What is a Hernia?
A hernia is a protrusion of part of the abdominal contents through the abdominal wall at a site of weakness. The commonest site for this to happen is the inguinal canal in the groin. The weakness may be congenital (present from birth) or acquired as one gets older. The usual symptoms are a lump in the groin or discomfort or both.
Why repair it?
The usual reasons for repairing a hernia are to get rid of the lump and the associated discomfort. In addition there is a small risk of strangulation in inguinal hernias. Strangulation is a condition in which the contents of the hernia, usually the small bowel, become trapped in the hernia and their blood supply becomes impaired. This complication is accompanied by pain and vomiting.
Laparoscopic or Open repair?
The great majority of inguinal hernias are repaired with a laparoscopic (key hole) technique. In both laparoscopic and open inguinal hernia repair a polypropylene mesh is inserted to cover the weakness after a peritoneal sac, if present, has been ligated. Laparoscopic repair has the advantage of less post-operative pain and a quicker recovery and is the preferred technique for the great majority of patients.
Polypropylene mesh has been used for decades in groin hernia (femoral and inguinal) repair with a remarkably low rate of complications. Its use is associated with a significant reduction in recurrence rates over most non-mesh techniques. Please feel free to discuss any concerns about mesh repair with me. Please refer to the attached position statement on mesh in inguinal hernia repair from the New Zealand Association of General Surgeons. The “Shouldice operation” is an effective non-mesh alterative open operation that I am happy to perform but is not my preferred option. This non mesh technique can only be performed as an open technique.
The operation is usually performed under general anaesthesia but can be performed under local anaesthesia (open repair only). It takes about 20 to 40 minutes. A peritoneal sac, if found, is ligated and the posterior wall of the inguinal canal is reinforced with polypropylene mesh patch. A long acting local anaesthetic is placed in the wound so that it is comfortable when you wake up. A shower proof dressing applied.
What can I expect when I get home?
If you have your operation in the morning you have the option of going home in the evening, generally people having a hernia repair in the afternoon go home the next morning. You will be given a script for an anti-inflammatory or Tramadol for 5 days and regular Panadol for as long as required, usually a few days after you discontinue the anti-inflammatory.
The wound in the groin is closed with an absorbable stitch so there are no sutures to remove. The wound is dressed with a shower proof dressing that is removed by you about seven days after the surgery.
When can I drive?
This is an important question as reaction rates are reduced in the early days after hernia surgery. Three days is generally considered the time that you should abstain from driving after laparoscopic repair and a week following open repair.
What to look out for after Surgery
Minor bruising is not uncommon but increasing redness, pain and fever may indicate a wound infection, if there is any concern please contact me without delay. Minor thickening of the fat beneath the scar persists for about six weeks.
More information needed?
“Informed consent for surgery is a process not a piece of paper”! If you require more information on any aspect of your condition or proposed treatment please make an appointment to discuss your concerns.
New Zealand Association General Surgeons position statement
Mesh hernia repair
There has been much controversy in the media recently regarding transvaginal mesh prolapse repair and its potential associated risks of infection, erosion and chronic pain (1). Unfortunately, the media have portrayed the outcomes of this one gynaecological procedure to include all surgical use of mesh for hernia repair. It has caused unnecessary widespread patient stress and anxiety throughout New Zealand.
The use of mesh in General Surgery to repair hernias of the groin or the abdominal wall is well established internationally and is considered the procedure of choice (2). For ventral hernias with fascial defects greater than 2cm in diameter mesh must be used to reinforce the tissue repair (3). If not the hernia recurrence rate without mesh is unacceptably high. For groin hernia repair most surgeons worldwide use mesh for the repair.
The use of mesh for abdominal and groin hernia repair is safe. Chronic pain may occur after hernia repair in less than 10% of patients. However, it is important to remember that chronic pain after groin hernia repair is higher for patients having non-mesh repair compared to mesh repair(4). Mesh infection after abdominal hernia repair is uncommon, less than 1 % (5). For laparoscopic inguinal hernia repair it is even lower.
The use of surgical mesh is an important part of the curriculum for general surgical training and NZ general surgeons have extensive experience in the use of mesh for hernia repair.
The good results of mesh hernia repair in general surgery should not be bought into disrepute by categorising all mesh repairs as the same.
Steven Kelly, General Surgeon, Christchurch on behalf of the Executive, New Zealand Association of General Surgeons (NZAGS).
For further information please contact NZAGS on (04) 384 3355.
1. Mesh blamed for agony still used in Ops. The New Zealand Herald, Sunday 25.05.14
5. Aufenacker TJ et al. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 2006 Jan;93(1):5-10