What is a hernia?
A hernia is defined as an “abnormal protrusion of an organ through an orifice.” A loose translation of this is that there are certain things that are meant to be held in place by a layer of muscle, but the layer either gets a hole in it or (more commonly) enlarges a normal hole to the point where some organ can poke through.
What types of hernias are there?
Your muscles don’t have many weak points, and so there are only a few places where hernias occur. Groin hernias are most common, and can be further classified into inguinal and femoral hernias. Incisional hernias are next-where a previous incision gets stretched out to the point where an organ can come through the muscle layer and cause a bulge under the skin. Less common (and more interesting to us surgeons) are “Spigelian” hernias that come out through a specific place in the lower abdomen, and lumbar hernias that come out in the lower back. Hiatal hernias are also-literally speaking-hernias. But they are treated differently and discussed in a different section.
Treatment of hernias
The standard treatment for most hernias is surgery. Surgeons have been calling this into question recently, however. For incisional hernias in particular, repair can sometimes be difficult, and it is always worth a careful consideration of the risks vs. benefits of the procedure. Even for one common type of groin hernia (inguinal hernia) where repair is more reliable, the American College of Surgeons is sponsoring a study of observation vs. repair in a group of patients if they have no symptoms. In most hernias, however, surgical repair is the standard.
What about laparoscopic repair for groin hernias?
There are several mainstream techniques for hernia repair-open (through a groin incision), laparoscopic (through a scope), and preperitoneal patch (sort of halfway between the other two). They are all pretty good, and none of them is perfect. The best way to compare them is by their recurrence rate (the chance that the hernia will come back) and their morbidity (how much and how long they will put you out of commission). Studies on this are contradictory and vary wildly, and the estimates that follow are meant to be a realistic conglomeration.
The advantage of the laparoscopic technique is less pain during the first one to two weeks after surgery. This may allow you to return to work in about half the time of an open repair. Early results on effectiveness look to be about as good as the open technique. But the technique has not been in use long enough to reliably know the ten-year recurrence rate. In addition, laparoscopic hernia repair is difficult if you don’t want to have a general anesthetic.
The open repair is a relatively longstanding technique. As such, we know that the ten-year recurrence rate is about 1%. You can usually plan on about a week out of work for a desk job, and four weeks to get back to heavy lifting.
The patch technique uses a smaller groin incision to approach the hernia from the same direction as the laparoscopic technique, but avoids the dissection and equipment required to repair the hernia laparoscopically. Again, early results are good but we are still waiting to get reliable numbers on the ten-year record.
Despite extensive research to determine the “best” technique, surgeons arrive at different conclusions. You and your surgeon should both be comfortable with the technique you choose.
What about laparoscopic repair for incisional hernias?
Laparoscopic repair has been used as an alternative to open repair for incisional hernias. Theoretically, this allows for better visualization of the hole (or holes) that the hernia is coming through, since we are looking at it from the inside. There have been some very good results with laparoscopic repair of incisional hernias that are probably due to better visualization-reducing recurrences for complex hernias from 30% down to about 10%.
Laparoscopic incisional hernia repair may be one of the few cases where the laparoscopic alternative is actually a “bigger” operation than the open alternative, however. Many surgeons think that, by using the lessons learned from the laparoscopic approach, they can reproduce the good results of the laparoscopic technique using an open, less invasive approach.
As with any surgery, there is a risk of bleeding, infection, or anesthetic reaction with hernia repair. Another risk more specific to hernia repair (whether open or laparoscopic) is an injury to the organ that is coming through the hernia-usually intestine.
Inguinal hernias also have the testicular supply attached directly to the hernia sac. This consists of the artery and vein that carry blood, and in the male the vas deferens that carries sperm. Any of them can be injured during dissection. Even if the artery and vein are not injured directly, the reaction from dissection can cause them to clot off. In a worst case scenario this can lead to loss of the testicle.
There are alternative types of hernia repair, and you and your surgeon should choose the one that suits you best. The only alternative to surgery, however, is observation. There is no exercise that will make it go away. Frankly, we don’t know very accurately what happens with observation because we don’t do it very often. The risk is that the hernia will get stuck out (incarcerated), then become strangulated (swell up to the point the blood supply gets cut off) and gangrenous (dead). In truth, you will usually get some warning of this, but occasionally it comes out of nowhere.
With observation of inguinal hernias, a truss will sometimes help keep the hernia in. But if the hernia is out and the truss is pressing on it, it can actually make the situation worse.
You can expect to get most of your preoperative instructions when you go for your Same Day Surgery preoperative evaluation appointment. Usually you are not supposed to eat or drink anything after midnight, but the anesthesiologist will frequently make adjustments to this, especially if there are medications you need to take after midnight.
When you finish your appointment they will probably be able to tell you what time to show up on the day of surgery. As the surgery schedule for that day becomes clearer, however, you may get a phone call the day before your planned surgery modifying the time somewhat.
Day of Surgery
On the day of surgery you’ll come in, get an i.v., and get some sedative just before surgery to help you relax. You probably will not remember a whole lot more because the sedative has the side effect of making you forget.
After the operation the next stop is Recovery Room, usually for about an hour of intensive monitoring. If everything is routine you can expect to go straight back to the Same Day Surgery area.
After you get home it’s normal to have some oozing from the incision(s). Sometimes this is more than the dressing will absorb, and it will need to be changed to a new piece of gauze. Usually light pressure and/or ice packs will slow the drainage. It is very rare for this oozing to be a problem, but if you keep saturating gauze dressings we need to know about it and may need to check it.
Another surprise that can be alarming is discoloration of the skin around the surgical site. In males after groin hernia repair, this may include the penis and scrotum. Sometimes you won’t see this for several days, because it takes time for the “bruise” to reach the surface. If the color is bluish, brownish, greenish, yellowish or some combination of these it’s probably normal. If it’s red, especially if it feels thickened and increasingly painful, we may need to check it.
Within twelve hours the incision should be “sealed”. By the morning after surgery it is OK to bathe or shower with soap and water. If you need to clean up before then, stick to a sponge bath.
You’ll be somewhat sore after you get home. But it is OK to resume your previous activity as tolerated. You don’t have to worry that you are going to “pull something loose”. Recurrences are rare, but if they occur it’s going to happen anyway-early return to previous activity does not make them any more likely. The pain is there to tell you when to stop, though, so pay attention to it.
You can usually return to light duty work in about three days to one week, and heavy-duty work in about two to four weeks.
Hernia surgery usually does not require any special diet. The pain pills may make you constipated, however, so you may need to take a dose or two of Milk of Magnesia to get things started.
What to Expect
When you return home you can go up and down stairs and fix yourself something to eat and drink on the day of surgery. You probably won’t want to do much else. On the day after surgery you can probably get out of the house, but don’t drive yourself and don’t get too far away from a place where you can lie down if you begin to feel tired and sore. To see if you are ready to drive, get in the car and try to pull your foot up off the gas and put it on the brake without hesitating. If you can do that, you should be ready to drive. Needless to say, you can’t drive if you are under the influence of pain medication.