What are inguinal hernias?

An inguinal hernia is a protrusion of abdominal contents, quite often bowel or abdominal fat, through a weak area in the groin.

What are the typical symptoms and physical findings associated with an inguinal hernia?

The most common symptom of an inguinal hernia is a bulge that you will feel in the groin. This is mostly felt when you strain the tummy muscles, like when you cough, sneeze, or lift a heavy object. The bulge become more prominent towards the latter part of the day and can usually reduce when you lie flat. However, as the time pass by then these can give rise to other symptoms. Inguinal hernias can be painful if they are stuck there and are not able to reduce or if it leads to obstruction of that part of the bowel or if the blood supply to the affected segment of bowel is compromised. If the bowel segment is obstructed then, one will have symptoms of bowel obstruction like, bowel not opening, distension of the tummy and vomiting.

You will see an obvious bulge in your groin. However, in the early stages, the bulge is only seen when you cough of sneeze of lift a heavy object. When you keep the palm of your hand over the lump, you will feel a soft swelling and if it is large, you will feel the bowel movements under your palm.

How do they differ between direct and indirect hernias?

If the hernia comes through the deep inguinal ring (where the vas difference in a man or the round ligament in a woman exists the tummy), then we call it an indirect inguinal hernia. If it comes more medially, then we call it a direct hernia. The differentiation of the type (direct vs indirect) is more of a discussion about their aetiology and of their anatomy – but has minimal relevance to how they are treated.

What are the key factors to consider when deciding between open or laparoscopic surgical repair for an inguinal hernia?

Laparoscopic (keyhole) operations of inguinal hernias give better short-term results compared to open approach. However, the long-term results, in terms of recurrence is the same. Laparoscopic (keyhole approach) will leave you with smaller scars which will disappear with time, gives you less pain as you recover, get you back to your normal activities early and let you mobilise early.

Laparoscopic (keyhole) approach is the preferred options given its favourable short-term outcomes compared to the open approach. It is particularly preferred in bilateral (both sides) hernias and in recurrent hernias after open repair. However, if the hernia is big, or descending into the scrotum or if the BMI is high, laparoscopic (keyhole) approach is technically difficult and is not favoured.

What are the potential complications of inguinal hernia repair surgery, and how can they be managed or prevented?

Inguinal hernia operations are a very common operation type and are safe. However, as with any operation, they carry certain risks. Fortunately, they only happen rarely.

Most common complication after inguinal hernia operation is chronic groin pain. This is because of nerve injury at the time of dissection and because of inflammation around the mesh.  Around 5% of patients will end of having chronic groin pain after inguinal hernia repairs. However, most of the time the pain is only mild to moderate, and the usual pain relief will control it, but it can last for few months. Meticulous dissection at the time of repair will reduce the incidence, but occurrence cannot be completely prevented.

There is a risk of damage structures that are closely related to the hernia sac (bowel, vas difference and testicular blood supply). These are rare. If the bowel is injured, usually it is visible at the time and can be repaired. However, if there is an injury to the vas difference and testicular blood supply; they are unfortunately permanent and cannot be repaired – but fortunately they are very rare. If the vas difference is injured, sperms will not be conducted on that side, however, there will be no functional difference as the vas difference of the opposite side is still intact. If testicular blood supply is compromised, then the testis on that side will shrink in size.

Wounds are at risk of infections. The surgeon will take all the precautions to prevent this happening. Although bleeding could occur, it is rare and can be controlled.

The anaesthesia related complications are related to your general health and your anaesthetist will explain these before the operation.

In cases of recurrent inguinal hernias, what are the most common causes and approaches for surgical repair?

About 2% of Inguinal hernia repairs can fail. They can fail due to technical or patient related factors. A meticulous repair by the surgeon is the most important factor to prevent a recurrence. However, there are few patients related factors that can predispose someone for a recurrence. They are higher BMIs, smoking, pre-existing connective tissue disorders and undue straining of abdominal muscles during the recovery time – usually within the first four weeks, like lifting heavy objects, continued cough, or sneezing.

Surgical approach for a recurrence depends on the initial approach. If the recurrence is from a previous open repair a laparoscopic (keyhole) approach for the second operation is preferred. However, a second open repair is an option too. An open approach is the option for recurrence after laparoscopic (keyhole) repairs.

Is use of mesh in inguinal hernia repairs bad?

Meshes had been in use for hernia repairs for about 50 years now and are considered very safe. Recent bad publicity about meshes were all about mesh around female reproductive organs and is not related in hernia repairs.

There are few traditional non-mesh repairs of inguinal hernias. They all rely on the local tissues to repair the hernia – however, it is the weakness of the very same tissues that gave the hernia in the first instance and as such can’t be relied upon. Moreover, such non-mesh repairs would always approximate tissues under tension – which then will fail under tension. As such, for these two reasons, surgeons have moved away from non-mesh repair for so long to reduce the chance of recurrence.

Although adding a mesh to the inguinal hernia repair increase the chance of pain and infection; the advantage of the mesh outweighs the small negative effects.