HERNIA REPAIR

"Open" surgery                                           "Laparoscopic" surgery

Basic principles

Since a hernia is an abnormal protrusion of an organ through an opening, the basic principle of repair involves returning the organ to where it belongs and then restoring normality by closing the opening. This basic principle runs through all the surgical techniques described for hernia repair. The method that is employed by the surgeon is usually one that will have been carefully considered with your best interests in mind. You will have plenty of opportunity to discuss the options available to you and you will be a part of the decision-making process.

A surgeon always considers risk versus reward when deciding on the management of the patient. Some patients are risk takers whilst others are risk averse. Thankfully, in the case of hernia surgery the risks are largely very small and rare whereas the rewards can be substantial. This makes the decision to operate a relatively easy one and the discussion with you will centre more on the relative risks and benefits of the techniques available for your hernia. A few things come into the reckoning when deciding which technique to use:

1.       what benefits might come to you now

2.       what benefits might come to you in the future

3.       your fitness overall and your medical history

4.       your activity levels and recreational pursuits

5.       your employment status and the nature of your work

6.       your domestic situation e.g. support at home

7.       whether you have one hernia or more

8.       whether you have had previous abdominal or hernia surgery

9.       what harm may come to you from the technique

10.     what risks of recurrence of the hernia come from the technique

11.     what importance you attach to the position or size of the scars

12.     whether you can tolerate a general anaesthetic or not

Definitions and jargon

A “primary” hernia is a hernia that has never been repaired before and which is declaring itself for the first time. A “recurrent” hernia is a hernia that has been previously repaired but reappeared. “Unilateral” means on one side only, whilst “bilateral” means on both sides of the body. We use the term “open surgery” to refer to surgery in which an incision is made directly over the part that we are operating upon, whilst the term “laparoscopic surgery” or “keyhole surgery” is used to describe surgery in which incisions are made into the abdominal cavity away from the area that is being operated upon but which allows us to perform the surgery using instruments and a camera that are placed into the cavity i.e. instead of our hands and our eyes. These terms may be used on your booking forms, your consent forms or when dealing with insurance companies and it is important that you are clear about what is being planned for you.

Laparoscopic and open hernia repair - what you need to understand

Both laparoscopic and open surgery for hernia follow the basic principles of returning the hernial contents to the abdominal cavity and placing a mesh across the weakened area. In open surgery this is achieved by working from outside inwards, whilst with laparoscopic surgery this is achieved by working from inside outwards. It is very important that you realise that both techniques are safe and effective, that most patients suffer no complications and that most patients make good and relatively speedy recoveries. It is also important to remember that no two patients are alike. Some patients make excellent recoveries whilst others are a bit slower and hearing anecdote from other patients who have been through hernia surgery should not cloud your judgement. The National Institute for Clinical Excellence (NICE) is an independent body that examines the medical evidence for treatments and NICE concludes that both techniques are safe and effective alternatives for hernia repair. Remember too that statisticians can easily mislead a patient when discussing average or median recoveries and that recovery can be defined in many different ways. Below is a table comparing these two methods.

OPEN SURGERY

LAPAROSCOPIC SURGERY

Wound(s)

1 wound, 7-10cm, below the underwear line

3 wounds: one 3cm, two 1cm, at the belly button and hip level

Skin closure

Absorbable beneath the skin

Absorbable beneath the skin

Anaesthetic

General OR spinal (+ local anaesthetic afterwards)

General ONLY (+ local anaesthetic afterwards)

Recurrence rate

3% at 5 years

6% at 5 years

Infection rate

Minute

Minute

Risks / dangers

Very small

Small

Return to manual work

4-6 weeks

3-5 weeks

Urine retention

Very uncommon, especially under 70 years old or women

Uncommon, especially under 70 years old

Postoperative pain

Same as laparoscopic

Same as open

Chronic groin pain

3-5%

1-5%

Unsuitable patients

None

Overweight, unfit, chest disease, previous abdominal surgery (some cases)

In some hospitals, only 1 technique is available - either because laparoscopic surgery is not funded or because the surgeon has not trained in laparoscopic hernia repair. Remember that NICE suggest that both procedures are good and that only when having two hernias repaired simultaneously or when having a recurrent hernia repaired is there a slight advantage perhaps with the laparoscopic approach.

In my experience it boils down to what the patient deems to be important to them. Assuming that he or she is fit enough for a general anaesthetic and have only one hernia to be repaired, I see two groups emerging:

      a) Patients who want the safest possible operation, the most durable results and who are not concerned about shaving a few days off the time taken to return to physical work or by the size of the scar. These patients tend to opt for OPEN surgery.

      b) Patients who are desperate to be physically back to normal at the earliest opportunity, who value the cosmetic benefits of smaller wounds and who don’t mind the additional risks of the hernia recurring. These patients tend to opt for LAPAROSCOPIC surgery.

Surgeons certainly have their preferences too! It is both a privilege and a duty to share with you our own experiences with these two techniques and to offer you advice on which option might be most suitable for you.

What happens on the day?

Clear instructions will have been provided to you at your pre-assessment appointment about what to bring with you to hospital and what you may eat or drink on the day of your surgery before you come in. There will be a certain amount of paperwork to get through to check you in. You will then be visited both by the surgeon and by the anaesthetist who will discuss the surgery and the anaesthetics respectively with you. You will need to sign a consent form to proceed with surgery. This contains all of the information about the way the surgery is being performed and about the risks of the operation. You will be changed into suitable theatre clothing and you are likely to be offered elasticated compression stockings to reduce the risk of deep vein thrombosis (clots in the leg veins). A marker pen is used to identify the side and site of your surgery.

You will be taken down to the theatre either walking or in a wheelchair (if your mobility is poor), accompanied by a nurse and a porter who will check you into the theatre. You enter an anaesthetic room which is attached to the theatre where you will meet the anaesthetist and their assistant. In this room you will be prepared for your operation, with safety checks performed, prophylactic antibiotics given and monitoring attached to you. If you are having a general anaesthetic you will be put off to sleep in that room and then awaken in the recovery area of the theatres once it is all over. Once you are under anaesthetic or adequately numb from a spinal anaesthetic, you will be wheeled into the actual operating theatre where your surgeon and the theatre nurses will be awaiting your arrival.

A routine groin or umbilical hernia repair generally takes just 30-45 minutes to perform. However, the necessary safety procedures and preparation, together with the time taken for you to come round from the anaesthetic, mean that you are away from your room for up to 2 hours. When you are deemed to be sufficiently awake and have adequate observations being reported on you, you will return to your bed on the ward and you will be visited by your surgeon. If it has been determined that you will be for a day case, you will be allowed to go home later that day. Otherwise, you will be staying overnight. There is a resident doctor in the building and a nightshift who will look after you through the night but your surgeon is always available to you if he is needed. You will be visited by your surgeon before you can go home as it is important to reiterate the advice on what to do in the recovery period. An appointment will be made to review you in the outpatient clinic in approximately 4 weeks’ time.

When can you go home?

In order to safely release you back to the community, there are a number of prerequisites or milestones to reach. These include:

1. you must be comfortable at the site of your operation with the painkillers that you may take home with you

2. you must be adequately mobile and steady on your feet, especially if you have stairs to negotiate at home

3. your observation chart must be satisfactory (pulse rate, temperature, BP etc)

4. your wound must be satisfactory and we must be happy that you can manage it yourself

5. you must have eaten and kept your food down

6. you must have passed urine since the operation

7. you must have sufficient support at home

As soon as you achieve these milestones you may go home with our blessing, otherwise you would have to discharge yourself against medical advice.

Advice on your recovery at home

Pain:

All operations by their nature cause a degree of pain. During the anaesthetic you will be given pain relieving medication and there will also be local anaesthetic injected into the skin at the end of your operation. The local anaesthetic will last approximately 6 to 10 hours by which time you ought to be able to eat and drink and therefore take oral medication. You will be provided with medication that both relieves pain and settles inflammation. In the first couple of days after surgery most of the pain arises from the raw endings of nerves that are cut. There is a natural inflammatory response to a wound and this results in swelling and warmth in the wound over the ensuing days. This may produce a tightness or dull throbbing pain. Any bruising that is present will exacerbate this. Thereafter, as the inflammatory process settles and the body becomes accustomed to the presence of a wound, pain should abate.

I recommend that you use regular painkillers in the first week after your surgery, regardless of whether you happen to experience pain at that time, so that should more pain suddenly emerge you require less additional pain relief to get you through that episode. Use the analogy of a car travelling along a flat road that suddenly finds a hill rising up before it: if it has momentum behind it then it doesn’t need much acceleration to quickly get it over the hill, whereas if it is stalled at the bottom of the hill it takes longer and needs more throttle to get it up and over. If you are a male, you may find that movement of the scrotum and its contents tugs at the groin operation site internally. Wearing tight briefs or a jock strap will help to lift the scrotum and support it, preventing it from adding insult to injury.

It is important that you minimise the disturbance to the wound in the first 48 hours. I would therefore suggest that you spend the first two post-operative days with your feet up on a couch with a footstool as much of the time as possible. You may get up and about to visit the loo, answer the phone, make a cup of tea etc. but try to stay off your feet. Conversely, on the third post-operative day your swelling will have reached its peak and the wound will start to set and become a little stiff. Excessive stiffness contributes to chronic pain, as does a failure to keep mobile. I would therefore suggest that from 72 hours onwards you take a gentle stroll at least once or twice a day, perhaps up to a mile or two. Be sure to avoid uneven ground or slippery conditions as a fall at this early time could disrupt your hernia repair. Although it will be uncomfortable to walk, you will find that you will cross the pain barrier and find it more comfortable either later in the walkk or later in the day.

If you do suffer with unusually severe pain, please contact the hospital or your GP just in case you have developed a complication in the wound. Remember that time heals and that given sufficient time wounds almost always settle completely.

Wound care:

Your wound is not waterproof for the first three days. I would therefore suggest that you wear the dressings that you have been provided to protect the wound. You may shower in the first three days but do not soak in a bath. There are spare dressings provided and you can use these yourself if the dressing should lift when it is wet. Beyond 72 hours, the wound can be left exposed to the elements (not direct sunshine!) and you may forego addressing if you wish. Allowing the wound to breathe is often helpful. If the wound is a little weepy, then use the dressings that are provided to protect your clothing from the discharge.

Your stitches are dissolvable and you therefore do not need to have these removed.

You may well have quite extensive bruising. It is hard to predict who will have bruising and who will not, or to what degree your bruising will occur. It is not uncommon after a groin hernia repair to see the genitals quite discoloured. Should there be an unusual amount of bruising and swelling together, this could indicate a clot of blood has formed in the wound and you should contact the hospital or your GP immediately. Your wound will naturally be slightly swollen anyway and this often leaves the wound quite hard in the first three months. This is a natural healing response in fatty tissue beneath the skin.

If you have hair in the vicinity of your wound, it may grow back in the line of the wound. This can sometimes lead to an ingrown hair which can be extracted with tweezers. If you are unlucky enough to experience an internal suture coming out of the wound, it probably won’t yield when you tug on it! Please contact the hospital staff who would gladly remove it for you.

You should anticipate a degree of numbness or perhaps even unusual sensitivity in the skin just beneath the scar line. This may be a simple response in the nerve endings that are irritated by the recent surgery. If the nerve endings have been cut it may take up to 6 months for the sensation to reappear.

Physical activity:

The degree of physical activity that you are permitted to undertake will depend of course on your preoperative levels of activity. For the average patient, the advice below pertains. You should go for a walk as described above from the third day onwards. Any further physical activity that you feel encouraged to do and confident to do you are welcome to do. Exercise common sense in what might be a dangerous pastime e.g. stumbling, wrenching or slipping and listen to your body: it will tell you either immediately or later that day whether you have done too much.

You should refrain from lifting heavy objects or exerting pressure from within your abdomen e.g. pushing or straining. You are unlikely to injure your groin from simple activities like carrying a tea tray or an average bag of groceries. The word “heavy” can mean different things to different people. I would advise against the lifting of any object weighing more than 5 kg (11lbs) in the first 3 to 4 weeks.

If you wish to exercise, you may cycle on a static exercise bicycle from two weeks onwards and you may swim from two weeks onwards provided that your wound is healing well. Do not lift weights in a gym or run or cycle on the open road in the first four weeks. Sexual activity between you and a partner is permissible. Be mindful of the fact that certain positions are not suitable and that vigorous activity may injure.

Stretch your trunk (and your wounds) by twisting slowly to your left and to your right until you feel the wound begin to hurt a bit. Hold it in that position for 20 seconds and then relax again. The same tip can be applied to flexing sideways or extending. Just think of that old advice: "shoulders back, chest out, chin up"! If you wish to increase your activity levels by actually exercising, I suggest a power walk or static exercise bicycle cycle or swimming (if your wounds are healing well) from 2 weeks onwards. Do not lift weights, run or cycle on open roads for 4 weeks.

Long-term issues:

You will be reviewed in the outpatients clinic at which time your wound will be examined and your progress will be assessed. This is typically four weeks after your surgery, by which time most of your surgical symptoms will have eased. If you have further problems beyond that appointment you may need to see your GP or be reassessed by your surgeon.

Numbness or sensitivity in the surrounding skin may take several months to settle. A small minority of patients may have grumbling pain in the groin and need to take painkillers to ease this. If this does not help or your pain is worsening, please ask your GP to put you back in touch with your surgeon who can ensure that no complication has arisen. Occasionally a small focus of irritation e.g. a reaction to an internal suture is the cause of this trouble and it can be remedied. If no obvious cause can be seen, you may require an ultrasound scan of your groin.

If pain fails to settle with usual analgesia and there is no obvious cause to treat, you may be referred to pain specialist to manage the pain better. This might include injecting into the wound area to kill the nerves causing pain.

A very unusual problem is that of varicose veins in your scrotum called a varicocoele. This condition may cause aching in the testicle and it can be relieved through a minor procedure performed by a urological surgeon.

You have approximately a 3 to 6% risk of getting a further hernia, so be aware of any lumps that reappear in the groin. You also have a 15% risk of developing a novel hernia on the opposite side. This cannot be avoided by having a sedentary lifestyle.

Most patients recover very nicely and are able to return more or less to their old self. If you did have a very high activity level prior to surgery, you must take time to build yourself back up to this performance level. Have realistic expectations that a repair job is never going to restore your anatomy to the brilliant state it was in during your younger days.

Driving: You may not drive in the 24 hours after your surgery. Check your car insurance policy to see what, if any, restrictions are placed in your contract as regards driving after surgery. Most policies say either 1 week, 2 weeks, or on the advice of your surgeon. There is no medical evidence to show that driving a normal vehicle in normal circumstances will injure keyhole wounds or an "open" technique hernia wound. It thus relies on common sense - you decide when to drive. It is very important to consider the legal responsibilities of taking control of a vehicle: you must be able to take all reasonable actions expected of a driver in all circumstances i.e. your wounds (or any other consequence of your surgery and anaesthetic) are not a valid reason for failing to drive in a "normal" way. For example, you must be able to slam on the brakes, wrench the steering wheel and swerve to avoid a child that has run across your path.

What complications can occur?

All surgery carries with it some element of risk and these risks are part and parcel of surgery: without risk, nothing can be gained. Remember that you would not be going through this surgery if it was more likely to cause harm to you than your hernia can cause. Remember too that very few patients suffer complications and the majority of operations and recoveries are uneventful. Some of the risks described below are serious, but these are very rare. The majority of complications are a nuisance rather than a serious health problem. No list can be complete, but the most frequently noted complications are:

-          Bleeding: All cutting surgery causes some bleeding, but it is called a complication when bleeding occurs that warrants an unplanned return to the operating theatre to stem the bleeding, or when bleeding is so heavy that a blood transfusion is required. If your bleeding has resulted in substantial blood loss, you might need blood transfusions or iron supplementation. This is vanishingly rare in both forms of hernia surgery.

-          Infection: Infection in keyhole wounds is less likely than in larger incisions. The same applies for getting "chesty" or suffering post-operative pneumonia. Wound infections in our hospital after keyhole and open hernia surgery are vanishingly rare. You will be given prophylactic antibiotics whilst the operation is underway anyway. Resistant bacteria like MRSA  causing wound infections are virtually unheard of in our hospital.

-           Wound healing: Some wounds stubbornly refuse to completely heal  and gape open when the sutures dissolve. Others  may only weaken much later in your life and this gives rise to a hernia called an incisional hernia. Such hernias arising from keyhole wounds are rare. For both techniques, a recurrent hernia could form in the groin. This is more common after keyhole surgery than after open surgery, but only 6-3% of cases, respectively, suffer a recurrence. A wound might conversely even heal too well and cause a thickened, unsightly scar called a hypertrophic scar. This is more likely if your previous scars have done the same. These may need to be treated by a dermatologist or you might choose to see a plastic surgeon about having the scar revised.

-     Chronic groin pain: Most wounds heal eventually without pain, but a very small number of cases of persisting or chronic pain occur. These patients may need to take pain killers indefinitely or see a pain specialist. It might have an easily identifiable cause, like an infection or a stitch to which you have reacted, in which case another surgical procedure could be offered to deal with it.

-          Adhesions: these are best described as internal scar tissue. They form as an unfortunate consequence of natural healing in the abdominal cavity, but in some individuals the process is excessive, leaving behind scars that connect the organs of your abdomen to one another or to your abdominal wall. They are unavoidable and unpredictable. These only apply to keyhole surgery, not open surgery for hernias. Adhesions are thought to be one of the reasons that some people have chronic pain after surgery. If you are very unlucky, adhesions might result in you being hospitalised in the years ahead with an intestinal blockage caused by your intestines getting tangled in an adhesion.

-          Blood clots: Known as DVT (deep vein thrombosis), these rarely occur in day case surgery. Prophylactic measures appropriate for you will be taken to mitigate against these coming to pass, such as elasticated stockings, compression inflation devices, blood thinning medication, early mobilisation. DVT can lead to varicose veins and they can even be fatal if they should float to the lungs. Your risks are extremely small, but certain people have greater risk factors than others, something we identify at your pre-assessment visit. I suggest that you wear your elasticated stockings for at least 4 weeks.

-     Urinary retention: This complication is much more common in men than women, probably because they have an underlying bit of prostate trouble. It is also more common if hernias of both sides are repaired simultaneously. It is also more likely with keyhole surgery than open surgery. Should this happen, a catheter will be passed to relieve the bladder. If it persists, you may need to see a Urologist.

-     Varicocoele: This is similar to a varicose vein, but it affects the veins in and around the testicle and scrotum. It results from disturbance to the flow of these veins as they pass through the groin. It can lead to aching in the testicle or it can cause the testicle to wither. This complication is extremely rare. 

-     Ilioinguinal nerve disruption: This small nerve runs adjacent to the hernia as the hernia emerges through the muscle layers. It may already be compromised by pressure from the hernia. During surgery it may be stretched, bruised or cut. After surgery it may become trapped in your scar tissue as this forms. The consequence may be a patch of numbness, sensitivity or (rarely) pain in the skin over a patch just below your scar. This usually recovers, but very slowly. 

-    Internal organ injury: This applies only to keyhole surgery, not open hernia surgery. Since instruments have to pass into the abdominal cavity, and dissection takes place in the vicinity of some important organs, it is possible (though extremely unusual) to injure something inadvertently whilst operating.

GETTING IN TOUCH IF YOU NEED HELP

You will be given clear instructions on how to quickly summons help whilst on the ward. If you should need to stay overnight, a Resident Medical Officer (RMO) is resident in the hospital to attend to you in the first instance. This doctor is able to deal with many emergency situations, as are the well qualified resident nursing staff. If necessary, Mr Bradford will be called both for advice and to attend - he is on-call for you at all times until you are discharged and he can be at your bedside within just a few minutes in an emergency.

Once at home you have access to medical advice in several ways:

1. Call the hospital to speak to the nurse on duty and/or the RMO

2. Call your local GP surgery (during hours)

3. Call the Out of Hours GP service (after hours)

4. Call the emergency services (999) or attend your nearest A&E services

As a general rule, unless it is an emergency rather call the hospital in the first instance for advice on who is best placed to attend to your needs. We have a low threshold for having a quick look ourselves if we are concerned that a complication might have arisen: usually it is a false alarm. If either your GP or the hospital staff feel that Mr Bradford needs to be contacted about you, they will track him down. In the event that your problem has arisen some days later, and Mr Bradford is away, you might have to default to the NHS services for assistance.