Abdominal and inguinal hernia repair

What is a hernia

A hernia occurs when soft tissues covered with the peritoneum (a membrane which forms the lining of the abdominal cavity) protrude through an area of weakness in the abdominal cavity. It is a very common disease that can only be treated by means of surgery. The symptoms of hernia include pain, a bulge in the area and sometimes intestinal obstruction. The patient is often able to feel the bulging tissue in the affected area. Most commonly, it develops in the groin, navel or in scars following previous abdominal surgeries. Diaphragmatic hernia is a special type of hernia.

Hernia can be inborn or acquired; often, it is the result of weak spots in the abdominal wall and increased intra-abdominal pressure (due to constipation, enlarged prostate, etc.). If the bulging tissue of a hernia can be pushed back into the abdominal cavity it´s called free hernia. The causes of a hernia that can´t be pushed back into the abdominal cavity are strangulation, adhesions between the tissue and its cover or the size of a hernia. The above-mentioned strangulation is a complication which may lead to a situation whereby the blood supply to the herniated tissue is cut off and intestinal obstruction occurs. If no emergency treatment is provided the strangulated tissue may die off which is dangerous, especially for intestines because it may lead to peritonitis. Adhesions, infection of the herniated tissue or intestinal congestion are other complications that may occur.

Who should undergo hernia repair

If you develop a hernia it generally doesn´t improve or diminish without surgery. Some conservative approaches may postpone surgical repair. Without surgery, hernias as well as the risk of complications tend to increase, in particular, it can get strangulated, intestinal obstruction may occur and a huge hernia may be impossible to push back into the abdominal cavity during surgery. Pushing a very large hernia back into the abdominal cavity may lead to an increased intra-abdominal pressure that pushes the diaphragm up and obstructs breathing.

Before the procedure

A physical exam (inspection and palpation of the affected area) is usually all that is needed to diagnose a hernia. It is important to take the patient´s history, especially if bulging in the area is reported. Sometimes, an ultrasound test is used. If confirmed, the surgeon will explain the procedure and anesthesia and inform you about any risks related to the surgery. You may ask any questions, in particular, questions related to the procedure, your expectations and concerns, during the discussion.

When making a binding appointment, you will be provided with an information sheet on how to prepare for the surgery, including information on eating, drinking, smoking and taking or discontinuing some medicines, which will be explained to you. Complying with all the recommendations is necessary for the surgery to run smoothly and for event-free healing.

What´s the procedure for hernia repair

The surgery is done in an OR under general anesthesia. In many cases, it is necessary to introduce a drain at the end of the procedure that is usually removed during the first three days after the surgery. After surgery is completed, the patient is moved to a recovery room where he/she will be monitored until completely stable. Any pain can be treated with pain killers. During surgery, the surgeon will separate the hernia from the surrounding tissue, dissect it or push it back into place in the abdomen. Stiches using inabsorbable material (individual stitches or continuous suture) will close the solid fibrous structures in the area. Often, mesh is used to strengthen the abdominal wall and reduce the risk of another hernia in this particular site.

Inguinal hernias are treated by means of an open surgery when an incision is made in the groin on the affected side and, after the hernia sac is separated from the surrounding tissue, it is pushed back and the above-mentioned solid structures are closed with stitches. Sometimes, mesh patches or a mesh plug, or their combination (a so-called tension-free hernioplasty) are used in the internal inguinal ring. Another technique is laparoscopic hernia repair which uses an instrument called a laparoscope (a camera). During the procedure, the abdominal cavity is filled with carbon dioxide in order to create and maintain a distended abdomen with separated abdominal structures to have room for operation. Usually, the hernia sac is separated inwards and the abdominal defect (i.e. the site through which the hernia was bulging out) is covered with a plastic mesh and fixed by staples or screws made of inert metal. This hernioplasty has an advantage of dealing with both direct and indirect hernias and/or femoral hernia and it is also used to perform a bilateral repair for a bilateral hernia.

Femoral hernia can also be treated both by classical approach and laparoscopically. A simple suture of fibrous structures or a mesh used to plug the femoral canal are also used in open surgery. Femoral hernias tend to develop unnoticed until strangulation.

For umbilical hernias, an incision is made near the belly button to access the hernia sac that is separated from the surrounding tissue and removed. Solid fibrous structures are sutured using inabsorbable stitches in two layers that are put over each other like a roof. Hernioplasty using a mesh is necessary for large hernias. For large umbilical hernias with inflammation around the navel, it is sometimes necessary to remove the entire belly button. In these cases, the risk of poor healing of the surgical site is reduced; however, it is necessary to take into account the cosmetic effect of the surgery (missing belly button after the surgery).

For hernias that develop following previous abdominal surgeries, it is often necessary to use a mesh patch during an open surgery. All other steps remain the same.

For a diaphragmatic hernia in the area of the esophageal hiatus (an opening in the diaphragm through which the esophagus pass), the principle of the procedure is to reduce the opening by means of one or several stitches and to make a cuff around the abdominal part of the esophagus using the upper part of the stomach. This surgery is done both as an open procedure through an incision in the epigastrium and as a laparoscopic procedure (with 5 small incisions in the epigastrium).

After the surgery

In the hours immediately after surgery, you may feel pain in the surgical site. This pain is natural and it will be reduced by means of pain-killers. After discharge, you will use drugs to treat pain that your treating physician will prescribe to you. You should be pain-free within 24-48 hours. Sometimes, vomiting occurs which is an adverse effect of anesthesia, in particular general anesthesia, and it usually subsides within 6-12 hours after surgery. You may start walking within a few hours of surgery. The client is discharged to home care within several hours or days after surgery, depending on the procedure. Sutures are removed according to the type of the material and stitches within 7-10 days. After the procedure and discharge, it is necessary to avoid increasing the intra-abdominal pressure for 6-8 weeks, e.g. get up sideways, avoid lifting more than 3-4 kg in the first month and avoid abrupt moves (jerks, snatches). The period for which the patient is unable to work depends on his/her profession. It can last up to 8 weeks for people who perform heavy manual labor. The abdominal wall can cope with full stress after about 3 months. Using a mesh and the laparoscopical procedure reduce the period.