INGUINAL HERNIA REPAIR

What is a hernia?

A hernia is also known as ‘rupture’. It is defined as the protrusion of the viscus through a normal or an abnormal opening in the abdominal wall. It is akin to a hole in the pocket. If the hole is small, a finger goes through it; if large the entire hand can go through it. Also if the hole is small, it may be difficult to retrieve the finger that has inadvertently gone through it.

Where can I expect to see a hernia?

A hernia can occur in the groins, umbilicus and several other sites in the body. It is commonest in the groin, because the upright posture of humans puts maximal strain on that region.

Are there holes in the groins?

Yes. These are there to let the testes and its cord to go down into the scrotum. Due to age, injury or due to congenital causes these openings which are normally closed by muscles become big and let the lining of the abdominal cavity (peritoneum) with or without the bowel to enter this producing a bulge called the hernia.

My doctor mentioned the term Inguinal. What is it?

Inguinal is the region of the groin where the cord structures pass. The wall behind it may be weak producing a bulge called the direct hernia or the hole in the wall may be lax producing a indirect hernia or there may be both when it is a pantaloon hernia. If the hernia is really large, it may go down into the scrotum and in this case we call it Inguinoscrotal hernia.

Low down in the groin there is also another opening – the femoral canal – which can become weak (mostly in women) and produce a Femoral hernia. It is also a groin hernia.

Does it always need to be repaired?

Yes in most instances. Especially the femoral hernia, mentioned above. This is because bowel can get trapped in it (incarceration) and become gangrenous. Much like the finger going through a hole in your pocket and being unable to get it out. Your doctor will be able to describe this in greater detail to you. In some elderly individuals who are unfit for a anaesthetic, and the hernia is not causing any trouble, the doctor may decide to leave it alone.

How is it repaired?

Quite simply, by strengthening the posterior wall of the groin i.e behind the cord structures in your groin. The way it is strengthened varies from surgeon to surgeon, but the commonest method is to put a piece of sterile mesh. The hernia itself is dissected off the cord and reduced and the hole through which it has come out is narrowed down.

How long will I be off work?

Generally two weeks and then light duties are advised for a further four weeks (No, heavy lifting).

When can I drive?

Generally, driving is best avoided for two weeks after the procedure. This is primarily to avoid any pain from sudden thrusting movements. After that a trial run in an empty parking lot will give you the necessary confidence to use the pedals satisfactorily.

When can I resume sex?

Whenever you are comfortable. Impotence and every conceivable type of sexual dysfunction have been major complaints of an occasional patient following inguinal hernia repair. Such complaints are not true complications of inguinal hernia repair because there is no anatomic or organic relationship between sexual function and inguinal hernia.

What complications should I be aware of?

This is an area of hernia surgery, which you should be fully aware of, before the procedure is undertaken so that the consent you sign is an informed consent. The following are a list of complications, which can occur.

a)       Ischaemic orchitis and testicular atrophy – This is a condition that can occur after hernia repair, consists of a painful, tender and swollen testicle and spermatic cord; often associated with fever. Characteristically, it does not become obvious until two or three days after the operation. This may resolve completely or progress to testicular atrophy; only rarely does the testicle become gangrenous. In about one third of patients with this complication, the testicle shrinks completely. Nevertheless, the testicle can still and does produce the hormone – testosterone. Later on, the testicle may get pulled up into the groin.

How common is this?

Fortunately, it is rare. If you have never had a hernia repair before and your hernia is not the huge type described above (reaching into the scrotum), the chances of getting this problem are less than 1 in a 1000.

If on the other hand your hernia is big, going down into the scrotum and has never been operated upon before then the chances of getting this problem is 1 in 200.

Finally, if you have had one or several operations on the hernia before, the chances are 1 in 20.

 

IT IS IMPORTANT THAT YOU ARE AWARE OF THIS POSSIBILITY. REMEMBER IT IS RARE.

Why does this happen?

Nobody knows for sure. What is well known is that it happens when the dissection has to be extensive or if associated lumps are removed from the testicle such as cysts, hydrocoeles. Sometimes there is a fatty lump with the cord in the groin. Removing this can interrupt the venous blood flow and cause this problem. Although not removing it can mean the presence of the groin lump and the patient may feel that no surgery has been done, or that the hernia has come back!!!!

Is there anything that the surgeon can do to prevent this problem?

Hernia experts all over the world are generally agreed that this infrequent problem arises despite the most meticulous dissection. In other words, there is no way of predicting this problem. There is probably no single surgeon who can truthfully say that he has not seen this problem in one of his patients!!

What is the treatment for this?

Generally, antibiotics, anti-inflammatory drugs are prescribed. Further surgery is not performed. A prosthesis may be inserted into the scrotum if the testicle has almost completely disappeared.

b)      Haemorrhage, Haematoma and Ecchymoses.

These can happen after any operation, more often after a repair done under Local anaesthesia. Often the clot, which forms in the groin resolves spontaneously and there is bruising in the groin, scrotum and Penis. This will look alarming to you but remember that it will resolve usually over the next three weeks and usually there are no serious sequelae. Occasionally, if the clot is big, it may need surgery to remove the clot and control any bleeding. Once again this is a rare problem.

c)       Numbness and Paraesthesia.

Virtually all patients have numbness and tingling after inguinal hernia repair. Most often, it is localised to a small triangular area just below and toward the midline to the incision. In most cases this is temporary and disappears with time. Occasionally this may persist and worry the patient.

Once again, remember, there is no relation between this problem and whether or not the underlying nerves have been damaged. In other words this is completely unpredictable.

d)      Groin Pain.

This is alarming to the patient who would quite understandably rush to his doctor fearing a recurrence. In most cases it disappears spontaneously. Common causes are – abdominal muscle strain, nerve entrapment, neuroma (swelling in the groin nerves), periostitis of pubic tubercle (inflammation in the little bone at the root of the penis) and inflammation in one of the tendons (called the adductor tendon).

Usually such pain disappears if the offending exercise ceases. Occasionally, however the pain may persist for months or years and sometimes can be quite severe and disabling. In these cases, injection of the tenderest area with a local anaesthetic may bring temporary relief. Steroids may be injected as well.

When can this occur?

Groin pain after hernia repair can occur as early as two weeks or as late as one year after surgery. It is generally accepted that the hernia repair may be the initiating event when it appears early. In late appearing cases, the hernia repair is the unlikely cause. Once again, it is emphasised that however meticulous the surgeon has been the problem can arise. In other words it is an unpredictable problem.

How common is this problem?

If you have never had a hernia repair on that side before, the chances are 6 in a 1000 cases. If you have had the operation before, then the chances are 2 per 100 cases. 

Does this problem ever require surgery?

Only in rare cases where the doctor feels it is due to nerve entrapment and even then, injection of absolute alcohol can be tried first to permanently block the nerve. If that does not work, then surgery to excise the nerve from the scar tissue is performed.

e)       Recurrence

This is by far the most frequent complication. Techniques have evolved over the years to prevent this problem as far as possible. Hence the evolution of repairs such as Mesh repair, Plug and patch hernia repair, Shouldice repair etc (you can ask your surgeon about these repairs).

Despite all the best efforts, certain percentages of patients invariably develop recurrence and this is due to poor tissues in the groin. This has been confirmed by microscopic studies of the tissues among patients who develop recurrence.

What would be the recurrence rate of say a mesh repair?

The quoted figure is about 1-5%. The figure varies from series to series. It is difficult to standardise patients into comparable groups.

f)        Other complications

There are some other complications, which are very rare and it is advisable not to worry about them. They are so rare that your operating surgeon may not have seen them in his lifetime.