What is a Hernia?
A hernia is simply caused by the internal contents of the body bulging through the body wall that normally contains it. This is a bit like tyre blisters where the pressure inside the tyre pushes a bulge through a weakness in the tyre wall. Most people will notice a lump/bulge or in some cases just pain or discomfort that is made worse by movement or exertions. The bulge may be pain free. There may be a history of severe coughing, straining from heavy lifting or sporting injury. The hernia or bulge may (reducible) or may not (irreducible) disappear when you lie down.
Most hernia usually contains fat or intestines. Most hernia will enlarge over time resulting in increasing pain and likelihood of strangulation. You will often experience severe pain, nausea and vomiting when the hernia is strangulated. This can stop the blood flow and result in gangrene of the trapped portion of the intestine. A strangulated hernia is life-threatening and requires immediate surgery.
How are they diagnosed?
Most hernias are pretty obvious, as you will normally notice a lump. Most of them can be diagnosed easily by careful examination. Sometimes an ultrasound or CT scans are used to help find them.
All hernias should be repaired to prevent problems like strangulation. In essence hernias are treated by repairing and strengthening the weakness in the body wall where the hernia bulges through. This is usually achieved by placing a mesh over the hernia that will close off the defect as well as reinforcing the area. This can be achieved by the traditional method of open surgery where a larger cut is placed over the hernia and the mesh put in place to effect repair or by laparoscopic (keyhole) surgery.
Keyhole or traditional open surgery?
Whichever approach is used the principle of repair remains the same. For most types of hernias, keyhole surgery undoubtedly has the advantage over open surgery. These include less pain, quicker recovery to full activities allowing earlier return to sporting activities, driving, superior cosmesis and lower infection risk. The decision to choose which approach depends on factors like the experience of your surgeon, importance of time taken to return to full activities. This is particularly important if the person participates in a lot of sporting activities or has an active job. Laparoscopic surgery can only be done under general anaesthetic but traditional open surgery can be done under local anaesthetic. Most importantly in Experienced hands, the risks from surgery should be no different between the two approaches.
Types of Hernia:
There are many different types of hernia. The most common type is inguinal (groin) hernia; other types of hernias include femoral, paraumbilical/umbilical (belly button) hernia, epigastric (ventral) hernia, incisional (surgical site) hernia, Gilmore's groin (Sportsman's) hernia and Spigelian hernia.
Inguinial: This is a hernia in the groin area. This type of hernia is more common in men because the testis pass through the tummy wall as they descend from near the kidneys to the scrotum leaving a tunnel making it more prone to developing a hernia. When the inguinal hernia enlarges they very often go into the scrotum. Inguinal hernia can be sub-classified into a direct or indirect hernia but in truth this does not effect the way the hernia is repaired.
Surgery: Traditionally these are repaired by open surgery (an incision of about 6-10cm) when the hernia is reduced and a mesh placed over the hernia defect and sutured in place (Lichenstein hernia repair). Nowadays these hernias (single and both sides) can be repaired laparoscopically (keyhole) with 2 or 3 small cuts of 1 to 2cms.
Recovery: Laparoscopic repair is far superior to open repair especially when its is a double (right and left side) hernia repair. Even for just a single side, laparoscopic repair is still better in terms of pain. Irrespective to whether repair of one or both sides, you can expect to be completely pain free within 2 weeks following laparoscopic surgery. As for open surgery you may expect to double this time. You should not drive a car until you are comfortable and pain free. The time it takes to start driving after surgery varies from person to person. In general it takes about 5 to 7days after laparoscopic surgery before attempting to drive and slightly longer after open surgery. If in doubt you should always discuss this with your doctor before driving.
The hernia is approached from the inside (trans-abdominal; TAP) of the tummy or from within the tummy wall (totally-extraperitoneal; TEP). The hernia is reduced and a piece of mesh can be placed over the defect and fixed in place with tacks on the inside. This is likened to repairing a puncture by patching it from the outside (open surgery) or placing the patch on the inside of the tyre. The risk of recurrence of hernia with both repairs should be below 7%. Chronic groin pain can occur after inguinal hernia repair. The risk is about 40% following open surgery but is much less following laparoscopic repair (20%).
Femoral hernia: This is a hernia that can often be mistaken for a lymph node or vice versa. It appears usually at the top of the inner thigh just below where an inguinal hernia appears. The hernia is often about the size of a small grape. They are more common in women especially in someone who has lost weight recently. Femoral hernias often are irreducible and tender.
Surgery: Like inguinal hernias these can be repaired by open or laparoscopic surgery. The hernia can be repaired by simple suture repair or with mesh repair.
Recovery: Recovery is usually within 2 weeks.
Paraumbilical / Umbilical hernia: Also known commonly as the belly button hernia. The hernia usually contains fat but can trap a loop of intestine as well. It can be quite painful. This type of hernia is common in pregnant ladies and usually spontaneously closes after childbirth. About 1 in 5 don't spontaneously close and will require surgical treatment.
Surgery: Most of these hernias are small and can be repaired by open surgery through a pretty small incision. A mesh is usually used to repair these as research has demonstrated that simple suture repair results in higher recurrence rate. Larger hernias may benefit from keyhole surgery.
Recovery: Recovery is usually within 1 to 2 weeks.
Epigastric (ventral) hernia: These hernias are often small and appear in the mid-line. These are caused by weakness in the tendon strip that holds together the tummy muscles (your six packs) on either side. Like the umbilical hernia, these hernias often contain fat and occasionally intestines.
Surgery: Pretty much the same as for paraumbilical hernia repair. The size of the incision needed is usually so small making keyhole repair nonsensical. A mesh may be used to repair these.
Recovery: Recovery is usually within 1 to 2 weeks.
Incisional hernia: This is a hernia that occurs at the site of a previous surgical incision. Being overweight, chronic cough and having a wound infection makes you more prone to developing it. Incisional hernias can be simple or can be very complex.
Surgery: Traditionally open surgery with insertion of a mesh has been the standard repair. The development of new mesh technology has made laparoscopic (keyhole) surgical repair possible. In open repair the mesh can be simply sutured on top of the hernia (onlay), within the tummy wall (Stoppa or sublay) or inside the tummy (inlay). The recurrence rate after an onlay repair is about 20% compared with 7% with Stoppa technique. The early result of laparoscopic repair is promising showing a recurrence rate of about 10%.
Combine this with less pain, quicker recovery makes keyhole repair an attractive option. Now we are able to offer single incision laproscopic repair which will speed up recovery with even less pain than standard laparoscopic surgery (See SILS surgery).
Recovery: This depends on the size of the hernia and approach. For laparoscopic repair you can expect to be fully recovered at about two weeks even for a large hernia. In the case of open repair this may extend to 4 to 6 weeks for large hernias.
Spigelian hernia: This is a rare hernia that occurs in the lower outer part of the tummy wall. The bulge from this is usually very subtle and difficult to find. They may not cause any symptoms but often do cause discomfort.
Surgery: Can be treated by open or laparoscopic surgery with a mesh repair.
Recovery: Recovery is usually within 1 to 2 weeks.
Gilmore's groin (Sportsman's hernia):
Sportsman's hernia, obturator nerve entrapment, pubic osteitis and adductor tendinitis are the four main causes of groin pain in athletes. London surgeon OJ Gilmore first described and named this condition in 1980. Patients complain of chronic groin pain exacerbated by sudden twisting movements like kicking, sprinting and activities that increase the pressure inside the tummy like coughing or sneezing. Notable sufferers include Michael Owen, Johnny Wilkinson, Ashley Giles and many sports personnel. Although named sportsmans hernia, there is actually no true hernia (no bulges). The problem lies in the disruption of the muscular tendons in the groin area resulting in weaknesses in the hernia orifices.
The pain is located near the pubic tubercle and is worse in the evening after vigorous exercise or the following morning. Even though it is called a hernia, a hernia is often not identifiable on physical exam or imaging. The specific injury is a tear in the conjoint tendon/transversalis fascia. A sportman's hernia usually presents as chronic groin pain that flares with activity and does not hurt during periods of inactivity.
Investigations & Treatment:
Ultrasound, magnetic resonance scans and other forms of X-rays may be used. Rest and avoidance of exacerbating factors are the first line of treatment. This will often offer temporary relief but surgery is frequently required for long term cure. The key to the treatment of sportsman's hernia is to repair and reinforce the damaged area.
Traditional treatment for sportman's hernia is an open hernia repair with sutures. This often confines the athlete to an extended period of rest before resuming physical activities. This is because a lot of tissue and musculature are cut or disrupted just to expose the damaged area before even attempting the repair.
The key to early return to physical activities is to minimise any tissue disruption during surgical repair. Modern laparoscopic (keyhole) repair is achieved using only one or two tiny cuts (0.5-2cm) with minimal tissue disruption. Keyhole surgical repair of sportsman's hernia has been shown to be equally effective as traditional open surgery but with much shorter recovery and earlier return to physical activities. The damaged area is repaired and reinforced with a mesh. With the use of modern mesh material my patients are able to resume physical activities 5-7 days after surgery and resuming full activities within 14 days with appropriate physiotherapy support and supervision.
Non-Surgical Treatment: Initial treatment is rest, physiotherapy and wearing warm compression pants. This is often a stop gap before surgical repair of the musculotendinous injury.
Surgical: Historically this involves open surgery but recent studies have demonstrated equally good result from laparoscopic repair. The advantage of laparoscopic (keyhole) repair is the ability to return to training at a much earlier date. It is important to undergo a structured returned to sporting activities.
Recovery: Rest is an important part of the recovery process in Sportsman's groin. With open surgical repair the recovery period is expected to be around 6 to 8 weeks. With laparoscopic repair that causes less tissue damage to repair the damage groin allows much faster return to activity and many patients often return to activity 1 week following operation. Recovery from Gilmore's groin is best supported by physiotherapy to get the best result.