Well let’s start with a definition first, hernias occur essentially when the intra-abdominal
contents move through a defect in or around the abdomen to create a lump. There are various
types of hernias, some more common than others, the more common ones being in the groin, so
called inguinal and femoral hernias. Another common hernia can occur around the bellybutton,
so called paraumbilical hernia, also you can get hernias through old surgical scars and
these are aptly named incisional hernias. There are rarer types of hernias but perhaps
that’s a discussion for another day. A hernia happens when intra-abdominal contents
and they can be bowel, fat or an organ protrude through a defect in the abdominal wall. Sometimes
these defects can be congenital, inherent or actually akin to a design defect and other
times those defects can be acquired, an example of that is through an old surgical incision
site. Some of the more common hernias including inguinal or groin hernias occur because particularly
in men there are inherent congenital weaknesses within the groin. These weaknesses are actually
leftover from the descent of the testicle which has to journey from inside the abdomen to
essentially outside of the body by the time you are one and they leave these little holes
in the groin through which hernias can develop.
The only real option today, is unfortunately
surgery. The real question is when do you operate and that’s an interesting one. I
think most people would agree that if the hernia, wherever it is, is very big, or is
very painful, or is getting in the way of work or daily activities it should be repaired.
The debate exists around the smaller, less symptomatic, less painful hernias but that
said the debate really only exists to be fair in the UK. Around the world, including north
and south America, Europe, Antipodes, Far East etc. the general consensus even in these
small hernias, particularly the inguinal hernias is they should be repaired because if you
don’t repair them, with time they tend to get bigger, the bigger they get the more complex
they are to repair eventually and the more likelihood of something going wrong and although
it’s a small risk, there is a risk of strangulation and that’s where the contents of the hernia
can lose their blood supply very suddenly and in some cases that can be extremely serious
and even fatal if not acted upon immediately. In the UK we are performing fewer particularly
groin hernia surgeries in the NHS and this I think is unfortunate. Hernias, again particularly
groin hernias have found themselves onto the so called “low priority” lists or “of
limited clinical effectiveness" lists and therefore are not being commissioned by the
clinical commissioning groups. I think this is a mistake and the Royal College of Surgeons
have put out a positions statement saying that this really should not continue, there
is now a parliamentary working group which is looking into this, as is the action for
campaign on hernias which will hopefully try and reverse these decisions. It’s also interesting
that the world health organisation backs up the view of the rest of the world that even
in small asymptomatic hernias if the patient is young, fit and active they should be repaired.
Laparoscopic or to give it another term keyhole surgery which tends to use a few small incisions
can be used very effectively in certain hernias. Certain hernias lend themselves particularly
well to keyhole treatment and I would say the groin, inguinal and femoral hernias fall
into that line. Incisional hernias have to be treated on a more bespoke basis, some are
suitable for keyhole surgery but some, especially the larger ones, probably are not. Belly button
or paraumbilical hernias because they're small are probably not best treated by keyhole surgery
as the advantages are not that great.
Keyhole or laparoscopic surgery particularly
lends itself to groin hernia repair and certainly in my practice I do ninety percent of my groin
hernias using the keyhole method today. The keyhole method confers a number of very significant
advantages. Firstly as you would expect the pain is less intense and of shorter duration
and people generally recover in a shorter period of time. To give you some examples,
for a keyhole operation most of my patients tend to be pain free by the end of the first
week and back to work within a week, possibly two, they're certainly driving, most of them
within two to three days and back to full activity within two weeks. With open surgery,
that’s a single, larger cut actually in the groin then you could probably double,
or even triple those timeframes. Another advantage of groin keyhole surgery is that we can routinely
look at the other side, now that’s not something you can do in open surgery, you wouldn’t
make a cut just to have a look but in about ten percent of people we recognise that they
are going to develop a hernia on that side and we can do something about it and in fact
that makes no difference to the patients recovery. The final advantage and I think for me personally
this is probably the biggest one is that after groin hernia surgery, one of the complications
is long term chronic groin pain, now this doesn’t always have to be debilitating but
it certainly can be a nuisance and people do complain about it. We quote for open surgery,
more traditional surgery, about four to ten percent risk, with keyhole surgery it’s
less than one percent. I have performed personally over fifteen hundred keyhole groin hernia
operations and I’ve seen chronic groin pain in about three, possibly four patients so
it really is much lower incidence. Laparoscopic surgery is not always best used
in groin hernia surgery and this applies particularly to the elderly or frail and the reason for
that is because you need a general anaesthetic to successfully complete a laparoscopic operation,
whereas with an open inguinal hernia repair you can safely do that under local anaesthetic,
so if the patient isn’t fit for general anaesthetic then maybe an open repair is better
for them.