Inguinal hernias: frequently asked questions

Mr Vijitha Chandima Halahakoon, a highly renowned consultant general surgeon answers your frequently asked questions about inguinal hernias.

What is an inguinal hernia?

An inguinal hernia is a protrusion of abdominal contents, quite often bowel or abdominal fat, through a weak area in the groin.

What are the typical symptoms and physical findings associated with an inguinal hernia?

The most common symptom of an inguinal hernia is a bulge felt in the groin. This is mostly felt the tummy muscles are strained, such as when you cough, sneeze, or lift a heavy object. The bulge becomes more prominent towards the end of the day and can usually reduce when you lie flat.

However, as time passes, they can give rise to other symptoms. Inguinal hernias can be painful if they are stuck, if they lead to obstruction of that part of the bowel or if the blood supply to the affected segment of the bowel is compromised. If the bowel segment is obstructed, you will have symptoms of bowel obstruction such as the bowel not opening, distension of the tummy and vomiting.

You will see an obvious bulge in your groin. However, as mentioned, in the early stages the bulge is only seen when you cough, sneeze or lift a heavy object. When you keep the palm of your hand over the lump, you will feel a soft swelling and if it is large, you will feel the bowel movements under your palm.

How do they differ between direct and indirect hernias?

If the hernia comes through the deep inguinal ring, we call it an indirect inguinal hernia. If it comes more medially, then we call it a direct hernia.

The differentiation of the type (direct vs indirect) is more of a discussion about their aetiology (causation) and of their anatomy, but has minimal relevance to how they are treated.

What are the key factors to consider when deciding between open or laparoscopic surgical repair for an inguinal hernia?

Laparoscopic (keyhole) operations of inguinal hernias give better short-term results compared to the open approach. However, in terms of recurrence, long-term results are the same. A laparoscopic operation will leave you with smaller scars which will disappear with time, give you less pain as you recover, permit you to return to normal activities early and let you mobilise early.

The laparoscopic approach is the preferred option due to its favourable short-term outcomes, compared to the open approach. It is particularly preferred in bilateral hernias and in recurrent hernias after open repair. However, if the hernia is big, or descending into the scrotum or if the BMI (body mass index) is high, this approach is technically difficult and is not preferable.

What are the potential complications of inguinal hernia repair surgery, and how can they be managed or prevented?

Inguinal hernia operations are extremely common and are safe. However, as with any operation, they carry certain risks which, fortunately, are very rare.

The most common complication following an inguinal hernia operation is chronic groin pain. This is due to nerve injury at the time of dissection and inflammation around the mesh.  Around 5% of patients will have chronic groin pain after inguinal hernia repair, which is usually mild or moderate. Pain relief can control it, but the pain can last for months. Meticulous dissection at the time of repair will reduce the incidence, but occurrence cannot be completely prevented.

Additionally, there is a risk of damage to structures that are closely related to the hernia sac (bowel, vas deferens and testicular blood supply), but it is highly unlikely that this damage will occur. If the bowel is injured, usually it is visible at the time and can be repaired.

However, any injury which does occur is, unfortunately, permanent and cannot be repaired. Fortunately, these injuries are very rare. If the vas deferens is injured, sperm will not be conducted on that side, however, there will be no functional difference as the vas deferens of the opposite side are still intact. If the testicular blood supply is compromised, the testis (testes) on that side will shrink in size.

Additionally, wounds are at risk of infections following surgery, however, the surgeon will take all the precautions to prevent this happening. Although bleeding could occur, it is rare and can be controlled.

Any anaesthesia-related complications are related to your general health and will be explained before the operation.

In cases of recurrent inguinal hernias, what are the most common causes and approaches for surgical repair?

About 2% of Inguinal hernia repairs can fail. Failure can occur due to technical or patient-related factors. A meticulous repair by the surgeon is the most important factor to prevent a recurrence.

However, there are some patient-related factors that can predispose someone to a recurrence:

• Having a higher BMI.
• Smoking.
• Pre-existing connective tissue disorders.
• Straining of abdominal muscles during the recovery time (usually within the first four weeks) such as lifting heavy objects, continued coughing, or sneezing.

The surgical approach for recurrence depends on the initial approach. If the recurrence is from a previous open repair a laparoscopic (keyhole) approach for the second operation is preferred. However, a second open repair is an option too. An open approach is an option for recurrence after laparoscopic (keyhole) repairs.

Is the use of mesh in inguinal hernia repairs bad?

Meshes had been in use for hernia repairs for about 50 years now and are considered very safe.

There are few traditional non-mesh repairs of inguinal hernias, which rely on the local tissues to repair the hernia. However, it is the weakness of the very same tissues that gave the hernia in the first instance and as such can’t be relied upon. Moreover, such non-mesh repairs would always approximate tissues under tension – which then will fail under tension. As such, for these two reasons, surgeons have moved away from non-mesh repair for so long to reduce the chance of recurrence.

Although adding a mesh to the inguinal hernia repair increases the chance of pain and infection, the advantage of the mesh outweighs the small negative effects.

If you are suffering from a hernia and would like to discuss this with Mr Halahakoon, do not hesitate to book a consultation by visiting his Top Doctors profile today.