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What is a Hernia Repair?
A hernia repair is an operation to repair a hole in the wall of the abdomen or groin. The most commonly performed hernia repair is the inguinal hernia.
It is important to make a distinction between groin hernia, the most commonly carried out repair and other forms of abdominal wall repair where a hernia has arisen, for example, in an incision or scar after a previous operation. These are more difficult and the complications rates are much higher.
An inguinal hernia can be repaired by making an incision on the skin. This type of open operation is a perfectly acceptable and safe way to have an operation. Its major benefit is that it is very well understood, it is safe and it has a low recurrence rate. In good hands, scarring is minimal and nearly all patients can have their surgery as a day case procedure.
Laparoscopic surgery or ‘key hole’ surgery is a minimal-access technique that allows the hernia repair to be undertaken without the need to open the abdominal wall.
Typically, three small incisions are made for the laparoscope and operating instruments. There are two main approaches for the laparoscopic repair of inguinal hernias.
Transabdominal preperitoneal (TAPP) repair
This involves access to the hernia through the abdominal cavity. Mesh is inserted through the peritoneum and placed over all potential hernia sites in the inguinal region. The peritoneum is then closed over the mesh.
Totally extraperitoneal (TEP) repair
During this procedure, the hernia site is accessed between the layers of the abdominal wall, without entering the peritoneal cavity. TEP repair is considered to be technically more difficult than the TAPP technique, but it may reduce the risk of damage to intra-abdominal organs.
Both techniques are safe and are performed by the surgeons at OneWelbeck. Key hole surgery is particularly beneficial in recurrent hernias (ones which return after previous operations) or bilateral hernias. Even for standard, single-sided hernias, there are some advantages to keyhole surgery, namely reduced pain both in the initial post-operative period and more long term. In open repair, chronic groin pain occurs in around 10% of patients. This is halved in key hole surgery to around 3-5%.
The scarring is also reduced in keyhole surgery. Rather than one incision in the groin, there are three tiny ‘keyholes’. One just off the umbilicus, measuring around 2 cm and then two 0.5cm cuts between the umbilicus and the pubic bone, in the midline. When these heal, there’s very little to see.
Finally, patients are able to recover more quickly from the keyhole technique and to get back to activities of daily living, such as walking and working, than they are after open surgery.
What is the purpose of a Hernia Repair?
Typically, a hernia operation is performed if a hernia causes discomfort or because of cosmetic reasons. The decision to operate may also be made with you based on the risk that the hernia may increase in size or become obstructed in later life.
What are the benefits of Hernia Repair?
This operation will treat the hernia and will prevent it from causing you symptoms or from becoming strangulated.
What are the risks of Hernia Repair?
Hernia repair is a common and safe operation, and the likelihood is that your surgery will go well. However, all surgery has risk, no matter where and how you have it performed. Of course, there are specific complications for each procedure that your surgeon will discuss with you and these vary for every patient and procedure. But, there are some general complications that you should be aware of.
1. Hernia recurrence:
The hernia may come back after surgery. This occurs rarely (2-3%), but rates vary depending on the type of surgery you have planned.
2. Chronic pain:
This is poorly understood, but some patients complain of pain in the groin that lasts for more than 3 months. The rates vary considerably in the literature, and the exact mechanisms are unknown. Because the pain resolves within 6 months in about a third of cases, anti-inflammatory medication is a reasonable initial treatment.
3. Pain during sexual activity can occur in some patients:
This is a particular risk in young patients. However it does not influence fertility and you can still have children normally after hernia surgery.
It is extremely rare to require a blood transfusion after this surgery, but it is possible to develop a local collection of blood around the surgery site known as a haematoma. This is usually managed conservatively but rarely it may need to be drained. Don’t be concerned if you notice a little bit of bruising around the hernia site, this is very common and will usually settle on its own.
A localised collection of fluid at the surgery site can occur and fill the space where the hernia used to be. Typically, this is managed conservatively, but occaisionally it may need to be drained.
6. Wound infection:
This occurs in a small number of cases. Typically, it is superficial and self limiting and it can be treated with antibiotics. More rarely, the mesh can become infected with bacteria. In this scenario it may be necessary to remove the mesh, and further surgery is indicated. If the wound becomes hot, red or discharges pus, seek urgent help from your surgeon.
7. Urinary retention:
Some men who have a large prostate may have difficulty passing urine after hernia surgery. In this instance, it may be necessary to site a catheter. This can delay discharge from hospital, and you may be started on medication for the prostate. Typically, the catheter is removed at 24 hours.
8. Bowel injury:
With a TAPP repair, there is a very low risk of injury to the bowel. If detected this will be repaired at the time of surgery. However, if undetected this can cause severe abdominal pain post operation and in some instances it may mean another operation is indicated.
How is a Hernia usually treated?
Most hernias are repaired using a synthetic plastic woven sheet, known as a mesh. In recent years there has been some controversy about the use of mesh, as these have caused significant complications in women having surgery to repair a prolapsed vagina. However, this is quite different from the repair of an inguinal hernia. The use of mesh has been shown to be safe and to significantly reduce the risk that a hernia will recur. Therefore it remains the standard of care. More information on this can be found from:
- The Royal College of Surgeons of England: https://www.rcseng.ac.uk/news-and-events/media-centre/press-releases/rcs-response-to-hernia-mesh-complications/
- The British Hernia Society: https://www.britishherniasociety.org/wp-content/uploads/2018/11/BHS-mesh-safety-leaflet-for-patients-2018.pdf
What are the alternatives to a Hernia Repair?
In patients who do not have symptoms, there is no absolute indication to have surgery.
Some patients choose not to have surgery and their symptoms can be managed with simple pain relief. Occasionally patients can be managed with a truss to support the hernia and prevent pain.
What is the recovery from a Hernia Repair like?
If you have surgery at OneWelbeck you will go home on the same day. You will need to rest until the effects of the anaesthetic have passed (usually a few hours). You may need pain relief to help with any discomfort as the anaesthetic wears off. Pain after this operation is very low, usually controllable within a day or two with medication you can buy over the counter, such as simple paracetamol and ibuprofen.
It usually takes two weeks to make a full recovery from this operation, but this varies between individuals.
If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice. Your surgeon may give you a short supply of stronger painkillers when you’re discharged from hospital along with other medicines, such as laxatives, anti-inflammatories and occasionally medicines to protect your stomach lining from the stress of surgery and the side effects of the anti-inflammatories. These will be issued with instructions.
You will need to arrange for someone to escort you home. Try to have a friend or relative with you for the first 24 hours after your surgery.
Frequently Asked Questions
1. What do I need to do before surgery?
If you smoke, you will need to stop as this increases your risk of getting a chest and wound infection, which can slow your recovery. Stay as active as you can. Please stop eating or drinking anything except water for six hours before your surgery and stop drinking water two hours before your surgery.
2. What will happen when I am admitted for surgery?
When you arrive at hospital, the nurse will check your heart rate, blood pressure and test your urine. You will be asked to put on a gown and to wear compression stockings to help prevent blood clots forming in the veins in your legs.
Your doctor will complete the consent process started in the clinic, by signing, or re-signing, with you the Consent Form. The doctor will discuss with you what will happen before, during and after your procedure.
3. How should I care for my wound?
Your wounds will be covered by a water proof dressing. Wear this dressing in the shower (not the bath, which will soak them off) for the first week. At the end of the first week, remove them and place them in a bin.
Underneath you may see flaky, crusty substance, often purplish in colour. This is glue. It is waterproof. Don’t actively remove it, simply leave it but continue to shower (not bathe) for another week. Slowly it will flake and fall off. If it hasn’t by 14 days, then gently peel it off in the shower or wash it off. At 14 days you can return to swimming and bathing and the wounds will be completely healed. There are no stitches to remove – these are hidden in your body and your body dissolves them over time.
4. When can I drive or use machinery?
General anaesthesia temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 24 hours afterwards. There is no exact timing restriction on your driving. You must be able to perform an emergency stop and be free of any physical restrictions due to your operation, be comfortable in the driving position and be able to safely control your car. Broadly speaking, you will most likely need to refrain from driving for at least a week and often closer to ten days. You should be free from the distracting effect of pain or the sedative or other effects of any pain relief medication you are taking. You should inform your motor insurer of your operation so that you’re aware of their recommendations and any restrictions.
5. When can I return to normal activity levels?
Following laparoscopic hernia repair you should refrain from any exercise beyond normal daily activity for two weeks. This includes swimming, gym work, running or strenuous gardening. Your surgeon will usually review you around 2-3 weeks after the surgery and will then allow a graduated return to activity, initially avoiding heavy lifting and very strenuous activity for a further two weeks. By six weeks post operatively, you can do whatever you wish, including high intensity training, weight training and vigorous cardiovascular activity.
6. When can I go back to work?
If you have a desk job or work from home then whenever you are able to manage this is up to you. If you do more manual work or have to travel a lot then most people take one week off work. You should refrain from all vigorous exercise, lifting, running, gardening and the like for 2 weeks.
7. When can I fly?
Usually 2-3 days after your surgery as long as it was uncomplicated and you feel comfortable to travel. It does depend slightly where you are going, and on individual patient factors.
8. What should I eat and drink after the operation?
Eat sensibly as the anaesthesia, painkillers and surgery may make you feel slightly nauseated – so have small light meals. Avoid rich, spicy or fatty foods and alcohol for 48 hours after the surgery but after this you should be able to return to a normal diet.