Hernia : Inguinal Hernia

What is a hernia?

A Hernia is a lump or swelling that can be felt in the wall of your abdomen or groin area. Usually the muscles in your abdomen are tight and strong enough to keep your abdominal contents in place.  Hernias occur in areas where there are points of weakness in the abdominal wall. The weak area allows part of the bowel or fatty tissue to ‘push through’ and this is what causes the lump or swelling to appear, called the hernia sac or pouch.  The most common areas for hernias to occur are in

• The navel (belly button), known as an Umbilical hernia
• The middle of the area between the breast bone (sternum) and navel (belly button), known as an epigastric hernia
• Via a scar from a previous operation, known as an incisional hernia
• The groin – two types – a femoral hernia OR
• The groin, known as an inguinal hernia

Anyone can get a hernia, whether male, female, young, old, fit or unfit.

In this leaflet we are talking about your inguinal hernia. These are more common in men but women can have them too.

Types of Inguinal Hernia

There are two different types:

• An indirect hernia is where you are born with a weakness in the muscles in your abdomen. For boys, the testes drop from the abdomen into the scrotum (the bag that holds the testes) through a gap called the inguinal canal. Usually the gap closes soon after being born, but if the gap remains open part of the bowel can slip or fall through it at some point in the future. Females also have an inguinal canal which is usually narrower than in males and they too, can have an indirect hernia in this area of weakness.

• A direct hernia usually happens when you strain your abdomen. It is called a direct hernia because the hernia (lump of bowel or fat) pushes directly through the weak point rather than slipping or falling through it.

What affects an inguinal hernia?

Causes which raise the pressure in your abdomen affect hernias. Things like coughing, straining when on the toilet, obesity, heavy lifting or certain sports and movements. However, there is no good evidence that either occasional lifting or regular sporting activities are risk factors. You may find when you carry out certain activities mentioned in this paragraph that your hernia appears larger or painful, or that when you lay flat the hernia disappears. You may find sexual intercourse uncomfortable or stop having intercourse. You will know what affects your hernia the most.

What does a hernia feel like?

Your hernia may feel uncomfortable or tender, especially when you bend, stretch or lift. These symptoms may not be there all the time. In men the hernia can slip or move down into the scrotum, making it sore and swollen. You may feel gurgling inside the lump which is caused by the section of bowel that is trapped there. You may feel a burning sensation in your groin or a sharp pinching sensation.

Your hernia may disappear when you lay flat or it might stay sticking out. Sometimes you may be able to reduce or push back the hernia lump into its place, although this does not usually fix the problem in the long term, often the lump reoccurs.

How are hernia’s diagnosed?

Your hernia is usually diagnosed by the healthcare professional taking a medical history from you and carrying out an examination. You may need other investigations to help diagnose you, such as special X-rays via Ultrasound, CT-scan or MRI scan. Sometimes you may have been having an investigation for a different problem entirely, that picks up an incidental finding of a hernia that you were not aware of and you may be referred to a surgeon due to this.

Are hernia’s serious?

Not everyone with a hernia has symptoms, such as pain, but you are usually aware of the lump being present. Usually having a hernia is not a serious health problem. Often hernias tend to get bigger overtime, rather than disappearing.

Not every hernia requires an operation. Current National and European Guidelines suggest that if your hernia is causing you no or minimal symptoms (awareness of the lump but no pain), that your hernia can be monitored. However your surgeon may still offer repair on the basis that your hernia weakness will not go away.

If your hernia is reducible (can be pushed back into place) and not causing you any significant problems, you and your surgeon may choose to ‘watch and wait’ rather than having surgery to correct it. Surgery can be considered in future as a planned procedure.

If your hernia is irreducible (can’t be pushed back into place) it is more likely that you will need a planned or elective operation to repair it sooner. You and your surgeon will be able to discuss your options.

However, there are times when your hernia may become more of a problem for you and you may require an emergency operation. There is a small risk of your hernia becoming strangulated. This means that the blood supply to the piece of bowel trapped in your hernia has been cut off. If blood stops flowing to this part of the bowel, it can die. 

If this occurs your hernia is likely to be irreducible (cannot be pushed back into place) and you may notice that the skin in the hernia area changes colour, red or bruised/black in appearance). Alongside this the bowel can become obstructed (meaning fluid/food cannot flow through the bowel) and may perforate (a tear in the bowel) leading to infection or sepsis (a complication of infection). You may experience pain, nausea or vomiting.

Strangulated hernias are uncommon and it is difficult to predict whose hernia may become strangulated. It does require emergency surgery straight away. Untreated strangulated hernias may result in death. About five people in every one hundred people need emergency surgery for a first hernia.

What does a hernia repair involve?

Your hernia can be fixed by a small operation. It is one of the most common types of operation performed by surgeons. There are two options to consider:

Open Surgery – This is where the surgeon makes an incision (cut) in your skin to reach the hernia  The groin cut will be about 5 to 10 centimetres long (about 2 inches to 4 inches). The contents of the hernia (bowel/fatty tissue or organs) are pushed back into the correct place. The area of weakness in the muscle wall is strengthened with a thin synthetic mesh patch (see What is Mesh section), secured in place and the cut in your skin is usually closed with absorbable sutures (meaning stitches that dissolve and do not need removed). A dressing is placed over the wound.

You may think that open surgery can only be carried out under a general anaesthetic, where you are asleep. If fact not every open hernia repair requires this.

For some people the hernia can be repaired using local anaesthetic, where a numbing medicine is injected into your skin so that you don’t feel the operation but are awake Sometimes you are given a mild sedative medicine so that you are relaxed and don’t remember being awake during your hernia repair. A spinal anaesthetic may be suitable, where an injection is put into the spinal canal and numbs the lower half of the body.

Laparoscopic (keyhole) Surgery – This is where your surgeon makes several small incisions or cuts in your abdominal wall/groin skin and muscles. The number of cuts can vary depending on which technique your surgeon thinks will work best for you. Usually it is two cuts – one just below your Umbilicus (belly button) and one lower down your abdomen.

A laparoscope (a thin flexible telescope-like tube) is inserted through one of the cuts. A small video camera attached to the laparoscope allows your surgeon to see your hernia on a screen. Gas, called carbon dioxide, is gently blown into your abdominal cavity which creates a space in your tissues and organs, so that the surgeon can see more clearly to repair your hernia.

 Via the second cut, special instruments are inserted into your abdomen and are an extension of your surgeon’s hands. This enables your surgeon to move tissue and pull your hernia back into the correct position from where it was protruding through your muscle, so that your lump disappears. A thin synthetic mesh patch is used in this technique to strengthen the hole or weak spot in your muscle layer (see section on What is mesh). All the instruments are removed and the carbon dioxide gas is allowed to escape. The small incisions/cuts in your abdomen are closed with sutures or special skin glue. Small dressings are placed over the cuts to protect them.

Laparoscopic surgery always requires a general anaesthetic, meaning that you are asleep during the operation.

What is mesh?

Mesh is a surgical device that looks like a small patch of woven material. The majority of patches for hernia repair, are made from woven nylon or polypropylene. These types are usually used in your hernia repair. Some meshes contain titanium, absorbable material and biological collagen (made from animal or human cells), these types are not normally used for hernia repair as they absorb into your body within about 6 months, increasing the risk of your hernia reoccurring.  You can discuss this with your surgeon.

Why use mesh?

Mesh may not be required for all people who have a hernia repair. The traditional approach was for many years, to stitch the hernia and muscle layers in place, to close the gap in the muscle. However the best evidence suggests that using a mesh in your operation significantly reduces the risk of your hernia reoccurring when compared to the traditional approach. Mesh repair is now considered the better option to repair hernias. You can discuss this with your surgeon.

What happens to the mesh in a mesh repair?

• The mesh is surgically put in place using fine stitches, glue or staples. Overtime the tissue grows into and around the mesh to keep it in place. The mesh does not dissolve, it is usually considered a lifelong device. Non-absorbable mesh will remain in the body indefinitely but may undergo some degradation over time. It is used to provide permanent reinforcement to the repaired hernia.

• Studies show that the use of the synthetic mesh patch reduces the risk of another hernia occurring to less than 5 in every 100 cases

• It is very rare for mesh to be rejected by the body. There is a very small risk (1 in 2,000 - 3,000 people) of the body rejecting the mesh. If this were to happen, you may develop inflammation, pain, excessive swelling/drainage or pus from the hernia repair area, a high temperature, nausea/vomiting or abdominal stiffness. You may experience difficulty urinating or passing stools,  If this were to occur you are usually treated with medication such as antibiotics, but if this does not resolve the issue ,the mesh may need to be removed. The occurrence rate for mesh removal is very low at 0.3 percent.
• There is a very small risk the mesh may migrate or move position.
• There is a small risk of chronic pain with mesh insertions, approximately 1 in every hundred people.
• Mesh may cause some scar tissue formation, called adhesions, but less so than the traditional stitches method.

Overall the use of mesh to repair your inguinal hernia is considered the better option, as the associated risks are very small and mesh minimises the risk of your hernia reoccurring. You can discuss this with your surgeon.

If surgery is recommended your surgeon will discuss with you which type of surgery (open or laparoscopic) may be suitable for you. There are several factors that influence this discussion, including but not limited to, inability to have a general anaesthetic, allergies, major scarring from previous surgery, bleeding disorders, pregnancy (especially during the final three months of pregnancy).

You will usually be assessed prior to elective/planned surgery via a pre-assessment consultation where your individual health is assessed. For example blood pressure issues, diabetes, smoking or other health factors can influence if an operation or anaesthetic is suitable. This is to ensure that your surgery is as safe as possible and that adjustments can be made if required to any medication you may be on, prior to surgery.

On rare occasions surgery may not be possible due to underlying health issues.  For example, if you are older and have another serious illness, such as heart problems or breathing problems. Talk to your doctor about whether it’s best to have hernia surgery or to leave it alone.

What are the risks?

All operations have risks and your surgeon should discuss them with you before your hernia repair.

Anaesthetics can have side effects. These are more common with general anaesthetics. The most common side effect is feeling nauseous for a while after you wake up.

Anaesthetics can also cause allergic reactions in some people. You should tell your doctor before your operation if you have any allergies.

Problems that can happen in the short term

The list of possible complications below might look long and worrying. But remember, these are just things that might happen, not that definitely will. Most people have no problems with hernia surgery.

You are more likely to have problems during or after hernia surgery if you smoke or if you are very overweight.

Complications that can happen during or soon after the operation include:

• Heavy bleeding under the skin after the operation. If the blood builds up and clots, your groin will swell and feel tender. This causes a large bruise called a haematoma. Haematomas often go away by themselves. But if the bleeding doesn't stop you might need an operation to stop it
• A temporary build-up of fluid in the groin area. Doctors call this a seroma
• An infection deep inside your groin or in the wound on your skin. This is very rare. But if it happens you will need antibiotics to treat it
• Injured blood vessels and organs. This is more common with keyhole surgery. In men, it's possible to damage the tube (called the vas deferens) that carries sperm from each testicle to the penis. If this happens, you might not be able to produce sperms
• In laparoscopic surgery a Gas embolism (a bubble of carbon dioxide gets into a blood vessel); this can be life threatening but is very rare.
• Switching to an open operation. Your surgeon might start the operation using the keyhole method but then might need to cut open your groin part way through
• Temporary swelling in the testicles. It's common for men to have a slightly swollen testicle on the side of the operation for a few days after the operation. But in some men, the testicles become very large and painful. This is called testicular atrophy. It happens if the blood supply to the scrotum or testicles is cut off during the operation. With a groin hernia repair in men, there is a small risk that the tube which carries sperms, or the artery that goes to the testicle, could be damaged during the operation. If the tube carrying sperms is damaged, then fertility will rely on the sperms from the other testicle (which are usually quite enough). If the artery is damaged, then the testicle may shrivel up or may need to be removed. These risks are higher during surgery for a recurrent hernia, but are still very unusual (less than 1 in 100).

Possible longer-term problems

Problems that can last a long time or that can start some time after your operation include:

• Long-lasting groin pain. This is a common complication of this kind of surgery. It happens to about 10 in 100 people. Some people have pain that drags on for months or even years. This is called chronic groin pain. This probably happens when nerves get trapped in the stitches or mesh or become damaged during the operation.

People describe it as a stabbing, gnawing, and tugging pain in their groin and upper thigh. It can be bad enough to affect people’s quality of life. For example, it can affect your mood and your relationships. In some people it’s so serious that it affects their sleep and their ability to walk.

Chronic groin pain seems to be more common in people who were in a lot of pain before their operation, and it seems to happen more often with open surgery than with keyhole surgery

• Numbness in your groin. If nerves are damaged during the operation your groin area might go numb. The feeling should return, but in some people it takes months or even years. This problem is more common after open surgery

• Your hernia coming back. This affects about 2 in 100 people. Your hernia might be more likely to come back if you smoke, because smoking affects the healing process.

• Deep vein thromboses/pulmonary embolism (blood clots) are rare but possible after hernia repair. If you are at particular risk, we can take precautions to reduce the risk. This may be the case if you or a close relative has previously suffered a blood clot. Moving your legs and feet as soon as you can after the operation and walking about early, all help to prevent thrombosis.

What can I expect afterwards?

In Cumbria there is an option to have your operation done in either a clinic outpatient setting or in hospital if you are having an Open Surgical repair of your hernia.  If you have laparoscopic surgery your operation is always carried out in hospital. You can talk to your doctor about these options.

Your hernia repair is usually carried out as a day case. This means you do not need to stay in hospital or clinic overnight. You will need someone to drive you home and to stay with you overnight.

Sometimes you may need further monitoring and require a hospital stay overnight or for a few days. This is more common for people with other serious health conditions such as diabetes, heart conditions, breathing conditions or who have a weakened immune system.

Straight after the operation: a nurse will take your temperature, pulse, and blood pressure regularly. You might feel a little nauseous from the anaesthetic. But you should be able to get up and eat and drink normally within a few hours.

Your groin will feel sore and uncomfortable for a while after your operation. But you'll be given painkillers. If you’re still in pain, you should tell your nurse. Being in pain can slow your recovery. You might need a higher dose or a different painkiller.

If the pain is severe or lasts longer than a week, you should see your doctor, as you could have an infection or a trapped nerve.

People who have keyhole surgery tend to have less pain than those who have open surgery.

At home: taking gentle exercise when you get home can help healing, but you should avoid doing sport or heavy lifting for a while.

Drink plenty of water and eat foods that are high in fibre (such as wholemeal bread and green vegetables) to prevent constipation. Straining to empty your bowels can put pressure on your abdomen.

If you had open surgery, the dressing stays in place for two to five days. Most dressings are waterproof, but check this with your surgeon or a nurse before you take a shower or bath.

You'll have scars either in your groin or on your abdomen, but the redness should fade.

Back to work. It will take two to three weeks before you can get back to your usual activities, such as walking, working, and sport. But you might recover faster if you've had a keyhole operation.

People with physically demanding jobs take about four weeks off, while people who work sitting down tend to take less than two weeks off.

Sex. You might find sex painful or uncomfortable at first, but its fine to have sex as soon as you feel ready.

Driving. It's best not to drive for the first few days while your groin is healing. This is because you might not be able to brake suddenly if you need to, and the impact of stopping might hurt and could cause the hernia to come back.

What should I do if there is a problem?

Because complications are extremely rare, you will not normally be given a follow-up appointment in the outpatient clinic. However, your GP can be contacted if you were to experience any of the following:

• persistent severe pain

• persistent bleeding

• fever  

• An inflamed or discharging wound

If your GP cannot help please feel free to call the ward or department where your operation was carried out. Your Consultants Secretary can also be contacted so that they can update your Surgeon.

Further information

If you are worried or unclear about any aspect of your hernia repair, please ask the doctors or nurses for more details at your Pre-assessment appointment before your operation or when you come into hospital. They are never too busy to answer your queries or listen to your concerns.

We hope this leaflet has been of use to you in explaining what an inguinal hernia is and what your options are.

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