic risks are too high or if you choose not to have a full anaesthetic. This means that you will be awake, but the area is numbed using several injections so that you don’t feel any pain. The advantages of LA include anaesthetic safety and earlier discharge, but cannot always be tolerated by everyone, and cannot be used for large hernias.
Once we agree to go ahead with surgery, you will need to attend a pre-op assessment clinic, at which a number of routine checks and sometimes blood tests will be performed. You should do everything you can to maintain your health and fitness before an operation; we call this pre-habilitation. Smoking is strongly discouraged as it not only affects your breathing and the risk of anaesthetic problems, but can increase wound healing and infection problems and increases the chance of the hernia coming back in the future. For some complex and component separation surgeries I will not offer an operation to you if you smoke. Improving your heart and lung fitness, with regular exercise, taking all your usual medications, and avoiding the risks of infections immediately before your operation is also advised. I never tell patients with a hernia not to exercise. Regular vitamin and mineral supplements, especially if your diet can be variable, help make sure your body is ready for the healing after surgery.
You will meet the anaesthetist beforehand and a full general anaesthetic is used, so you will be asleep during the operation. 3–4 small cuts (of 0.5 to 1.5cm) are made in the abdomen so that a camera (laparoscope) and instruments can be passed through the abdominal wall into the peritoneal cavity. The hernia contents are reduced and space created behind the layer(s) lining the abdominal cavity so a piece of mesh material can be placed to cover the hernia area(s). Sometimes, for specific hernias, a special coated mesh is used inside the abdominal cavity and fixed in place. The lining of the peritoneal cavity is restored and the area and incisions are injected with local anaesthetic for post-operative pain relief. All cuts are closed using dissolvable stitches.
You will meet the anaesthetist beforehand if a full general anaesthetic is used or local anaesthetic will be injected by me. A single cut is made over the hernia (typically 8 cm for groin hernias) or by re-opening the previous scar of an incisional or complex hernia. The contents of the hernia are reduced, and the sack excised or fixated, and a piece of mesh is secured with stitching, in the right anatomical space, to reinforce the weakened areas. This can be where complex component separation techniques are required, which would be explained to you beforehand. Afterwards the area is injected with local anaesthetic for post-operative pain relief and the skin closed with a dissolvable stitch. For large hernias, a special vacuum dressing may be used, especially for incisional hernia.
Meshes do not always have a good press, but when used correctly, especially for hernia surgery, they are considered the standard of care for many hernia operations. For many hernia operations without a mesh, the operation is pointless as failure, or recurrence, rates are too high. Indeed, even with a mesh, there is still a chance of the defect (‘hernia’) coming back in the future, but this is usually very small (2–5%). I generally will not do most hernia operations without the placement of a mesh, and I accept that there will never be a perfect mesh with 100% benefit and a zero complication rate. Nevertheless, the aim is to place most (non-special coated) meshes away from any intestine/organs, which gives rise to the mesh problems in the media at the moment. I also offer patients a range of mesh types, simple synthetic, gripping and newer bio-absorbable (Phasix) meshes, and this can be discusses in the clinic, together with the costs of these meshes, and the benefits of each - see resources page for downloadble document. However, with any healing operation that involves a mesh, pain is always a complication of surgery, including chronic pain syndromes.
If you are undergoing simple groin, paraumbilical or ventral hernia repair you can be discharged on the same day as the operation (daycase). You would be ready to be discharged around 3–6 hours following surgery, if your pain is controlled with tablet painkillers, you can walk, and you have eaten and passed urine. 10% of patients may not go home if they do not meet these criteria, or have an operation later in the day, or if you do not have someone to take you home and stay with you overnight. Occasionally an overnight stay is advised by the anaesthetist, or for larger or complex hernia surgery, you may be required to stay in hospital until I am happy your recovery is progressing.
All stitches are dissolvable. The glue or waterproof dressings used are suitable for the shower, after 2 days, and can be removed or cleared after 7 days, but you should not soak in a bath for 7 days. Standard recovery takes 1–2 weeks after laparoscopic (keyhole) surgery, but can be longer for open surgery depending on the length of the operation and the size of the incision. Recovery after keyhole surgery for return to full activities including sport, exercise, gardening or DIY and heavy lifting is 4–6 weeks more. Again, open hernia surgery can be similar for smaller hernias but may take 10–15 weeks more after open incisional hernia, or component separation, surgery.
If you experience any of the above, it is important that you contact your GP as soon as possible and it is important, if you have had keyhole surgery, to make them aware of this. (Some hospitals may provide you with a contact number if you experience problems in the first week and it would be advisable to ask if they provide one).
