A hernia is a weakening, bulge or protrusion through an area of the abdominal wall, either in the groin or along the upper abdominal wall. The area of weakness can be caused by a previous surgery or by a natural opening or weakening that body has as a result of normal development.
There are multiple types of hernias. 99 percent of hernias are either hiatal hernias, abdominal wall hernias or groin hernias. Hiatal hernias are discussed in the section that is labeled gastro-esopageal reflux disease, while groin hernias usually occur in men. The hernia develops as a result of a natural weakness men have where the testicle descends into the scrotum. This weakness can later manifest itself as a hernia or a bulge during coughing or straining. Abdominal wall hernias are also called ventral hernias. These are usually the result of a previous incision, or they are located in the ”belly button” region.
Inguinal hernia symtpoms
Symptoms of hernias can vary. Usually the onset of inguinal hernia symptoms is very gradual, and often, people do not have symptoms at all. Many times, however, people go to the doctor after noticing a sudden bulge, experiencing sudden pain or noting a sudden change in presentation, usually after lifting heavy equipment or heavy objects. They can also present with repeated attacks of coughing or straining to urinate or perform any task that causes increased abdominal wall pressure. Chronic constipation or difficulty defecating can also bring on the symptoms of a hernia.
In most cases, however, these aforementioned activities are usually the ‘straw that breaks the camel’s back’, because hernias are often present for quite some time before that central event.
Surgery for hernias is usually not an emergency. It is an elective surgery, and will remain as such as long as the hernia is not incarcerated and causing pain. When a hernia bulges and sticks out, and a person is unable to push the bulge back in and be pain-free, this could be a sign that a vital intra-abdominal structure is having its blood flow and blood supply constricted, and that area of tissue may die. These types of situations are emergencies, because if something like your intestines are stuck in a hernia that cannot get back inside your abdomen, this can be fatal.
For these reasons, if you do have a bulge that you cannot reduce and you are having constant pain, experiencing changes in skin color, or the area is tender, you should seek medical attention immediately.
Inguinal hernias
Groin hernias, or inguinal hernias, are the most common sites of a hernia. Although they do occur in women, the overwhelming majority of hernias appear in men. At BMI of Texas, we prefer to repair groin hernias robotically, as this leads to reduced pain and allows people to return to work much more quickly. In addition, a laparoscopic or robotic approach allows doctors to examine both the right and left sides where hernias could form, which can prevent wrong-site surgery. The locations of the incisions are exactly the same, whether the groin hernia is on the left or right.
There are several different types of groin hernias. Groin hernias can be direct inguinal hernias, indirect inguinal hernias or femoral canal hernias. All of these types of hernias can be repaired robotically. People do not necessarily know what type of groin hernia they have until the surgery is over. Knowing what type of hernia someone has is really not important before surgery.
When we repair groin hernias, we use “mesh,” which is like a screen on a door. It looks like netting and has an almost fiberglass-type appearance to it. This netting or mesh acts like a scaffold on a building. When the mesh is placed in its proper location, it is fixated into place and the body forms a scar that is much more durable and stronger than what our bodies normally could create.
Typically, robotic hernia repairs take under an hour, and when surgery is over, we generally have our male patients wear a jock strap or an equivalent for at least two to three weeks. We ask them to keep the scrotum elevated whenever possible to reduce any discomfort, as well as to minimize any potential swelling that can occur. There are no restrictions on diet or exercise after laparoscopic groin hernia surgery.
Ventral hernias
Ventral hernias like groin hernias are abnormal protrusions through a weakened area in the abdominal wall. Weaknesses of the abdominal wall usually occur at the belly button or what is called the umbilicus. However, an overwhelming number of abdominal wall hernias occur at previous incision sites, which are natural areas of weakness. When someone has surgery and you close the abdominal wall back up, it is never able to reach 100 percent of the strength it had before surgery. For these reasons, these areas of weakness can turn into hernias.
Ventral hernias are best treated laparoscopically or robotically. Usually through three or four small incisions, we are able to not only clean off the entire abdominal wall, but also introduce mesh into the abdomen to act as a scaffold so that a much more durable scar can form. The mesh that is used on the abdominal wall is much like the mesh used in the groin, except it is usually of a different material that is appropriate for intra-abdominal placement.
Hernias of the abdominal wall can be very, very complex, especially if the hernia goes below the level of the belly button or umbilicus. Ventral wall or abdominal wall hernias can be repaired laparoscopically, and these operations are fairly painful because we use a combination of absorbable screws and sutures to keep the mesh from migrating. If you are seeing a surgeon about an abdominal wall hernia repair to be performed laparoscopically or robotically, it is very important that the doctor incorporate two techniques: a transabdominal fixation, as well as “tacking.” These approaches must be employed to ensure adequate sturdy repair to keep the mesh from migrating.
The size of the mesh that is used can be surprisingly large at times. The mesh must have a significant amount of overlap, because it can often shrink in size.
Note: the decision to use mesh is not taken lightly. We may want to discuss with you repairing the hernia with just suture instead of mesh because occasionally patients can develop chronic pain issues as a result of the mesh placement and fixation.
Preparing for groin hernia surgery
There is really no medical treatment for hernias aside from surgery, and they will not heal spontaneously on their own. Generally, hernias will increase gradually over time. Most groin hernias are repaired on an outpatient basis.
Complications of groin hernia surgery include infection and bleeding, which occurs any time you have an operation. There is approximately a 1 percent or less chance of having a hernia recurrence, where the hernia surgery fails. Men may injure the testicle, vas deferens or spermatic cord and its associate vessels. It is also possible to develop chronic pain, numbness or a requirement for future surgery.
Recovery: Inguinal hernia
After your groin hernia surgery, you typically go to the recovery room for one to two hours, where your anesthesia wears off. At that time, the staff makes sure you can ambulate and urinate. When you have a good handle on your pain control, you are discharged from the surgery center. Most people are able to gradually return to the activities of daily living over the next several days, and it is appropriate to ask for a week or so off from work. There are, however, no true physical restrictions and you could go back to work right away. It is not uncommon for there to be some bruising or swelling around your testicles, scrotum and penis, and bruising may occur several days or several weeks later, but it is usually painless. We ask you to follow up at our office for your post-op checkup approximately two to three weeks after surgery. Most patients avoid any strenuous activity after surgery for the first week or so, but there are no true physical restrictions.
Recovery: Ventral hernia
The recovery from a ventral hernia can be a bit more arduous than that of an out-patient groin hernia surgery. Laparoscopic ventral hernia repairs often require one or two nights in the hospital, largely due to pain control. Some narcotics are usually required for at least the first night or so. Immediately after surgery, you are asked to walk, and when we can adequately control pain and you are able to ambulate, you are usually discharged home.
Much like groin hernia surgery, there are no physical restrictions after a laparoscopic ventral hernia repair with mesh. Although the abdominal wall may have many more hernia defects, once the mesh is in place, there are no significant physical restrictions. This is not to say that you will not be very sore, and that soreness may last for several weeks—and even a month or more in varying degrees. Rest assured, however, there is nothing you can do physically that would make the hernia come back or the hernia repair fail. However, you will often feel some pulling, tearing, stretching or “catching” pain at the area, especially where the four sutures are holding the mesh in place. These areas of soreness usually go away within the first week or so after surgery.
After surgery
Patients usually see us about two to three weeks after surgery, and during that time, you can go back to work. Everyone has different comfort levels about returning to work, but it is certainly appropriate to ask for two weeks or so of recovery following your abdominal wall hernia surgery.