Repair of Hernia – Part One

When a hernia occurs a part of the bowel or abdominal fat, normally within the abdomen, protrudes out through a weakened part. An inguinal hernia is the commonest type and occurs in the groin. There is a small gap deep in the wall of muscle in the abdomen, just above the ligament in the groin, through which the veins and arteries course to reach the testicle. If the gap or the tissues around it stretch or weaken then part of the peritoneum (lining of the abdomen) can protrude through. This protrusion can occur, with fat or bowel bulging out, on vigorous activity, coughing or standing.

Aching and discomfort can be caused by the bulge of the hernia but the protrusion generally returns back into the abdominal area when the person lies down, with the necessity to manually press it back into place at times. Aching can occur without any visible bulging and then a doctor’s examination is needed to find the hernia. A very longstanding hernia may develop into a very large protrusion, even going so far as to fill up a man’s scrotum. A very large hernia like this will likely remain protruded most of the time and be very difficult to relocate.

Inguinal hernias occur less frequently in females than males but femoral hernias, a different type, occur more frequently in females and can mostly be found on examination by a specialist. Femoral hernias are more likely to need to be repaired.

Most hernias are just a nuisance due to causing a bulge and the tendency to ache, symptoms which are annoying but not medically important. Strangulation is the most serious complication where the bowel fills the hernia sac and becomes trapped there, potentially cutting of its blood supply. It needs to be operated on immediately, with a likely removal of a damaged area of bowel. It is not common for bowel to become strangulated and hernias can exist for years without this happening. Bowel obstruction can develop as the bowel becomes trapped and this needs operating on even if the blood supply is still working.

An operation is the only permanent cure for a hernia and can prevent the long term presence or increase in size of the hernia. Hernias can cause discomfort and strangulation can occur but is not common. An operation is not mandatory if the hernia is not causing any trouble and patients should discuss this with their surgeons. A symptomatic hernia can be held in place by a truss which needs to be put on before the patient gets up and makes the hernia bulge. A symptomatic hernia is mostly much better treated by an operation. Having medical problems or being older should not stop hernia repair due to the safe use of local and general anaesthetics.

A groin incision about 12 centimetres in length is used for the repair of a hernia, with an opening of a layer of muscle and then the careful separation of the bulging hernia sac from the veins, arteries and tube to the testicle. The protruding fat or bowel from the abdomen is compressed back in and the sac is then stitched back into the abdominal cavity or tied off at its narrow neck area.

The weakened area is then repaired and strengthened and the hole for the veins and arteries to the testicle is recreated back to its usual size. The hernia will be likely to return if it is not repaired, with surgeons typically using a plastic mesh which they stitch over the herniated area. Stitches can also be used without employing the mesh and this is more likely in femoral hernias. Good long term results have been shown with both techniques and the typical chance of hernia recurrence is 2%.

A hernia can be performed as an open operation or by using a laparoscope, using a general anaesthetic. The surgeon inserts the scope into the abdomen just under the tummy button and then pumps gas into the abdomen to separate the muscle layers in the lower groin and abdomen. The surgeon makes two very small (5mm) incisions in the low abdomen so that instruments can be inserted, by which the mesh of plastic is introduced and the hernia repaired.