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Frequently asked questions
What is a hernia?
A hernia is a defect in the abdominal wall allowing contents from
inside the abdomen to protrude through.
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Are their different
types of hernias?
Yes there area number of different types of hernias of the abdominal
wall. The commonest types are inguinal, umbilical, paraumbilical,
femoral and incisional. There are other rarer types such a spigelian
and lumbar. In addition there are hernias at other sites. The most
common being a hiatus hernia in which the stomach slips up through
the diaphragm into the chest. This can be associated with a number
of problems the commonest of which is gastro-oesophageal reflux
which we experience as heartburn.
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Is a hernia
dangerous?
The danger of a hernia lies in the fact that it is possible for the
abdominal contents entering the hernia to become stuck. Should this
occur the hernia becomes increasingly painful and cannot be pushed
back.
If the hernia contains bowel then it will become blocked (intestinal
obstruction}. This produces colicky abdominal pain in addition to
the constant pain experienced within the hernia, abdominal
distension, vomiting and a variable degree of constipation. Patients
may hear a lot of gurgling coming from their abdomen as the bowel
contracts vigorously in an attempt to overcome the blockage. With
time, the blood supply to the bowel may be cut off leading to it
rupturing and the development of peritonitis. This is a serious
complication requiring emergency surgery. It is to avoid the
possibility of this serious complication occurring, that doctors
recommend the repair of the majority of hernias as a matter of
routine.
So the answer is yes hernias can be dangerous, on occasions leading
to the need for an emergency admission to hospital and an emergency
surgery.
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How can
a hernia be repaired?
The way in which repair is performed depends on the type of hernia.
The commonest type of hernia seen is inguinal which appears in the
groin. The methods of repair can be divided into open operations and
laparoscopic procedures.
In the open operation a cut approximately 8 cm long is made in the
groin, the hernial sac is removed and the weakness, through which
the hernia came, repaired. There are a number of possible ways of
repairing the weakness although most surgeons now use a piece of
plastic mesh. This is placed over the defect and stitched down. The
mesh remains in place permanently.
The repair of an inguinal hernia using a laparoscopic approach is a
modern innovation. Like the open technique it uses a mesh, but
unlike the open technique the operation can be performed through
three small cuts, the largest of which is 15mm in size.
There are two different laparoscopic approaches: transperitoneal and
extraperitoneal. These names are often abbreviated to TAPP (trans
abdominal preperitoneal approach) and TEP (total extraperitoneal
approach). In the former the abdominal cavity is entered. In the
latter the operation can be completed without the need to enter the
abdominal cavity.
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With all these different ways of repairing an inguinal hernia
which
one should I choose?
The open mesh repair and laparoscopic repairs have similar success
rates and so from that point of view there is really nothing to
choose between them. Equally, both can normally be performed as a
day case (the patient goes home on the day of surgery). A
laparoscopic repairs requires a general anaesthetic and relaxation
of the abdominal wall in order to allow the space required to
perform the operation to be created. So if you do not want to be put
to sleep for your operation, or it is not thought safe to put you to
sleep, then you cannot have a laparoscopic approach. You will have
to have your hernia repaired under local or regional anaesthetic as
an open procedure.
It is unlikely that the surgeon will offer a choice between TAPP and
TEP laparoscopic operation. It may be that they have had experience
at both techniques but likely that they will have chosen to offer
one technique only. The technique employed is less important than
the fact that the surgeon should be comfortable with the technique
they choose and perform the operation effectively and safely.
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What are the differences between open and laparoscopic repair of an
inguinal hernia?
The major differences are in the amount
of postoperative pain, the time to start walking and the time taken
to return to work which have been shown to be less in patients
undergoing laparoscopic repair (6 to 18 days less). Wound numbness
is also less after laparoscopic hernia repair. One study showed a
slightly increased quality of life after laparoscopic, as apposed to
open, repair.
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Will I be in pain
after the operation?
We understand that this is a major concern for patients and
acknowledge that most operations lead to some degree of
postoperative pain or discomfort. We take great care to minimise
postoperative pain using a variety of techniques. At operation we
infiltrate local anaesthetics into wounds and provide patients with
pain killers to go home with. We recommend that these be taken
regularly for the first 48 hours.
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What are the
dangers of laparoscopic repair?
There is a higher chance of injury to major vessels and bowel in
patients undergoing laparoscopic operations (4.7 per 1000 at
laparoscopic operations as apposed to 1.1 per 1000 at open
operations). All injuries occurred with the TAPP and non-with the
TEP technique.
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When will I be able
to return to work?
This will depend upon the type of work you do. Interestingly, what
restricts your return to work is not worries about the risk of the
hernia coming back (manual workers have less chance of a hernia
coming back than office workers) but the degree of pain and
discomfort. Office workers will be able to return after a few days
or a week whereas those whose job involve a lot of physical activity
may require two or three weeks off work.
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Which is
better open or laparoscopic repair?
There is less postoperative pain, less wound numbness and an earlier
return to work in patients undergoing a laparoscopic repair. If the
TEP repair is chosen, the risk of major vascular or bowel injury is
the same as for the conventional open operation. Laparoscopic and
open operations are equally effective in repairing the hernias. At
the end of the day, each individual will have their own idea of
which is the right approach for them. Many people choose a
laparoscopic approach but a number still prefer the open operation.
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Can
other types of hernia be repaired laparoscopically?
Yes they can, incisional, umbilical and paraumbilical hernias can
all be repaired laparoscoically. If the hernia is small, and
therefore the cut through which it is repaired also small, then
there may be little difference in the amount of postoperative pain
between an open and laparoscopic repair. If repairing a hernia
requires a larger cut then a laparoscopic approach is probably
better.
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Are there any types of inguinal hernias which are better repaired laparoscopically?
The National Institute of Clinical Excellence (NICE) has reviewed
the question of whether hernia repairs should be performed
laparoscopically or at open operation. They recommend that a
laparoscopic repair is appropriate for patients with a hernia in
both groins and or where the hernia has come back after being
repaired previously.
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