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Repair of Hernia " Part One"

A hernia occurs when a weakened area of the abdominal wall allows a bulge of fat or bowel from the abdominal contents to protrude outwards. This happens most commonly in the groin and is known as an inguinal hernia. There is a ligament passing across the groin and just above this there a small passage which allows the blood vessels supplying the testicle to pass through. If this passage or the surrounding structures weaken or stretch then part of the stomach lining or peritoneum can bulge through the gap, particularly on standing, coughing or vigorous activity. 

The area of the hernia can give discomfort by bulging, and the hernia bulge settles back into the abdominal cavity on lying down although they sometimes need to be replaced gently by the hand. There does not have to be an obvious protrusion for aching to occur and an examination will be needed to find the hernia. A hernia can be very large, particularly if it has been present for a long time and it can fill up the scrotal sac in a man. If it gets this far the hernia may remain out for much of the time and be very difficult to replace.

Inguinal hernias occur less frequently in females than males but femoral hernias, a different type, occur more frequently in females and can mostly be found on examination by a specialist. Femoral hernias are more likely to need to be repaired.

Hernias are usually troublesome only because they cause a bulge and aching whilst the most serious risk of a hernia is strangulation which means the bowel which becomes completely trapped and its blood supply may become cut off. The produces sudden severe pain and requires an urgent operation when the affected piece of bowel may need to be removed. Strangulation is not very common and many people have hernias for years without them ever becoming strangulated. Obstruction of the bowel can also occur it the bowel becomes trapped and this demands an operation even if the blood supply has not been cut off.

Hernias can only be permanently cured by operation, as leaving them may allow them to increase in size or at least remain as troublesome, although there is a small risk of strangulation and continued discomfort. A hernia does not have to be operated on if it is not causing undue symptoms and surgeons can discuss the pros and cons with their patients. To hold a troublesome hernia within the abdomen a truss can be used but it needs to be applied before a person gets up and the abdominal pressure increases on activity. Operation is a superior treatment for a hernia which is giving symptoms and being of advanced age or having medical complications should not prevent repair being performed due to safer general and local anaesthetics.

A groin incision about 12 centimetres in length is used for the repair of a hernia, with an opening of a layer of muscle and then the careful separation of the bulging hernia sac from the veins, arteries and tube to the testicle. The protruding fat or bowel from the abdomen is compressed back in and the sac is then stitched back into the abdominal cavity or tied off at its narrow neck area.

A repair is then done to strengthen the weak area and to restore the hole for the arteries and veins of the testicle to its normal small size. The repair is necessary to prevent the hernia from coming back. This is usually done by stitching a plastic mesh over the whole area. Occasionally stitches are used without a mesh, for example in femoral hernias. Both these methods have been shown to give good long term results, and the chance of the hernia coming back is about 2% (1 in 50) for most people.

Some surgeons do the operation laparoscopically, under general anaesthetic. The telescope is inserted just below the tummy button and gas is introduced through the telescope to open up the space between the muscles in the lower part of the abdomen and groin. Two tiny 5mm incisions are made in the lower abdomen for further instruments to be inserted which are used to place a sheet of plastic mesh to repair the hernia.

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