Hernia

You have been diagnosed with a hernia. This leaflet will explain:

• what a hernia is and what the different types are

• how a hernia is repaired

• what complications can develop, and

• what happens during and after surgery.

If you have any further questions, please speak to your surgeon.

What is a hernia?

What causes a hernia?

You can be born with a hernia or you can get one later in life. Sometimes it may happen following surgery.

What sort of trouble can hernias cause?

A hernia may cause no pain or discomfort at all, you may simply notice a lump. Often the lump disappears when you lie down.

Some people feel discomfort, aching, or an actual pain at the area where the lump appears. This is often worse towards the end of the day, when you have been on your feet a lot. Any physical activity can aggravate the discomfort or pain.

You may find that the discomfort reduces or stops when you lay down and push / massage the lump away. When you do this, the contents of the hernia are pushed back into your abdominal cavity.

How are hernias diagnosed?

A doctor diagnoses most hernias after a physical examination.

Some hernias may need special tests, like ultrasound scans or dye tests, to confirm their presence, especially if they are very small.

Are there different types of hernias?

Yes. Hernias occur in several different areas of the body.

Can hernias develop complications?

Most hernias do not develop complications but remain simply as a lump, which may be painless or cause minor discomfort. However, complications can develop, and some are listed below.

• Irreducible: this means that the hernia lump never goes away. This is most common with femoral and inguinal types of hernias. If you have a hernia which does not go away, you should have it looked at by a doctor. Particularly if the hernia lump becomes painful or you start being sick.

• Obstructed: this means that part of your bowel has become stuck within the hernia, blocking your bowel from passing food and fluid along.

  • This will result in colicky or cramp-like pains in your tummy (like trapped wind, the pains come and go in waves) followed by vomiting.

  • You will stop passing wind from your back passage.

  • Your hernia lump will be hard, often painful, and will not go away. If this happens you must immediately go to your GP or hospital Emergency Department.

• Strangulated: if this happens, it means that so much bowel or omentum has squeezed into the hernia through the gap in your muscles that it cuts off its own blood supply and the tissue in the hernia dies. This can happen in just a few hours, which is why it is a surgical emergency. This is the most severe complication that a hernia can have.

  It causes severe pain at the site of the lump. Sometimes several hours later the skin over the lump becomes red and you have a griping pain in your tummy. This may lead to vomiting and all bowel activity stopping (you stop passing wind from your back passage and your bowels do not work (you stop pooing)). If this happens you must go immediately to your GP or your nearest Emergency Department. This is a very rare complication of a hernia.

• Skin changes: the skin overlying a longstanding hernia can become stretched and thinned. At its worst, an ulcer can develop.

What is a hernia repair?

To repair a hernia, the split in the muscle layer that has produced the gap needs to be closed. Your surgeon will do this either:

• with strong permanent internal stitches, or

• by patching the gap with an artificial permanent patch called a mesh.

Most hernias are now repaired with mesh. The mesh is made from synthetic (artificial) material. It is usually placed deep within the layers of muscle, so that you are unaware it is there.

It is important to perform a tension free repair to reduce the risk of the hernia coming back. This is only possible using mesh.

Do all hernias need surgery?

No. Some small hernias, which are not causing discomfort, can be left alone.

Sometimes a small hernia will continue to grow. After months but usually after several years, it may reach a size where it causes discomfort or is large enough to cause doctors concern that it could develop complications.

If your hernia grows significantly larger, tell your GP and they will refer you back to the hospital.

How can I prepare for my surgery?

While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:

• feel in control

• leave hospital sooner, and

• get back to normal more quickly.

To help with this, you may be contacted by a member of the One You Kent (OYK) team. OYK work in the community, and help patients improve their general health. This includes help and advice on:

• Stopping smoking

• Losing weight

• Getting more exercise

More information can be found on the following web sites.

• One You Kent (Kent Community Health)

• Fitter Better Sooner Toolkit (Royal College of Anaesthetists)

What are the risks to having hernia repair surgery?

All operations carry a risk. There are general risks that are common to all operations.

• Wound infection: the skin around your wound may go red and painful, or your wound may leak pus. Around one in 20 patients will have this complication, usually after they are already at home. Ask your GP or practice nurse to check your wound if this happens, as you may need antibiotics.

  The wound may ooze a little bit of blood or clear fluid for the first 48 hours, needing a change of wound dressing.

• Bruising: it is quite normal to have some bruising around your wound. Often this does not appear until after you have gone home from hospital. Occasionally a very large bruise may form, which takes one or two weeks to go away.

• Haematoma: this means a collection of blood. In hernia operations, this usually happens beneath your wound, forming a lump. A large lump may take several weeks to go away (disperse). As it disperses, bruising usually appears.

  With keyhole surgery of groin hernias, the haematoma may appear in the area where your hernia lump was. It is important not to mistake this haematoma for the hernia returning.

• Chest infection: if you develop a cough or feel short of breath after your operation, you may have developed a chest infection. This is rare if you are fit and healthy. You are at high risk of this if you have a lung disease (such as chronic bronchitis, emphysema, or severe asthma) and moderate risk if you are overweight or a smoker.

• Internal bleeding: this is rare (occurring in less than one in 1000 hernia operations). You may need a blood transfusion or second operation to stop the bleeding.

• Allergic reactions to antibiotics or anaesthetics: this is rare (occurring in less than one in 100 operations). If you have had a bad reaction to an anaesthetic or any medication before, tell your surgeon or anaesthetist before your operation.

• Blood clots in the legs: also known as deep venous thrombosis (DVT). The blood clot may move from your leg to your lungs (pulmonary embolus), which can be a life threatening condition. A fit healthy person has a very small risk of DVT. Your risk is higher if you:

  • are overweight

  • are a smoker

  • have poor general health

  • have difficulty walking, or

  • have had a DVT before.

  To reduce your risk of developing a DVT, we will encourage you to get out of bed as soon as possible after your anaesthetic. Staff may also give you an injection of a medicine called heparin, which reduces your chance of developing a large pulmonary embolus.

  While you are on bed rest, you should exercise your calf muscles by moving your feet up and down.

• Ischaemic orchitis: this is a very rare complication of inguinal hernia repairs in men. The blood supply to the testis gets affected, causing them to become painful, small and to stop working. This is more common in patients undergoing repair of their inguinal hernias for the second time (one in 50 as compared to one in 1000 for first time patients).

Complications due to the mesh itself

All types of mesh used to repair hernias are made of synthetic material. The mesh is not absorbed by the body but remains permanently in place. This is why they are so successful in repairing hernias.

Rarely, there can be problems related to the mesh itself.

• Infection: all mesh is sterilised and free of germs when it is put into your body. However, everyone carries germs on their skin, and there is a small risk that your skin germs could get on the mesh at the time of surgery. If this happens, it can cause an infection. To help prevent this, the anaesthetist will give you antibiotics during your operation.

  Mesh infection is a rare complication if your hernia repair is a planned operation, effecting less than one in 200 patients.

  Once mesh is infected, antibiotics may not get rid of the infection, and you may need to have the mesh removed by further surgery. Having the mesh removed may result in the hernia coming back.

• Bowel obstruction / bowel fistula is a very rare complication. It can only happen if your bowel is in direct contact with the mesh. In many hernia repairs this contact does not happen. Even where a bowel is in contact with mesh, it is rare for this to cause a problem. Bowel can be in contact with the mesh in keyhole (laparoscopic) surgery of epigastric hernias, umbilical / paraumbilical hernias, and spigelian hernias. Here, we use a mesh with protective linings.

  Less often, bowel may come in contact with mesh during keyhole surgery of inguinal or femoral hernia repairs. Open hernia repairs where mesh may be in contact with bowel include ventral, epigastric, and umbilical hernias. It is very uncommon for mesh to get in contact with bowel in open hernia repairs of inguinal or femoral hernias.

  Open inguinal mesh hernia repair can give rise to chronic (long-term) pain in your groin. This can happen in up to one in 10 patients having the operation. This is almost unheard of in keyhole repair of inguinal hernias.

Can hernias come back?

Yes. The use of mesh has reduced the number of hernias that come back (called “recurrence” of a hernia). The risk of a hernia coming back depends on many factors.

• The type of hernia you have.

• The size of hernia (larger ones are more difficult to patch successfully).

• The hernia is recurrent (it has been repaired before but has come back again).

• If you are diabetic you heal less well.

• If you have an emergency operation.

• If you have a heavy physical job or regularly perform very strenuous exercise.

• If you are on medication which impairs healing, for example steroids or cancer drugs.

• If you have a chronic (long-term) cough.

Can I have keyhole surgery to repair my hernia?

This depends on what type of hernia you have, its size, and whether your surgeon is trained in keyhole (laparoscopic) surgery.

Keyhole surgery will repair your hernia using several small cuts on your tummy, rather than one large cut (open surgery)). Both keyhole and open surgery aim to close or patch the gap in the muscles that is the hernia.

• Keyhole surgery may not be an option for some hernias.

• Keyhole surgery has to be performed under a general anaesthetic.

• Keyhole surgery always involves using mesh.

• Keyhole surgery generally gives less pain and has a quicker recovery after surgery compared to open surgery.

• Keyhole surgery is more complicated to perform than open surgery.

Your surgeon will discuss your options with you. They can advise you whether your hernia is suitable for open or keyhole repair.

The National Institute for Health and Care Excellence (NICE) has assessed the benefits of keyhole versus open hernia repair only for inguinal hernias. They concluded that mesh should be used during keyhole surgery for:

• inguinal hernias which have come back after a previous repair (recurrent inguinal hernias), and

• bilateral inguinal hernias (having a right and left sided hernia at the same time).

NICE also concluded that patients with a single inguinal hernia should be offered the choice of open or keyhole surgical mesh repair.

Are there any disadvantages specific to keyhole surgery?

Yes.

Keyhole surgery involves placing hollow metal tubes the width of a pencil or larger, through the muscle of your abdominal wall. This muscle protects the contents of your abdomen (such as bowel and bladder) from harm. On rare occasions these metal tubes may puncture something. Your surgeon usually sees when this damage happens, and repairs it. If this happens, it may stop the surgeon from completing your operation. This is a rare complication.

If your surgeon does not see this damage during your operation, you may become unwell in the hours or days following your surgery. This alerts the doctors looking after you to the fact there is a problem. If this happens, you may need major surgery to correct the problem.

How soon can I go home after my operation?

To be able to go home you must be able to drink, eat light meals, walk about comfortably, and pass urine normally. Sometimes a patient booked in for day surgery has to be kept in overnight because they cannot achieve all of these.

Your surgeon will have given you an estimate of how long you will be in hospital at your clinic visit.

How will I feel after my surgery?

Most people need to take tablet-type painkillers after their operation. If you had keyhole surgery, you may only need these for a few days. If you had open surgery, you may need to take them for longer.

Everyone is different when it comes to pain. We can only give you an estimate about how you will feel.

Will I need to have somebody to look after me at home?

After day surgery, have a responsible adult stay with you for 24 hours after your surgery. You may feel tired and woozy after surgery, so it will be helpful to have someone look after you and make you hot drinks and light meals. They can also phone the hospital for you if you have a problem.

After the first 24 hours, arrange for someone do your shopping or run errands for you. If possible, do this until you are able to move around on your own.

What will I be able to do when I go home?

• It is normal to feel tired and a bit sore for several days. You should rest and eat only light meals for the first day or two.

• Avoid alcohol while taking painkillers stronger than paracetamol.

• Your bowels may be constipated (you cannot go for a poo). This is a result of missing normal meals around the time of your surgery, and a side effect of taking many painkillers. It should settle by itself, but if not you can buy a gentle laxative from any chemist.

• Make sure you walk around every couple of hours during the day. This keeps the blood circulating in your legs and reduces the chance of a blood clot forming in your legs.

• If you feel sore, take your painkillers regularly so you can move about. If you are still feeling sore and need painkillers after you have finished the supply given to you by the hospital, contact your GP for more. This is rarely necessary.

Younger people will usually return to normal more quickly than an older person.

How should I care for my wound(s) at home?

The ward nurse will explain this to you before you leave hospital. If you have any questions, please ask them.

• Most surgeons use skin stitches which go away (dissolve) by themselves, and cover wound(s) with a light dressing.

• Remove your dressing 5 to 7 days after your surgery. Only replace it before then if your wound is oozing or bleeding (the hospital will give you a fresh dressing for this). After 5 to 7 days leave your wound uncovered, unless told otherwise by the hospital.

• After 48 hours wounds are usually sealed enough for you to have a shower. You may have a bath five days after your surgery, if your wound is clean and dry.

• It is normal for your wound to feel hard and tender for several weeks. It is also normal for you to feel a lump under your wound, as this is the healing ridge of tissue. The scar will be red and often remains red for many months.

• Contact your GP practice nurse, if the skin around your wound:

  • becomes red extending more than one inch (2cm) from your scar, and

  • this does not go away within 24 hours of you noticing it.

  This could mean that you have developed an infection and need antibiotics.

When can I return to work?

This depends on the type of work you do and the type of hernia you had. You can usually return to a desk job after 2 weeks. A heavy manual job will need longer off work, sometimes this can be 6 weeks.

When can I drive again?

You must not drive within 24 hours of a general anaesthetic. It is also recommended that you do not drive while on strong painkillers, as they may make you sleepy. Otherwise, once you can comfortably use all the controls in the car, it is safe to drive. This means being able to perform an emergency stop and being able to turn round in your seat to safely reverse your car. Most people find they need a week to recover enough to drive safely.

Check with your insurance company if they have any specific rules related to the type of operation you have had. This is particularly important for professional drivers.

When can I exercise again?

Doctors opinions vary about this, because of a lack of any detailed study into this question. Your surgeon will be able to give you their opinion based on your type of hernia and the type of sport you want to do.

Will I have a follow-up appointment?

Most surgeons do not see patients after a hernia repair, as recovery is usually straightforward. If you have any problems, speak to your GP and they will refer you back to your surgeon if they have any concerns.

Is it possible to be too unfit for hernia surgery?

Yes, usually due to heart or lung problems. However, many health conditions can make someone at high risk of dying from surgery. If this happens, the surgeon will advise the patient not to have surgery. An anaesthetic doctor also examines the patient to help us decide whether they are fit for surgery or not.

If you still wish to have the operation, you can ask for a second opinion from another consultant surgeon. We will arrange this or we will ask your GP to arrange it for you.

In certain cases, if your hernia is producing symptoms but is not too big and you are unfit to have general anaesthetic, your surgeon can repair the hernia under local anaesthesia.

What if I have any questions or concerns when I return home?

If you have any queries (especially if you are getting increasing pain, redness, or swelling after 48 hours), please contact Day Surgery on the numbers below or your GP.

• Canterbury Day Surgery Centre, Kent and Canterbury Hospital, Canterbury
  Telephone: 01227 783114 (7:30am to 8pm)
  Telephone: 07887 687645 (8pm to 7:30am)

• Day Surgery, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 234499 (7:30am to 8pm)
  Telephone: 07887 651162 (8pm to 7:30am)

• Channel Day Surgery, William Harvey Hospital, Ashford
  Telephone: 01233 616263 (24 hours a day, 7 days a week)