HERNIA CLINIC OF BRISBANE
David J Phillips
M.B., B.S., F.R.C.S. (Ed) F.R.A.C.S.
SURGEON
OPEN GROIN (INGUINAL) HERNIA REPAIR
What
is on ‘open’ groin (Inguinal) hernia repair.
The standard operation involves an incision about 8 cms in
length through the skin and outer layer of abdominal wall muscle
overlying the groin. The hernial sac and its contents are freed
from the surrounding tissue and returned to the abdominal cavity.
The defect and surrounding weakness are then repaired using a
single nylon sheet of mesh, which is stitched or stapled
in place without tension. Older methods of surgical repair
involved suturing the groin area under some tension, which led to
a great deal of post operative pain, slow recovery, and a pretty
high hernia recurrence rate as tight sutures will often cut
through weak tissues with time.
My preferred method of open hernia surgical repair is to use a
double layer of mesh, called a Prolene
Hernia System, with reinforcing mesh being placed deep to
all muscle layers and a second layer of connected mesh
positioned, and fixed, in the standard position deep to the outer
of the body’s three muscle layers. I believe that this
method reduces the already low risk of a hernia recurrence even
further, and because of the method of its fixation, it leads to a
shorter post operative recovery time.
There are several means of repairing open hernias and every
surgeon has their favourites. The type of repair will also depend
on the particular patient’s build, size of hernia and
previous surgery. Another method I sometimes use is called the Kugel Hernia Patch.
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Same Day Surgery
In many patients a light general anaesthetic together with a
large volume of long acting local anaesthetic injected at the
time of surgery will allow them to be discharged from hospital
within a few hours of the surgery. Oral analgesic tablets are
given to use at home for a few days as required. Same Day surgery
is the only method used in the United States, where hernias are
commonly repaired under local anaesthetic and sedative tablets,
rather than under a general anaesthetic. This is because U.S.
insurance companies will not pay for an overnight hospital stay.
Some patients will remain in hospital overnight, as sometimes
an injection of major narcotic is required or medication needed
to stop post operative vomiting. Pain relieving tablets taken
orally are then usually sufficient. The occasional patient will
be in hospital longer than one day, if there are other medical
complications.
If same day surgery is your chosen method you will be given
strong pain relieving tablets to take home and you may return to
the hospital that night for an injection if you feel this is
necessary.
Most patients will take oral medication for some days
following surgery.
Sutures placed under the skin will be used and these do not
have to be removed.
Day surgery offers a cost saving in that the cost of an
overnight stay is more expensive. Some health funds have no
‘copayment’ for day cases and you should check with
your health fund.
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| Post
operative advice following Open Hernia Repair. |
- You may undertake unrestricted activity. Be
guided by the discomfort in your wound. "Let
your body do the talking".
- You cannot damage your operation. The mesh used
is stronger than your own body tissues and
stitches or staples hold the mesh in place until
it is incorporated into your tissues.
- You may lift or strain as much as you wish,
depending on how sore the wound is.
- Do not lie around in bed for long periods. Get
mobile quickly as recovery time is much reduced.
- Don’t drive for some days until you can
easily manage as your insurance may be
invalidated.
- Return to work when you feel able to do so. You
may return to any activity which is comfortable
unless your employer tells you to stay away.
- Modern methods of hernia repair with mesh are not
the same as older methods. Your recovery time is
reduced by several weeks.
- In general terms office workers could expect to
return to work after two to three weeks but would
still be somewhat sore and therefore limited in
mobility.
- Most heavy manual workers can return to work
after 3 to 4 weeks although earlier return is
encouraged. Return to lighter duties before this
is quite possible.
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| Return to
topics |
Possible
complications following Open Hernia Repair.
- Heart and chest problems can occur after a
general anaesthetic, especially in smokers.
- Inability to pass urine after operation is not
uncommon especially in older males who may have some
enlargement of the prostate gland. A temporary tube (catheter) may have to be passed into the
bladder to relieve the obstruction. Very occasionally a
prostate operation will become necessary some days later.
- Infection of the wound. This is not at all common
and it presents some days after surgery with increasing
swelling, redness and continuing throbbing pain. It may
require a small incision to be made under local
anaesthetic to release any pus which has formed, and
possibly antibiotics will be necessary. Very rarely long
term infection of the mesh can occur and this major
problem can only be settled by an operation to remove the
mesh.
- Discharge. A small amount of clear fluid discharge
from one end of the wound is usually related to
irritation by the dissolving sutures and settles without
any treatment apart from dressings.
- Bruising and swelling. The incision and scrotum
may be discoloured or a little swollen or black and blue.
This is very common and is no cause for concern. A firm
swelling of blood will usually be reabsorbed over some
weeks. Very rarely a very large collection of blood will
require the wound to be drained.
- Unexpected damage. A very small risk exists of
damage occurring to the blood supply of the testicle.
This is much more likely (but still rare)
if there has been previous hernia surgery in the area.
Adjacent large blood vessels can be damaged and require
repair or even the bladder or bowel can be damaged rarely
if an unusual hernia exists. Damage is extremely rare.
- Trapping of nerves. Several small nerves run right
through the area of a hernia repair and in an isolated
few cases a nerve can become pinched by either a stitch,
staple or scar tissue. This can result in a very painful
tender spot. It may settle with time, with injections
locally into the tender spot, or in rare cases with a
further surgical exploration. In an extremely rare
patient, unexplained wound pain can persist.
- Scarring Usually this is insignificant as it is
well hidden in the groin.
- Recurrence of the hernia. In large series of
hernia repairs by modern tensionless mesh repairs the
chances of a recurrence is well under 1% over many years.
Older methods have all led to a lifetime recurrence rate
of between 10 and 15%. Difficult, very large, or
recurrent hernias may require a substantially modified
surgical procedure to reduce the risk of recurrence.
