Groin hernia surgery (an inguinal hernia operation)

The muscles around your tummy (abdomen) are usually strong enough to keep your intestines (bowels) and organs in place. If there are any weak spots in the muscles, an internal part of your body can push through these areas. This is called a hernia and may need to be repaired with surgery. The most common type is an inguinal hernia, which affects the groin.

Mr Niteen Tapuria, Consultant General Surgeon at Highgate Hospital, answers your frequently asked questions about inguinal hernias.

What is an inguinal hernia?
An inguinal hernia is when your intestine protrudes (bulges) through a weakness in the muscle wall of your groin.

What causes an inguinal hernia?
The wall of your tummy (the abdominal wall) is made up of a sheet of tough muscles and tendons (bands of tissue). They stretch from your ribs to your groin. The abdominal wall acts as nature’s corset or support garment. It holds all the internal organs, especially the intestines, in your abdomen.

If a weakness or gap develops in your abdominal wall, an internal part of the body (usually the intestine) can push through the area. This causes a lump in your groin. Some people are born with a weakness in their groin and others develop a weakness over time.

Who is likely to get an inguinal hernia?
Some things can increase your risk of getting an inguinal hernia:

• Age: An inguinal hernia is most common in children aged between 0 and 5 and adults aged between 70 and 80. The risk of an inguinal hernia increases with age because your muscles can become weaker as you get older.
• Gender: Men are about eight times more likely to get an inguinal hernia than women.
• Family history: You are more likely to get an inguinal hernia if you have a close family member with the condition. This could be a parent, child, brother or sister.

Inguinal hernias are also more common if you:

• have a connective tissue disorder (a condition that affects the connective tissue supporting the organs and other parts of the body)
• previously had an operation to remove your prostate gland
• are overweight
• already have a hernia on one side of your body
• have a persistent, heavy cough
• strain when you go to the toilet
• have chronic constipation (infrequent bowel movements for several weeks or longer)
• are pregnant
• lift heavy weights
• are a smoker

Can an inguinal hernia become dangerous?
Many people have an inguinal hernia for years and never need surgery, but sometimes the hernia may become strangulated. This is when the loop of intestine that forms the hernia becomes twisted. It can cause a bowel obstruction (blockage), which can be dangerous if left untreated. In this situation, you would usually start vomiting (being sick) and your abdomen would swell. You would also become constipated and might be in acute pain. If this happens, you should go the Accident and Emergency Department of your nearest hospital straight away. You may need an urgent operation.

Do I need surgery to treat an inguinal hernia?
In some cases, your inguinal hernia may stay the same and not cause you any problems. You may then be able to delay surgery safely and watch for any symptoms. This approach is called watchful waiting. However, if the hernia cannot be pushed back into your abdomen with gentle pressure and is painful, it is likely to get worse over time.

Although the risk of strangulation is low, nearly 70% of patients decide to have hernia surgery within ten years due to pain. If the operation is done as an emergency or at a late stage, the outcome may not be so good.

You need to think carefully about how much the hernia bothers you and how you feel about the risk of having surgery. This may depend on whether you have any other health problems.

A hernia never gets better by itself and medicines cannot cure it. An abdominal support (truss) may help you feel more comfortable, but will not heal or repair your hernia. The truss is a pad attached to a belt. It can sometimes cause harm by putting unnecessary pressure on the hernia. This can make it more difficult to have an operation.

Surgery is usually recommend if your inguinal hernia is painful or getting bigger. If your hernia becomes acutely painful or you cannot push it back into place, you may need to have the problem repaired urgently. It is important to get an expert medical opinion.

How is an inguinal hernia fixed during surgery?
During an inguinal hernia operation, the surgeon pushes the lump (bulge) back into your abdomen and strengthens the weakness in your abdominal wall.

An inguinal hernia can be repaired under either:

• a local anaesthetic, which makes the area being treated numb while you are awake
• a general anaesthetic, which affects your whole body by sending you to sleep during the operation

Some patients need to have a local anaesthetic because a general anaesthetic is considered a high risk. Other patients may choose to have a local anaesthetic because this is their personal preference. However, I recommend having the operation under a general anaesthetic because this is more comfortable and can be performed faster. If you have a local anaesthetic, we cannot use keyhole surgery to repair the hernia.

An inguinal hernia can be fixed by an open repair or keyhole (laparoscopic) repair:

Open repair
Open hernia surgery is when your surgeon makes a cut to push the lump back into your abdomen. This is a perfectly safe type of surgery associated with minimal pain and scarring. The chance of the hernia returning is only about 2 in 100.

Your surgeon makes a single cut, usually over the hernia lump. They push the part of your bowel bulging through the abdominal wall back into position. The surgeon also strengthens and reinforces the muscle wall around the hernia with a piece of fine mesh material. This helps to prevent another hernia. The cut is then closed with stitches.

Keyhole (laparoscopic) repair
Keyhole or laparoscopic hernia repair is a type of minimally invasive surgery. Your surgeon makes three or four small cuts over the hernia instead of one larger cut. They insert a thin tube called a laparoscope, which contains a light and camera. This allows the surgeon to see the inguinal hernia clearly and repair it with tiny instruments. They pull the hernia back into place and use mesh material to strengthen the weak area of muscle. The small cuts in your skin are then sealed with stitches or surgical glue.

There are two types of keyhole operations:

• Transabdominal preperitoneal (TAPP) repair: During this surgery, your surgeon inserts tiny instruments through the abdominal wall and the lining covering your abdominal organs called the peritoneum. They take down this lining temporarily and move the hernia back into its proper position. Your surgeon then puts a mesh into a pocket of the peritoneum and reattaches this layer to the abdominal wall.
  The TAPP technique is useful if you have hernias on both sides of the groin or your diagnosis is uncertain. This surgery involves a slightly higher risk of injuring the bowel or developing scar tissue around the mesh
• Totally extraperitoneal (TEP) repair: During this surgery, your surgeon inserts tiny instruments between the layers of the abdominal wall. They do not enter the peritoneum and the hernia is sealed with a mesh from outside this thin layer.
  TEP repair is considered to be technically more difficult than the TAPP technique. There is a slightly higher risk of pain, but TEP repair may reduce the risk of damage to the abdominal organs.

Are there any risks if I have an inguinal hernia operation?
Inguinal hernia repair surgery is a routine operation that is normally very safe. As with all surgical procedures, there are risks involved but we take steps to minimise these. Short-term risks and complications may include:

• Bleeding: You may have some bleeding inside your groin or from your wounds after the operation. If this happens, we will treat the bleeding. You may need a blood transfusion (when you are given blood from someone else) or another operation.
• Collection of blood (haematoma): Blood can sometimes collect at a wound site and may need to be drained.
• Bruising: You may get a little bruising around your wound sites. This is normal and settles over time.
• Wound infection: If you have a high temperature and you wound becomes inflamed (hot and red) and sticky, you need to see your GP. A wound infection can be treated with antibiotics. You do not usually need to be re-admitted to hospital.
• Injury to surrounding structures: During the operation, there is a small risk of damage to nearby parts of the body. These can include the bowel, bladder and blood vessels.
• A recurrent hernia: A hernia may sometimes return after surgery. Only about 2 in every 100 patients have a recurrent hernia if a mesh is used during their operation.
• Temporary difficulty in emptying your bladder: A small number of patients may find it difficult to pass urine immediately after surgery. If this happens, we may need to insert a flexible tube called a urinary catheter to empty your bladder. This is removed before you go home.
• Chronic pain or numbness: There is a small risk of long-lasting pain or numbness in the groin area. This happens less often with keyhole (laparoscopic) surgery.
• Scarring: You will have between one and four small scars after your hernia operation, depending on the type of surgery.
• Hydrocele: Men may get a build-up of fluid called a hydrocele in the scrotum (testicles). This usually improves with time, but in rare cases you may need an operation to treat it.
• Damaged blood supply to the testicles: Men may have this complication because of reduced blood flow to the testicles after surgery, but it is rare. Depending on how much damage there is, you may need to have another procedure.
• Mesh infection: If the mesh used during your operation gets infected, you will have inflammation (increased pain or discomfort) around your wound. You can be treated with medication, but if this does not help we may need to remove the mesh.
• Blood clots: There is a low risk of deep vein thrombosis (blood clots in the leg veins) or pulmonary embolism (blood clots in the lungs) during hernia surgery.

How can I prepare for my inguinal hernia operation?
Before any operation, it is a good idea to try and get as fit as possible. This will make it easier to recover. Here are some tips:

• Losing weight: If you are overweight, you can get diet advice and support to reach a healthy weight from your GP or practice nurse. Losing weight helps to reduce risks or complications during your anaesthetic and operation.
• Stopping smoking: If you smoke, we recommend that you try to stop. This can be challenging, but your GP or practice nurse can give you advice and support. Smokers are more likely to get chest infections or blood clots after surgery.

What happens after my inguinal hernia operation?
After your operation, you are taken to the hospital recovery unit. Not everyone remembers waking up in the recovery unit. Specially trained nurses look after you until you are ready to return to your ward. If you are in any pain or feel sick, the nurses can give you some medicine to make you feel more comfortable.

If I have an inguinal hernia operation, do I need to stay in hospital?
Most people can have an inguinal hernia operation as a day case patient and do not need to stay in hospital overnight. However, you may need to stay in hospital if:

•  you are in pain
• have other health problems
• do not have anyone to stay with you for the first 24 hours after the operation

What happens when I leave hospital?
When you leave hospital, we give you a discharge note. A copy is also sent to your GP. This note has information about your care, including whether you need to have stitches removed or dressings changed. Please ask your nurse if you need a fit note (a statement of fitness to work).

Our pharmacy gives you simple painkillers to take home.

When can I have a bath or shower again?
During the first week after an inguinal hernia operation, we advise you not to soak in the bath and have a shower instead. This is to help avoid a wound infection.

When can I have sex again?
You can have sex again when you feel comfortable, unless you have been advised not to by your doctor.

When can I drive again?
You can start driving again when you feel comfortable and can carry out an emergency stop without any pain or discomfort. It is best to ask your car insurance company for their advice on driving after surgery.

When can I return to work?
When you can return to work after an inguinal hernia operation depends on the type of job that you have. You may need to take one or two weeks off work, but this period may be longer if you have a manual job.

When can I start exercising again?
Gentle exercise can help you to recover after surgery. However, it is important not to do any abdominal exercises or heavy lifting for six weeks after your inguinal hernia operation.

About Mr Niteen Tapuria
Mr Niteen Tapuria, Consultant General Surgeon, has a specialist interest in open and keyhole (laparoscopic) inguinal hernia surgery.
To make an appointment with Mr Tapuria at Highgate Hospital, please call 020 3918 9522 or complete this form.