Over 120,000 hernia operations are performed every year in the UK, making it the most common surgery nationwide. However, the incidence of hernias is probably significantly higher than this figure as hernias don’t always cause symptoms. This means you may have one but not know it. When symptoms do occur, surgery is almost always recommended. But this wasn’t always the case.
As recently as 10 years ago, a “watchful waiting” approach was adopted. This involved keeping an eye on the hernia alongside weight control to delay the need for any kind of intervention. However, both the UK’s National Institute for Health and Care Excellence (NICE) and the Royal College of Surgeons have since debunked this approach. They found that the longer someone delays getting their hernia treated, the more likely they will need emergency surgery, which increases the risk of complications.
So, if you’ve got a hernia that is causing you symptoms, it’s time to seek treatment. But how do you know if you have a hernia? What exactly is a hernia? And what are your treatment options?
Broadly, a hernia refers to a part of the tissue inside your body pushing out through the muscle or tissue that is meant to be holding it in. By far the most common type of hernia occurs in the groin — these hernias can be divided into inguinal hernias and the less common, femoral hernias.
Femoral hernias are more common in women and inguinal hernias are more common in men but both men and women can develop either type.
An inguinal hernia occurs when tissue inside your abdomen pushes out. It can be direct, where the tissue pushes through a rupture or breakdown of the abdominal muscles, or it can be indirect, where the tissue pushes through a passage in your abdominal muscle wall called the inguinal canal.
A femoral hernia also involves tissue in your abdomen pushing outwards through the abdominal muscle wall. However, rather than pushing through your inguinal canal, it pushes through a passage in your abdominal muscle wall called the femoral canal.
It isn’t only adults that can develop a hernia. In infants and young children, umbilical and paraumbilical hernias are common. Although they are usually small and don’t cause any symptoms, they can occasionally cause problems and need surgery.
Sometimes a hernia can develop as a result of surgery on your abdomen. These are called incisional hernias and can be caused by small or large cuts made through your abdominal muscles during surgery. After surgery, the muscle layer is closed up. However, if it breaks down, an incisional hernia can form.
There are several other types of hernia. This includes hiatus hernia, where a widening of the gap in your diaphragm allows part of your intestines to push through and cause acid reflux, as well as other rare types of hernia, such as a spigelian hernia which occurs in the lower abdomen.
Aside from abdominal surgery, the main risk factors for developing a hernia are straining to open your bowels, age and certain types of physical activity.
The ages at which hernia risk is elevated occur from birth to around age one and then in later life, after age 40, as your muscles become less elastic and weaker.
Physical activities that increase your hernia risk include taking part in sports such as golf and football, or other activities that involve a lot of lifting and straining.
In men, specifically, prostate problems increase the risk of a hernia. Men are also up to 10 times more likely to develop an inguinal hernia than women. This is because men have more structures, namely the vas deferens (the ducts that carry sperm) and arteries that supply the testicles, running through the abdominal muscle in their groin — this makes the muscle here inherently weaker.
Hernias often do not cause any symptoms and when they do, the symptoms may vary depending on the type and severity of your hernia.
For inguinal, femoral and incisional hernias, you may notice a swelling or lump in your groin or abdomen that may disappear when you lie down. You may also experience an ache, discomfort or shooting pain, especially when you bend over or lift something up. You may feel a pressure or weakness in your groin, as well as be constipated.
If you think you have a hernia and you experience sudden severe pain, vomiting, difficulty opening your bowels or passing wind, or your hernia can’t be pushed back in, is firm or tender, go to A&E. You may have a blocked bowel (obstruction) or the blood supply to the tissue trapped in your hernia may be cut off (strangulation). Both conditions need urgent medical treatment.
As mentioned earlier, a hernia that causes symptoms can only be effectively treated with surgery. Hernia surgery is divided into two categories: open and laparoscopic, more commonly known as keyhole.
Up until the 1980s, open surgery was the only way to reliably repair hernias. Even today, in some cases, it may still be the only option available due to the type or size of your hernia, or whether or not it flattens when changing position or applying pressure (reducibility).
There are two main types of open surgery — with mesh or without mesh.
Open hernia surgery with mesh
Open surgery with mesh involves making a cut in your groin over the hernia. Your surgeon will cut down to the muscles and carefully reposition the tissue that has pushed through the muscle wall. Next, a plastic mesh will be placed over the area where the hernia occurred and sewn into place, making sure to split the mesh around any structures running through the muscle to prevent damaging them.
This technique, developed in the 1980s by the Lichtenstein Hernia Institute, is called the Lichtenstein tension-free hernia repair. Today, it is still considered the gold standard for open hernia surgery with mesh.
Open hernia surgery without mesh
When it comes to open surgery without mesh, the most well-known approach is the Shouldice technique, first developed by Canadian surgeon Edward Earle Shouldice in the 1940s and subsequently improved over the decades.
This wasn’t a new idea. Back in the 1880s, Italian surgeon Eduardo Bassini pioneered treating hernias by stitching together muscles. Shouldice refined this approach by stitching up different tissue layers with stainless steel wire.
The Shouldice technique is still used across the world, including at the Shouldice Hernia Center in Canada, named after Edward Earle Shouldice.
The controversy over mesh surgeries
You may have heard about mesh surgeries back in 2017 when they hit the headlines. It was revealed that some women who had vaginal mesh implants as part of surgery to treat bladder incontinence or pelvic floor problems were experiencing chronic (long-term) pain as a result. The mesh was used as a sling to hold up organs and tissue, however, this strain on the mesh caused it to erode, leading to significant complications.
This prompted a review into the use of mesh, not just in gynaecological surgeries but also in hernia surgery. It was found that the use of mesh to treat hernias is appropriate as the mesh is placed flat against the muscle and is therefore not under tension. This reduces the risk of complications as compared with the use of mesh as a sling in gynaecological surgery.
Keyhole hernia surgery took off in the 1990s and is now a more popular approach for hernia repair, where possible, as the recovery period is shorter and the complication of chronic pain after surgery is even lower than for open hernia surgery. Keyhole hernia surgery involves making several small cuts into the abdomen; one to insert a tiny camera and two for inserting surgical instruments.
There are two types of keyhole hernia surgery:
Both TEP and TAPP are equally effective.
Once space is made around the hernia and the protruding tissue is repositioned, a mesh is slipped into place and sewn in.
If you have a hernia on both sides of your body (bilateral hernia), keyhole hernia surgery is preferable. This is because both hernias can be dealt with through the same cuts, avoiding the need for two larger cuts to be made on either side of the body as with open hernia surgery.
Keyhole hernia surgery is, however, not always possible eg with very large hernias that, in men, extend into the scrotum, or hernias that can’t be pushed back in. In these cases, open hernia surgery is needed.
Every surgery comes with risk and whichever type of hernia surgery you have, there is a chance that you will experience complications.
Complications during surgery include bleeding, which can lead to a swelling called a haematoma in your groin or scrotum. In rare cases, surgery can cause inadvertent damage to your intestines.
After surgery to treat incisional hernias, there is also a risk of adhesions forming ie bands of scar tissue that cause parts of your small intestine to become stuck.
Perhaps the most concerning complication for anyone undergoing hernia surgery is pain after surgery. Surgery for groin hernias comes with a 10-12% risk of post-surgery pain for up to three months. The risk of developing chronic pain due to trapped nerves is around 5%. In both cases, the risk is the same whether or not your surgery uses mesh.
There is also a small risk that your hernia will return at the same site. The risk is slightly greater for hernia surgery without mesh (Shouldice technique) compared with hernia surgery with mesh — the risk with mesh is below 10%.
Most hernia surgeries are carried out as day cases, which means you can go home on the same day as your procedure.
Open hernia surgery can be performed under local anaesthetic, so you won’t feel any pain and will be responsive. This allows your surgeon to ask you to perform certain manoeuvres, such as coughing, to check the repair is effective.
Keyhole hernia surgery can only be performed under general anaesthetic, so you will be asleep throughout.
After your surgery, you will feel some pain but this shouldn’t stop you from being able to walk around and perform light activities. You can take over-the-counter painkillers to manage your pain. Most surgeons recommend avoiding excessive lifting but this will depend on your particular case.
Each of the different types of hernia surgery used today is largely successful in treating hernias. Consequently, the current focus of innovation in the field is on further reducing the risk of chronic pain after surgery. Some headway has already been made with the development of a technique to reduce the risk of trapped nerve pain (laparoscopic triple neurectomy).
Research also continues to develop new types of mesh made of more advanced materials. But perhaps the most futuristic avenue of research is the potential for artificial intelligence (AI) to predict hernia surgery outcomes and the use of robotics in hernia surgery.
It’s important to note that robotic surgery is not automated — there is always a surgeon at the helm controlling the robotic arms. However, the flexibility of the robotic arms makes certain manoeuvres easier than with standard keyhole instruments held by human hands.
Robotic hernia surgery is currently being developed, in particular, to treat large hernias and incisional hernias. However, at the moment, the robotic platforms aren’t any more successful than standard keyhole surgery and actually take longer and cost more. So for now the success of your hernia surgery lies in the capable hands of your surgeon.
Spire Healthcare offers the very latest in both keyhole and open hernia surgery. What’s more, our surgeons bring a wealth of experience in each of the current, approved techniques. Combined with our excellent quality control systems, you can look forward to effective treatment for your hernia.
Mr Alan James is a Consultant Upper Gastrointestinal and Laparoscopic Surgeon at Spire Gatwick Park and the Surrey and Sussex Hospitals NHS Trust. Graduating from Oxford University and King’s College London, Mr James went on to train in the South East Thames region. Today he specialises in treating gallstone disease, anti-reflux surgery, and laparoscopic and open hernia repair.