Inguinal Hernia repair

What is a Laparoscopic Groin Hernia Repair?

The word “Laparoscopic” is the medical term for keyhole surgery. Three or four little cuts are made in your tummy and tiny tube shaped instruments are passed into these incisions. The first tube (known as a Laparoscope) is connected to a high intensity light and a video camera so that the surgeon can see what is happening inside you. The surgeon then uses miniature instruments to return the protruding tissue back into the abdominal cavity. To provide space for the surgery to be performed, your tummy is filled with carbon dioxide (a harmless gas). A piece of mesh (a strong, but flexible man-made material) is inserted over the weak area in the abdominal wall to strengthen it. The mesh remains inside the body permanently to reinforce the weak area. Once the operation is completed, the carbon dioxide gas is allowed to escape before the cuts are stitched together.

What is a Groin Hernia?

A hernia is a weakness in the muscles of the abdominal wall (tummy). This weakness may allow a section of intestine (bowel) or fat to bulge out under the skin. The most common site for a hernia is in the groin (the area between the thigh and the tummy). This hernia is called a groin hernia. A groin hernia can occur on either or both sides. The bulge may appear during vigorous activity or when coughing or straining, and usually disappears when lying down. The bulge is usually seen or felt in the scrotum, groin or abdominal wall.

Benefits of Surgery

The main benefits are the relief of pain and discomfort caused by the hernia and avoidance of future obstruction (blockage) or strangulation. Strangulation occurs when part of the intestine (bowel) bulges out of the hernia defect and becomes stuck and loses its blood supply. This causes the hernia to suddenly become very painful and hard and will require an emergency operation to repair it.

What would happen if my hernia was left untreated?

The long-term course is for a hernia to become steadily worse. There is also the risk of the hernia becoming strangulated.

Are there any alternatives to surgery?

There is no acceptable non-surgical medical treatment for a hernia. A hernia does not get better over time, nor will it go away by itself. The use of a truss (a padded hernia belt) can keep the hernia from bulging, but is usually only recommended for patients who are not fit enough for surgery.

The only permanent remedy for the condition is to repair the hernia surgically.

Are there any alternatives to Laparoscopic Hernia Repair?

An alternative to laparoscopic hernia repair is a traditional “open” hernia repair. This involves an incision about two to four inches long in the lower tummy/groin. Both types of hernia repair can be performed as day case surgery.

Am I a suitable candidate for laparoscopic surgery?

Laparoscopic surgery is not suitable for everyone, particularly if you have had previous abdominal surgery or underlying medical conditions. The surgeon will need to assess your suitability for general anaesthesia and your medical and surgical history. The surgeon will need to consider the nature of the hernia, whether it affects one or both sides of the groin and whether it is your first hernia or a re-occurrence. The National Institute for Clinical Excellence (NICE) has reviewed this procedure and recommends that laparoscopic surgery can be used as one of the treatment options for the repair of inguinal hernia. You can obtain more detailed information about this procedure from their website www.nice.org.uk.

Not all surgeons undertake Laparoscopic surgery and only surgeons specially trained in these techniques will undertake Laparoscopic Hernia Repair.

What are the advantages and disadvantages of laparoscopic surgery over “open” surgery?

One of the benefits of laparoscopic hernia surgery over “open” hernia surgery is that you can usually return to work and normal activities more quickly. There may also be a lower risk of developing persistent numbness and pain after surgery and a smaller incidence of wound infection. (This numbness occurs, at the wound site, after the small sensation nerves in the skin are cut at the time of the operation). Another advantage of laparoscopic surgery is that the surgeon can view both sides of the abdomen, so if there is a hernia on the other side there is an opportunity to repair that at the same time.

The disadvantage of laparoscopic surgery is that there is a slightly higher risk of injury to surrounding structures or tissues (such as the bowel, bladder and blood vessels inside the abdomen) than there is in traditional “open” surgery.

The surgeon will discuss all the risks and benefits of both open and laparoscopic surgery. This will enable you to choose between the procedures and help you to decide which is the best treatment option for you.

What happens before the operation?

Prior to admission you will need to have a pre-operative assessment. This is an assessment of your health to make sure you are fully prepared for your admission, treatment and discharge. The pre-operative assessment nurses are there to help you with any worries or concerns that you have, and can give you advice on any preparation needed for your surgery. Before the date of your admission, please read very closely the instructions given to you. If you are undergoing a general anaesthetic you will be given specific instructions about when to stop eating and drinking, please follow these carefully as otherwise this may pose an anaesthetic risk and we may have to cancel your surgery.

You should bath or shower before coming to hospital.

Getting ready for the operation

When you come into hospital for your operation you will be asked some routine questions about your general health, the medicine you take at the moment and any allergies you have. You will be asked to sign a consent form to confirm that you have read and understood this information leaflet. You will be able to discuss the operation with your surgeon.

How long will I be in hospital?

As this is a day case procedure you will be expected to go home on the day of your surgery.
However, depending on the circumstances and your overall health you may need to stay in hospital overnight.

What sort of anaesthetic will I have?

Laparoscopic hernia operations can be carried out under a general anaesthetic only and you will be fully asleep. Your anaesthetist and surgeon will discuss the reasons for this with you.

How much pain can I expect?

It is normal to experience some pain and soreness around the incision sites, particularly over the first few days. It is, therefore, important for you to take painkillers regularly over the first two to three days (but remember that you should not exceed the stated maximum daily dose).

After your discharge if the level of pain is not controlled, your local GP or chemist should be able to offer you advice. If your pain should become increasingly worse you should consult your GP. You may notice some discomfort for several weeks after the operation. On rare occasions, a more chronic discomfort may persist. Whilst the full reasons for this are not known, it may, among other things, be a result of nerve damage. This may require further investigation or treatment.

How do I care for my wound?

You can remove any dressings the day after your surgery. You may then shower and bathe as required. If you notice that the wounds become increasingly swollen, painful, or if a discharge develops, arrange to see your Practice nurse or GP. It is quite common after hernia repair for men to notice marked swelling and bruising of the scrotum and penis. This will subside over a couple of weeks. If this occurs, it is advisable to wear supportive underwear. As the wounds heal, you may notice a numb area below the wounds. This may be due to disturbance to the nerves during surgery. Whilst in most cases sensation will gradually return the numbness may be permanent.

Can I eat and drink normally after the operation?

Yes, you can return to your normal diet as soon as you are ready. You may feel bloated or constipated for a few days. You may experience occasional feelings of nausea (sickness) and loss of appetite over the first week or so. Eating a high fibre diet and increasing your fluid intake will help to maintain a regular bowel movement. You should normally open your bowels within 2-3 days of your operation although this may be uncomfortable at first. If you do feel you are becoming constipated mild laxatives should help. If you do not have laxatives at home your local pharmacist should be able to give you advice.

What activities will I be able to do after my surgery?

You can return to normal physical and sexual activities when you feel comfortable. You can undertake gentle activities immediately after the operation if it feels comfortable to do so. activity, back to normal for you, over the next few weeks. If you experience an increase in pain it may be because you have done too much.

When will I be able to drive?

You should avoid driving for at least seven to ten days. Before driving you should ensure that you are able to perform an emergency stop, have the strength and capability to control the car, and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance.

When can I return to work?

You can return to work as soon as you feel well enough. Depending on how you are feeling and the type of job that you do, you will generally need about two weeks off work. If you have a job that involves heavy lifting or strenuous activity you may need at least four to six weeks off work.

All surgery has some risks and complications do occasionally occur. Most complications are mild and easily resolved.
Specific risks of Laparoscopic Hernia Repair are:

• In approximately 5 in 100 cases the keyhole method does not work and the surgeon may have to convert to a traditional “open” hernia repair.
• There is a small risk that the instruments used in keyhole surgery may cause damage to large blood vessels, the bladder or the intestines. This may require further surgery to repair the damage.
• Rarely, damage may occur to the testicular vessels, leading to swelling, pain or shrinkage of the affected testis. There is a chance (up to 5 in 100) that the hernia may come back, requiring further surgery.
• Occasionally, damage to the nerves or tissue during hernia repair may cause long term pain or numbness. This may require further investigation or treatment.
• There may be extensive swelling and bruising of the testicles, scrotum and penis.
• Occasionally, some blood (haematoma) or fluid (seroma) can build up in the groin after surgery and make the area swell and feel tender. Whilst this swelling will often settle, sometimes you may need another small operation to stop it.
• Difficulty in passing urine shortly after surgery may occur, requiring the temporary insertion of a catheter to empty the bladder.
• A hernia may develop around one of the wound sites. This may require corrective surgery. Testicular pain is frequent but usually only lasts for a short period after surgery.
• Other potential complications in male patients -
• In men, the stalk that attaches the testicle to the body (spermatic cord) passes through the groin (inguinal) canal. The spermatic cord contains the testicle’s blood vessels and the sperm duct (vas). These structures can be damaged during inguinal hernia surgery but the risk is small (one in one hundred).
• Damage is more common when a recurrent inguinal hernia is repaired. The testicle may shrink as a result (atrophy) but this does not cause any change in masculinity or fertility provided that the other testicle is normal.

The risks of surgery are assessed on an individual basis, as they can vary depending if you have any underlying health issues. Please discuss this with your Consultant.

Other general risks of surgery are:

• A wound infection may develop which may need treatment with antibiotics. A post-operative bleed may occur, requiring further corrective treatment.
• There is a small risk of a clot forming in the leg veins (Deep Venous Thrombosis or DVT) associated with any form of abdominal surgery. This is the same type of clot that passengers on long aeroplane flights may develop. A DVT may cause the leg to swell and occasionally the clot may break loose and lodge in the lung (Pulmonary embolism or PE). Overall the risk of a DVT or PE is small and we will take active measures to minimise this risk to you.
• A DVT is more likely if you are overweight or smoke. You can reduce the risk of developing a DVT by getting up and walking about as soon as possible after your operation.
• A DVT may only be obvious after you have gone home. If you notice any swelling of the calf or more rarely the thigh, or you experience pain or tenderness in the calf, or notice that your leg is shiny or discoloured you should seek medical advice quickly. You should also contact a doctor immediately if you develop shortness of breath or pain on breathing following surgery.
• There is an increased risk of post-operative complications if you are overweight or if you smoke.

When should I seek help?

- If you develop a fever above 38C or chills.
- Persistent vomiting or nausea.
- Increasing abdominal pain or distension.
- Increasing pain, redness, swelling or discharge of any of the wound sites. - Severe bleeding. Difficulties in passing urine.

Where should I seek advice or help?

If you are unwell or develop any of the symptoms above please contact your GP or 111. If you are not unwell but do wish to discuss a problem please contact your surgeons secretary via One health and they will arrange for you to be seen in clinic.