Published in Panorama
Treating an inguinal hernia
A hernia is an abnormal protrusion of intra-abdominal contents through a defect in the abdominal wall. It is a lump that results from a part of the intestine or bowel, slipping through this weakness in the abdominal wall and 75% of all hernias are Inguinal hernias are those which occur in the groin, as a result of weakness around the skin folds of the hip joint, says Dr.Qurban Hatim Pamina, General and Laparoscopic Surgeon, Zulekha Hospital, Sharjah.
Groin hernias may be direct, indirect or femoral, according to who is affected and at what stage in life they are affected, explains Dr.Qurban. “A Direct Inguinal Hernia usually comes in middle age, around the ages of 30 – 40 and is usually related to increase in abdominal pressure. This pressure itself may result from obesity, liver cirrhosis with some amount of fluid in the abdomen, chronic cough, difficulty in passing urine, older patients with prostate problems, chronically constipated patients and pregnancy.”
Elaborating on the nature of Inguinal hernias, Dr.Qurban continues, “The Indirect Inguinal Hernia most commonly occurs in children, which may be present at birth and is more common in males, though it can occur in females also. This hernia will come from outside of an artery called the inferior epigastric artery. It occurs in newborns, in infants in the first year of life and in any age group up till the middle age or even later. Most of these are parcongenital in the sense that the person is born with the defect but the hernia is evident in his later life, may be even in the 3rd, 4th, or 5th decade of his life! The hernia is located in the inguinal canal, the location of the spermatic cord in males. It is typically discovered when it descends into the scrotum.”
Femural hernia which is rarer than the other types of hernia, is seen mostly in middle-aged and elderly obese women who have given birth several times.
What are the symptoms of an Inguinal Hernia? “When a new hernia develops, in the initial phase, it will usually be seen as an abnormal protrusion when the patient stands; it’s a visible swelling in the groin,” explains Dr.Qurban. “If it happens suddenly when something has given way following for instance a bout of heavy weight lifting, it might appear as a bulge with acute pain. But usually, groin hernias come without pain and as a lump in the groin, which initially, when the patient lies down, will disappear; it is not even noticed at this stage by the patient, unless it’s large. Because of the weight of the intestines which are attached to the back of the spine, some patients feel a dragging pain in the region. The pain can sometimes radiate up to the scrotum. As it gets larger, patients sense discomfort and are unable to comfortably get into their underpants.”
What are the diagnostic measures taken to confirm the presence of a groin hernia? “Hernia is basically a clinical diagnosis,” explains Dr.Qurban. Besides this an ultra sound of the inguinal canal, scrotum and patent sac are done. However, the best confirmatory diagnostic tool remains the MRI of these regions.”
Can the symptoms of Inguinal Hernia mimic symptoms of other disorders? “Yes. What happens is, if the hernia is very small or it is insipient, that is, it is just coming up, you’ve got to differentiate it from all other groin and scrotal problems, especially hydrocele of the scrotum where there is water around it; varicocele where there are extra veins in the region. All these problems can have pain in the scrotum and abdomen just like an early inguinal hernia. But once the hernia is very large, then the diagnosis is obvious and you cannot confuse them, except if the hernia is so large that it covers the scrotum with the testes completely and then you might miss associated problems like a hydrocele or varicocele which co-exists with a hernia. This is the reason for doing an ultrasound and MRI.”
Once diagnosed, what is the course of action? The objective of any groin hernia operation is to repair the defect in the abdominal wall. The three basic surgical approaches are the traditional open repair, using the patient's own tissue, open tension-free repair in which mesh is used to cover the defect and laparoscopic repair, a tension-free repair also utilizing mesh. Open techniques of hernia repair can be performed under local, regional, or general anesthesia, while laparoscopic hernia repair requires general anesthesia.
Dr.Qurban is emphatic: “The rule of the thumb in Hernia is, as soon as you find it, repair it. Because the larger it gets, the more damage it causes and the repair then becomes more difficult. The repair is relatively simple and can be done in two ways. The first is an Anterior Approach where you make a cut in the groin and reduce the Hernia. You push the contents back and cut or repair the extra sac through which it is coming out and repair the muscular defect present in the region through sutures or mesh.”
Describing the second method, Dr.Qurban continues, “The other is the Posterior Approach where instead of pushing the hernia back, you pull it out. This can be done either by the Open surgical technique or with a laparoscope.”
What are the risks involved in the surgery? “It’s a simple surgery,” assures Dr.Qurban. “The field of work has to be clean, otherwise recurrence rate, particularly from infection can be high. There are not a lot of structures around that you can damage though there are some major vessels running below the groin which supply blood to the legs. So this is the only structure that has to be taken care of. Repair of a hernia is a work of art and in deft hands, no problems should occur and you can operate with impunity. Done skillfully, the recurrence rate can be as low as 1%”.
Moreover, the surgery can be done under local anesthesia; hence there is no contra-indication to the surgery itself, observes Dr.Qurban. “Even if the person is very old and debilitated, if it is done under local anesthesia, he cannot be harmed.”
What post surgical precautions need be taken? Patients are usually asked to refrain from carrying heavy weights for at least one month following surgery. “Carrying a child or a heavy weight is not allowed for at least 1 – 1 ½ months until the pain and the hernia settle down. However, if the procedure has been a laparoscopic one, done from behind with a mesh inserted in the region, the patient can lift any amount of weight from day one! This is so because the more the patient lifts, the net which we put from behind, fits more strongly to the muscular defect. On the other hand, if we have done the surgery from the front and inserted the mesh, carrying weights will blow off the mesh!
What can untreated groin hernia lead to? While surgery is the only effective treatment for groin hernia, left untreated, there is risk of strangulation. Generally, severe morbidity and mortality are avoided by prompt diagnosis in people with groin hernias, thereby avoiding impending strangulation, but fatalities from such strangulation is not unknown, says Dr.Qurban.