The inguinal canal is a naturally occurring oblique passageway that crosses the abdominal wall connecting the inside and the outside of the abdomen. In males it contains structures running to and from the testes. In females it contains the round ligament that connects to the uterus.
An inguinal hernia is a protrusion of an intra-abdominal structure through or along the inguinal canal. These structures may include intra-abdominal fat, bowel, and occasionally bladder or an ovary. ‘Direct’ inguinal hernias bulge directly through the back wall of the inguinal canal. ‘Indirect’ inguinal hernias protrude obliquely along the canal and can go all the way into the scrotum (males) or labia (females).
Indirect inguinal hernias account of 60% of adult inguinal hernias and almost all the inguinal hernias in children. They occur because of a ‘patent processus vaginalis’. This is a normally occurring passageway in the inguinal canal that facilitates the descent of the testes from the abdomen into the scrotum at or around the time of birth. If this passageway persists and is narrow, fluid can gather around the testis. This is known as a hydrocoele. If the passageway is wide enough, an indirect inguinal hernia can occur. These are more common in men. In women the hydrocoele or hernia can protrude into the labia majora.
Direct inguinal hernias occur because of a weakness in the back wall of the inguinal canal. They bulge directly forward into the groin through an anatomical window called Hasselbach’s triangle. This is bordered below by the pubic bone and on its sides by the rectus abdominus (6-pack) muscle and the inferior epigastric artery. These hernias tend not to protrude into the scrotum or labia and do not go down a patent processus vaginalis.
Inguinal hernia usually presents as a bulge in the groin. They are usually painless but can be painful during periods of activity, if they are large, or get stuck. The hernial contents can usually be manually pushed back (reduced) into the abdomen. If it cannot be reduced, it is known as ‘irreducible’ hernias. A hernia that was reducible and suddenly becomes irreducible is called an ‘incarcerated’ inguinal hernia. If the contents of the hernia lose its blood supply, it is known as a ‘strangulated’ inguinal hernias. This is a surgical emergency, as it takes approximately 6-hours before the damage to the contents of the hernia is irreversible.
There are three main methods – one open and two laparoscopic. The method used depends on whether there has been any surgery to the area in the past and on the preference of the patient after an open discussion with their surgeon.
Open inguinal hernia repair
This is the traditional method of hernia repair. Under general anaesthetic, a 7-10cm incision is made in the groin on the side of the hernia. The front wall of the inguinal canal is opened and the hernia is located and reduced. In males, the blood supply to the testis and the tube that transports sperm from the testis (vas deferens) are identified and protected. The ilioinguinal nerve with traverses the canal and is the nerve to the skin of the groin is also protected. Once the hernia has been reduced, the back wall of the inguinal canal is reinforced, usually with non-absorbable mesh. The mesh is permanent. The front wall of the inguinal canal is then repaired. The skin is closed with absorbable sutures and dressed with a waterproof dressing.
Laparosopic inguinal hernia repair
This is the ‘keyhole’ surgery method of inguinal hernia repair. There are two approaches – the first is conducted within the abdominal wall and does not enter the abdominal cavity itself, and the second does enter the abdominal cavity. The first is preferred by this practice. A 1cm incision is made below the bellybutton and a balloon is inserted and inflated within the abdominal wall to create space. The balloon is removed and a camera is inserted. Then two 5mm incision are made below the bellybutton to insert the instruments used the fix the hernia. The hernia is reduced and a non-absorbable permanent mesh is placed to reinforce the back wall of the inguinal canal, similar to an open repair. The instruments are then removed. The wounds are closed with absorbable sutures and dressed with a waterproof dressing.
Prior to your operation you may need to attend a Preadmissions Clinic. Your fitness for surgery will be assessed, tests may be ordered and referrals to other specialists arranged if required.
You cannot eat for 6 hours prior to your operation. You may sip water for up to 2 hours prior to your operation. Fasting decreases the risk of vomiting and aspiration during induction of anaesthesia. Aspiration can cause pneumonia and a prolonged stay in hospital.
Inguinal hernia repair is usually done under general anaesthesia. You will be asleep during the whole procedure. The anaesthetist will discuss the anaesthetic with you prior to your operation. They will see you in the pre-operative area and accompany you to the operating theatre.
Following the operation, you will wake up in the recovery area. You will feel a little disoriented and may feel a little nauseous. Immediate post-operative pain is usually minimal but it common to have some discomfort around the wound sites.
The staff in recovery are equipped to help you. Once you are awake and oriented, you will be taken to a ward bed. After a few hours, and once the nurses are satisfied that it is safe, you can get out of bed. Gentle activity such as walking is encouraged.
Most patients are able to go home on the same day as their surgery. Some patients stay in hospital for at a night or two.
There are no dietary restrictions or special dietary supplements that are required after inguinal hernia repair. You may require opiate-based medication for pain relief for the first day or so. After that, simple analgesia such as paracetamol and ibuprofen should be sufficient. You may bathe and shower. The wound is waterproof and can get wet.
You can resume most normal activities after three to five days. You should avoid strenuous physical activity, vigorous exercise and heavy lifting (>5kg) for four weeks after your operation. It increases the risk of hernial recurrence. Once this period has passed and you feel that you have recovered, you may return to your normal physical activities.
Post-operative swelling around the wound is normal and usually resolves within a month or so. No specific wound management is needed in the first two weeks while the dressings are on. After this, gentle scar massage is advisable for 10 minutes two or three time a day for 6 months. You may use whatever moisturising lotion you like (e.g. sorbolene, bio-oil etc.) but creams with Vitamin E should be avoided for the first post-operative month. Alternatively, you can keep the scar covered with a silicon strip for 12 hours a day for 6 months. These strips are available from the chemist. Initially the scar will be pink. Over 6-12 months, the scar will fade until it becomes pale.
General Risks of Surgery
These may include nausea and vomiting following your anaesthesia, minor allergies to medications or antiseptic solutions, blood clots in the operative wound and minor wound infections.
More serious complications may occur in patients who have pre-existing risk factors. They are rare in otherwise well people. They include severe allergic reactions, blood clots in the legs (deep venous thrombosis) which can travel to the lungs (pulmonary embolus), cardiovascular complications such as heart attack, delayed wound infection and chest infection.
These can complicate any type of surgery and can usually be treated with a short course of oral antibiotics. Uncommonly, IV antibiotics or further surgery is required.
Damage to intra-abdominal organs
Inadvertent injury to nearby organs such as the small intestine, bladder or major blood vessels are rare. If it does occur, a return to the operating theatre may be required.
Mesh infection is rare but well described. It can be challenging to treat non-operatively and the mesh often has to be removed surgically.
Chronic Groin Pain
This is well described complication of hernia surgery and occurs in up to 10% patients. The cause may be related to mesh type, weight and configuration, devices used to fix the mesh, tissue and/or nerve damage, recurrence of the hernia, and/or exacerbation of pre-existing groin pain by the surgery. The risk for chronic groin pain is increased by high levels of immediate pre- and post-operative pain. For most patients, the pain resolves by 6-months.
Recurrence of Inguinal Hernia
The rate of recurrence of inguinal hernias after a mesh repair is about 0.5% or 1 in 200. It is even lower for a laparoscopic repair. There are numerous factors which contribute to hernial recurrence. These include surgical technique, the characteristics of the hernia, and the pre-existing health of the patient with an increased risk in patients who are overweight, smoke cigarettes, and have a chronic cough. If an inguinal hernia recurs, more surgery is usually required to fix it.
A follow-up appointment should be arranged in rooms three to six weeks after your operation to check on your progress and recovery. At this appointment, your wounds will be assessed, and any further investigations and management arranged.
There is no specific law covering surgery and driving. It is not advisable to drive immediately after surgery. In general, in order to return to driving, you must:
This pamphlet is intended to provide you with information and does not contain all known facts about inguinal hernia repair. Treatment may have uncommon risks not discussed in this pamphlet. Please do not hesitate to ask any questions you may have.