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inguinal hernia: what you need to know

INTRODUCTION

An inguinal hernia appears as a bulge in the groin or scrotum. This occurs when the intestine bulges through the opening in the muscle in the groin area. A reducible hernia can be pushed back into the opening. When intestine or abdominal tissue fills the hernia sac and cannot be pushed back, it is called irreducible or incarcerated. A hernia is strangulated if the intestine is trapped in the hernia pouch and the blood supply to the intestine is decreased. This is a surgical emergency. Inguinal hernias account for 75% of all hernias and are most common in men.

SYMPTOMS

The most common symptoms are:

Bulge in the groin, scrotum, or abdominal area that often increases in size with coughing or straining.
Mild pain or pressure at the hernia site.
Numbness or irritation due to pressure on the nerves around the hernia.
Sharp abdominal pain and vomiting can mean that the intestine has slipped through the hernia sac and is strangulated. This is a surgical emergency and immediate treatment is needed.

TREATMENT OPTIONS

Surgical Procedure

Open hernia repair — An incision is made near the site and the hernia is repaired with mesh or by suturing (sewing) the muscle closed. Laparoscopic hernia repair — The hernia is repaired with mesh or sutures inserted through instruments placed into small incisions in the abdomen. Many patients become symptomatic after the first 1 to 2 years and cross over to surgery due to increased pain on exertion, chronic constipation, or urinary symptoms.

Surgical Treatment

The type of operation depends on hernia size and location, and if it is a repeat hernia. Your health, age, anesthesia risk, and the surgeon’s expertise are also important. An operation is the only treatment for incarcerated/strangulated and femoral hernias. Your hernia can be repaired using either an open or laparoscopic approach. The repair can be done using sutures only or by adding a piece of mesh.

Open Hernia Repair

The surgeon makes an incision near the hernia site and the bulging tissue is pushed back into the abdomen. Most inguinal hernia repairs use mesh to close the muscle. An open repair can be done with local anesthesia.

For an open mesh repair: The hernia sac is removed. Mesh is placed over the hernia site and attached using sutures sewn into the stronger tissue surrounding the hernia site. Mesh plugs may also be placed into the inguinal or femoral hernia space. The mesh plug fills the open site and is sutured to the surrounding tissue. An additional mesh patch may be applied and may or may not be sutured. Mesh is often used for large hernia repairs and may reduce the risk that the hernia will come back. The site is closed using sutures, staples, or surgical glue.
For a suture-only repair: The hernia sac is removed. The tissue along the muscle edge is sewn together. This procedure is often used for strangulated or small defects (less than 3 cm).

Laparoscopic Hernia Repair

The surgeon will make several small punctures or incisions in the abdomen. Ports (hollow tubes) are inserted into the openings. The abdomen is inflated with carbon dioxide gas to make it easier to see the internal organs. Surgical tools and a laparoscopic light are placed into the ports. The hernia is repaired with mesh and sutured or stapled in place. The repair is done as a Transabdominal Preperitoneal (TAPP) procedure, which means the peritoneum (the sac that contains all of the abdominal organs) is entered, or as a Totally Extraperitoneal (TEP) procedure.

NONSURGICAL TREATMENT

Watchful waiting is an option if you have an inguinal hernia with no symptoms. Hernia incarceration occurred in 1.8 per 1,000 men who waited longer than 2 years to have a repair. Femoral hernias should always be repaired because of the high risk (400 of 1,000) of incarceration and bowel strangulation within 2 years of diagnosis. Trusses or belts can help manage the symptoms of a hernia by applying pressure at the site. A truss requires correct fitting, and complications include testicular nerve damage and possible incarceration.

BENEFITS AND RISKS OF YOUR OPERATION

Benefits — An operation is the only way to repair a hernia. You can return to your normal activities and, in most cases, will not have further discomfort. Possible risks include — Return of the hernia; infection; injury to the bladder, blood vessels, intestines, or nerves; difficulty passing urine, Continued pain and swelling of the testes or groin area. Risks of Not Having an Operation — Your hernia may cause pain and increase in size. If your intestine becomes trapped in the hernia pouch, you will have sudden pain, vomiting, and need an immediate operation.

RECOVERY AND DISCHARGE

Thinking Clearly

If general anesthesia is given, or if you are taking narcotic pain medication, it may cause you to feel different for 2 or 3 days, have difficulty with memory, and feel more fatigued. You should not drive, drink alcohol, or make any big decisions for at least 2 days.

Nutrition

When you wake up from the anesthesia, you will be able to drink small amounts of liquid. If you do not feel sick, you can begin eating regular foods.
Continue to drink about 8 to 10 glasses of water per day.
Eat a high-fiber diet so you don’t strain while having a bowel movement.

Activity

Slowly increase your activity. Be sure to get up and walk every hour or so to prevent blood clot formation.
Patients usually take 2 to 3 weeks to return comfortably to normal activity.
You may go home the same day after a simple repair. If you have other health conditions or complications such as nausea, vomiting, bleeding, or difficulty passing urine, you may stay longer.
Persons sexually active before the operation reported being able to return to sexual activity in 14 days (average).

Work and Return to School

You may return to work after 1 to 2 weeks after laparoscopic or open repair, as long as you don’t do any heavy lifting. Discuss the timing with your surgeon.

Wound Care

Always wash your hands before and after touching near your incision site.
Do not soak in a bathtub until your stitches, Steri-Strips, or staples are removed.
You may take a shower after the second postoperative day unless you are told not to.
Follow your surgeon’s instructions on when to change your bandages.
A small amount of drainage from the incision is normal. If the dressing is soaked with blood, call your surgeon.
If you have Steri-Strips in place, they will fall off in 7 to 10 days.
If you have a glue-like covering over the incision, allow the glue to flake off on its own.
Avoid wearing tight or rough clothing.
It may rub your incisions and make it harder for them to heal.
Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.
Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.

Bowel Movements

Avoid straining with bowel movements by increasing the fiber in your diet with high-fiber foods or over-the-counter medicines (such as Metamucil and FiberCon). Be sure you are drinking 8 to 10 glasses of water each day.

Pain

The amount of pain is different for each person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during anesthesia.

WHEN TO CONTACT YOUR SURGEON

Contact your surgeon if you have:

Pain that will not go away.
Pain that gets worse.
A fever of more than 101°F (38.3°C).
Continuous vomiting.
Swelling, redness, bleeding, or bad-smelling drainage from your wound site.
Strong or continuous abdominal pain or swelling of your abdomen.
No bowel movement by 2 to 3 days after the operation.

SMGH

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