|
Patient
Advice and Information
Groin Hernia
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon
Essex.
1.
What is a hernia?
A hernia is an
abnormal protrusion of intra-abdominal tissue through a defect in
the abdominal wall. Is usually caused by a weakness in the
muscles of the abdomen. In both men and women, hernias most commonly
occur in the inguinal region [75-80% of all hernias], followed by
hernias after previous surgery [incisional hernias, 8-10%] and
umbilical hernias [3-8%]. Approximately 5% of men will develop an
inguinal hernia in their lifetime.
2. What is the
cause of hernia development?
Hernias occur because
of a combination of factors.
.
Congenital
defects of
the abdominal wall.
.
Loss of tissue
strength and elasticity, usually due to aging.
.
Trauma,
especially after previous abdominal surgery.
.
Increased
pressure within the abdomen
[stomach] caused by: heavy lifting, pregnancy, constipation,
obesity, difficulty in passing water due to prostatic hypertrophy,
coughing, asthma and lung disease.
3. What are the
symptoms of a groin hernia?
You may have felt pain
in the groin area or may have noticed a lump appearing from
time to time, especially when you strain. The lump is due to a small
part of your abdominal contents coming out through the weak area in
the groin. It may be tender, may feel like bowel and is
usually reducible with gentle pressure. The lump usually
increases in size over the years and this is also related to
physical activity.
The risk of serious
complications like intestinal obstruction and strangulation
[bowel stuck to the hernia] is about 5-10%.
4. Is there only one
type of groin hernia?
There are 2 types of
groin hernias, femoral [appearing low, at the crease] and
inguinal [higher, may reach the scrotum], which are subdivided
in direct and indirect inguinal hernias.
.
 Indirect
inguinal hernia. 10
times more common in Imen than women, 5 times more common than
direct, occurring, on average, on the 5th decade of life
[but may occur from infancy to old age], having a medium risk of
serious complications.
. Direct
inguinal hernia.
Is related to age and physical activity, appears at an older age and
is much less often associated with serious complications. Often it
may be decided not to treat it surgically.
.
Femoral hernia.
Appears on the side of the femoral vein. Is much more common in
women [although inguinal hernias are more common that femoral
hernias in women] and the risk of serious complications is high
[30-40%]. Therefore, surgery is always indicated.
5. What are the
treatment options?
As a general rule,
groin hernias should be operated upon, in order to prevent the
development of serious complications.
For elderly people with
severe underlying medical conditions or a direct inguinal hernia, it
may be decided that surgical repair may not be needed.
The use of truss may
keep the lump inside, but may cause damage to the tissues, therefore
is not recommended. Avoidance of anything that increases the
intra-abdominal pressure [coughing, lifting objects, constipation
etc.] usually suffices.
There are a variety of
procedures of repairing a groin hernia described. All have some
advantages and disadvantages, and this is the reason why all of them
can be employed. In general terms, there are 3 types of procedures:
·
Procedures that use your own tissues to reinforce the wall
[Bassinin, Maingot, Halsted, Girard, Shouldice, McVay, etc]. May
cause some more pain initially, but have a minimal incidence of
chronic pain.
·
Procedures that use a prosthetic nylon mesh
[Lihtenstein, mesh plug, Stoppa]. They cause less postoperative
discomfort, but have a higher risk of late chronic pain
·
Laparoscopic repairs
[They cause almost no
discomfort, but have the higher and earlier recurrence rate].
As a general rule, if you
are young, the tissues are strong and the hernia is indirect, usage
of your own tissues is probably the best choice; for elderly people
with direct hernias, mesh repair may be preferred, For recurrent
hernias and in obese people with bilateral hernias, laparoscopic or
extraperitoneal repair [Stoppa] may sometimes be the a better
option.
6. What are the results
of surgical repair?
.
Surgery is
successful in more than 99% of the cases. The only significant
risk is wound infection. The more significant late risk is pain from
nerve entrapement [especially when a plastic mesh had been used]
.
The risk of
recurrence [return of the hernia in the future]
is only 1-2%.
Your
Groin Hernia Operation
1. Before your operation
You may be called for a
pre-admission visit about a week before the actual date to
make sure you are fit and well for the operation. The latter is
usually performed as a day case. However, if you are having both
groins operated upon, or if you have any medical problems, it is
usual to remain in hospital overnight.
Day case surgery
means that after surgery, when you recover from anaesthesia [3-4
hours] your escort will take you home, with all instructions given
to you before [by the surgeon] and after surgery [by the nursing
staff].
2. Coming into
hospital
You will be asked to
come in either the day before [rarely] or the morning of your
operation without drinking anything after midnight. Please bring
with you all the medicines you are taking to show to the doctor.
A nurse, who
will note your personal details will receive you in the ward and she
will ask about any other conditions you suffer from. The surgeon
who is to perform your operation, and the doctor who will give you
anaesthesia will also visit you. Many people are concerned
about anaesthetics, so please ask the anaesthetist if you have any
specific worries so that he may reassure you. All of these people
are ready to answer any questions that you may have, so please ask.
The operation site
needs to be shaved. You will be shown exactly where when you arrive
on the ward.
You will be asked to
sign a consent form that the procedure has been explained to
you and you agree to go ahead.
3. The operation
This is usually
performed under general anaesthesia. Local anaesthesia may be
occasionally used.
The standard operation
involves a 6-8cm cut in the groin.
The surgeon will select
the type of procedure that suits you better based on the type of
your hernia and your overall condition.
In almost all cases the
skin stitches used are dissolvable.
4. Mobilisation
and going home
.
You will be able
to make a few steps and go to the bathroom when you recover
from anaesthesia and then walk to the car that will take you
home. The earlier the patient is out of bed and walking the better;
however, for the first week take things easy. You will
increase your activities gradually.
.
Three times a
day take
a short walk [a few hundred meters would do, but more if you
wish] to avoid stiffness of the muscles and joints.
Some slight
discomfort is normal.
.
In the first
week after surgery you may need to take a mild pain killer,
such as paracetamol, to relieve discomfort. Some times the surgeon
may prescribe a stronger pain killer [diclophenac] for the first 3
days.
.
Occasionally,
some severe local twinges of pain may occur in some patients
and may persist for a couple of months.
5. What next?
.
The wound is
waterproof after 4-5 days and a shower can be taken at this
time.
.
You should
avoid driving for 7-10 days, for two reasons: firstly, the
effects of anaesthetics linger on and your reaction times may be
slower than normal. Secondly, in an emergency, because of pain, your
response time may be prolonged, and it is essential that you are
able to perform an emergency stop without pain. If in doubt, delay
until you are happy.
.
Walking,
swimming, cycling and light exercise are allowed
as long as the wound is comfortable.
.
Avoid lifting
heavy objects
and all strenuous sports for 4 weeks
.
In the majority
of cases there is no need for follow-up. However, if you feel
so, or if you have any problem the surgeon will be happy to see you
again.
6. What
complications should you look for?
.
Sometimes a
little blood will ooze from the wounds for the first 12-24
hours. This usually stops on its own. If necessary, press on the
wound for 10 minutes. If bleeding continues after doing this twice,
phone your General Practitioner or the ward.
.
Some skin
bruising is usually present after 2-3 days but should cause no
concern as it disappears in 7-10 days.
.
It is usual to
have some thickening around the wound. This is scar tissue
ands will soften up within a few months. The scar will be red to
begin with but will fade with time and leave a white line. However,
if the thickening is accompanied by excess swelling, redness and
much pain may represent wound infection and you should see
your General Practitioner who will prescribe antibiotics. Extremely
rarely the infection is deep and may not respond to antibiotics. If
nylon mesh had been used for the repair, the wound may have to be
re-opened and the mesh to be removed.
.
You may notice
some numbness in the scar and the groin area, which is common
and settles within a couple of months.
.
Some patients
experience odd sensations in the first few months following
hernia repair, described as dragging or pulling sensations and
though to be related to pulling on nerves during the operation and
the healing process. If they do occur, they settle within a few
months.
.
An extremely
rare complication is pain in the upper thigh or the genitalia due to
nerve entrapment within the stitches. If it does not settle,
then repeat surgery to remove the constricting stitches should be
considered.
.
The groin cut is
along the crease skin lines and the scar will continue to fade
for 6-12 months and quite often is not visible at all, leaving
just a white line.
7. Return to
normal activity?
You can return to work
when you feel sufficiently well, generally after a week to ten
days. If you have a job that involves much standing and weight
lifting, you may need up to six weeks off work. Your General
Practitioner will advise you about returning to work in the light of
your progress after the operation.
Return to top of page.
Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist. |
