Miss Boorman specialises in a range of hernia treatments.

Epigastric Hernia

What does the operation involve?

Surgery to repair an epigastric hernia is usually performed under a general anaesthetic. Your anaesthetist will discuss the options with you and recommend the best form of anaesthesia for you. You may also have injections of local anaesthetic to help with the pain after surgery. You may be given antibiotics during the operation to reduce the risk of infection. The operation usually takes about half an hour.

Your surgeon will make a cut over the hernia and free up the ‘hernial sac’.

If only fat is pushing through, your surgeon will either remove the fat or push it back. If contents of the abdomen are also pushing through, they will place the contents back inside the abdomen.

Your surgeon will remove the hernial sac and close the weak spot with strong stitches or a synthetic mesh (for larger hernias). They will then close the skin.

What should I do about my medication?

You should let your doctor know about all the medication you are on and follow their advice. This includes herbal remedies and medication to control diabetes and blood pressure. If you are on beta-blockers, you should continue to take them as normal. You may need to stop taking warfarin or clopidogrel before your operation.

What can I do to help make the operation a success?

If you smoke, stopping smoking several weeks or more before an operation may reduce your chances of getting complications and will improve your long-term health.

Try to maintain a healthy weight. You have a higher chance of developing complications if you are overweight. Regular exercise should help prepare you for the operation, help you recover and improve your long-term health. Before you start exercising, ask a member of the healthcare team or your GP for advice.

You can reduce your risk of infection in a surgical wound.

• In the week before your operation, do not shave or wax the area where a cut is likely to be made.
  
• Try to have a bath or shower either the day before or on the day of your operation.
  
• Keep warm around the time of your operation. Let a member of the healthcare team know if you are cold.

What complications can happen?

1. Complications of anaesthesia

Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic.

2. General complications of any operation

• Pain, which happens with every operation. The healthcare team will try to reduce your pain. They will give you medication to control the pain and it is important that you take it as you are told so you can move about and cough freely.
  
• Bleeding during or after surgery. This rarely needs a blood transfusion or an operation but it is common to get some bruising around the cut.
  
• Infection of the surgical site (wound). It is usually safe to shower after 48 hours. However, you should check with a member of the healthcare team. Let the healthcare team know if you get a temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics but you may need an operation.
  
• Unsightly scarring of the skin.
  
• Blood clot in the leg (deep-vein thrombosis – DVT). This can cause pain, swelling or redness in your leg, or the veins near the surface of your leg to appear larger than normal. The healthcare team will assess your risk. They will encourage you to get out of bed soon after surgery and may give you injections, medication, or special stockings to wear. Tell the healthcare team straightaway if you think you might have a DVT.
  
• Blood clot in the lung (pulmonary embolus). This happens if a blood clot moves through the bloodstream to your lungs. If you become short of breath, feel pain in your chest or upper back, or if you cough up blood, you may have a pulmonary embolism. You should tell the healthcare team straightaway or, if you are at home, go to your nearest Accident and Emergency department immediately or call an ambulance.

3. Specific complications of this operation

• Developing a lump under the wound. This is caused by a collection of blood or fluid and normally settles over a few weeks.
  
• Injury to structures within the abdomen. This is rare but may need further surgery.

How soon will I recover?

• In hospital

After the operation you will be transferred to the recovery area and then to the ward. You should be able to go home the same day. However, your doctor may recommend that you stay a little longer. If you do go home the same day, a responsible adult should take you home in a car or taxi and stay with you for at least 24 hours. You should be near a telephone in case of an emergency. If you are worried about anything, in hospital or at home, contact a member of the healthcare team. They should be able to reassure you or identify and treat any complications.

• Returning to normal activities

You should not drive, operate machinery (this includes cooking) or do any potentially dangerous activities for at least 24 hours and not until you have fully recovered feeling, movement and co-ordination. If you had a general anaesthetic or sedation, you should also not sign legal documents or drink alcohol for at least 24 hours.

To reduce the risk of developing a blood clot, make sure you follow carefully the instructions of the healthcare team if you have been prescribed drugs or have to wear special stockings.

A member of the healthcare team will tell you if you need to have any stitches or clips removed. You should gradually increase how much you walk around over the first few days after your operation. You may need to take painkillers to help you.

You should be able to return to work after one to two weeks but this may vary depending on the extent of surgery and your type of work.

Your doctor may tell you not to do any manual work at first and you should not do any heavy lifting for six weeks.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, you should ask a member of the healthcare team or your GP for advice.

Do not drive until you are confident about controlling your vehicle and always check your insurance policy and with your doctor.

• The future

Most people make a full recovery and can return to normal activities. However, the hernia can come back (risk: less than 1 in 20). This depends on the size of the hernia, the strength of your abdominal muscles, if you are overweight or if you have underlying medical problems. The hernia can come back many years later and may need further surgery.

Summary

An epigastric hernia is a common condition caused by a weakness in the abdominal wall between the umbilicus and sternum. If left untreated, an epigastric hernia can cause serious complications.

Surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early.

Femoral Hernia

What happens during femoral hernia repair surgery?

A variety of anaesthetic techniques are possible. The operation usually takes less than an hour. Your surgeon will make an incision (cut) in your groin and remove the "hernial sac". They will strengthen the muscle layer with stitches and may insert a synthetic mesh to cover the weak spot.

Going home after femoral hernia repair

Recovery from hernia repair is usually very quick. You will probably go home the day of the surgery. You will be mobile very soon after the procedure and will be encouraged to increase how much you walk around over the first few days post-surgery. Many patients return to normal day to day activities within the first week. 

You should not do any heavy lifting or strenuous activity for one month. Please discuss your return to work with your surgeon prior to discharge from the hospital. Occasionally the hernia comes back.

What complications can happen?

Every surgical procedure has a risk of complications. Be sure and discuss any concerns you might have about these risks with your surgeon.

General complications of any operation:

• Pain
• Bleeding
• Infection in a surgical wound
• Blood clots
• Unsightly scarring

Specific complications of femoral hernia repair surgery:

• Developing a lump under the wound
• Difficulty passing urine
• Injury or narrowing of the femoral vein
• Injury to structures within the hernia
• Temporary weakness of the leg
• Injury to nerves

Inguinal Hernia

What happens during inguinal hernia surgery?

Inguinal hernia repair may be carried out under a local or a general anaesthetic.

A local anaesthetic means you'll be awake during the procedure, but the area being operated on will be numbed so you won't experience any pain.

A general anaesthetic means you'll be asleep during the procedure and won't feel any pain.

Once the anaesthetic has taken effect, the surgeon makes a single cut (incision) over the hernia. This incision is usually about 6 to 8cm long. 

The surgeon then places the lump of fatty tissue or loop of bowel back into your abdomen (tummy).

A mesh is placed in the abdominal wall, at the weak spot where the hernia came through, to strengthen it.

When the repair is complete, your skin will be sealed with stitches. These usually dissolve on their own over the course of a few days after the operation.

You should be able to go home the same day or the day after surgery. It's important to follow the hospital's instructions on how to look after yourself. 

This includes eating a good diet to avoid constipation, caring for the wound, and not straining yourself too soon.

Most people make a full recovery from inguinal hernia repair within 6 weeks, although many people can return to driving, work and light activities within 2 weeks.

Are there any risks from the operation?

An inguinal hernia repair is a routine operation with very few risks. But a small number of hernias can come back at some point after surgery. 

Other potential complications of an inguinal hernia repair include:

• blood or fluid building up in the space left by the hernia (this  usually gets better without treatment) 
• painful swelling and bruising of the testicles or the base of the penis (in men)
• pain and numbness in the groin area caused by a nerve being damaged or trapped during surgery 
• damage to the blood supply to the testicle
• damage to the vas deferens (the tube that carries sperm to the testicles)

Complications are more likely if you're aged over 50, smoke or have another illness, such as heart disease or breathing problems.

Incisional Hernia

Treatment options for incisional hernias

Incisional hernias can be managed conservatively. Some people find wearing supportive underwear or corsets helpful.

Incisional Hernia Surgery

In the past, the gap that the hernia bulged out of was simply closed and sewn shut. Incisional hernias often appear in the same place. Nowadays a fine synthetic mesh is usually placed on the affected area too. This helps strengthen the abdominal wall.

At operation, the abdomen is cut open, the gap that the hernia protrudes through is closed from the outside, and a mesh is placed on it to strengthen it.

If an incisional hernia occurs within the first few weeks after an abdominal operation, the hernia isn’t repaired immediately. This gives the abdominal wall time to recover. Incisional hernias are generally only repaired several months after the surgery that led to them was carried out.

What risks are associated with surgery?

Surgery can lead to injuries in the abdominal cavity. The wound may also become infected in the first few days after surgery. About 15 out of 100 people experience pain after surgery, but it often goes away after a few days or weeks. In some cases the pain becomes permanent, though. Possible causes of pain include nerves that were damaged, scar tissue sticking together, or the mesh being too tight.

Sometimes fluid builds up around the mesh after surgery. The fluid may have to be removed using a hollow needle (puncture aspiration). In about 5 out of 100 people, the incisional hernia recurs within the first few years after the hernia operation.

Do incisional hernias always have to be operated on?

If incisional hernias don’t cause any problems or complications, they don’t necessarily have to be operated on. However, this type of hernia often gets bigger over time, and there is a small risk that part of the intestine might become trapped.

When deciding whether or not to have surgery, the patient’s age and other medical conditions play a role too. It is best to discuss the advantages and disadvantages of having surgery with a doctor.

When are incisional hernias more difficult to treat?

Because large incisional hernias are often very unpleasant, many people who have them would prefer to get treatment. However, large hernias are a lot harder to operate on than small hernias.

Many people who have large incisional hernias are very overweight, have weak abdominal muscles and also have other medical conditions. This increases the risk of complications after surgery. The most suitable type of surgery will then depend on a range of individual factors.

Women who would still like to have children are also in a special situation. Their abdominal muscles have to be able to stretch a lot during pregnancy to make room for the growing baby. Because synthetic mesh is less elastic than natural muscle tissue, doctors are concerned that women who become pregnant will have a greater risk of complications. Unfortunately, there is very little scientific research in this area.

Most women who have an incisional hernia will probably be able to wait until they are sure they don’t want to have any (more) children before having surgery to repair the hernia. When hernia surgery is necessary in women who might still have children, doctors tend to recommend not using a mesh. But if the hernia is repaired without using a mesh, the risk of the hernia recurring is higher – particularly during pregnancy.

Spigelian Hernia Repair

You will be admitted on the day of surgery unless there are any medical or technical reasons, which may require you to be admitted the day before.

Most patients go home on the operation day (day case), some will be required to spend 1-2 nights in hospital.

Surgical repair can be carried out under general anaesthetic or local anaesthetic.

The choice depends partly on which you prefer and partly on what your anaesthetist and surgeon think is best.

The incision is usually made in the abdominal wall overlying the site of the hernia.

The pouch (hernia sac) is first dealt with and the weakness in the abdominal wall is strengthened. This is done using permanent stitches or a patch of nylon mesh that is stitched in place; the wound is then closed using an invisible dissolvable stitch and covered with a waterproof dressing or skin glue. 

What are the risks/complications of surgery?

• Wound haematoma – bleeding under the skin can produce a firm swelling – like a bruise. This may simply dissipate gradually or leak out through the wound. If there is a lot of fluid this may occasionally result in you having to return to theatre in order for it to be dealt with.

• Wound infection – minor wound infections do not need any specific treatment. Antibiotics are given during the operation to minimise the risk of deep-seated infection.

• Recurrence – fortunately recurrence after hernia surgery should be rare (1-5%).

These risks/complications will be explained and discussed with you when the surgeon asks you to sign the consent form.

What should you expect after surgery?

You will commence fluids as soon as you are able, if tolerating fluids you will progress to a light diet.

Abdominal wound pain/discomfort is to be expected after the operation. Therefore pain relief consisting of injections or tablets may be required in the first 24-48 hours.

It is important to avoid constipation and straining when you go to the toilet. Take plenty of fibre in your diet and drink plenty of fluids. If you find you continue having difficulty with your bowels on your return seek advice from your GP.

You may resume sexual relations as soon as this feels comfortable to do so. 

After the operation activity is encouraged. You should avoid suddenly putting extra strain on the wound for at least 4 weeks. However, it is essential you progressively increase your activity day by day.

It is wise not to drive for at least 1 week; some people feel they need a little longer. Usually if you can get in and out of the bath without any discomfort and/or assistance you can consider driving and over time, increase the distance of your trips. However, please check with your insurance company, as some policies carry restrictions that vary with individual companies.

If your work does not involve heavy lifting or violent exercise, then return to work could be as soon as 2-3 weeks. If it does, then it is safer to wait for a further 2-4 weeks.

If this advice is not heeded, the repair could give-way and the hernia will recur.

Some swelling or bruising around the wound site is not unusual and there will be some discomfort and tenderness where the incision has been made.

In the period following you operation you should seek medical advice if you notice any of the following problems:

• Increased pain, redness, swelling or discharge of the wound

• Persistent bleeding

• Difficulty in passing urine

• High temperature

• Nausea or vomiting

Umbilical/Paraumbilical Hernia

You can be given a local or a general anaesthetic. The choice depends partly on which you prefer, and partly on what your anaesthetist and surgeon think is best.

In some cases when the hernia is relatively small and your general medical condition does not allow you to tolerate the stress of a general anaesthetic, the operation can be done under local anaesthetic.

Having a general anaesthetic means that you will be completely asleep during the operation.

Having a local anaesthetic means that you will be awake during the operation, you will feel that something is being done at the area of the operation but will not feel pain.

A cut is made near the tummy button. Any fat or bowel in the hernia is pushed back or removed. The weakness is mended/closed usually with strong stitches.

Another alternative is to reinforce the weak spot with a piece of synthetic material (mesh). This is usually done when the tissues around the weak spot are not strong enough to be stitched up together with strong stitches or when the weak spot is so big that it is impossible to close it with stitches alone.

The synthetic patch is placed on top of the weak spot and is stitched to the healthy tissues around it. Soon scar tissue develops above and under the patch and this makes it very strong and makes it less likely that the hernia can come back again.

The skin is then closed up, usually with invisible dissolving stitches.

The appearance of your tummy button may change after the operation and rarely may have to be removed, especially if the hernia is large.

You may well be able to have the operation on the day you come in and go home the same day. Some people may need to stay in for a day or two depending on your health.

Possible complications

If you have this operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs.

The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
Complications are rare and seldom serious. If you think that all is not well, please let the doctors and the nurses know.

Bruising and swelling may be troublesome, particularly if the hernia is large. The swelling may take four to six weeks to settle down.

Serious bleeding that might require another operation to stop it happens in less than 1% of cases.

Infection happens in 1 to 2% of cases and usually settles down with antibiotics in a week or two.

The infection can cause more trouble in situations where the hernia was repaired with a synthetic patch.

The patch is a foreign body and if it gets infected it makes it difficult to control the infection with the antibiotics. If this happens, you may require antibiotics for a longer period of time and, very rarely, you might need another operation to remove the patch. In this case, you will most probably need another operation in the future to repair the hernia again.

Extremely rarely (1 in 2000 cases) the bowel or other organs of the abdomen can be damaged during the operation and if this occurs you will need another operation to fix the problem.

Aches and twinges may be felt in the wound for up to six months.

About 1 to 2 % of patients experience some pain longer than that (chronic pain) and if this happens the doctors will you discuss with you the best way to deal with the problem.

Overall the chances of the hernia coming back again are between 3 to 5%.

The chances of the hernia coming back are higher if the hernia was very big, you are overweight or your tissues are not very healthy and they are not healing well for example if you are elderly or diabetic.

Complications are rare and seldom serious.