- Hernia repair surgery
- Open hernia repair surgery
- Why is a hernia operation necessary?
- How do I know if I have a hernia?
- Hernia treatment options?
- Is everyone a candidate for laproscopic hernia repair?
- Benefits of having laproscopic hernia surgery
- Risks of not having hernia surgery
- Risks and complications of surgery
- Specific risks from laproscopic hernia surgery include
- What if the operation cannot be performed by the laparoscopic method
- After the hernia operation
- Discharge instructions
Hernia Repair Surgery
Associate Professor Bartlett repairs most hernias laparoscopically using keyhole hernia surgery.
Laparoscopic hernia repair is an operation performed to fix defects in the abdominal wall musculature using small incisions, a telescope (laparoscope) and a mesh patch. Compared to the traditional open surgery approach, laparoscopic hernia repair offers a quicker return to work and normal activities, with less pain, for some patients. Most types of hernia can be repaired using the laparoscopic technique. More recently, another minimally-invasive technique has been the advent of robotic hernia repair. Rarely, a traditional open technique is required to repair a hernia. A/Prof Bartlett will discuss the risks and benefits of the various approaches to ensure that you chose the best surgical approach for your hernia.
Open Hernia Repair Surgery
The traditional, “open” method of repairing groin hernias is occasionally recommended.
The most common reason for this is hernia recurrence following laparoscopic repair. Open repair is also preferable in patients that are at high risk for a general anaesthetic, as it can be performed under local anaesthetic. The open approach is performed using a long (7-10cm) incision (cut) in the groin.
Why is a hernia operation necessary?
When a hernia occurs, it means the layers of the abdominal muscle have weakened, resulting in protrusion of the intra-abdominal contents.
In the same way that an inner tube pushes through a damaged tyre, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a balloon-like-sac. This can allow a loop of bowel or abdominal tissue to push into the sac. If the hernia contents become incarcerated there is a risk of strangulation, that will likely require emergency surgery. A hernia does not get better over time, nor will it go away by itself. The common areas where hernias occur are in the groin (inguinal, or femoral), belly button (umbilical or paraumbilical) and the site of a previous operation (incisional). See Hernia section.
How do I know if I have a Hernia?
The most common symptom of a hernia is pain or discomfort and/or presence of a lump.
You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting. In the early stages the lump usually disappears (spontaneously reduces) when lying at rest or while sleeping. The pain may be sharp and immediate or a dull ache that gets worse towards the end of the day. Severe, continuous pain, redness and tenderness are signs that the hernia may be trapped (incarcerated) or strangulated. These symptoms are cause for concern and should see a doctor immediately.
Hernia treatment options?
A surgical operation is the only means to repair a hernia.
There are no medical treatments that will help to repair the defect in the abdominal wall. Some people manage the hernia with an abdominal support (trusss), but this is only for the management of symptoms. A/Professor Bartlett will explain the various hernia surgery options. In some situations, where there are other significant medical issues, it may be more appropriate to leave the hernia as it is.
Non Surgical Hernia Treatment
There are no non-surgical curative options to repair a hernia. The use of a truss (abdominal support) used to be prescribed. A truss applies support to the weak area, but it is not a cure and can be uncomfortable and cause excoriation (skin break down). It is often ineffective and is usually reserved for people who are not fit for an operation due to other medical conditions.
Laparoscopic Keyhole Hernia Surgery
The modern approach to surgical repair of groin hernia using laparoscopic (keyhole) repair. Laparoscopy or keyhole surgery is performed under general anaesthetic. A 10mm incision is made in the abdomen immediately below the umbilicus (belly button) and a further two 5mm incisions in the midline between the umbilicus and pubic bone (pelvis). Carbon dioxide gas is blown (insufflated) into the abdomen to lift the abdominal wall away from the internal organs so expose a space. A laparoscope (a long thin telescope) connected to a special camera is inserted through the 10mm port into your abdomen, allowing the surgeon to view the hernia and surrounding tissue on a video screen. Other instruments are inserted into the 5mm incisions (ports) to help develop the space and reduce the hernia. A soft and flexible piece of surgical mesh is placed beneath the abdominal wall, but outside the peritoneal cavity, to prevent the hernia from getting out through the hole in the abdominal wall. It is important that the mesh is kept out of the abdominal cavity, and left in the pre-peritoneal space. This prevents the bowel becoming adherent to the mesh, and causing the well publicised complications. The mesh is then tacked onto the pubic (pelvis) in the midline to hold it in place. No sutures or tacks are placed into the abdominal musculature, as this is associated with an increased risk of post-operative chronic pain. The instruments are removed and the gas is allowed to escape before closing the incisions.
Traditional Hernia Surgery
In a few patients who are not suitable for laparoscopic surgery the open or traditional approach is used. The most common reason for this is hernia recurrence following laparoscopic repair. Open repair is also preferable in patients that are at high risk for a general anaesthetic, as it can be performed under local anaesthetic. The open approach is performed using a long (7-10cm) incision (cut) in the groin. In most instances patients following open repair require longer recovery but the long term results are similar. Like with the laparoscopic repair, mesh is used to bridge the defect and secured in place using sutures. Most other types of hernia (see HERNIA section) are repaired using an open technique. This involves making an incision (cut) over the area of herniation and placing mesh or primarily closing the defect in the abdominal wall. It is A/Professor Bartlett’s preference to place the mesh beneath the abdominal musculature, but outside of the abdominal cavity (Sublay mesh repair). Bio-mechanically this leads to a stronger repair, is less prone to the development of fluid collections (seroma) and keeps the mesh out of the abdominal cavity. In situations where it isn’t possible to keep a barrier between the mesh and the abdominal contents, it is preferable to use either absorbable mesh or mesh that is covered by a barrier that prevents adhesions. These issues will be discussed with you by A/Professor Bartlett, prior to your surgery to ensure that you are comfortable with the proposed operation.
Is everyone a candidate for laparoscopic hernia repair?
Only after a thorough examination can your surgeon determine whether laparoscopic hernia repair is right for you.
Laparoscopic hernia repair is particularly recommended for people who have had their hernias repaired before (a recurrent hernia) or for people who have hernias on both sides (bilateral hernias). The laparoscopic procedure may not be best for some patients who have had previous abdominal surgery or underlying medical conditions or who are very overweight. A/Professor Bartlett will have you make a decision regarding which approach is best for you.
Benefits of having Laproscopic Hernia Surgery
Although open, mesh-based, tension-free repair remains the gold standard for the treatment of groin hernias, laparoscopic hernia repair, in the hands of adeqately trained surgeons, produces excellent results.
A number of studies have shown laparoscopic repair of inguinal hernias to have advantages over conventional repair, including;
- Reduced postoperative pain
- Diminished requirement for opioid analgesia
- Earlier return to normal activity
- Lower incidence of chronic pain
Laparoscopic repair has some disadvantages as well, including the following:
- Increased cost
- Longer operation
- Steeper learning curve for the surgeon
- Higher recurrence and complication rates early in a surgeon’s experience For many other types of hernia, in particular incisional hernia (see HERNIA section) there are greater advantages in undertaking an open approach. A/Professor Bartlett will discuss these issues to ensure that you are informed of the potential risks and benefits of each approach.
Risks of not having hernia surgery
In most instances the hernia will probably get larger over time if left alone.
Depending upon the size of the hernia and the defect in the abdominal wall the hernia contents may become trapped (incarcerated) and potentially strangulated (ischaemic). This may result in the bowel within the hernia becoming gangrenous (part of the bowel dies). This is a surgical emergency and may necessitate removal of part of the bowel. In patients who have an easily reducible hernia that has been present for many years, and not progressively increased in size, it may be preferable to leave it as is. This is usually the case in the elderly, or in those patients with multiple significant medical problems. In situations where a general anaesthetic is associated with a prohibitive risk, it may be preferable to have the hernia repaired under local anaesthesia or a regional block. In the majority of cases it is preferable to repair the hernia, due to the potential risks, and the greater difficulty achieving a good result as the hernia gets larger. A/Professor Bartlett will help you decide if the risks of hernia repair are less than the risks of leaving the condition untreated.
Risks and complications of surgery
Although the operation is considered safe as with any other surgical procedure there are risks associated with undergoing surgery.
The main complications of are bleeding and infection, both of which are uncommon following hernia repair. In a small number of patients fluid can accumulate adjacent to the mesh. This is referred to as a seroma. This is more common following open hernia repair, especially following repair of large incisional hernia. It usually resolves spontaneously, but may require aspiration in the post-operative period using a small needle under local anaesthetic. Complications pertaining to the use of mesh are rare if the mesh is used appropriately. Other complications that can occur during any operation may include: Adverse reaction to general anaesthetic; Secretions may collect in the lungs causing a chest infection; Clotting may occur in the deep veins of the leg. Rarely, part of this clot may break off and go to the lungs. This can be life threatening; Circulation problems to the heart or brain may occur, which could result in a stroke; Death is possible during or after an operation due to severe complications. The risk of a serious complication is very small – less than 1 in 1,000 patients will have a serious complication.
Specific risks from a laproscopic hernia operation include:
Damage to large blood vessels causing bleeding in one in five hundred people.
What does this mean?
Emergency blood transfusion (one in one thousand people), and abdominal surgery.
Injury to the bowels
Injury to the gut in one in three hundred people, or other organ such as the bladder.
What does this mean?
More surgery to repair the injured organs will be needed.
Need for open surgery
Keyhole surgery may not work and the surgeon may need to do open surgery (less than 1% of people). This is more common in patients who are overweight.
What does this mean?
Open surgery requires a bigger cut in the groin and may be more painful.
Trouble passing urine after the operation
A temporary problem due to spasm of the bladder muscles and side effect of opiate analgesia. It is more common in older men.
What does this mean?
A catheter (plastic tube) is put into the bladder to drain the urine away. This is usually temporary.
Swelling of the testicle and scrotum
In male patients, the testicle and the contents of the scrotum may swell due to the surgery or bleeding during or after surgery. Also the penis may show bruising.
What does this mean?
In almost all cases this resolves. Rarely the swelling of the scrotum may be drained using a needle. The testicle may stop making sperm and it may shrink (1 in 200 patients for first repairs and 1 in 100 for recurrent repairs).
Swelling at the site of the hernia persists after surgery
This is usually caused by a seroma or collection of tissue fluid under the skin and is common when larger hernias have been repaired.
What does this mean?
The fluid can be drawn off with a needle in clinic if necessary but will disappear in time if left alone.
Injury to sperm tube (Vas Deferens)
The tube carrying sperm from the testicle to the prostate may be injured which may reduce fertility in 1 in 200.
What does this mean?
Results in a partial vasectomy as the other spermatic cord is not affected with unilateral hernia repair.
Change to testicle
The testicle may sit a little higher in the scrotum after surgery.
What does this mean?
A change in physical appearance is unusual – it usually settles with time and no action is necessary.
Ongoing pain or discomfort in groin
One of the small nerves in the groin can be cut or caught in a stitch or scar causing long term burning and aching in the groin in 1 in 50. This is much less common after laparoscopic surgery compared to open surgery.
What does this mean?
Rarely this may require injections or long term medication to control the discomfort.
Bleeding into the wound
Possible bleeding into the wound after the surgery.
What does this mean?
This can cause swelling, bruising or blood stained discharge. Very rarely further surgery is required to stop the bleeding.
Hernia comes back
The hernia may come back in approximately 1 in 50 patients. The rate of recurrence of the hernia is the same for open surgery or laparoscopic surgery.
What does this mean?
Further surgery to repair the hernia. This is usually approached by an open technique.
Hernias at the wound sites
A weakness can happen in the wounds where instruments were passed into the abdomen, with the development of a hernia.
What does this mean?
Hernias usually need to be repaired by further surgery.
Adhesions (bands of scar tissue)
Adhesions can form and cause bowel blockage and possible bowel damage. This is extremely rare.
What does this mean?
This may require further surgery to cut the adhesions and free the bowel.
Increased risk in obese patients
An increased risk of wound infection, chest infection, heart and lung complications and thrombosis.
Increased risk in smokers
Smoking slows wound healing and affects the heart, lungs and circulation. Hernias are twice as likely to recur in smokers.
What does this mean?
Giving up smoking before the operation will reduce the risk of wound infection, chest infection, heart and lung complications and thrombosis
What if the operation cannot be performed by the laparoscopic method
In a small number of patients the laparoscopic method is not feasible.
Factors that may increase the possibility of converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, in particular prostate surgery, or bleeding problems during the operation. The decision to perform the open procedure is a judgement decision made either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety, and is rarely needed.
How long will I be in hospital after henia surgery?
With Laparoscopic hernia surgery most patients who are fit and well can be admitted on the day of their operation and go home later on the same day. Older patients or those with heart, chest or urinary problems may need to stay overnight. In patients undergoing open groin hernia repair, they may need to stay one night in hospital. Patients that have large and complex hernias, then they may require additional nights in hospital depending upon their comfort and mobility.
How should I prepare for my hernia operation
Preparation for surgery will be discussed with you by A/Professor Bartlett and will depend on your history and current condition. For a straightforward groin hernia, there isn’t anything in particular that one needs to do. A/Professor Bartlett will provide you with instructions regarding when to fast from, and where to present for surgery. In patients with more complex hernia they require
- Additional imaging
- Consultation with other specialists
- Change in medications you currently take to minimize bleeding complications.
If you have any questions, or concerns, please contact, A/Professor Bartlett or his team and ask prior to your planned date for surgery.
After the hernia operation
Will I need pain relief after a hernia operation?
With any operation you can expect some discomfort in the wounds. This will mostly be during the first 24 – 48 hours. We will give you pain killers (analgesia) that you should take regularly for the first two to three days which the nurse will discuss with you before discharge. Occasionally patients may experience shoulder-tip pain from the gas but this should settle very quickly. Hot packs can sometimes help or gentle walking will help to ease this. Most patients find that the discomfort wears off within 4 – 5 days. If you have prolonged soreness and are getting no relief from the prescribed pain medication you should call A/Professor Bartlett or his team to let them know.
How do I care for my wound after a hernia operation?
The wounds are covered with dressings that should stay on for 3 days. The incisions are closed with dissolving stitches that do not need to be removed. If you have any concerns about your wounds at any time, please let A/Professor Bartlett or your general practitioner know.
Can I drive after a hernia operation?
Legally you are not permitted to drive for the first 24 hours following sedation or general anaesthesia. Most patients following laparoscopic hernia repair take 2-3 days before they feel sufficiently comfortable to drive. If the operation has been performed by an open technique then it may take a few more days. Before driving you should ensure that you could perform a full emergency stop, have the strength and capability to control the car, and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance, and you should check with the conditions of your insurance policy as they do vary.
Do I need to change my diet after a hernia operation?
In general no. Some patients develop constipation following the operation as a result of the medications given at the time of surgery. A high fibre diet and or simple laxatives may help to combat the effects of constipation. You should also drink plenty of water.
How will hernia surgery effect my BLADDER?
Some patients (5%) develop urinary retention (they have trouble initiating a urinary stream) after inguinal hernia repair. It tends to be more common in males, with increasing age, and in patients undergoing open repair. If it occurs, the treatment may include a temporary insertion of a urinary catheter which is usually removed the following day. Occasionally you may need to go home with the catheter in situ and we will arrange for it to be removed in around 3 days time. All patients eventually regain their baseline control of initiating a urinary stream. Bladder injury during the surgery is extremely rare. If you have had prostate surgery in the past, you should discuss this risk with your surgeon. It may be advisable to approach the hernia repair differently. Urinary infections are extremely rare, but have been reported. The nurses will ensure that you have passed urine before you leave the hospital, although you may find that the force of your stream is not back to normal for 24 hours, it will gradually improve.
How will my MOBILITY be effected post hernia operation?
Prior to leaving the hospital the nursing staff will ensure that you are able to ambulate. You are encouraged to be up and about the day after surgery. For the first few days after surgery you should take frequent short walks to avoid the possibility of postoperative clots in the legs and chest. Most patients are able to resume their normal daily activities by 5-7 days. If the operation was performed by an open technique then you will need to avoid straining or lifting anything more than 6kg for 6 weeks.
How will SLEEP and REST be effected after a hernia procedure?
It is not uncommon to feel more tired than normal in the first few days after your operation. This is perfectly normal and you should rest whenever you feel tired. If you are uncomfortable then you may wake, so ensure that you take adequate analgesia prior to sleep.
Will I experience BRUISING after a hernia operation?
Bruising may develop around the wounds which may look quite alarming. However, it is nothing to worry about and will fade in 2 – 3 weeks. There is not usually any bruising in the groin but some may appear around the base of the penis and underneath the scrotum. This is nothing to worry about and will fade in 2 – 3 weeks. Rarely, if you have had a large hernia repaired you may develop a lump again at the site where the hernia used to be. This is a collection of fluid called a seroma. It usually absorbs back into the body in a couple of months but if it causes discomfort then the doctor will be able to draw off some of the fluid with a needle when you come back to the clinic.
How soon can I shower after a Hernia Operation?
You can shower or bath as soon as you wish following the operation as the dressing are waterproof. It is best to try and leave the dressings and steristrips on for at least 3 days. Once you have removed your dressings, clean them and pat the wounds dry with a clean towel and then leave them open to the air.
How soon can I RETURN TO WORK after a hernia operation?
You can return to work as soon as you feel up to it. This will depend on how you are feeling and the type of work that you do. If you have a relatively sedentary job then you may feel ready to return within 3-4 days. If you are involved in manual labor or heavy lifting you need to remain on light duties for at least 3-4 weeks. In patients that have had open hernia repair it is usually recommended that you avoid lifting anything more than 6kg for the first 6 weeks. A/Professor Bartlett is happy to answer any questions you may have regarding this as it will depend upon your hernia and the work that you do.
Will I need to see the surgeon again after the hernia operation?
You will be followed up by A/Professor Adam Bartlett’s team at 2-3 weeks following the operation to assess your recovery and to discuss any concerns that you may have. If you have problems before this please contact the rooms to make an appointment, contact A/Professor Bartlett directly, or make contact with your GP. In the event of an acute problem, please go the hospital emergency department and let A/Professor Bartlett know.
What is the risk of using surgical mesh for hernia repair?
There has been much controversy in the media recently regarding transvaginal mesh prolapse repair and its potential associated risks of infection, erosion and chronic pain. Unfortunately, the media have portrayed the outcomes of this one gynaecological procedure to include all surgical use of mesh for hernia repair. It has caused unnecessary widespread patient stress and anxiety throughout New Zealand.
The use of mesh in General Surgery to repair hernias of the groin or the abdominal wall is well established internationally and is considered the procedure of choice. For ventral hernias with fascial defects greater than 2cm in diameter and all adult groin hernias, mesh must be used to reinforce the tissue repair. If not the hernia recurrence rate without mesh is unacceptably high. Mesh can significantly reduce hernia recurrence rates.
The use of mesh for abdominal and groin hernia repair is safe. Chronic pain may occur after hernia repair in less than 10% of patients. However, it is important to remember that chronic pain after groin hernia repair is higher for patients having non-mesh repair compared to mesh repair. Mesh infection after abdominal hernia repair is uncommon, less than 1 %. For laparoscopic inguinal hernia repair it is even lower.
The use of surgical mesh is an important part of the curriculum for general surgical training and NZ general surgeons have extensive experience in the use of mesh for hernia repair.
Are there alternatives to mesh?
There are a number of alternative techniques that have been described for hernia repair that do not use mesh. They all require an open technique, as they can not be performed laparoscopically. Other than the Shouldice operation, they have all been found to have a higher rate of hernia recurrence compared to the mesh repair.
What is the risk of recurrence?
All hernia repairs are subject to a very low, but definite, recurrence rate. Most recurrences will occur in the first 2-3 years. The recurrence rate for groin hernia repairs is about 2% in most surgeon’s experience. The repair of larger hernia, in particular incisional hernia is associated with a higher rate of recurrence. Other patient related factors also play a role, including BMI, medications, chronic illness and patient activity.
Is there a risk of chronic groin pain following inguinal hernia repair?
Chronic groin pain, mild or severe, is defined as the presence of pain, discomfort present for more than 3 months after surgery. According to a number of studies even a healthy male with no previous history of groin pain can occur in up to 5% of patients undergoing any type of inguinal hernia repair. While the general risks of developing this chronic discomfort exist, in our hands this complication is rare.
Here are some guidelines to follow for your first few weeks at home:
- You will be given tablets to take for pain management when you leave the hospital. Please take them as directed.
- If you have a history of gastric (stomach) or duodenal (peptic) ulcers then avoid taking non-steroidal anti-inflammatory drugs (NSAIDs) such as asprin, voltaren or ibuprofen.
- It is recommended that you take 1g (two 500mg tablets) of paracetamol (panadol) four times a day for the first 4-6 days.
- If you experience constipation, any laxative is okay including dietary supplements such as kiwifruit, kiwi crush or prunes.
- Gentle walking for the first 2-3 days then full walking as tolerated.
- Don’t put yourself to bed, keep moving regularly, and sit in a chair rather than staying in bed.
- It is illegal to drive or operate machinery for 24 hours following a general anaesthetic.
- Most people feel sufficiently comfortable to drive a car within 2-4 days – be guided by your symptoms, and discuss with either your general practitioner or A/Prof Bartlett if you are concerned.
- Avoid straining or lifting more than 6kg for 2 weeks, then get back to normal level of activity, appreciating that you would have lost physical condition during the recovery.
- You may return to work when you feel ready.
- You may resume your normal diet when you feel up to it. There are no dietary restrictions.
When to call the doctor
- Abdominal pain that is getting progressively worse – you should feel a little better each day. The discomfort may take a couple of weeks to completely disappear.
- Redness (erythema) or foul smelling drainage from the incisions, as this may indicate infection.
- Temperature greater than 38oC
- Vomiting or diarrhoea lasting more than 24 hours
If you have
Constipation: This is common due to the narcotics taken during the general anaesthetic and post-operatively for pain management. There are a number of different types of laxatives that you can get over the counter at the pharmacy, or by prescription. Alternatively, dietary supplements such as prune juice or kiwi fruit are usually just as effective. Ensure that you drink plenty of fluid.
Bruising: It is not unusual for bruising to appear a day or so after the surgery in the groin. In men, this usually extends around the base of the penis, and depending upon the extent of dissection, may involve the scrotum. It usually resolves over the first week. Wearing supportive underwear often helps to limit the bruising. If you feel it is getting worse, or becoming painful, please notify A/Prof Adam Bartlett
Pain: Discomfort is to be expected after this operation and it usually fades by the end of the first week, but sometimes can last for many weeks. Each day, the pain should be similar or better than the day before, but it will fade slowly. If the pain is worsening daily or persists beyond two weeks, then you need to make contact with either your General Practitioner or A/Prof Adam Bartlett.
Headache: Some patients experience headaches after operations. It usually relates to dehydration. If the headache persists beyond 24 hours, then make contact with your General Practitioner or A/Prof Adam Bartlett.
Shoulder pain: this may be common for several days after laparoscopic procedures, due to air trapped under the liver. It is often relieved by heat packs. If it persists for more than 2 days, then you should contact A/Prof Adam Bartlett.
Swelling where the hernia used to be: This is common, especially when the inguinal hernia was direct. It usually represents, fluid (seroma) or blood (haematoma) collecting. It may persist for a number of weeks, then your body resorbs the fluid. If it persists, beyond 4 weeks, it may require aspiration using a needle to draw off the fluid. If it becomes painful or red, then please contact A/Prof Adam Bartlett.
The incision(s): It is normal to have a little redness, that becomes purple and/or “black and blue” around the incisions. This represents bruising from the surgery. It should appear, then fade within days. If you feel it is getting worse, or becoming painful, please notify A/Prof Adam Bartlett.
Dressings: Your incisions are dressed with two layers: on the skin are Steri-strips which reduce tension across the incision. Leave these for 10 days or until they fall off, whichever occurs first. Over the strips is proof dressing. The nurses may change this dressing prior to you leaving the hospital. Try and leave it on for three days after surgery. Thereafter you can peel it off when ever you wish. You can shower with the dressings on, and once they have been taken off just leave them open to the air.
Follow Up Visit
When you leave the hospital, the nursing staff will inform you of your post-operative review with A/Prof Adam Bartlett which is usually 1-2 weeks after your operation. If you have any concerns or questions, please call the rooms at +64 6 6234789. If it is after hours or urgent, contact A/Professor Adam Bartlett on his mobile +64 21 2414647.