The basics - Hernias may need urgent treatment

Early diagnosis is essential, says Mr Stephen G E Barker.

Strangulated hernia requires immediate surgical repair
Strangulated hernia requires immediate surgical repair

A hernia represents a body part that has pushed through its usual retaining boundary.

Gut coming through the abdominal wall adjacent to the umbilicus represents a paraumbilical hernia.

Gut coming through the deep inguinal ring, low in the abdomen, gives rise to a common type of hernia, an inguinal hernia.

Many types of hernia occur, but each is associated with a potential weakness in the abdominal wall, for example, a ventral hernia appearing in the abdominal midline where the muscles are deficient and fibrous tissue alone sits.

Wounds are naturally weaker than the 'normal' tissues around them and incisional hernias are not uncommon.

Incisional hernias are of particular concern (up to 10,000 per year presenting), as many could be prevented in the first place and they can be expensive to treat.

Approximately 100,000 inguinal hernias present to the health service each year in the UK. Men are affected far more commonly than women. Approximately 15,000 paraumbilical hernias occur, which are more common in women.

Most patients will rack their brains to think of the singular event that caused their hernia to appear, true aetiologies remain unclear, though there is some familial tendency.

Symptoms
The symptoms associated with the appearance of a hernia can vary dramatically. Often, discomfort or pain precedes the appearance of any lump. Alternatively, a lump may seem to appear suddenly and be virtually asymptomatic.

Paradoxically, it is when hernias first appear that they can be at their most dangerous, with strangulation a possibility.

With inguinal hernias, the frequency of strangulation is about one in 500.

Features that should alert the patient to seek help include experiencing increasingly severe pain overlying the lump (or across the abdomen), or the lump hardening, with the skin starting to redden and heat.

Strangulation
For strangulated hernias, patients are likely to be given strong painkillers and relaxants so that the lump can be reduced.

Failure to reduce means prompt surgery is required. Success at reduction is likely to mean being sent home, but this should be accompanied with an outpatient appointment and a date for hernia repair.

Femoral hernias have a particular reputation for strangulation and should not be left alone. About 5,000 femoral hernias present in the UK each year and are more common in women than men. The frequency of strangulation is as high as 5 per cent if left alone. Patients should be seen promptly and should always be given a date for elective surgery.

Diagnosis
Patients often self-diagnose or seek an opinion as their ability to work or play sport is affected. Occasionally, they are worried that the lump may be cancer.

A short clinical history and rapid examination are usually all that is needed to diagnose a hernia. Confusion can occur with muscular strains in the groin so referral may be needed if uncertain.

Hernias in younger, active patients are best dealt with by surgery but in older people without any symptoms they can be left alone. Femoral hernias should never be left because of the risk of strangulation.

Scarring after surgery
Patients also present for cosmetic reasons and it can be hard to explain that treating the hernia may result in further problems.

For example, with inguinal hernias there is a trend towards laparoscopic repair.

With an open approach, the incision can often be confined within the pubic hairline and the scar will be invisible when underclothes or a swimsuit are worn. With the laparoscopic approach, there are likely to be 3cm x 1cm incisions, which are visible and difficult to hide.

Furthermore, repair of a ventral hernia (or divarication) will often result in major disappointment. The bulge will be replaced with a visible midline scar and some of the abdominal bulge often remains.

Patient information
Explaining outcomes in realistic terms is crucial - patients must be reminded that surgery can come with complications.

In older people for whom there are no problems associated with their long-standing hernia, especially if they have a relatively sedentary lifestyle, or significant concurrent illness, I often suggest that they do nothing but simply live with what they have got.

Some will have self-treated with trusses, and there is no doubt that they can work well, However, I do not recommend them because they can cause adhesions to form between the hernia and surrounding structures internally, and they are difficult to keep clean.

Complications of surgery
For those who need or want surgery, it is important that possible outcomes are explained. The most obvious complication is recurrence.

In the NHS, the estimate of recurrence of inguinal hernias at three years is 7 per cent. In specialist hernia centres, this drops to less than 1 per cent.

With recurrence surgery, the complication rate is higher and the greater the number of recurrence operations, the greater the likelihood of yet another recurrence returning.

Minor, superficial wound infection should be dealt with promptly using antibiotics.

Postoperatively, patients should be warned to seek help promptly if they notice a persistent serous discharge, or if the surrounding skin becomes red and hot.

However, if the infection is deeper, the mesh will most likely need to be removed. Fortunately, the wound infection rate is well below 1 per cent.

Of less seriousness, but often debilitating, is the possibility of chronic discomfort and with it, general unhappiness following the hernia repair. This problem affects 2 per cent, and patients seem more likely to suffer if they have had prolonged pain preoperatively. Its resolution is often very difficult.

I suggest that patients massage the operative area with baby oil, vigorously, twice daily. If this fails, I suggest ibuprofen gel as an anti-inflammatory. Simultaneously, I ask them to undertake physiotherapy: stretching the area through exercise.

Care after surgery
For the majority of patients, day-case surgery is available. More major hernia repairs might necessitate several days in hospital.

In all cases, in the postoperative period, it is very important that the implanted prosthesis be allowed to 'bed down' so that reinforcement occurs.

The timeframe for recovery varies, but is never less than 8-10 weeks. During this time, the patient should be reminded to avoid continuous heavy lifting or to undertake very strenuous activity. Usually 'let your body be your guide' is a sensible maxim for what can undertaken.

Mr Barker is senior lecturer in surgery and honorary consultant vascular surgeon at University College London and the University Hernia Clinic, London

KEY POINTS

  • Hernias are common.
  • Their true aetiology remains unclear.
  • Often they can be left alone, but when surgery is indicated it is best undertaken by a specialist using modern techniques and materials.
  • Complications are relatively few, but must be explained carefully.
  • Successful surgery is the most common outcome, with the patient able to return to work and all normal activities.

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