Hernias of the groin
If you have a lump in your groin you may have a hernia. Of course, there are many other possible causes for a lump in the groin and you need to see a doctor to confirm the diagnosis. However, if you do have a hernia, you may be thinking about whether or not this needs treatment. Here I will explain what you need to consider when making up your mind about how, where and when you should undergo surgery.
In this discussion, we will only consider planned surgery and not emergency surgery. We will also focus on inguinal hernias and we will address femoral hernias in another blog post.
If you would like an appointment to discuss having your hernia hernia or if you are considering surgery, you can make an appointment with me here
Having treatment for a hernia need not be stressful
What is an inguinal hernia?
The word “hernia” is from the Latin word “rupture”. An inguinal hernia is a protrusion of the lining of the abdominal cavity known as the peritoneum through a weakness in the abdominal wall in the groin. It often contains intestine or other abdominal contents and it usually presents as a lump. This is completely asymptomatic in about one third of patients, although some patients complain of discomfort which is typically described as a ‘dragging sensation’. Very rarely, hernias can be life-threatening if the bowel within the peritoneal sac strangulates and/or becomes obstructed. You will know if this happens because the pain is very severe, and most patients become very unwell. Around 98% of inguinal hernias are found in men because of male anatomy, but women are also commonly affected.
Should I have my hernia fixed?
If your hernia causes you no symptoms and there is no significant cosmetic problem from the lump, it is quite safe to leave it. Several studies have shown that watchful waiting is safe, but in patients who pursue this strategy, about one quarter will come to surgery within two years and 70% will undergo surgery at 10 years. Importantly, the risk of requiring emergency surgery for a strangulated hernia is very low (3% at two years). So, it really comes down to how much the hernia bothers you and how you feel about the risk of having surgery. This conversation varies from patient to patient as some may have health problems that makes having an operation more difficult.
If you are symptomatic, then the plan is different and surgery is typically recommended. Similarly, if your hernia prevents you from doing your job or engaging in any form of physical activity then you should think about having it fixed.
The use of a truss (hernia belt) for a groin hernia in men is controversial. Data to determine whether their use prevents hernia complications are lacking and I will only recommend this in specific cases.
If your hernia becomes acutely painful, or you cannot push it back in, you may need to have this repaired urgently. So please see an expert opinion!
What tests will I need?
You need to be seen by an expert and undergo a clinical examination. The surgeon should take a full history from you and examine both the lump itself and the testicle (in men).
Based on the examination, the surgeon will very often be able to tell you whether a hernia is present and what type of hernia you have (e.g. inguinal vs. femoral). Sometimes, no formal investigation is necessary, but on other occasions the diagnosis may be more challenging.If there is any doubt, I would recommend a dynamic ultrasound scan (dUSS) as the first line investigation.(1) The radiologist will ask you to take a deep breath and try and breathe out forcefully against a closed mouth and nose. This raises the pressure in the abdomen and demonstrates the hernia on the ultrasound.
An ultrasound is also a good way of checking that there is no hernia on the other side, as this may influence treatment strategy down the line.
An Magnetic Resonance Imaging (MRI) scan is considered if the dUSS is negative and the groin pain persists, OR if the cause of pain is not deemed likely to be due to a hernia by the surgeon. The MRI is therefore often used to assess for causes of groin pain other than a hernia. For example, some groin pain actually originates in the hip and it may be referred to the groin.
How should I have my hernia fixed?
The surgical repair of a hernia is a very common procedure. In England, approximately 70,000 surgical repairs of inguinal hernia are performed each year. However, there are many different ways to repair a hernia, and you should discuss these with your surgeon. Here I will go through the major points you should discuss with your surgeon when you discuss possible treatment options.
1. The first question to ask is what type of anaesthetic should I have? Hernias can be repaired under local anaesthetic, and this is necessary in some patients because a general anaesthetic is considered a high risk. However, many patients I treat choose to have a local anaesthetic as it is their personal preference. The only significance of this, is that local anaesthetic precludes the use of key hole (laparoscopic surgery), and it means you will need to have an open operation. I generally recommend general anaesthetic as it is more comfortable and the surgery can be performed faster.
2. Most hernia repair operations occur as a day case operation. This means that you come in and have the operation and go home on the same day. Most patients are suitable for this type of surgery but you will need to meet certain criteria. You have to be medically fit enough, but you will also need someone to escort you home and stay with you after the surgery. If you would like to stay in hospital overnight, this can be arranged, as some patients like to have the security of having medical staff nearby.
3. The common method for repairing a hernia, requires the use of a plastic mesh. This revolutionised the treatment of hernias, as it definitively demonstrated that it reduced the chances of a hernia coming back after surgery. It is therefore used in almost all types of hernia repair, although there is some debate amongst surgeons about the best type of mesh to use and the best way to fix it into position. Mesh in inguinal and femoral hernia repair is now considered to be safe, and many millions of operations have been performed this way.
4. The next question to ask, is what type of hernia and how many hernias do I have? The treatment of hernias on one side of the groin (unilateral) can be different to those on both side (bilateral). Similarly, hernias that have been previously treated with an operation (recurrent hernias) are treated differently to new hernias (primary hernias).(2) I will briefly outline a common treatment strategy below.
5. Should I have an open operation of a key hole (laparoscopic) operation? An 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 ( around 2%). In good hands, scarring is minimal and nearly all patients can have their surgery as a day case procedure. Laparoscopic 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
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
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.
A nice explanation of hernias can be see here:
I tend to suggest a laparoscopic approach if I believe that there is a risk of chronic pain. This is typically in young patients, or those who presented with a small hernia or severe groin pain. I also recommend this approach in women because of the risk of undiagnosed femoral or contralateral inguinal hernias. Finally, bilateral inguinal hernias and recurrent hernia should also be repaired laparoscopically.
TEP and TAPP are equivalent and have some advantages over standard open repair. A recent review of nearly 60,000 patients found a lower risk of complications and post-operative pain. I personally favor the TAPP repair, as I have been trained in this technique, but evidence also suggests a lower rate of chronic pain after TAPP and a lower hernia recurrence risk than with TEP. TAPP also has a lower post-operative bleeding risk, although the post-operative seroma rate (a collection of serous fluid under the skin) is higher.(3)
Assuming that your surgeon has the specific expertise and sufficient resources available, either a very acceptable way to have your hernia repaired, and you should discuss both with your surgeon. If you have a hernia recurrence, most guidelines suggest that a laparoscopic hernia repair has a lower recurrence rate and less post-operative pain.(4) However, if your hernia was repaired with a laparoscopic approach at the first operation, an open repair is indicated.
What can I do prior to my surgery to ensure it goes well?
There are several things you can do to help ensure your hernia surgery goes well.
1. The first thing is to do is to stay as active as possible. This will reduce the risk of complications from your anaesthesia and that you get back on your feet as quickly as possible.
2. If you smoke, it is essential that you try and stop prior to your operation. The longer you can stop before you have your surgery the greater the benefit. I will typically recommend nicotine patches in any patient that smokes.
3. If you have diabetes, you should see your GP and ensure that you have very good control of this.
4. Finally, there is very good evidence that obesity is a major risk factor for complications. Therefore I advocate weight reduction if at all possible prior any operation. Exactly how much and at what rate weight should be lost is dependent on the individual.
5. You should discuss your exact pre-operative instructions with your surgeons, as again this will vary. However, if you are taking anticoagulants be sure to discuss these medications specifically. Generally, we recommend you take your medications as normal until the dayfo the surgery.
What are the complications of surgery?
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. 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 to 3%), but rates vary depending on the type of surgery you have planned. A study of 41 randomized trials showed no significant difference in recurrence rates between open mesh and laparoscopic repairs.(5) However, another recent analysis of 27 randomized trials, showed a higher risk of recurrence of primary hernias after TEP laparoscopic repair (but not TAPP) as compared with open repair.(6)
2. Chronic pain. This is poorly understood, but some patients complain of pain in the groin that lasts for more than three months. The rates vary considerably in the literature, but the consensus is that approximately 10% of patients who have undergone an inguinal herniorrhaphy have some chronic pain, and in 2 to 4% it interferes with daily living. damaged or trapped nerves (neuropathic) or scar tissue or a reaction to the prosthetic material (nociceptive); however, the exact mechanisms are unknown. Because the pain resolves within 6 months in about a third of cases, antiinflammatory medication is a reasonable initial treatment.
3. Pain during sexual activity can occur in approximately 11% of patients. This is a particular risk in young patients.(7) However it does not influence fertility and you can still have children normally after hernia surgery.(8)
4. Bleeding: 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 an will usually settle.
5. 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.
6. Seroma: A localised collection of fluid at the surgery site can occur and fill the space where the hernia used to be. Typically, this is either managed conservatively, but occaisionally it may need to be drained.
7. Wound infection: This occurs in about 2.5% of cases. Typically, it is superficial and self limiting and it can be treated with antibiotics. More rarely, the mesh can be come 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.
8. 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.
Post operative care: How should I manage my wound and when can I return to normal activity after hernia surgery?
Within the UK, there is a very large variation in the advice given to patients after hernia surgery.(9) I therefore tend to recommend consistent advice for all my patients on the following:
1. Immediate recovery: You should be up and out of bed on the first day of surgery. It is good to walk around but you should avoid unnecessary exertion. I typically recommend that you don’t lift anything heavier than a kettle for two weeks.
2. Showering: keep the wound dry for 48 hours. After this time, you can shower as normal, but replace the dressing after the shower with a dry one. I typically use dissolvable sutures that don’t need to be removed and some glue. This may flake, but try to avoid picking at it. Its job is to keep the wound dry and clean.
3. Work: Your return will vary on your job and on the type of surgery you have had. If you have a very manual job, you may need up to 6 weeks off surgery. However, you should be back to work between 1 and 2 weeks after surgery if you work within an office.
4. Driving: You should not drive for one week after surgery. You must have stopped taking any strong pain killers and you must be able to safely use the emergency brake. Your insurance company should be informed about your operation. Some companies will not insure drivers for a number of weeks after surgery, so it’s important to check what your policy says. Driving too soon may invalidate your insurance cover.
5. Gym: You will require a graded return to the gym. I typically recommend that you do not use the gym for four weeks after surgery, and then return with graded aerobic exercise and weights can be used in a similar fashion from 6 weeks. Avoid swimming for at least two weeks, as the wound needs to be completely dry.
6. Sex: It is usually safe to return to a normal sex life after 2 weeks from the surgery. However, this will vary from patient to patient.
If you would like an appointment to discuss having your hernia hernia or if you are considering surgery, you can make an appointment with me here
Further patient information can be found at these links.
Hernia Guidelines
Many of the recommendations given here have been taken from international guidelines published on the treatment of hernias. More information can be found below:
The U.K. National Institute for Health and Care Excellence
The Society for Surgery of the Alimentary Tract
The International Endohernia Society
The Agency for Healthcare Research and Quality
References:
1. Niebuhr H, Konig A, Pawlak M, Sailer M, Kockerling F, Reinpold W. Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS). Langenbecks Arch Surg. 2017;402(7):1039-45.
2. Kockerling F, Bittner R, Kuthe A, Stechemesser B, Lorenz R, Koch A, Reinpold W, Niebuhr H, Hukauf M, Schug-Pass C. Laparo-endoscopic versus open recurrent inguinal hernia repair: should we follow the guidelines? Surg Endosc. 2017;31(8):3168-85.
3. Kockerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, Weyhe D. Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair: A Registry-based, Propensity Score-matched Comparison of 57,906 Patients. Ann Surg. 2017.
4. Kockerling F, Bittner R, Kuthe A, Hukauf M, Mayer F, Fortelny R, Schug-Pass C. TEP or TAPP for recurrent inguinal hernia repair-register-based comparison of the outcome. Surg Endosc. 2017;31(10):3872-82.
5. McCormack K, Scott NW, Go PM, Ross S, Grant AM, Collaboration EUHT. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003(1):CD001785.
6. O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255(5):846-53.
7. Pommergaard HC, Burcharth J, Andresen K, Fenger AQ, Rosenberg J. No difference in sexual dysfunction after transabdominal preperitoneal (TAPP) approach for inguinal hernia with fibrin sealant or tacks for mesh fixation. Surg Endosc. 2017;31(2):661-6.
8. Kohl AP, Andresen K, Rosenberg J. Male Fertility After Inguinal Hernia Mesh Repair: A National Register Study. Ann Surg. 2017.
9. Grewal P. Survey of post-operative instructions after inguinal hernia repair in England in 2012. Hernia. 2014;18(2):269-72.
