• What is a hernia?
• What do hernias contain?
• Types of hernia
• Symptoms
• Complications
• Why operate?
• What operation?
• Advantages of keyhole surgery for hernia
• Types of keyhole surgery
• Surgery for incisional hernia
• Sportsman’s groin
• View a laparoscopic incisional hernia repair
• View a sublay operation
• view laparoscopic groin hernia repair

What is a hernia?

A hernia is an abnormal defect in the abdominal muscular wall through which the abdominal contents protrude. Typically a hernia will be prominent when the patient is up and about or on straining. The hernia will reduce when the patient lies down.

What do hernia’s contain?

Any intra abdominal organ can be pushed into a hernia. Typically fat and bowel are involved.

The incisional hernia is less obvious when lying flat	The incisional hernia bulges when the patient strains to sit

Types of hernia

Hernias are described by location, complications and prior operations
Groin hernias may be inguinal or femoral, primary or recurrent (if a past operation has failed). They often effect both sides where they are termed bilateral.
Midline hernias include umbilical epigastric and ventral. Laterally placed hernias include spigelian and lumbar.
Incisional hernias develop through the site of an operation.
Hiatus Hernia involves the stomach being pushed up through a defect in the diaphragm. Hiatus hernia is associated with acid reflux.

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Symptoms

Hernias typically present with a lump which goes away at rest. The hernia may be painful. Continuous pain or a lump, pain and vomiting can suggest a complication.

Complications

If the contents of the hernia will not go back when the patient tries to push them in this is termed incarceration. Incarceration can lead to strangulation when the blood supply to the hernia contents is restricted and cut off. If bowel is incarcerated it may be blocked leading to bowel obstruction.

Why operate?

Most hernias in adults require an operation to repair them. This is because they never heal up on their own. They often enlarge making repair more difficult and the may become painful or complicated by strangulation. An individual assessment of risk and benefit is required in each case by a specialist.

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What operation
Hernias can be repaired under local or general anaesthetic. Mesh is used for the repair of most hernias as recurrence after mesh hernia repair is less common than after hernia repair without mesh. Keyhole surgery can be used in many cases.

Advantages of keyhole surgery

As with many operations the small incisions used in keyhole surgery give rise to less pain, a more rapid return to normal activity and few local wound related problems.
If keyhole surgery is used bilateral hernias can be repaired at the same operation without any additional cuts.
Recurrent hernias can be repaired without cutting through old scar tissue. Open surgery for recurrent hernias is more prone to damage to associate anatomical structures such as (in men) the vas and testicular artery. Recurrent hernias often occur in several places and all defects are covered in mesh with keyhole surgery making further recurrence less likely. Open surgery for recurrence is more prone to wound related problems such as haematoma and infection.
Critically in groin hernia open mesh repair has a significant chance of leaving the patient with long term wound pain or changed sensation in the groin skin. This can be very disabling and may not be treatable. Keyhole surgery is 5 times less likely to cause problems of this type. The national institute for clinical excellence has recognised these facts and for this reason I recommend keyhole surgery for the majority of patients with groin hernia of all types. Keyhole surgery is also possible for some incisional hernias.

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Types of keyhole surgery

Keyhole surgery requires general anaesthesias. For groin hernias the mesh is placed in the extra peritoneal space. This can be achieved by a totally extra peritoneal operation (TEP) or a trans-abdominal pre-peritoneal operation (TAPP). The choice between TEP and TAPP is tailored to the individual patient. For incisional hernias the approach is always trans-peritoneal and special mesh is used to reduce bowel adhesions. View a laparoscopic inguinal (Groin)hernia repair

Mesh location in groin hernia repair.
Think of the abdominal wall as a dam and a hole in the dam as the hernia. In open hernia surgery a mesh patch is place on the outer surface of the dam, the water can push it off. In keyhole surgery the mesh patch is on the water side so that the water holds the patch in place.

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Surgery for incisional hernia

Incisonal hernias occur is around 15% of surgical wounds. We hope that the incidence of incisional hernia will be reduced by wider application of keyhole surgery. In the interim patients commonly present with a hernia in an operation wound typically when the wound was infected at the time that it was made or when the patient was very ill at the time of the surgery. Poor healing is implicated and is also seen in obese patients.
I use two main types of repair for incisional hernias.
Sublay operation. Firstly for very large midline hernias a sublay operation gives a good result. The sublay operation is open surgery. Mesh is placed beneath the muscles which are brought together over the mesh. This has the advantage of getting rid of the large bulge of the hernia and keeping the mesh away from the superficial layers where it could become infected or ulcerate through. It is also possible to remove redundant skin and fat providing a cosmetic improvement. The downside is that this is major surgery with a chance of wound related problems. However the initial hernia is often severe. (View a sublay operation) Patient Story

Keyhole surgery (Laparoscopic incisional hernia repair) is a good option for small or medium sized hernias. No major incision is required. A special mesh is used to prevent adhesions to the bowel. (View a laparoscopic incisional hernia repair)

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Sportsmann’s groin

Typically seen in young men and also known as footballer groin or Gilmoor’s groin after the surgeon who originally described it. It is characterised by unilateral groin pain or gradual onset not associated with a bulge or clinically apparent hernia where other injuries have been excluded by clinical examination. The problem is thought to be a tear in the tissue locally. When correctly diagnosed sportsmann’s goin responds well to totally extra-peritoneal mesh repair (TEP).