What is a hernia?

A hernia is a weakness in the abdominal wall and may result in the intestine slipping out to create a bulge. Hernias tend to develop in the groins, navel or in a previous incision. Some are present at birth. Most develop slowly. Causes include straining, obesity, persistent coughing.

Signs and symptoms

You may see or feel a lump under the skin or in males a bulge in the scrotum. Straining or coughing makes this more obvious. The lump may disappear when lying down. A hernia can be present without an obvious lump. It can be painful or cause a burning sensation. Sometimes they can be present for years before causing symptoms. If it does not disappear it may be trapped or incarcerated.

What can happen?

A hernia does not get better on its own - it can only get bigger. The bigger the defect the bigger the operation required to fix it. Severe pain may indicate obstruction, incarceration (intestine is stuck and can not get back inside) or strangulation of the intestine; emergency surgery is then required.

Treatment

For temporary relief, one could try limiting one's activities and avoid heavy work. A truss (hernia belt) can help keep a hernia from bulging but eventually will fail. A truss also causes scar tissue to form around the hernia making subsequent repair more difficult.

Surgical options

There are two main options.

1) Open repair: This traditional repair using mesh has been the gold standard for a number of years. Repair can be carried out with local anaesthetic and sedation.

2) Laparoscopic repair has evolved over ten years. It is performed under general anaesthesia. In randomised trials of over 5560 patients, laparoscopic repair was associated with a significant shorter recovery time, fewer cases of persistent pain and a reduction in numbness compared with open repair. There were also fewer wound infections and haematomas. Recurrence was similar between the two groups.

NICE has recently updated its guidance and now recommend laparoscopic surgery as a treatment options for all hernias provided that it is performed by appropriately trained surgeons who regularly carry out the procedure.

Bristol Laparoscopic Associates have performed over 1000 laparoscopic hernia repairs since 1996. 

Discuss these options with your doctor.

Advantages of totally extra peritoneal TEP laparoscopic repair of inguinal hernias

• Tension free mesh on the inside of the abdominal wall. Similar to patching a tyre or a bath plug.
• Two tiny incisions.
• Short general anaesthetic
• Diagnosis and treats unsuspected hernias.
• No pubic shave required
• No disturbance of normal structures in the groin
• Allows the use of large pieces of mesh if necessary
• Fast recovery, return to normal activities and work.
• Recurrence is as good as if not better than the best open method
• TEP is the best option for patients with:

                    a. Poor tissues, healing obesity.

                    b. Large hernias.

                    c. Need to return to work quickly.

                    d. Sportsmen, both professional and amateur.

                    e. Bilateral hernias.

                    f. Recurrent hernias.

Disadvantages of open hernia repair

• Requires 6-8 cm groin incision
• Painful once the local anaesthetic has warn off (muscle spasm).
• Post-operative tissue swelling
• Frequent complications - wound infection, scrotal haematoma, neuroma, numbness
• A minimum of six weeks to full recovery.
• Long term disability: chronic pain (5%), testicular ischaemia (1%).
• Mesh encompasses spermatic cord - potential for problems
• Mesh can induce excessive fibrosis, which can be palpable and irritate nerves.
• Meshes and plugs shrink with time
   

Laparoscopic TEP hernia procedure

• Under general anaesthesia a 1cm incision is made at the umbilicus
• A balloon is used to create a space between the muscles of the abdomianal wall and the peritoneum which contains the bowel etc.

• The space is filled with carbon dioxide to keep it open.

• A video telescope is used to view this space.
• A second 5mm trocar is placed mid way between the umbilicus and pubic bone.
• The hernia is dissected from the back of the muscular defect & the cord structures.
• A polypropylene mesh is placed over the defect & fixed with titanium tacks. 

• The space is filled with local anaesthetic & the wounds closed

The majority of patients are discharged home the same day with a supply of pain killers - paracetamol and dicolfenac.  Most patients experience little pain, however, from time to time, some discomfort will be felt for a few weeks. To a large extent this is dependent on the size of the hernia and the individual patient.

Patients can shower at any time and dressings can be removed at a week. Most are able to drive within 3 days.

The great advantage is that patients can return to normal activity very quickly. If a patient has an office job they can usually resume work within 3-4 days. If the job involves heavy manual work, then it is advisable to take two or three week so as to allow the mesh to be incorporated into the body's tissues prior to resuming heavy lifting.

Post operative care post TEP repair

• We will discharge you home when you are comfortable and have passed urine spontaneously.
• We will send you home with some pain killers.  regular paracetamol really does work - use them.
• It is normal to experience some nausea and occasionally vomiting following an anaesthetic.  If you have severe pain and vomiting call the hospital direct for review.
• Do not be alarmed if some old blood weeps out from around the tummy button incision.  Clean the area with a tissue and cover with a plaster.
• Eat and shower normally.
• The sutures are dissolvable.
• We place no restrictions on physical activity.  Exercise as you feel comfortable.  We suggest walking 1 to 3 miles each day.  It really will shorten your recovery and postoperative pain.
• Anticipate some bruising of the genitals.  It is normal and develops in response to gravity.
• Drive when you are comfortable - 3 days is usual.
• Return to work when you feel able.  Three days is appropriate for most professionals.  If your job entails manual work, 10-14 days is more appropriate.
• A small number of patients experience some referred pain and a burning sensation on the skin of the leg and scrotum.  This is a temporary neuropathy.  Symptoms usually subside within 1- 4 weeks.  If they are very troublesome and stop you walking amitriptyline 10mg nocte can help.

Rehabilitation Programme

Week 1		Day 1: Stand upright and walk 10 minutes 4 times a day (10 minutes).  Drive when you feel comfortable (from day 3 onwards) Return to work (sedentary occupation) when comfortable & motivated (day 3 onwards)
Week 2		Return to full time work: Sedentary occupation Walk for 30 minutes twice a day for 4 days Brisk walking, jogging, gentle running, step-ups, swimming.  Sexual intercourse
Week 3		Return to work: Light work Running in straight lines Gentle sit-ups and press-ups Moderate gentle lifting (10 kgs)
Week 4		Return to work: Heavy manual work Swimming (crawl), cycling, sprinting, twist & turn, kick, play Heavy lifting (15 kgs) Avoid sudden movement
Week 5		Any Activities Allowed