INGUINAL HERNIA


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    An Inguinal Hernia can be defined as an anatomical defect (orifice) through which intra-abdominal viscera (bowel or fat) tend to exit and locate in an abnormal form, in this case the groin, testicle or labia in females.

    Disease. An inguinal hernia will tend to show as a lump in the groin, testicle or labia in females that enlarges or causes pain when the patient coughs’, sneezes , lifts anything heavy or any other activity that increasing the intra-abdominal pressure. The patient upon noticing this groin lump becomes concerned and feels discomfort. It can be found both in men and women but is more common in males. Having this hernia ballooning in your groin is the least of the problems, if left untreated it can lead to the following complications

    Possible complications without surgery:

    1. Incarceration. In this case the hernia comes out but it will not go back in, it’s trapped. This causes significant discomfort and pain; it can also lead to intestinal obstruction when the bowel is involved.

    2. Strangulation. This can follow incarceration and it involves the cessation of blood flow of the involved structure, if it’s the intestine this will die due to the lack of blood supply and it can even end in bowel gangrene, causing a major catastrophe that puts life at risk and forces the surgeon to have to remove the dead bowel to resolve the problem.

    Diagnosis. An inguinal hernia is frequently diagnosed by the patient or diagnosed by a family member. It is important to always get the final diagnosis by a family doctor and/or by the Surgeon.

    In females one can find a lump in the groin or in the genital labia and can either be left or right. In males the lump can be found in the groin and in large hernias it can reach the testicle sometimes deforming it to the size of a grapefruit or even larger. The hernia lump can be either soft or firm and sometimes we can listen to bowel sounds within it.

    Complications without surgery:

    Some of the complications if left untreated are:

    1.- Continued enlargement of the hernia. Since the hernia is an anatomical defect it will never repair by itself or with exercise. The only consequence if not repaired is its enlargement that will affect the patient’s daily activities or sport activities.

    2.- Incarceration. As mentioned previously.

    3.- Strangulation. As mentioned previously.

    4.- Incapacitating pain. In some patients overall those heavy lifters, the pain from their hernia will interfere with their daily work, sometimes causing disability, this why some employers would not hire and individual with a hernia, until this is fixed.

    Treatment.

    A) Medical Treatment. There is no Medical Treatment; no medicine will cure the hernia.

    In Previous times there where special devices that would compress the groin where the hernia would present itself; however this devices should be considered only of historical interest. Groin hernias should be repaired surgically. It is fair to say that losing weight will always aid and be beneficial in the surgical management of all hernias.

    B) Surgery. Inguinal hernias require surgical correction. In general, modern surgery involves placement of mesh in order to repair the inguinal hernia, in both the open and the laparoscopic technique. In children and young adults, frequently all that is required, is high ligation of the hernia sac and no mesh and in some other cases the local tissues and structures in the region can be used solely to repair the hernia if this are strong and of good quality.

    Possible Complications related to Surgery.

    Among many other complications I will mention:

    1.- Recurrence. There is no hernia repair that is 100% guaranteed. If the patient is not careful and continues to lift heavy objects or increases considerable in body weight, the repair may be broken and the hernia may recur.

    2. Chronic groin pain. This can happen on the side of the repair even if the surgery turned out perfect and even without hernia recurrence. In the majority of instances the pain will lessen with time, but it can last up to two years or may be permanent and be incapacitating.

    3. Inguinal cord injury. The Vas Deferent can be cut or injured. This tubular structure transfers sperm and if this occurs is just like a Vasectomy. The blood supply to the testicle can be interrupted causing inflammation of the testicle or testicular atrophy.

    4. Local Neuritis of the small nerves of the groin. This causes severe pain in the region and the pain can even irradiate towards the back following the nerve distribution. If this little nerves are cut, the patient can feel a local numbness in the inner aspect of the thigh, however in the majority of cases, it lasts only for a limited period of time; the sensation will be regained eventually.

    5. Bowel injury. A rare complication. This can happen at the time of reduction of the hernia during surgery or at the time the mesh is placed.

    6. Infection. This can happen at the wound level or deeper, even towards the testicle; it will require treatment with antibiotics and in rare ocations additional surgery. It is most frequently seen in diabetics.

    7. Bleeding. Bleeding can be mild only producing bluish discoloration of the genitals and is of little concern. When the bleeding is moderate it may cause a mass in the region of the wound and in most instances it will require only observation; the local mass can take up to two months to dissolve. Rarely the bleeding can be severe causing changes in the vital signs, if this happens it may require surgical exploration to correct the problem.

    8.Urinary Obstruction. The patient cannot urinate. This is due to an enlarged prostate first and secondly because of the use of pain medications. It occurs more frequently in males older than 65 years old and often requires placement of a urine catheter.

    Recovery.

    After inguinal hernia repair; in general it will take between 7 to 10 days for a functional recovery. Functional recovery refers to walking freely, sitting, standing and performing simple tasks. Full recovery can vary among patients and it will also depends on the type of work the individual performs; for example: complete recovery is different for a desk clerk in comparison to a construction worker. The surgeon can justify disability for 30 days for the construction worker and 10 days for the desk clerk.

    What should I expect after surgery?

    1. Pain. This pain should not be incapacitating but definitively limiting; it should not prevent you from walking but it will limit you from exercising and from lifting heavy objects. It will hurt a lot if you sneeze or cough. It will hurt when you strain in the toilette also, this is why I recommend natural stool softeners’ like Metamucil that has the Psyllium fiber and you can buy it in any supermarket or drug store over the counter; better to start taking it even before surgery to avoid constipation.

    2. Inflammation. This is expected naturally after surgery. The region around the wound and even the genitals can get swollen without major consequence; if the inflammation becomes severe you should call the surgeon.

    3. Bruising and bluish discoloration of the wound and genitals. This occurs sometimes due to local bleeding. The genitals can turn blue and purple and causes great concern for the patient. In the majority of cases only observation is all that’s required.

    4. Mild difficulty urinating. In the majority of cases this is experiences and is only temporary. In males older than 65 years old, a very large prostate can obstruct the urine flow; if this happens you should call your surgeon immediately because a urine catheter will need to be placed on a temporary basis, usually for a week.

    When should I call the Surgeon?


    Extreme pain. Incapacitating even for walking.
    Fever, Chills and feeling.
    Abdominal distension and abdominal pain.
    Wound drainage.
    If the draining fluid has a foul smell or has a creamy consistency signifies infection.
    Redness around the wound area. May signify infection.
    Persistent Nausea and vomiting; after the first day of surgery.
    Unable to urinate
    Low urine output.
    You may be under-hydrated. Painful swelling of one or two legs. Worrisome for deep vein clots.
    Any sign or symptom Call your Surgeon, never wait…

    Frequent general questions.

    What should I eat after surgery? The day of surgery and the day after you should eat light, preferentially liquids only; in case of vomiting it is easier to throw up liquids. Jell-O, coffee, tea, juices, water. No meats, pizzas, hot dogs, hamburgers or alike.

    When can I drive? In general you should wait one week. Pain in the groin area potentially can interfere with the operation of the break or accelerator; in addition you should wait until the effects of anesthesia are fully dissipated in order to have the full alertness needed for driving.

    When can I take a shower? After the second day of surgery. You can remove the outer dressings before showering and let the water run down the wound, however don’t touch the wound. After four or five days you can put soap on the wound.

    When will the staples be removed? If the Surgeon used staples to close the wound, this will be removed between 7 to 10 days after surgery; sometimes the Surgeon will choose to leave the staples for two weeks or even more depending on the case.

    When can I take off the steri-strips or tapes at the wound? After 7 days it is easier to remove the tapes when they’re wet in the shower. You can also leave them alone to fall by themselves, if you prefer.

    When can I do exercise. After 7 days it’s okay to walk without exertion or swim in the pool; after 3 weeks mild aerobics; after 4 weeks light gym without weights and after 3 months gym with weights, but start very light.

    When can I return to work? Office clerks, teachers, supervisors, Doctors: after 7 days of surgery; field workers, mechanics: after 2 weeks of surgery; Construction workers and heavy lifters: 3 to 4 weeks of surgery; High level athletes: 6 to 8 weeks. An important observation and warning: After hernia repair surgery, avoid always carrying heavy objects, “ permanently”

    When can I have sex? You should avoid intercourse the first 10 days after surgery, after this time you can do it, but be careful and avoid injuring the surgical site.

    Final recommendations

    Lose weight. Maintaining close to your ideal weight will help prevent hernia recurrence.

    Do not gain excessive weight. I you develop a large belly this will increase the intra-abdominal pressure exponentially and with this you will increase the risk inguinal hernia recurrence.

    Exercise moderately and strengthen your abdominal muscles. A muscular abdomen will resist the recurrence of inguinal hernia.

    Avoid lifting heavy objects. Even do you feel very strong and you know you can do it, avoid routine lifting and carrying objects more than 50 pounds. There is no hernia repair that will resist constant tensile forces exerted on the repair when you lift heavy objects consistently.

    Popular beliefs.

    1. Repair of an inguinal hernia will interfere with sexual performance. Unfounded and illogical. The repair of an inguinal hernia does not interfere with the nerves or the autonomic system involved in arousal, erection or sensation of the genital organs. It will be recommended to wait to have intercourse 10 days after the surgery to avoid injury to the surgical site.

    2. Your primary Physician tells you: You don’t need inguinal hernia repair until it gives you problems. Well, if you wait until it gives you problems you may end up in the Emergency Room with an incarcerated hernia or worse, with a strangulated hernia; both complications can put your life at risk. I believe that all hernias, of any size, at any age, on any patient should be repaired before complications arise. It is easier to repair a small hernia than a large one; the hernia defect will not disappear by itself and can only worsen with time unless it’s fixed by surgery. Repair of an inguinal hernia should be done on a planned schedule to prevent possible complications and to relieve any related symptoms.

    3. Repairing the inguinal hernia will interfere with digestion. No basis is found for this. Repairing a large inguinal hernia in fact may improve abdominal mechanics, improving defecation and alleviating constipation. It does not have to do anything with digestion.

    4. Inguinal hernias and prostate problems are related. This is true. One cannot ignore the relationship of a large prostate that produces obstruction of the urinary flow through the urethra and the increased intra-abdominal pressure needed to succeed in urination. This persistent and repetitive increase of abdominal pressure will weaken the groin areas and will end up in the formation of inguinal hernias, sometimes bilateral; this happens in males older than 65 years. It is not uncommon to recommend prostate surgery at the time of inguinal hernia repair.

    JORGE A ENRIQUEZ, M.D, F.A.C.S.