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Groin Hernia

What is a groin hernia?

A hernia is a defect in a wall that allows something to protrude through. An inguinal hernia is a defect in the muscle wall of the inguinal region (the groin), and the underlying fat protrudes through, though it can sometimes be bowel or another structure. Similarly for a femoral hernia, though the position is slightly lower and more midline.

Hernias often cause a swelling or bulge that comes and goes and an ache that worsens with straining. They do not in themselves cause severe pain, but a complicated hernia or a hernia with a torn muscle or irritated nerve can cause pain. A complicated hernia is one which is stuck and the contents could be dying and surgery is more urgent of course. Strangulation, where the contents are dying or dead, is an uncommon but potentially dire complication of a hernia.

Hernias never repair themselves. Surgery is the only way to repair hernias. All people with a hernia who are fit for surgery should consider having the hernia repaired sooner rather than later to prevent an urgent operation.

Route of a femoral hernia. The hernia sac follows the potential space along the femoral vessels. It may be palpable near the femoral ring or in the medial thigh. 


What operations are there?

There are 3 main surgical methods to repair a hernia: Suture, Open Mesh, Laparoscopic Mesh Repair. Each has their merits. The laparoscopic repair is preferred by many patients, because it has decreased pain, faster and easier recovery time, and less risks of nerve injury compared to the other operations. Also, laparoscopic repair enables numerous hernias to be repaired without any additional pain (compared with having one hernia repaired), and redo operations are much more successful when performed laparoscopically.

Suture repair is only seldom used in adults, because the recurrence rate is too high (15%) compared with other operations at only 2 to 3 %. Open mesh repair requires dissection through layers of muscle, which contain nerves to the sensitive groin area. This results in a painful and difficult recovery period and risk, though small, of permanent painful nerve injury. The design of this operation is not intrinsically stable. It is also focused on only the known hernias. However, there are several hernias that can occur together. Around 30 to 50% of people who have one groin hernia have another one that will require surgery at some stage.

Each of these pitfalls of the designs are avoided or overcome by the laparoscopic operations. These operations do not go through the muscle layers, do not go near the nerves to the groin, are intrinsically stable because the repair is done in front of the defect, and are able to visualise and simultaneously repair undiagnosed hernias without any additional recovery issues for the patient.

There are 2 main methods of laparoscopic inguinal and femoral hernia repair. They sound similar, TEP and TAPP*, but TEP is the most common, safest and has the better results. TAPP is useful in some situations such as for people who have had previous lower abdominal surgery.

It is not easy to describe these operations. It is recommended you visit our website to watch a video of these procedures for a better understanding.

*TEP (Totally ExtraPeritoneal), TAPP (Trans Abdominal PrePeritoneal)

 Incisions - TEP

How is a TEP done?

Three incisions are made below the umbilicus and the operative field visualised. The space between the peritoneum (thin membrane lining the inner side of the muscle wall) and the muscle wall is dissected down to the hernias staying entirely between the peritoneum and the muscle. The hernias are then reduced (returned to their proper position) and a space cleared for the mesh which is layed in front of the defect and tacked into position.

As this operation remains outside the peritoneum the structures within it (namely bowel) are more protected from the operation. If the peritoneum has been previously breached (eg previous surgery) then this approach will be technically very difficult and intra-operative conversion is sometimes made to a TAPP.


How is a TAPP done?

Three incisions are made in the upper abdomen and the operative field and the whole abdominal cavity visualised. The instruments pass through this cavity down to the hernias where the peritoneum over the hernias is temporarily removed and the space between the peritoneum and muscle wall is dissected and the hernias reduced. A piece of mesh is layed in front of the defect and tacked into position and then covered with peritoneum which is then tacked into position.


Operative Risks

For any operation there are risks, and in particular there is a risk of infection, bleeding and injury. The overall risk of major complications is less than 1%. The specific risks in laparoscopic hernia repair are bleeding (1 in 500) and injury to abdominal structures or organs (1 in 500). Surgery is required generally to repair these, and sometimes extensive surgery. The risks of the surgery are greater if there is scar tissue from previous surgery or conditions that have resulted in the matting down of adjacent structures. The most common outcome is no complications or a minor problem that will pass such as wound infection (5%).

Mr Draper has performed over 800 laparoscopic inguinal and femoral hernia operations with 0.3% complications and 1% recurrence rate. All figures are approximate.


Post Operative Recovery

Most people are ready to go home 1 or 2 days post surgery and need 2 weeks convalescence before returning to work. Postoperative problems such as pain and nausea are usually easily managed. The time takenesuming your usual level of activity is not easy to predict, as it depends on your background level of fitness, amount of pain and what you want to resume doing. As a general guide it takes about 2 weeks for most people to return to work, gradually reintroducing activities as tolerated.


More Information

This brief information sheet is best considered a reference to be used in conjunction with discussions with your surgeon. For further information discuss your operation in detail with your surgeon, or read other relevant Information Sheets and Patient Advice Sheets.


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