How is a groin hernia repaired?
The principles of groin hernia repair include careful dissection and ligation of the hernia sac, protection of the spermatic cord structures and cutaneous nerves and reinforcement of the posterior wall of the inguinal canal without tension using mesh.
What is a mesh?
The mesh is a permanent synthetic (plastic like) material that is woven like a net. Its biologically inert and acts as a scaffolding through which the healing tissue can grow. It allows us to repair hernias " tension-free" and reduce the chance of hernia to return.
What are the options for the surgical repair of groin hernias?
There are two ways to repair a groin hernia.
- Open (conventional) technique.
- Laparoscopic (keyhole) technique: also called endoscopic, minimal access, minimal invasive.
The type of operation depends on hernia size and location, your health, age, anaesthesia risk and previous surgery.
Open Groin Hernia Repair
The open technique has stood the test of time. It is usually done under a general anaesthesia but can also be done under spinal or local anaesthesia for patients who are not fit for a general anaesthetic. A four inch incision is made over the groin and the hernia is reduced and the abdominal wall is repaired with the mesh that is fixed in place. The skin is closed with dissolving stitches.
Laparoscopic Groin Hernia Repair
The laparoscopic technique is a newer technique done with three small cuts one for a video camera and two for thin instruments. The hernia is reduced and the mesh patch is applied and fixed in position against the inside of the abdominal wall, covering the holes from behind.
The technique I use is called Totally Extra Peritoneal (TEP) techinque. In this operation the abdominal cavity is not entered but instead a small cut is made near the belly-button and a space is created behind the abdominal muscles but in front of the peritoneum (the lining of the abdominal cavity) using a a special balloon and careful dissection. After removal of balloon the space is maintained by CO2 gas and a laparoscope with video camera at the end is introduced.
Two small cut are made for fine instruments that are used to dissect the hernia and place the mesh behind the abdominal muscle to cover the hernia defect. Because the peritoneal cavity is not entered in this technique the risk of injury to intestine is much reduced.
What are the advantages of laparoscopic groin hernia repair over the open technique?
What are the disadvantages of laparopscopic groin hernia repair?
- Requires general anaesthesia
- More technically demanding
- Risk of serious bowel or bladder injury
- Not suitable for patients who are on anticoagulants
Should all groin hernias be repaired using the laparoscopic technique?
No. There are a number of situations when the hernia is better off repaired with the open technique:
- Very large hernias
- Some patients with previous lower abdominal surgery especially prostate and urinary bladder surgery.
- Patients who cannot tolerate a general anaesthetic.
- Patients who need to restart anticoagulation very soon after surgery
How about hernias recurring after open repair?
Laparoscopic repair is vastly superior to doing another open repair for recurrent hernia. By going between the inner layers laparoscoic surgery avoid the scaring produced by the previous open repair and thus repair the hernia as if no previous surgery has been performed. This reduces the risk of another recurrence and the risk of damage to important nerves, testicular vessels and tube.
What are the complications of groin hernia repair?
- Bleeding: It is quite common to get some bruising near the wound and the scrotum. This is expected. However, more significant bleeding into the wound can occur and this may require a return to the operating theatre.
- Recurrence of the hernia: less than 1%
- Nerve damage and groin pain. Numbness in the groin is common after open surgery and this tend to improve with time. Up to 20% of patients after open repair develop groin pain due to entrapment of the nerve in scar tissue. Groin pain tend to settle with time but in some patients the pain is severe and affect the quality of life. The chance of this is less with the laparoscopic technique and this is one of the main reason I advocate laparoscopy for my patients.
- Mesh infection: This is very rare but may necessitate removal of the mesh by another surgery.
- Urinary retention: temporary inability to pass urine after surgery can occur in men with prostate enlargement. This will require insertion of a urinary catheter for short period. Patients with significant urinary symptoms prior to surgery may require a prostate operation.
- Injury to the testis, its tube or vessels. This can cause painful swelling of the testis followed by shrinkage of the testis. Rarely the testis dies requiring its removal. This is rare and men can live normally with one testis, although fertility may be reduced.
- Seroma formation (10%): this is a temporary fluid collection at the site of the original hernia and scrotum. This tends to settle with time.
- Damage to bowel or urinary bladder: This is a rare complication can be serious and require repair with a bigger operation.
- Cardiovascular problems: heart attacks and strokes. Both are very rare.
- Respiratory problems: pneumonia and aspiration.
- Wound infection or urinary infection
- Clots in the legs that may travel to the lungs. This is a rare but serious complication.
- Wound pain and abnormal (keloid) scarring.
- Death from general anaesthetic. This is very rare (1 in 40,000).
- Chipped teeth and sore throat form the insertion of the breathing tube.
- Drug reactions.
What to expect after groin hernia surgery?
Most patients will be able to go home on the same day. Some patients will be kept in overnight.
Local anaesthetic will be used in the wound. This will last for 6-12 hours. Panadol taken regularly is often enough to control the pain especially for keyhole surgery. If this is not enough then NSAIDs class drugs like Nurofen, Mobic, Brufen or Indocid can be used. These need to be used with caution in the elderly, patients with kidney disease and patients with peptic (stomach) ulcer disease.
All patients must be able to pass urine after surgery prior to be sent home. If you have difficulty passing urine then having a warm shower often helps. Rarely a urinary catheter need to be inserted.
The stitches are internal and these will dissolve. There will be thin paper tapes (Steristrips) covering the wound and on top of that there will be a water proof dressing. It is ok to have a shower but pat the wounds dry with a towel afterward. Bruising at the site of the wound and the scrotum is expected and is normal as is some blood stained staining of the dressings. However, more significant bleeding requires medical attention and review.
Remove the water proof dressing after five days. Leave the paper tapes until they fall by themselves. This will give you a better scar.
Some thickening like a ridge under the wound is expected. This will soften with time. It is normal to have a patch of numbness under the wound. This will improve with time as well.
You should not drive for at least a week after surgery and when you can respond in an emergency.
Walking and light activities are encouraged from day one.
Light exercise can be resumed when you feel comfortable. This varies between patients and you should listen to your body.
Heavy lifting (more than 10 kg) should be avoided for 6 weeks after open surgery and 2 weeks after laparoscopic surgery.
Swimming can be resumed two weeks after surgery.
Sexual activity can be resumes after one week.
When to return to work?
This depends on the job, level of activities and method of surgery (open versus laparoscopic).
Desk jobs (light activities) can be resumed within one week.
Jobs with moderate activities (lifting less than 20 kg) can be resumes with two weeks (one week for keyhole surgery).
Heavy jobs with frequent lifting of more than 20 kg) can be resumes after three to four weeks (two weeks for keyhole surgery).
I see most patients within 4-6 weeks after surgery. Usually one review is all that is needed and after that I see my patients on as needed basis. You should come and see me at any time if you one of the following:
- Fever >38 degrees or chills
- Increasing pain or redness around the incision
- Foul smelling or creamy wound discharge
- Increasing pain, nausea or vomiting
- If you are concerned about anything
Preparation for Surgery
- Shower at home the morning of the operation
- Do not shave the surgery site! This will be done in the operating room. Shaving at home increases the chance of wound infection.
- You need to fast for 6 hours prior to surgery. The time to fast depend on the time of your operation and the hospital will notify about that time. Generally, for morning operations, you should fast from midnight the night before and for afternoon operations, you should have a breakfast at 6 AM then fast. You can still take your heart and blood pressure medications with a small sip of water.
- If you are diabetic let me and the anaesthetist know to advice you about changes to your medications.
- Do not smoke for 4 weeks before surgery. Smoking increases the complications.
- Do not drink alcohol for 24 hours prior to surgery.
- Let me and the anaesthetist know If you are on drugs that thin the blood. Some of these drugs need to be stopped or changed a week before surgery to reduce the risk of bleeding.
- Stop herbal medications for two weeks prior surgery. Medications like Garlic, fish oil, St John's Wort, Ginseng, Ginko can increase the risk of bleeding.