What is inguinal hernia repair surgery

Inguinal hernia repair surgery is a surgical procedure to fix an inguinal hernia in your groin and prevent the serious complications that an inguinal hernia can cause. Inguinal hernia repairs are one of the most common general surgical operations performed in the world ¹. Approximately 600,000 inguinal hernia repair operations are performed annually in the United States ². Some are performed by the conventional “open” method. Some hernia repairs are performed using a small telescope known as a laparoscope.

Inguinal hernia is tissue that bulges out of a weak spot in the abdominal wall in your groin. Your intestine may bulge out through this weakened area. Inguinal hernia will not get better without surgery.

There are many treatment options for patients with inguinal hernias including watchful waiting, open primary repair, open tension-free repairs with the use of mesh prosthetics, and laparoscopic repairs which are typically performed with mesh prosthetics. You can also sometimes control the hernia with a truss (padded support belt) or simply leave it alone. Use of a truss (hernia belt) is rarely prescribed as it is usually ineffective. It may alleviate some discomfort, but will not prevent the possibility of bowel incarceration or strangulation.

During surgery to repair the hernia, the bulging tissue is pushed back in. Your abdominal wall is strengthened and supported with sutures (stitches), and sometimes mesh. This repair can be done with open or laparoscopic surgery. You and your surgeon can discuss which type of surgery is right for you.

Your surgeon will decide which kind of anesthesia you will receive:

• General anesthesia is medicine that keeps you asleep and pain-free.
• Regional anesthesia, which numbs you from the waist to your feet.
• Local anesthesia and medicine to relax you.

In open surgery:

• Your surgeon makes a cut near the hernia.
• The hernia is located and separated from the tissues around it. The hernia sac is removed or the hernia is gently pushed back into your abdomen.
• The surgeon then closes your weakened abdominal muscles with stitches.
• Often a piece of mesh is also sewn into place to strengthen your abdominal wall. This repairs the weakness in the wall of your abdomen.
• At the end of the repair, the cut is stitched closed.

In laparoscopic surgery:

• The surgeon makes three to five small cuts in your lower belly.
• A medical device called a laparoscope is inserted through one of the cuts. The scope is a thin, lighted tube with a camera on the end. It lets the surgeon see inside your belly.
• A harmless gas is pumped into your belly to expand the space. This gives the surgeon more room to see and work.
• Other tools are inserted through the other cuts. The surgeon uses these tools to repair the hernia.
• The same repair will be done as the repair in open surgery.
• At the end of the repair, the scope and other tools are removed. The cuts are stitched closed.

Before the inguinal hernia repair procedure

Tell your surgeon or nurse if:

• You are or could be pregnant
• You are taking any medicines, including drugs, supplements, or herbs you bought without a prescription

During the week before your surgery:

• You may be asked to stop taking blood thinning medicines. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), naprosyn (Aleve, Naproxen), and others.
• Ask your surgeon which drugs you should still take on the day of surgery.

On the day of inguinal hernia repair surgery

• Follow instructions about when to stop eating and drinking.
• Take the medicines your surgeon told you to take with a small sip of water.
• Arrive at the hospital on time.

After the inguinal hernia repair procedure

Most people are able to get out of bed an hour or so after this surgery. Most can go home the same day, but some may need to stay in the hospital overnight.

Some men may have problems passing urine after hernia surgery. If you have problems urinating, you may need a catheter. This is a thin flexible tube that is inserted into your bladder for a short time to drain urine.

Following instructions about how active you can be while recovering. This may include:

• Returning to light activities soon after going home, but avoiding strenuous activities and heavy lifting for a few weeks.
• Avoiding activities that can increase pressure in the groin and belly. Move slowly from a lying to a seated position.
• Avoiding sneezing or coughing forcefully.
• Drinking plenty of fluids and eating lots of fiber to prevent constipation.

Follow any other self-care instructions to help speed your recovery.

Inguinal hernia repair prognosis

Outcome of inguinal hernia repair surgery is usually very good. In some people, the hernia returns.

What is an inguinal hernia?

Weak spots can develop in the layer of muscle in your abdominal wall, resulting in the contents of your abdomen pushing through. This produces a lump called a hernia. An inguinal hernia is a common condition caused by a weakness in your abdominal wall, near the inguinal canal. This is a narrow passage in which blood vessels supplying your testicle pass through your abdominal wall.

Inguinal hernias are very common (approximately 75% of abdominal wall hernias) with other types of hernias occurring at weak areas of abdominal wall fascia ³. If left untreated, an inguinal hernia can be dangerous because your intestines or other structures within your abdomen can get trapped and have their blood supply cut off (strangulated hernia).

Two types of inguinal hernias may occur. These are classified as a direct and indirect hernia. An indirect hernia passes through the deep (internal) inguinal ring and is located lateral to the inferior epigastric vessels. A direct hernia passes through a weakened area of transversalis fascia in Hesselbach’s triangle (lateral edge of rectus abdominis, inferior edge of the inguinal ligament, and medial to inferior epigastric vessels). A Pantaloon hernia is a combination of a direct and indirect hernia.

Typically a hernia consists of visceral contents, a peritoneal sac, and overlying tissue (e.g., skin, subcutaneous tissue). Hernias may be reducible where the protruding contents can be replaced into the abdominal cavity either spontaneously or with manual pressure. Hernias may also be irreducible where the protruding contents are unable to be reduced. There are two classifications of irreducible hernias, incarcerated and strangulated. An incarcerated hernia is irreducible protruding content that is usually due to a small hernia neck ⁴. The tissue or contents protruding remain viable and are not causing an obstruction or inflammation. A strangulated hernia is irreducible protruding material in which blood supply has been compromised. Ischemia, often progressing to necrosis of the protruding tissue or contents, is considered a surgical emergency ⁵.

Inguinal hernias typically are asymptomatic until a bump or swelling of the groin is noted. Some patients may report pain when straining or during heavy lifting. Pain and discomfort are mostly associated with larger hernias usually requiring manual compression for reduction or lying supine with manual compression. Bilateral examination of the groin may reveal a mass that is either reducible or irreducible. An exam should be done supine, as well as, standing, with coughing and straining to identify small reducible hernias. The practitioner palpitates the external ring by invaginating the scrotum with an index finger to a point lateral and superior to the pubic tubercle. Coughing or straining during this examination is critical to the palpation of protruding tissue to diagnose a hernia.

What causes an inguinal hernia?

An inguinal hernia usually occurs when fatty tissue or a part of your bowel, such as the intestine, pokes through into your groin at the top of your inner thigh.

It pushes through a weak spot in the surrounding muscle wall (the abdominal wall) into an area called the inguinal canal.

Inguinal hernias occur mainly in men. Most are thought to result from ageing, although they can occur at any age.

This is because as you get older, the muscles surrounding your abdomen (tummy) can become weaker.

Inguinal hernias can sometimes appear suddenly after putting pressure on the abdomen, such as straining on the toilet if you have constipation or carrying and pushing heavy loads.

They have also been linked to having a persistent, heavy cough.

When is surgery needed?

Inguinal hernias can be repaired using surgery to push the bulge back into place and strengthen the weakness in the abdominal wall.

The operation is usually recommended if you have a hernia that causes pain, severe or persistent symptoms, or if any serious complications develop.

Complications that can develop as a result of an inguinal hernia include:

• obstruction – where a section of the bowel becomes stuck in the inguinal canal, causing nausea, vomiting and stomach pain, as well as a painful lump in the groin
• strangulation – where a section of bowel becomes trapped and its blood supply is cut off; this requires emergency surgery within hours to release the trapped tissue and restore its blood supply so it doesn’t die

Surgery gets rid of the inguinal hernia to prevent any serious complications, but there’s a chance it could return after the operation.

Laparoscopic inguinal hernia repair

The laparoscopic hernia repair is done with the use of a laparoscope (a tiny telescope) connected to a special camera is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen. Laparoscopic inguinal hernia repair is usually performed under a general anesthesia and usually takes about 30 minutes (less than an hour for a repair to both sides). Laparoscopic inguinal hernia repair is a technique to fix tears in the abdominal wall (muscle) using small incisions, telescopes and a patch (mesh). Laparoscopic repair offers a shorter return to work and normal activity for most patients. Laparoscopic inguinal hernia repair has become a valid option for repair of an inguinal hernia, although the primary indication for the use of laparoscopic inguinal hernia repairs has been for bilateral and recurrent inguinal hernias ¹. As more experience has been gained with the laparoscopic techniques, it is now used for the repair of the primary/unilateral inguinal hernia. Potential benefits of the laparoscopic approach include quicker postoperative recovery and possible decreased incidence of long-term groin pain ¹.

Laparoscopic inguinal hernia repair may not be best for some patients who have had previous abdominal surgery, prostate surgery, or underlying medical conditions.

Your surgeon will make several small cuts on your abdomen. Three separate quarter inch incisions are usually necessary. Your surgeon will insert surgical instruments, along with a telescope, inside your abdomen and perform the operation. Other cannulas are inserted which allow your surgeon to work “inside.”  The inguinal hernia is repaired from behind the abdominal wall. A small piece of surgical mesh is placed over the hernia defect, and it may be fixed in place using staples, adhesive sealant, or sutures.

Laparoscopic inguinal hernia repair techniques

There are two main ways to perform laparoscopic inguinal hernia repair:

1. the Transabdominal Preperitoneal (TAPP) approach and
2. the Totally Extraperitoneal (TEP) approach.

The two techniques similar except in the Transabdominal Preperitoneal (TAPP) approach the peritoneum is incised, and this requires closure after mesh placement. The laparoscopic port placements typically vary between the two techniques. In a Totally Extraperitoneal (TEP) technique, the e-ports are placed typically in a line from the pubic bone to the umbilicus. In the Transabdominal Preperitoneal (TAPP) technique, the three ports are placed at the umbilicus and the area of the mid-clavicular line at the level of the umbilicus on the left and right side of the abdomen. With these port positions, the surgeon can fix bilateral inguinal hernias either using the Totally Extraperitoneal (TEP) or Transabdominal Preperitoneal (TAPP) technique. In the Totally Extraperitoneal (TEP) approach, the preperitoneal space is entered at the level of the umbilicus and is not violated during the procedures. In the Transabdominal Preperitoneal (TAPP) technique, the surgeon must open and close a peritoneal flap that usually starts at the medial umbilical ligament and is incised laterally towards the anterior superior iliac spine. It is recommended that the surgeon close the peritoneal flap after mesh placement and this may be either done with sutures or tack fixation. This allows the mesh to be preperitoneal and not in contact with the abdominal cavity and viscera. Laparoscopic inguinal hernia repair, either by the Transabdominal Preperitoneal (TAPP) or Totally Extraperitoneal (TEP) method, involves placing a large mesh prosthetic that covers the entire myopectineal orifice. This allows for coverage of indirect, direct, and femoral hernias.

In general, outcomes related to laparoscopic inguinal hernia are similar to those of open inguinal hernia repair assuming the surgeon is adequately trained and competent in the technique. Several studies have reported the steep learning curve associated with a laparoscopic inguinal hernia, and it is important to understand this learning curve when evaluating outcomes associated with this procedure. When surgeons have overcome their learning curve, reported to be between 50 and 250 cases, potential benefits of the laparoscopic approach include quicker recovery and possible decrease incidence of long-term groin pain with equivalent recurrence rates to the open approach. Although there are many proponents of both the Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) techniques, outcomes are similar, and the choice of method is left to the discretion of the surgeon. Although there are subtle differences in some outcomes comparing laparoscopic and open inguinal hernia repair, in general, the outcomes are similar.

What happens if the operation cannot be performed or completed by the laparoscopic method?

In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” inguinal hernia repair may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather good surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

Laparoscopic inguinal hernia repair contraindications

There are no absolute contraindications to laparoscopic inguinal hernia repair except for the inability to tolerate general anesthesia. Patients at high risk for anethesia and unilateral inguinal hernia may be better served with an open repair under local anesthesia. Relative contraindications include large inguinoscrotal hernias (which should not be attempted early in the learning curve as they can be quite difficult operations) and patients on anticoagalation (secondary to the difficulty with dealing with posterative bleeding in the retroperitoneal space compared to dealing with bleeding after open surgery).

What preparation is required?

• Most hernia operations are performed on an outpatient basis, and therefore you will probably go home on the same day that the operation is performed.
• Preoperative preparation includes blood work, medical evaluation, and an EKG depending on your age and medical condition.
• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
• It is recommended that you shower the night before or morning of the operation with an antibiotic soap.
• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E may need to be stopped temporarily for several days to a week prior to surgery. Your surgeon will discuss this with you and provide instructions regarding your medications around the time of surgery.
• Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home. Smoking may increase the risk of the hernia recurring, or coming back after surgery. In some cases, your surgeon may require that you quit smoking prior to surgery.

Laparoscopic inguinal hernia repair recovery

You should be able to go home the same day or the day after.

• Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
• Once you are awake and able to walk, drink liquids, and urinate, you will be sent home.
• With any hernia operation, you can expect some soreness mostly during the first 24 to 48 hours.
• You are encouraged to be up and about the day after surgery.
• With laparoscopic hernia repair, you will probably be able to get back to your normal activities within a week. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.
• Call and schedule a follow-up appointment within 2 weeks after you operation.

Laparoscopic inguinal hernia repair recovery time

You may return to normal activities when you feel comfortable to do so, usually after a week. You do not need to avoid lifting but you may find it uncomfortable if you lift heavy weights during the first 2 to 4 weeks.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your doctor for advice.

The inguinal hernia can come back. This long-term recurrence rate is low in patients who undergo laparoscopic repair by an experienced surgeon. Your surgeon will help you decide if the risks of laparoscopic hernia repair are less than the risks of leaving the condition untreated.

Open inguinal hernia repair

Open inguinal hernia repair is done from the outside through a three to four inch incision in your groin or the area of the hernia. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect and remove the ‘hernial sac’. The surgeon will strengthen the muscle layer with stitches, usually inserting a synthetic mesh to cover the weak spot or repair the defect or hole, and close your skin.

Open inguinal hernia repair can be done with a local anesthetic and sedation, using a spinal anesthetic or a general anesthetic.

Open inguinal hernia repair surgery usually takes about 45 minutes.

Open inguinal hernia repair recovery

You should be able to go home the same day. Increase how much you walk around over the first few days.

Open inguinal hernia repair recovery time

You should be able to return to work after 2 to 4 weeks, depending on how much surgery you need and your type of work.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your doctor for advice.

The inguinal hernia can come back. Recurrence of hernias is the biggest concern with open inguinal hernia repair technique ³. Most commonly, the hernia will recur at the pubic tubercle, and without proper technique, this recurrence is more likely. Patient compliance with avoidance of heavy lifting or strenuous activity is also vital to reduce the rate of recurrence. Chronic pain has been described by many patients and is the main driving point of the great debate between preservation and sacrifice of nerves during dissection.

Inguinal hernia repair recovery

What to expect at home

After your inguinal hernia repair:

• If there are stitches on the skin, they will need to be removed at a follow-up visit with the surgeon. If stitches under the skin were used, they will dissolve on their own.
• The incision is covered with a bandage. Or, it is covered with a liquid adhesive (skin glue).
• You or your child may have pain, soreness, and stiffness at first, especially when moving about. This is normal.
• You or your child will also feel tired after surgery. This can last for a few weeks.
• You or your child will most likely return to normal activities in just a few weeks.
• Men may have swelling and pain in their testicles.
• There may be some bruising around the groin and testicular area.
• You or your child may have trouble passing urine for the first few days.

Make sure you or your child gets plenty of rest the first 2 to 3 days after going home. Ask family and friends for help with daily activities while your movements are limited.

Straining on the toilet because of constipation can cause pain around your wound. You can reduce your risk of constipation by drinking lots of fluids and eating plenty of vegetables, fruit and high-fiber foods, such as brown rice, wholemeal bread and pasta. A mild over-the-counter laxative may also help.

Managing Pain

Use any pain medicines as instructed by the surgeon or nurse. You may be given a prescription for a narcotic pain medicine. Over-the-counter pain medicine (ibuprofen, acetaminophen) can be used if the narcotic medicine is too strong.

Apply a cold compress to the incision area for 15 to 20 minutes at a time for the first few days. This will help the pain and swelling. Wrap the compress or ice in a towel. This helps prevent cold injury to the skin.

Wound Care

There may be a bandage over the incision. Follow the surgeon’s instructions for how long to leave it on and when to change it. If skin glue was used, a bandage may not have been used.

• A little bleeding and drainage is normal for the first few days. Apply antibiotic ointment (bacitracin, polysporin) or another solution to the incision area if the surgeon or nurse told you to.
• Wash the area with mild soap and water when the surgeon says it is OK to do so. Gently pat it dry. DO NOT take a bath, soak in a hot tub, or go swimming for the first week after surgery.

Diet During Recovery

Pain medicines can cause constipation. Eating some high-fiber foods and drinking plenty of water can help keep the bowels moving. Use over the counter fiber products if constipation does not improve.

Antibiotics can cause diarrhea. If this happens, try eating yogurt with live cultures or taking psyllium (Metamucil). Call the surgeon if the diarrhea does not get better.

Activity for Adults

Give yourself time to heal. You may gradually resume normal activities, such as walking, driving, and sexual activity, when you are ready. But you probably will not feel like doing anything strenuous for a few weeks.

Avoid drinking alcohol, operating machinery or signing legal documents for at least 48 hours after any operation involving general anaesthetic.

DO NOT drive if you are taking narcotic pain medicines.

DO NOT lift anything over 10 pounds or 4.5 kilograms (about a gallon or 4 liters jug of milk) for 4 to 6 weeks, or until your doctor tells you it is OK. If possible avoid doing any activity that causes pain, or pulls on the area of surgery. Older boys and men may want to wear an athletic supporter if they have swelling or pain in the testicles.

Most people are able to do light activities, such as shopping, after 1 or 2 weeks.

You should also be able to return to work after 1 or 2 weeks, although you may need more time off if your job involves manual labour.

Gentle exercise, such as walking, can help the healing process, but you should avoid heavy lifting and strenuous activities for about 4 to 6 weeks.

You may find sex painful or uncomfortable at first, but it’s usually fine to have sex when you feel like it.

Check with the surgeon before returning to sports or other high-impact activities. Protect the incision area from the sun for 1 year to prevent noticeable scarring.

Activity for Children

Toddlers and older children will often stop any activity if they get tired. DO NOT press them to do more if they seem tired.

The surgeon or nurse will tell you when it is OK for your child to return to school or daycare. This may be as soon as 2 to 3 weeks after surgery.

Ask the surgeon or nurse if there are certain activities or sports your child should not do, and for how long.

Follow-up

Schedule a follow-up appointment with the surgeon as directed. Usually this visit is about 2 weeks after surgery.

Inguinal hernia repair complications

Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair. There is a very low risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle. Difficulty urinating after surgery can occur and may require placement of a catheter, or tube to drain the bladder after surgery. You should ask your surgeon about ways to prevent this from occurring before your operation.

Bruising and swelling of the scrotum, the base of the penis, and the testicles is not uncommon with open and laparoscopic repair. This will gradually resolve on its own in the vast majority of patients.

Risks for anesthesia in general are:

• Reactions to medicines
• Breathing problems

General surgical complications:

• pain
• bleeding
• infection of the surgical site (wound)
• unsightly scarring
• blood clots

Specific open inguinal hernia repair complications:

• developing a collection of blood or fluid
• difficulty passing urine
• injury to structures that come from your abdomen and are within the hernia
• temporary weakness of your leg
• continued discomfort or pain in your groin
• injury to nerves
• damage to the blood supply of your testicle

Specific laparoscopic inguinal hernia repair complications:

• damage to structures such as your bowel, bladder or blood vessels
• developing a hernia
• injury to your bowel
• surgical emphysema
• developing a collection of blood or fluid
• continued discomfort or pain in your groin
• for men, discomfort or pain in your testicle on the side of the operation
• for men, difficulty passing urine
• for men, damage to the blood supply of your testicle.

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