Laparoscopic groin hernia repair

Brief description:
This is an operation to repair a groin hernia using a key hole technique. There are different types of groin hernias. They can be described as inguinal or femoral. Key hole surgery to repair a femoral or inguinal groin hernia is identical.
Laparoscopic groin hernia repair uses a mesh technique very similar to the standard open operation but instead of a cut in the groin you have three very small (1-2 cm) wounds after the operation.
Here, are explained some of the aims, benefits, risks and alternatives to this procedure.

What is a groin hernia?
A groin hernia is an abnormal protrusion through the abdominal wall into the groin. The protrusion contains a cavity (the hernial sac) which can be empty or it can fill with abdominal contents such as bowel. Often fat is the main component of a hernia. Typically, hernias are more obvious when standing or straining (for example coughing, heavy lifting, and digging) as this forces abdominal contents into the sac. Hernias usually develop over time for no obvious reason, although in some people there may be an inborn weakness in the abdominal wall. Occasionally a strenuous activity will cause a lump to appear suddenly. They may occur at any age and are more common in men than women.

Hernias may simply present as a painless bulge that enlarges with standing or coughing. Commonly they cause an aching discomfort or a dragging sensation. Occasionally a piece of bowel or fat can get stuck and twisted within the hernia. This is very painful and can lead to a strangulated hernia which can become a serious emergency requiring emergency surgery. It is often recommended that hernias be repaired to prevent such complications arising.

Is the laparoscopic technique better than the standard technique for my hernia?
The National Institute for Health and Clinical Excellence (NICE) has recommended that patients with two hernias (i.e. one in each groin) or those with recurrent hernias (hernias that have been previously repaired) should have their repairs performed by this technique. In addition, NICE now recommends that Laparoscopic repair should be discussed with all patients presenting with an inguinal hernia.

The amount of cutting used in this operation is less than the standard open technique; therefore recovery is usually quicker and less painful. Most patients are back to their normal activities within 10 to 14 days. Many patients return to work within seven days of surgery.

What alternative procedures are available?
An open hernia operation involves placing a mesh on the outside of the weak area in the groin through a 10cm cut overlying the hernia. It can be performed under a general or local anaesthetic. There is a slightly longer recovery period due to the bigger cut and also a greater risk of chronic pain in the groin from damage to the nerves there. Details of this can be discussed with you by your specialist.

Are there any disadvantages of having the laparoscopic operation compared with the open technique?
The only slight drawback is that you need to have a general anaesthetic. For most patients this is not an issue and modern anaesthetics have very low risks. However, if you are a patient with particular risk factors for getting complications from anaesthetics it may not be appropriate for you to have this technique. For patients who have had previous cuts in their abdomens, particularly below the tummy button this technique may not be possible. Your specialist will advise you.
You may have heard your hernia referred to as an inguinal or femoral hernia. The key hole technique repairs all these hernias at the same time.

Surgery for Groin Hernia
Hernia surgery is usually performed as a daycase procedure. Sometimes we will recommend you stay in hospital overnight after your operation. This will be discussed with you when you are seen in clinic and at the time of your operation.

During the operation
Before your procedure, you will be given a general anaesthetic. This is usually performed by giving you an injection of medication intravenously (i.e. into a vein) through a small plastic cannula (commonly known as ‘a drip’), placed usually in your arm or hand.
While you are unconscious and unaware your anaesthetist remains with you at all times, monitoring your condition and controlling your anaesthetic. At the end of the operation, your anaesthetist will reverse the anaesthetic and you will regain awareness and consciousness in the recovery room, or as you leave the operating theatre.
The operation involves an incision by your umbilicus (tummy button) and two further incisions. The incisions are about 1-2cm long each). Through these, we inflate your abdomen with carbon dioxide gas which is completely harmless.
An approximately 15 cm x 10 cm sheet of artificial mesh, mostly composed of prolene, which does not dissolve, is placed into the space directly behind the weak area in the groin. This prevents the bulge of the hernia from returning. It has the advantage of treating different types of inguinal and femoral hernias all in the one procedure. It is strong immediately and does not require long periods of convalescence. The mesh is made of the same material as stitches that are commonly used in other operations and does not normally cause any adverse reaction from your body. You will not be aware that it is there.
At the end of the operation, before you wake up, all the puncture sites in your abdomen will be treated with local anaesthetic so that when you first wake up there should be very little pain. Some patients have some discomfort in their shoulders, but this wears off quite quickly.
The cuts made will all be covered with small waterproof dressings.

After the operation
After your operation, you will wake up in the recovery room. You might have an oxygen mask on your face to help you breathe. You might also wake up feeling sleepy.
You will have a small, plastic tube in one of the veins in your arm attached to a bag of fluid called a drip.
While you are in the recovery room, a nurse will check your pulse and blood pressure regularly. When you are well enough to be moved, you will be taken to a ward.
Sometimes, people feel sick after an operation, especially after a general anaesthetic, and might vomit. If you feel sick, please tell a nurse and you will be offered medicine to make you more comfortable.

What are the wounds like? They will be closed with dissolvable stitches under the skin and have a see-through shower-proof dressing on them. These should be left on for five days after which they can be removed and the wounds left open to the air.

Will I have much pain? Immediately as you wake up from the surgery there will be very little pain as all the wounds are full of local anaesthetic. As this wears off you will have some discomfort and a pulling sensation around the tummy button wound. This will last between seven and fourteen days. We give you a pack of pain-killers which we advise you to take for the first three days regularly, regardless of whether you have pain or not.

Eating and drinking: You will be able to drink immediately after the operation and if this is all right and you do not feel sick then you will be able to eat something.

Getting around and about: After your operation we will try to get you mobile (up and about) as soon as you are comfortable. You will be allowed home when you are comfortable, have had something to drink and eat and have passed urine.

When you can resume normal activities including work: After surgery the only limitation that you will have is the discomfort from the three small stab incisions. You are encouraged to ensure you remain active (gentle walking) within a day or two of surgery. Most people who have had this procedure can resume normal activities after two weeks. During the first two weeks it is suggested you try not to lift anything heavier than 5 kilograms and certainly stop doing anything that causes you pain. You might need to wait a little longer (up to six weeks) before resuming more vigorous activity, such as manual labour, moving furniture or load bearing (such as weight training) activity at the gymnasium. When you will be ready to return to work will depend on your usual health, how fast you recover and what type of work you do. You will be given a certificate to cover the time off work you require. As a general rule, if you are able to do something without discomfort it is safe to continue doing this.

Driving: You should not drive until you are safe to do so; this is usually a minimum of SEVEN to TEN DAYS FOLLOWING SURGERY. Regardless, you should not drive until you can confidently press the brake pedal in an emergency. You also need to be mobile enough to look around and beside you as you normally would when driving. If you have a degree of pain, your ability to drive is compromised. If you are not sure about your ability to drive then you should see your general practitioner prior to starting.

Intended benefits of the procedure
To repair your hernia. This should reduce discomfort and prevent the hernia from bulging. It should also prevent the hernia from enlarging over time.
Hernias very rarely “strangulate”. This is when the hernia comes out and gets stuck. In this situation an emergency operation is required. If your hernia has been repaired it cannot strangulate, therefore this complication is prevented by repairing your hernia electively.

Does my hernia need to be repaired?
  • Not all hernias need to be repaired. If a hernia is not causing symptoms or enlarging it may not need to be repaired.
  • Hernias that are not causing symptoms are unlikely to develop serious complications such as strangulation.
  • Sometimes people have pain in the groin but no lump. This condition would usually not benefit from a hernia repair.
  • Ultrasound scans frequently diagnose groin hernias that cannot be seen or felt. We would usually be cautious to offer surgery if a hernia has not been seen or felt by you and cannot be identified when your surgeon examines you. This is because a hernia repair in this situation may be less likely to make you any better and the symptoms may be from another cause.
  • If you have other serious medical problems or are frail, then the risks of repairing the hernia may outweigh the benefits.
  • Your surgeon will advise you about surgery.
  • You need to decide whether you wish to go ahead with surgery and this is usually a decision best made in conjunction with your surgeon.

Is there a guarantee that the operation will be completed by the key-hole technique?
No. Unfortunately, there is never a guarantee that key-hole surgery will be possible. Occasionally there are technical reasons why conversion to an open technique is necessary. This is, however, unlikely (1-2% risk).

Will my hernia ever come back?
There is no method of hernia repair that can give a 100% guarantee that you will never develop another hernia in the same place after your operation. Fortunately, recurrence after hernia surgery should be rare. The lowest reported risk is with the mesh repair technique we use and is about one to five cases per hundred over five years. Patients who are obese have a greater risk of recurrence.

Serious or frequently occurring risks
  • Like all surgery there are some risks involved with laparoscopic groin hernia repair. However, this is a safe procedure and the risk of a serious complication is very low.

• The risks relate to both the anaesthetic and to the actual surgery itself. So long as you are fit the anaesthetic should not pose any significant concerns but this should be discussed with your anaesthetist.

Injury to intestine, bowel and blood vessels – Injury or damage to these structures can, very rarely, occur during any operation within the abdominal cavity. This is particularly the case if there has been previous surgery with scarring and structures are abnormally stuck to each other. Usually such an injury can be seen and repaired at the time of the operation, but occasionally may only become clear in the early postoperative period. If we suspect that you may have sustained such an injury, a further operation will be required. This will be performed as a keyhole operation but may need conversion to an open operation if necessary.

Conversion to an ‘open’ operation - All keyhole procedures carry a small risk of the need to convert the procedure to an ‘open’ technique. This is usually because of some technical difficulty during the procedure. If this is necessary, it may result in a much larger scar, a longer hospital stay and more postoperative pain and discomfort. However, if it is unavoidable, then we must have your permission to proceed to ‘open’ surgery should it be necessary.

Bleeding – This very rarely occurs after any type of operation. Your pulse and blood pressure are closely monitored both after your operation as this is the best way of detecting this potential problem. If bleeding is thought to be happening, you may require a further operation to stop it. This can usually be done through the same key hole incisions as your first operation. It is possible that you also may require a blood transfusion.

Testicular damage - Hernias in men develop very close to where the major structures to and from the testicle lie. These structures include the blood vessels to the testicles (arteries and veins) and the Vas deferens that carries sperm from the testicle. Hernia repair, whether carried out as a keyhole or open procedure is associated with a very small risk of damage to these structures. This can lead to development of pain in the testicle post-operatively or problems with having children in the future.

Wound Infection – This affect your scars (‘wound infection’). Fortunately, wound infections are most uncommon following key hole surgery. If they occur they are usually simply treated with a course of antibiotics. If the wound becomes red, hot, swollen and painful or if it starts to discharge smelly fluid then it may be infected. It is normal for the wounds to be a little sore, red and swollen as this is part of the healing process and the body’s natural reaction to surgery. It is best to consult your doctor if you are concerned. A wound infection can happen after any type operation.

Wound haematoma - Bleeding under the skin can produce a firm swelling of blood clot (haematoma), this may only become apparent several days after the surgery. This may simply disappear gradually or leak out through the wound. Any bruising that occurs tends to be on the lower abdomen and track down into the scrotum and base of the penis in men. This can look rather worrying. Do not be alarmed if this happens to you, it will resolve spontaneously over two to three weeks. A degree of visible bruising occurs in up to 25% of people having this surgery. If this is causing a lot of pain or you are worried, you should see your general practitioner or contact the Upper GI Surgical Unit on the numbers listed in this information sheet.

Deep vein thrombosis (DVT) and pulmonary embolus - All surgery carries varying degrees of risks of thrombosis (clots) in the deep veins of your leg. Keyhole surgery has a lower risk of this, and we also are able to get patients up and about much quicker after these procedures than after conventional ‘open’ procedures. We do, however, give you some injections to ‘thin’ the blood. We also ask you to wear compression stockings on your legs before and after surgery and also use a special device to massage the calves during the surgery.

Nerve damage - Several nerves cross the operative field in hernia surgery. It is usually possible to preserve them but some minor nerve injury, rather like a bruise, is common and usually returns to normal in time. Permanent numbness may sometimes occur. This risk is very low with key hole surgery.

Chronic pain – Rarely, some patients develop chronic pain after hernia surgery, in the region of surgery. It is not clear why some patients develop this and not others. It may be due to a nerve getting trapped in scar tissue. This pain can be treated with medications or injecting local anaesthetic or anti-inflammatory medications into the area. This risk is very low with key hole surgery.

Seroma – An accumulation of fluid adjacent to mesh that is used to repair a hernia is called a seroma. This is actually part of the body’s normal healing response. It may actually feel as if the hernia lump is still there! If the hernia is large it is expected that a seroma will develop – it will subside over a few weeks to months. Fortunately, in itself, a seroma is not serious and most people do not notice it. If a seroma causes discomfort it may need to be drained under local anaesthetic in the X-ray department. This is where a small drain is placed into the fluid and the fluid is removed.

Mesh infection – All artificial materials that are placed into the body carry a risk of becoming infected. This is very rare (estimated 1 in 500 chance). If this were to occur you would notice redness and pain around the hernia site, you may also have a fever and some smelly fluid escaping from the wound. Often this problem can be treated with powerful antibiotics, although a course of 4-6 weeks may be required. If the infection does not resolve then the mesh may have to be removed with an operation. This would mean that the hernia may eventually come back and several months or years later it may need to be repaired again.

Urinary retention – There is a small risk (5%) that immediately following your operation you will not be able to pass urine. This is usually more likely in men than in women. The reason is that a combination of medications and performing surgery near the bladder can cause muscular spasm of the region and block the outflow of the bladder. Additionally, if you have underlying prostate problems, such as poor stream or you have to frequently get up overnight to pass urine, you may be at increased risk of suffering urinary retention. If you become uncomfortable trying to pass urine after the operation, a catheter needs to be passed into the bladder. This is done under local anaesthetic. Normally, you stay overnight and the catheter is removed the following day after things have settled. Very rarely, the catheter may need to stay in for one to two weeks, after which the practice nurse at your GP surgery will remove it for you.

Scarring – Any surgical procedure that involves making a skin incision carries a risk of scar formation. A scar is the body’s way of healing and sealing the cut. It is highly variable between different people. All surgical incisions are closed with the utmost care, usually involving several layers of sutures (the sutures are almost always dissolvable and do not have to be removed). The larger an incision the more prominent it will be. Despite our best intentions, there is no guarantee that any incision (even those 1-2 cm in length) will not cause a scar that is somewhat unsightly or prominent. Scars are usually most prominent in the first few months following surgery, however, tend to fade in colour and become less noticeable after a year or so.

Other complications – We have tried to describe the most common and serious complications that may occur following this surgery. It is not possible to detail every possible complication that may occur following any operation. If another complication that you have not been warned about occurs, we will treat it as required and inform you as best we can at the time. If there is anything that is unclear or risks that you are particularly concerned about, please ask