MODERN TREATMENT FOR INGUINAL (GROIN) HERNIA

What is an inguinal hernia?
An inguinal hernia is protrusion of an organ or a tissue through a weak spot in a muscle in the groin region. As the inguinal hernia enlarges, it forms a sac and internal organs such as the intestines can fall into this sac creating a bulge. The bulge is most often visible when a person is standing and may temporarily disappear in lying down position.

How does one get an inguinal hernia?
An inguinal hernia can occur at any age. In children, an excessive natural weakness leads to a hernia (congenital hernia). In adults it is usually the strain from heavy lifting, substantial weight gain, persistent coughing or difficulty with bowel movements or urination that causes the muscles in the region of groin to weaken (acquired hernias). A hernia then comes out through the weakened area. This article focuses on inguinal hernias occurring in adults.

What symptoms does an inguinal hernia produce?
Inguinal hernias can produce different symptoms - the commonest being a protrusion in the groin particularly on straining during urination, during a bowel movement, or while lifting a heavy object. Sometimes there may be a sharp pain, a dull aching sensation or a vague feeling of fullness in the groin.

What happens if the hernia is not treated?
An inguinal hernia never gets better without treatment. In fact chances are that most would develop complications sooner or later. If the hernia can be pushed back into the abdominal cavity, it is referred to as a reducible hernia. This type is not an immediate danger to ones health. However, if it cannot be pushed back it is said to be non-reducible and this condition may lead to dangerous complications. It often means that a part of the intestine has got trapped in the hernia. In such cases there exists a risk of the flow of the intestinal contents getting blocked (intestinal obstruction) or the intestinal blood supply getting cut off (strangulation). When these complications occur the hernia becomes painful and the patient experiences abdominal pain, loss of appetite, nausea or vomiting. Such complications invariably require an urgent operation.

Can a hernia be treated with medicines?
No, unfortunately hernias cannot be treated with any medicines.

What about wearing a belt or a truss?
It is important to realise that a supportive belt or a truss does not prevent an inguinal hernia from growing bigger and certainly does not avoid the risk of blockage to the intestines. Therefore, a belt (truss) is not at all helpful and is not recommended as a treatment.

What is the best treatment?
An operation is the only permanent treatment for an inguinal hernia. In some patients this is required to relieve the bulge of the hernia or the pain and in others it is advised to prevent the risk of complications.

Are any tests required before the operation?
Most people require to have a few simple blood tests. Additional tests such as an x-ray of the chest or an ECG may also be needed depending on the patient's age.

What anaesthesia is used for the operation?
Generally, one of the following three forms of anaesthesia is used:

1. Local anaesthesia: is suitable for most patients. This involves injection of a local anaesthetic medicine at the site of the cut in the groin. An additional injection of sedative is often given through a needle in the arm to make the patient sleepy during the operation. The advantage of this method is that the patient is usually able to go home the same day. This is the method of choice in some elderly patients with medical illnesses like hypertension, diabetes or heart disease in whom a general or spinal anaesthesia may be contraindicated.
2. General anaesthesia: involves an injection through a needle in the arm to put the patient to sleep. The patient then breathes into a machine to remain asleep during the operation. The patient may have to stay in the hospital for about a day after a general anaesthetic.
3. Spinal anaesthesia: is one in which only the lower part of the body is made numb by an injection given in the back.

Often patients, particularly those who are anxious, prefer to have either a general or a spinal rather than local anaesthesia. It is best to discuss these issues with the surgeon before the operation and let ones preference for one type of anaesthesia or the other known to him.

How are inguinal hernias repaired?
By and large, there are two types of operations for repairing an inguinal hernia.

• The traditional open repair: This type of repair may be performed under local, spinal or general anaesthesia. A 10 - 15 cm incision is made in the groin; it cuts through layers of skin, fatty tissue and muscle to reveal the hernial sac. Contents of the hernial sac are then pushed back. Then the weak area is reinforced with a special nylon net or a mesh. Subsequently, the muscles and ligaments in the groin are stitched together in an effort to strengthen the area. The mesh stays in the body permanently and strengthens the area. Generally, it does not cause any side effects. With a mesh repair the rate of recurrence of hernia is as low as 1% - 2%.  However, as a large cut is made, the patient may have some pain / discomfort in the area of surgery for a week or more. Also the patient may not be able to permitted carry out all activities for upto six weeks. Moreover, if a patient has hernias on both the sides, as is often the case, the repair requires two separate incisions ? one in each groin.
• Laparoscopic hernia repair: This technique of hernia repair is performed under general anaesthesia. The surgeon makes a small (1cm) cut near the navel and introduces a cannula (a tube-like instrument) inside the abdomen or between the muscles of the abdomen. A laparoscope (a telescope) attached to a miniature video camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a video monitor. The surgeon operates by watching the image on the screen. Two additional cannulas are inserted through 5mm cuts to accommodate special long instruments. The surgeon then pulls the hernial sac back into the abdominal cavity and exposes the weak area in the abdominal wall from inside. This area is covered with a mesh that is fixed to the abdominal wall. Following the repair, the small incisions are closed with stitches.

The advantages of laparoscopic hernia repair are that it requires only 3 tiny cuts instead of the traditional 10 - 15 cm incision. As a result, patients experience much less pain after the operation, are able to perform their activities much sooner, and are able to return to work sooner than after the open operation. If a patient has hernias on both sides, they can be repaired through the same small cuts. In some patients after a previous open operation for hernia the hernia comes back (recurrent hernia). In such cases a laparoscopic operation is far better than another operation. The cost of the laparoscopic operation is marginally higher than the open procedure because of the specialized equipment used. However, this is more than compensated by the benefits the patients gets after a laparoscopic operation.

What happens after the operation?
How soon a patient starts drinking liquids and eating food after the hernia operation depends on the type of anaesthetic used. If an open operation has been performed using local anaesthesia, the patient may be allowed to eat and drink shortly after the operation. After an operation under spinal or general anaesthesia the patient is usually kept fasting for about four to six hours. Some patients may require a saline drip for a few hours. In the first few hours after recovery some patients may experience some nausea or headache (after a spinal anaesthetic).

What about the pain?
After any hernia operation there is some pain at the site of the cut for a few days. With the laparoscopic operation this is much less as compared to the open repair. The patients are always prescribed medicines to control the pain. Also, patients are encouraged to get out of the bed soon after the operation despite the slight discomfort. Over a period of time the pain gradually reduces and becomes almost negligible.

How soon can one resume work?
This depends very much on the nature of the job a patient does and the type of operation he has had. With the open repair patients may be advised take it easy for upto six weeks and they may not be allowed to lift heavy objects for upto three months. When a laparoscopic repair is performed, almost all activity is permissible within about 8 - 10 days after surgery and the patient return to work within 10 ? 15 days after surgery.

It can be said that the modern laparoscopic repair of inguinal hernia has revolutionized the way this common ailment is treated. If one were to require surgery for hernia laparoscopic repair forms the procedure of choice for most patients.