Hernia

What is Hernia?

The symptoms depend on the type of hernia, its causes and the severity.

A hernia is a bulge or protrusion of an organ or fatty tissue through a weakened area in the muscle or connective tissue in which the organ is enclosed.

A hernia can develop in any part of the body. However, the muscles of the abdominal wall are most commonly affected.

More About Hernia?

Hiatus Hernia Surgery Hernia Surgery Recovery Hernia Surgery Compared

Who is Affected by Hernia?

Hernia can occur in babies and in adults. Hernia in babies usually heals by itself within four years, but for others, hernia repair surgery or herniorrhaphy is the standard treatment.

Symptoms of Hernia

The main symptom is the appearance of a lump (a swollen area) in the region involved. The lump may be painless and only be felt on exertion such as lifting heavy objects, coughing, etc. Some hernias can cause pain during exertion.

The lump is not felt when the person is lying down; it becomes prominent on standing and particularly on straining. Some hernias can get strangulated, interrupting blood supply to the herniated tissue.

A hernia can protrude from a weak area or opening in the wall of the abdominal cavity. It is seen as a bulge over the skin, and often characterized with

Pain
Discomfort.

Hernias are more common in certain parts of the body. Hernias occur most commonly between the area of your rib cage and groin, such as the

abdomen
groin
upper thigh area, and
belly button area.

They can also occur in any place where you have had an incision from a previous surgery.

Hernia Diagnosis

A hernia can usually be diagnosed by physical examination (for example: for inguinal hernia, a lump can be seen or felt in the groin).

Ultrasound and X-rays are other tests that your doctor can order to diagnose hernia.

Types of Hernia

There are different types of hernias based on their location. The most common types are listed below.

Inguinal
Femoral
Incisional
Umbilical
Hiatal

Inguinal Hernia

Inguinal hernia appears as a bulge in the groin or scrotum, occurring more commonly in men than women. Part of the intestine protrudes through the lower abdominal muscle into the groin.

Femoral Hernia

Femoral hernia appears as a bulge in the upper thigh, is a loop of intestine, or another part of the abdominal contents, that has been forced out of the abdomen through a channel called the "femoral canal"(a tube-shaped passage at the top of the front of the thigh).

This type of hernia tends to occur in older people and is more common in women than in men.

Fat tissue or part of the intestine protrudes through the abdominal muscle into the femoral artery present in the upper part of the thigh.

Incisional Hernia

Incisional hernia may be caused by the scar if you have had abdominal surgery. Tissue protrudes through a previous surgical wound, which becomes structurally weak.

Umbilical Hernia

Umbilical hernia is a small bulge around the umbilicus (belly button). An umbilical hernia in an infant is caused by the incomplete closure of the muscles around the umbilicus.

Fat tissue or part of the intestine protrudes through the abdominal muscle near the belly button.

Hiatal Hernia

Part of the upper stomach protrudes through an opening in the diaphragm into the chest region.

Hernia Treatment

A hernia may need to be treated surgically as it may

have a risk of causing pain,
discomfort or
even becoming strangulated.

Hernia Surgery

A hernia repair is usually performed as an outpatient surgery with no overnight stay in the hospital.

The operation may be performed as an

Open Surgery
Keyhole Surgery - laparoscopic

There are two types of laparoscopic surgery these are:

The most commonly used laparoscopic surgical techniques for hernia repair are

transabdominal preperitoneal (TAPP) and
totally extraperitoneal (TEP) repair.

Open Hernia Surgery

About Open Hernia Surgery

To treat a hernia, your doctor may push the hernia back into its normal location and have you wear a belt to hold the hernia in place.

However, surgical repair is recommended for hernias that cause pain and other symptoms, and for irreducible hernias (structures cannot be returned to their normal locations) that are incarcerated or strangulated. Surgery aims at closure and repair of the muscle wall through which the hernia protrudes.

Open Surgery

Open surgery, also called Herniorrhaphy, for hernia can be done under general or local anaesthesia. Your surgeon makes an incision of about 5-10cm long (depending on the size of the hernia) to view and access the surgical site. Your surgeon pushes the part of the intestine that protrudes back into its normal position and repairs the weakened muscle layer by sewing the edges of the healthy muscle wall together. A synthetic mesh is often placed and sewn over the weakened area to provide additional support and strength, by a procedure called hernioplasty. The incision is closed after the procedure using dissolvable stitches.

Post-Operative Care

Following surgery, you

Can take a shower only after 48 hours post-surgery
Can go home the day of the procedure
Should avoid driving while taking pain killers as they induce drowsiness
Can resume daily activities slowly while strenuous activities should be resumed only after consultation with your surgeon
Use ice pack on the wound to reduce pain, prevent swelling and to lessen bloody discharge from the incision if present
Recover in about 3 weeks

Risks and Complications

Like most surgical procedures, hernia repair is associated with the following risks and complications:

Reaction to anaesthesia
Infection
Bleeding at operation site
Nerve damage and numbness of skin
Damage to surrounding tissue

Although the recurrence of hernias is seen in less than 5% of patients after surgery, you would need to follow preventive measures.

Laparoscopic Hernia Surgery

Why Consider Laparoscopic Hernia Surgery

Laparoscopic hernia surgery is a surgical procedure in which a laparoscope is inserted into the abdomen through a small incision. The laparoscope is a small fiber-optic viewing instrument attached with a tiny lens, light source, and video camera.

About Laparoscopic Hernia Surgery

Laparoscopic surgery is performed in a hospital operating room under general anesthesia. The procedure involves the following:

A camera attached to the laparoscope displays the image of the abdominal cavity on a screen.
The surgeon makes three small incisions over the abdomen to insert the balloon dissector and trocars (keyholes).
A deflated balloon along with the laparoscope is inserted and the balloon is inflated with a hand pump under direct vision.
Once the trocars (key holes) are placed, the keyhole instruments are then inserted to repair the hernia.
A sheet of mesh is inserted through the top keyhole and positioned and fixed in the abdominal wall to reinforce the repair and help prevent recurrent hernias. After completion of the repair the CO2 gas is evacuated and the trocars are removed and the tiny incisions are closed and dressed with a sterile bandage.

Indications And Contraindications

Indications for laparoscopic hernia repair over open repair may include recurrent hernias, bilateral hernias, and the need for earlier return to full activities.

Contraindications specific to laparoscopic hernia surgery include non-reducible inguinal hernia, previous peritoneal surgery, and inability to tolerate general anesthesia.

Medical conditions including upper respiratory tract or skin infection and poorly controlled diabetes mellitus should be fully addressed and the surgery should be delayed accordingly.

Advantages Over Open Surgery

Less post-operative pain with smaller incisions and faster recovery
No further incisions required for patients with hernias in both groins (bilateral hernia)
Ideal method for patients with recurrent hernias after previous surgery
Early discharge from hospital
Earlier return to work

Complications with Laparoscopic Hernia Surgery

Specific complications of laparoscopic hernia surgery may include

local discomfort and stiffness,
infection,
damage to nerves and blood vessels,
Bruising, and blood clots,
wound irritation and
urinary retention.

Post-Operative Guidelines

Pain medication will be provided and should be taken as directed.
Remove the bandage after 24 hours.
See GP for wound review after 5 days
Swelling in the groin, at the site of hernia may occur due to serum accumulation in the cavity left by reducing the hernial sac.
Bruising usually appears in the genital area, which is not painful and disappears over 1-2 weeks.
You are able to drive usually in 1-2 weeks time and resume normal activities when comfortable unless otherwise instructed.
Make a follow up visit approximately 2 weeks after surgery to monitor your progress.

The most commonly used laparoscopic surgical techniques for hernia repair are

transabdominal preperitoneal (TAPP) and
totally extraperitoneal (TEP) repair.

TAPP Repair

TAPP Repair is a minimally invasive surgical procedure is performed under general anaesthesia.

Your surgeon makes a small incision beneath the navel.
A needle is inserted through the incision and the abdomen is filled with gas. This allows your surgeon to view the internal organs clearly.
The needle is removed and a camera is inserted through the incision.
Further, 2 more incisions are made near the navel to introduce the surgical instruments. The peritoneum (a membrane that lines the abdominal cavity) is cut and the hernia sac is removed carefully.
A synthetic mesh is placed over the peritoneal opening and
then closed with sutures.

Pros & Cons of TAPP Repair

Disadvantage - can cause injury to adjacent abdominal organs.
Advantage - can be performed on patients who have undergone previous lower midline surgery.

TEP Repair

This procedure is also performed under general anaesthesia. Your surgeon makes small incisions below the navel. A balloon is placed in the preperitoneal space (space between the peritoneum and anterior abdominal wall) and filled with gas to separate the layers. The camera and the surgical instruments are passed through the incisions. Your surgeon exposes the hernial sac, repositions it and seals the hernia with a synthetic mesh. The incisions are then closed with sutures. The mesh slowly gets incorporated with the tissues of the abdominal wall. The advantage of TEP procedure is that it prevents the risk associated with damage to the internal organs as it is performed outside of the peritoneum.

As with all surgical procedures, TEP and TAPP hernia repair may be associated with certain complications, which include infection, bleeding, swelling and damage to the adjacent organs.

Inguinal Hernia - Mesh Repair

A hernia occurs when the internal organs of the abdominal cavity push through a weakened spot in the abdominal wall to form a bulge.

Hernias may be repaired surgically by closing the defect and using mesh to strengthen the weakened area. This can be performed in a minimally invasive manner using a laparoscope.

Hernia Disease

An inguinal hernia is a bulge that forms when a part of your small intestine or fatty tissue protrudes through a weak spot in the groin or into the scrotum or testicular sac.

A femoral hernia develops just below the lower abdomen and upper thigh, near the groin crease or skin folds around the vagina. The bulge pushes into the femoral canal through which nerves and blood vessels run into the thigh region.

Inguinal hernias commonly occur in men while femoral hernias are uncommon and mostly seen in women.

Hernias generally do not cause any symptoms, but may be discovered on a routine medical exam. Symptoms may include pain, aching, discomfort, or a heaviness in the groin. The bulge formed is more prominent when you stand, cough or strain, and may disappear while lying down as it slips back into the abdomen.

A hernia can sometimes become trapped or strangulated and cannot be pushed back into the abdomen. This is referred to as an irreducible hernia. It is a dangerous situation where the blood supply to the hernia is compromised and may require emergency surgery.

Indications

Small hernias that do not cause any symptoms are usually not treated but instead your doctor may follow a wait-and-watch approach.

Surgery is recommended for hernias that show symptoms, are enlarged or entrapped. Surgery may involve an open hernia repair with a larger incision or laparoscopic surgery, a minimally invasive approach with smaller incisions.

Laparoscopy is especially advised for patients with recurrent hernias, bilateral inguinal hernias and femoral hernias. However, it is not recommended for patients with very large hernias, strangulated hernias, prior pelvic surgery and intolerance to general anaesthesia. These would typically require an open approach.

Surgical Procedure

Laparoscopic hernia repair is performed under general anaesthesia. Your surgeon will make a few small incisions in your abdomen or groin through which a thin tube called a laparoscope and other special instruments are inserted. A video camera attached to the laparoscope sends magnified images to a monitor guiding your surgeon throughout the procedure. Your surgeon will push the bulge back into the abdomen and either stitch the abdominal wall or use a mesh to support the weakened wall.

Post-Operative Care

Laparoscopic repair of inguinal or femoral hernia is usually performed as an outpatient procedure so you will return home as soon as you recover from anaesthesia. You may have some swelling or bruising at the incision sites which is normal. Pain and swelling are mostly controlled with medications. It is important to avoid strenuous activity or heavy lifting for at least 2 weeks after the procedure.

Advantages & Disadvantages

Laparoscopic hernia repair is a minimally invasive procedure and as such is associated with less tissue damage and pain and a faster recovery compared to the open approach. This surgical approach allows you to return home the same day and get back to your regular activities sooner.