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Hernia

Any weakness in the abdominal wall muscle can allow the passage of fat or organs such as small bowel to push through. This can produce a hernia with the most common types including Inguinal hernia (groin), Incisional hernia (due to a previous incision/ operation scar), Femoral hernia (groin), Umbilical hernia (belly button), and Epigastric hernia (upper abdomen).

Herniae can often present with pain and/or a noticeable lump and require assessment and possibly surgery by specialised Surgeons.

Manchester General Surgeon provide a total care pathway for patients requiring hernia surgery.

Please select from the below drop downs to find out more information about different hernia conditions.

Sportsman's Hernia

A Sportsmans hernia is a condition characterised by chronic groin pain. There is no definable hernia identified with a rupture of muscles or tendons in the inguinal canal often attributed to the cause of the condition. Many professional footballers have had treatment for this condition.

As the case suggests, young athletes commonly present with this pain. It is especially common among football, hockey and rugby players, with a twisting action causing particular strain and discomfort. Simple walking does not usually bring the pain on, but excessive straining or stretching does exacerbate the symptoms. Various scans have been used to try and diagnose this condition, MR scans are often performed to try and detect a possible hernia or muscle rupture.

Sportsman hernia presents with persistent groin pain. Physical activity makes the pain worse, with rest recommended. There is usually no hernia associated with this condition.

The chronic groin pain requires treatment by a multidisciplinary team. Rest and physiotherapy are recommended initially with local anaesthetic and steroid injections offered as the first line treatment. Surgery is rarely contemplated but may be necessary for severe on-going pain after all other treatments have failed. The surgery requires the main 'conjoint' tendon to be released and reconstructed coupled with a tension-free mesh placement, to strengthen the repair. The surgery is combined with a careful follow up and physiotherapy program.

Recovery does not take long, with most patients being discharged within 24 hours of surgery. Complete recovery is based on individual needs and fitness of the patient. Patients are encouraged to start mobilising immediately after surgery and refrain from lifting heavy objects for at least one month. A return to full sporting activities is expected within four weeks.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection and a 1-2% risk of recurrence of the hernia.

Epigastric Hernia

An Epigastric hernia is a protrusion normally seen noted between the xiphoid process (breast bone) and the umbilicus (navel) as a result of weakness or opening of the underlying muscles or tendons.

Any person can present with an epigastric hernia but it is more common in men and has a strong association with obesity.

An epigastric hernia is usually asymptomatic but can present with pain and/or a notable lump. It can be aggravated by exercise and eating at times. On rare occasions if small it can also become very painful and irreducible (incarcerated). Usually it will contain fat overlying the bowel (extraperitoneal fat) but can also contain bowel in which case it managed as a surgical emergency (strangulated hernia).

If relatively asymptomatic they can be left alone. Small epigastric hernia, because of the risk of incarceration or strangulation, they are often offered surgical repair. Surgery involves an incision over the lump and closure of the defect with simple sutures. In some cases the repair is reinforced with a mesh. Smaller epigastric hernia can also be repaired under Local Anaesthesia.

Recovery is very quick, with most patients being discharged the same day. Complete recovery is based on indivdual needs and fitness of the patient. Patients are encouraged to start mobilising gently immediately after surgery and refrain from lifting heavy objects for at least one week. A return to full activities is expected within two weeks.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection and a 1-2% risk of recurrence of the hernia.

Femoral Hernia

A femoral hernia similar to an inguinal hernia and occurs in the groin area near the leg crease. It is often painful with an obvious lump

Femoral herniae are far more common in women and increase in incidence with age (typically old, thin women). During pregnancy women put weight on around their hips and upper legs, which stretches the femoral canal. This canal once stretched will allow the passage of fat and at times bowel through it, resulting in a hernia. Commonly the hernia containing a layer of fat, which lies over the bowel, called extraperitoneal fat.

A Femoral hernia usually presents as a painful lump in the skin crease of the leg. It can be difficult to distinguish a femoral hernia from an inguinal hernia in some patients. If irreducible may, a femoral hernia will require an immediate/ emergency operation due to possible strangulation of omentum or bowel (incarcerated or strangulated hernia). A patient will notice a very painful hard lump in the groin area in line with the leg skin crease. Like inguinal hernia repetitive coughing or straining, lifting heavy objects can increase the risk of developing a femoral hernia.

A Femoral hernia if presents as a tender irreducible lump is treated as an emergency with surgical repair recommended as soon as possible. The emergency surgery involves a small incision in the skin crease, with repair of the defect with in some case a single stitch. Rarely a mesh is used for the repair and in some cases if bowel is involved a small piece of bowel has to be removed.

Femoral hernia in the non-urgent setting can be repaired by open surgery under either local or general anaesthesia. Keyhole 'laparoscopic surgery' is also possible for femoral hernia and is usually recommended in this scenario.

Your Surgeon will discuss all the options with you and together a decision will be made on which type of hernia repair will suit you best.

Recovery is very quick, with most patients being discharged the same day. Patients are encouraged to start mobilising immediately after surgery and refrain from lifting heavy objects for at least two weeks and heavy duty activity for a possible further month. A return to full regular activities is expected within one week.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection and a 1-2% risk of recurrence of the hernia.

Incisional Hernia

An incisional hernia is a protrusion, which occurs through a defect in the site of a previous abdominal incision/ scar.

Any person that has undergone previous abdominal surgery can develop a weakness at the site of the previous scar. Obesity is a common risk factor. It is also more common in patients that may suffer from chronic constipation, a chronic cough and/or possible difficulty in passing urine.

An incisional hernia usually presents by a 'bulging' at or close to the site of the abdominal scar. It is particularly apparent on standing, lifting heavy objects and can disappear on lying down. The hernia presents and progresses over time and can be painful as well as unsightly. Other more serious complications include bowel obstruction presenting with nausea, vomiting and gross swelling of the abdomen. In some cases the bowel's blood supply can be cut off resulting in a condition called an 'incarcerated hernia' and this is a recognised surgical emergency.

Upon diagnosis, simple treatment measures involve the use of a specially designed corset or belt to support the hernia. Surgery is recommended to reduce the size of the hernia and help control symptoms of pain. The operation involves reducing the contents of the hernia into the abdomen and repairing the defect in the abdominal wall by using a suitably sized mesh, which reinforces the repair.

The operation can be performed by the conventional open technique utilising the previous incision or by a keyhole technique. The surgeon determines the type of repair possible.

Recovery is based on the type of operation that you have. Open surgery recovery is dependant upon the size of the hernia and generally patients are encouraged to start mobilising gently immediately after surgery and refrain from lifting heavy objects for at least two to three weeks. A return to full activities is expected within six weeks. Keyhole surgery has a quicker recovery time.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection and a 1-2% risk of recurrence of the hernia.

Inguinal Hernia

An Inguinal hernia is a protrusion in the lower abdomen or groin area. It often presents predominantly with a bulge in the groin area but can also present with pain and sometimes a burning sensation.

Anyone can present with an inguinal hernia, but they are more common in men and are associated with:

• Persistent coughing or straining (constipation, difficulty in passing urine)
Increasing weight (mild to moderate obesity)
• Pregnancy
• Keen sportsman, weight-lifting & cycling

An inguinal hernia usually presents with a lump or pain in the groin area. Exercise, coughing or sneezing can aggravate the hernial lump and some inguinal hernia can also protrude down into the scrotum (men). Small inguinal hernias usually disappear on lying flat. Inguinal hernia are usually reducible by simple pressure but can on rare occasions become very painful and irreducible (incarcerated or strangulated). Usually the hernia will contain a sac, which may have small or large bowel contents.

An inguinal hernia is often painful and due to the risk of possible incarceration and/ or strangulation surgical repair is recommended. Surgery is performed as a day case for the large majority of patients requiring no overnight stay and can be performed by the following techniques:

1) Open surgery under Local or General anaesthetic (it can also be performed with epidural anaesthesia, where you are awake but numb below your waist due to a simple anaesthetic given by a needle in your back)

2) Keyhole 'laparoscopic' surgery - This involves a General anaesthetic and predominantly the use of the totally extra-pre-peritoneal repair (TEP) please see below. This repair technique can also be combined with the Trans-abdominal (TAPP) approach for very large groin hernias.

3) TEP (totally extra-peritoneal repair) - This type of repair involves the creation of a space within the layers of your abdominal wall muscles and so does not involve going into the abdominal cavity and allows fixation of the hernia with placement of a mesh in this space once the hernia has been reduced.

The keyhole technique is not possible in a very small number of patients as there is no space present between the abdominal wall muscles/fascia. This can be seen in patients that have undergone previous surgery with an incision in the lower part of the abdomen due to a major abdominal operation, a caesarean incision and those with an open appendicectomy incision in the right lower part of the abdomen.

Recovery is very quick, with most patients being discharged home the same day. Patients that undergo inguinal hernia repair on both sides (bilateral) may require hospital stay overnight especially if they are older (>70). Patients are encouraged to start mobilising immediately after surgery and refrain from lifting heavy objects for at least one month as well as heavy duty activity for a possible further month. A return to full regular activities is expected within two weeks for keyhole surgery and up to one month for open groin hernia surgery. A patient information leaflet will be provided which details what possible wound problems can arise after surgery as well as a rehabilitation programme.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of bleeding in the abdominal wall and/ or groin, very rarely bleeding requires any intervention such as surgery. Older patients and those with large hernias may find more swelling in the area previously occupied by the hernia known as dead space (artificial space created by the hernia protrusion), which can be in the groin as well as the scrotum (in men). The dead space fills with fluid especially in the scrotum, and requires support with tight undergarments but not too tight. This swelling is called a seroma and settles in most patients in 1-3 months with some persisting longer. Occasionally a small bleed into a seroma presents with a haematoma or bruise, this again settles in time but can usually be unsightly for up to the first six weeks after surgery especially if in the scrotum, therefore, supportive undergarments are again suggested.

Another complication includes wound infection and a 1-2% risk of recurrence of the hernia. Specifically for inguinal hernia surgery the risk of groin pain and numbness is quoted as a long term risk seen in up to 2-6% of patients.

Men of increasing age can in some cases have difficulty in passing urine especially after keyhole hernia repair, this is because the prostate gland can swell. Some patients require a catheter passed into the bladder and may also need some medication, but this is temporary and in most patients the catheter can be removed after 24-48 hours. Very rarely a specialist in urology will be needed for advice.

The risks of underlying bowel complications are rare and are mainly associated with the keyhole (laparoscopic) technique and if they occur, are commoner with the TAPP over the TEP method.

Other very rare complications that have been described in the literature include injury to major blood vessels and the bladder but these again are predominantly associated with the keyhole (laparoscopic) technique.

Umbilical Hernia

An umbilical hernia is a protusion directly at the belly-button or navel. A hernia around the belly-button is commonly know as a para-umbilical hernia.

Umbilical herniae are commonly seen in newborn babies and young children. They are usually harmless and generally require no treatment and generally disappear as the child gets older. Adults generally present with paraumbilical hernias and are more common in patients who are overweight and women especially after pregnancy.

Umbilical hernia in adults can present with pain and are made worse by heavy lifting, straining or coughing. They are often reducible but at times cannot be reduced but are not painful. In some cases the umbilicus can present with a very painful lump, which cannot be reduced. If there is a change in the overlying skin with redness or a purple discolouration, most likely there is 'unhappy' bowel or fat and surgical repair is undertaken as an emergency (incarcerated/ strangulated). This can happen with umbilical and paraumbilcal herniae as the actual defect is usually quite small.

An umbilical/ paraumbilical hernia in an adult if painful and irreducible is often offered repair. As they have a tendency to become bigger and more unsightly over time, surgery is recommended generally for all patients.

Surgery involves a small incision under or above the umbilicus (belly-button) with the majority of hernia requiring stitches only. In some case if the hernia is large a mesh is inserted to help reduce the risk of recurrence and strengthen the repair.
Surgery can be performed under a local or general anaesthesia and does not normally require overnight stay.

Your Surgeon will discuss all the options with you and together a decision will be made on which type of hernia repair will suit you best.

Recovery is very quick, with most patients being discharged the same day. Patients are encouraged to start mobilising immediately after surgery and refrain from lifting heavy objects for at least two weeks and heavy duty activity for a possible further month. A return to full regular activities is expected within one week.

Your surgeon will advise on any specific complications and risks. For all types of surgery there is always a risk of wound infection and a 1-2% risk of recurrence of the hernia.

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