Clinic for Digestive Surgery

Hernia

What is a hernia?

A hernia occurs when the layers of the abdominal muscles have weakened, resulting in the protrusion of the abdominal contents through the defect. In the case of abdominal wall hernias, this is seen outwardly as an abnormal bulge or lump.

Abdominal wall hernias commonly occur in the groin (inguinal), belly button (umbilical) or at the site of an old scar (incisional). Hernias are often more obvious on straining (while coughing, sneezing or carrying a heavy load), and occasionally disappear on lying down. There might be pain or discomfort associated, and this is often worse towards the end of the day. In some cases, the pain can be severe and acute, especially when a loop of intestine or abdominal contents are trapped within the hernia.

What causes a hernia?

There are certain areas in the abdominal wall that are naturally potential sites of weakness. When ageing, chronic straining, injury or a surgical incision uncovers this potential, the layers of the abdominal wall weaken further and fail in the task of keeping the abdominal contents within the abdominal cavity. This then results in a hernia.

Sometimes, hernias can present during birth or childhood. These are termed as congenital hernias.

What are the potential complications of hernias?

Besides the discomfort, and physical impediment in large hernias, caused, hernias have a potential risk of incarceration and strangulation.

When a hernia is no longer reducible, it is termed as incarcerated. When this occurs, you will be at higher risk of strangulation. Strangulation is said to occur when the blood supply to the contents of the hernia is compromised. As a result, a loop of trapped intestine or abdominal contents can potentially turn gangrenous and cause continuous severe pain. When a loop of intestine turns gangrenous, a hole can develop as a result, causing spillage of intestinal contents.

What are the treatment options for hernia?

A hernia does not get better with time, or go away by itself without treatment. There are no forms of medication that will help either. Temporary measures like hernia belts (trusses) are usually ineffective and do not solve the underlying problem of the defect in the abdominal wall. The only effective treatment option is surgical.

Can I leave a hernia alone safely?

If the hernia is causing symptoms, the risks of incarceration and subsequent strangulation are likely to be higher and surgery is advisable to avoid having the need to have it done in an emergency when complications occur.

As for the hernia that does not cause any symptoms, watchful waiting is an acceptable option especially when the risk of surgery is high.

What are the surgical options available?

Hernia repair involves first reducing the hernia and the subsequent reinforcement closure of the defect in the abdominal wall. While defects used to be closed with sutures in older techniques, the current standard of repair now is recognised to be a tension-free repair with a mesh. The mesh used in hernia repair is normally made of synthetic material, which then promotes the ingrowth of organic bodily tissue, which in turn reinforces the closure of the defect.

The operation can be performed with either an open method or minimally invasive laparoscopic (key-hole) method. The open method involves a longer cut on the skin directly over the hernia and dissection through the layers underneath to access the hernia defect. This can also be accomplished through regional or local anaesthesia.

Laparoscopic hernia repair is performed through smaller key-hole incisions. With the aid of a camera on a telescope, the operation is performed through special longer instruments.

What are the complications of hernia repair?

Other than the potential risks associated with anaesthesia, the complications of hernia repair include bleeding, infection and seroma formation, and recurrence and nerve injury in the long term.

During the operation, there is a small risk (<1%) of injury to the organs around the hernia during the course of liberating the sac. These organs include the intestines, urinary bladder, nerves, blood vessels and the spermatic cords (which transport sperm from the testicles).

Seroma is a common post-operative collection and swelling of fluid at the hernia site. This can be mistaken for an early recurrence, as a lump is seen to recur. However, this is very often self-limited and disappears after a duration that depends on the initial size of the seroma.

Numbness is uncommon after hernia repair, and is often temporary. However, a persistent numbness and rarely, a sharp pain, might complicate matters in 1–2% of operations.

Recurrence of a hernia occurs in 2–3% of patients, and can occur anytime from the early post-operative period to many years after the wound has healed.

What are the advantages of laparoscopic hernia repair?

Laparoscopic hernia repair, while demanding a higher level of surgical expertise, is associated with less post-operative pain, faster recovery, and smaller scars compared to the open operation. The rates of recurrence are similar to the open operation, under expert hands.

Am I a candidate for laparoscopic hernia repair?

Laparoscopic hernia repair is not the best operation for certain patients, especially those with previous abdominal operations, or those with significant medical conditions. In a small number of patients, the laparoscopic operation cannot be safely completed, and needs to be converted to an open procedure. The decision to convert is always strictly based on patient safety.

What should I expect after surgery?

Immediately after the operation, if general anaesthesia was administered, you will be transferred to the recovery room until you are fully awake. As it is with all operations, there will be a mild discomfort at the operation site, but this should not be a severe pain. You might have a slight hesitancy and difficulty passing urine after surgery. If this is significant, you might require a temporary tube into the urinary bladder for as long as one week.

After your discharge, you can be expected to return to work within a week if your job is sedentary. However, a longer period of rest is required if your job requires significant physical activity. In either case, you will be advised to lay off heavy physical activity and heavy loads for at least 6 months after surgery.