Surgery for hernias

A hernia is caused by a defect or weakness in the abdominal wall muscles. It results in a bulge in the groin (inguinal and femoral hernias) or elsewhere, e.g the tummy button (umbilical hernia) or following previous surgery (incisional hernia). The first symptom is often discomfort in the area affected although a painless swelling may also be the first indication of a hernia. If a swelling is present the diagnosis is usually obvious to your doctor whilst discomfort in the absence of a lump may cause difficulty in diagnosis. When you are examined your doctor will at some stage ask you to cough as this raises the pressure within your abdomen and makes the hernia appear.

With certain types of painless hernias you may not require any treatment at all. In most cases however an operation is advisable. This is either because of discomfort or because of the risk of strangulation of the hernia. The swelling consists of what is called a hernia sac and its contents. The sac can be likened to a small balloon and is part of the lining of the abdominal cavity. Inside there may be just abdominal fat or more often bowel. Strangulation of a hernia occurs when the bowel inside the sac gets stuck in the abdominal wall defect. The bowel can then lose its blood supply and become gangrenous which is a very serious situation requiring emergency surgery.

All operations to repair a hernia seek to achieve the same aim, i.e removal of the swelling and closure of the abdominal wall defect. In most cases these days a piece of artificial material will be used to close the defect. This is referred to as a mesh repair. The operation can be performed using open or keyhole techniques.

The open operation (Lichtenstein repair) has been in use for many years and is a very effective way of dealing with a hernia. It does have some drawbacks however. It involves a painful cut in the groin and there is a 1 in 10 chance of chronic long-term discomfort following the operation. In addition there is a significant incidence of numbness below the scar. Other complications can include wound infection and very occasionally the mesh may need to be removed because of infection. The recurrence rate (chance of the hernia coming back again) is very low at approximately 1in 200 people.

The keyhole operation was first performed in the late 1980's and has proved to be a very effective procedure with a recurrence rate similar to the open mesh operation. The procedure is performed using three very small cuts in the abdomen, two of which are only 5 mm in length and the third 1cm long. One of the major advantages of this technique is that if a second hernia is present on the opposite side this can be repaired at the same time using the same incisions. An occult (not detected before the operation) hernia on the opposite side occurs in up to 30 percent of patients. The other major advantage of this procedure is that the incidence of chronic discomfort and numbness is extremely low in comparison to the open mesh operation. Wound and mesh infections are extremely rare.

The National Institute for Clinical Excellence (NICE) is a body set up by the Department of Health to assess new treatments and operations. This body has recently reviewed operations for hernia groin hernia and has concluded that the keyhole operation is a safe, effective and in many cases the preferred technique. It can be used for all types of groin hernia including recurrent (where the hernia has been repaired in the past and the repair has given way) and bilateral (both sides of the groin) as well as one-sided first time hernias which of course constitute the majority of cases.

Incisional hernias are a common complication of any abdominal operation and the chance of developing one increases with time. They result in an unsightly bulge in the abdomen underneath the scar and may be uncomfortable or even painful. Traditionally incisional hernias have been, and still are, repaired by reopening the old incision and most commonly inserting an artificial mesh to repair the defect in the abdominal wall. They can now be repaired using keyhole techniques where a piece of artificial material is placed inside the abdomen to repair the defect. The advantages of the keyhole approach are very similar to those seen with groin hernias,i.e. less discomfort, more rapid recovery and less complications. The operation can however sometimes be difficult or even impossible because of adhesions within the abdominal cavity as a result of the previous surgery. Your surgeon should be able to advise you as to whether a keyhole approach would be suitable in your particular circumstances. Note however that laparoscopic incisional hernia repair is an advanced procedure and should only be undertaken by surgeons with considerable experience of keyhole techniques.

For more information please visit our 'Patient Information' page where you can download information sheets relating to the specific operations.