WHO GETS HERNIAS?
Hernias are common. 5% of the population will experience having a hernia.
75% are inguinal, 15% unbilical, others are less common (including femoral).

WHAT CAUSES HERNIAS?
• Acquired Weakness
• Aging
• Obesity
• Pregnancy
• Smoking
• Nerve division (ilioinguinal nerve injury after appendicectomy)
• Predisposing Factors
Increased intra-abdominal pressure: obesity, pregnancy, ascites, peritoneal dialysis, cough, vomiting, straining, heavy lifting

Congenital
• Patent processus vaginalis
• Patent canal of Nuck (peritoneal pouch accompanying round ligament) for indirect inguinal hernia in female)

IS IT NORMAL TO HAVE A HERNIA?
• Hernias are not normal.
• Hernia is defined as an abnormal protrusion of cavity's contents through a weakness in the cavity wall.

CLASSIFICATION
• Inguinal / femoral
• Many classification systems exist for hernias.
• I Indirect inguinal hernia (congenital)
• II Indirect inguinal hernia (dilated deep ring)
• III Posterior wall defect
• A - direct, B - Pantaloon (massive), C - Femoral
• IV Recurrent hernia
• Other hernias include umbilical, paraumbilical, ventral, epigastric, Spigelian, incisional, ventral, lumbar etc.

DO I NEED SURGERY?
• Patients with inguinal or umbilical hernias who are asymptomatic or minimally symptomatic may be observed and managed operatively when symptoms worsen. This is known as 'watchful waiting'.
• Femoral hernias should always be managed with surgery unless surgery is contraindicated. The risk of bowel strangulation or incarceration (bowel stuck within hernia) is higher in femoral hernias.

SHOULD I HAVE OPEN OR LAPAROSCOPIC SURGERY?
• INGUINAL HERNIAS
• Laparoscopic inguinal hernia repairs are associated with quicker recovery and less groin pain than open surgery.
• Laparoscopic is the gold standard at least for bilateral inguinal hernias and for recurrent hernias.
• If there is a large inguinoscrotal component or if you have had previous intraabdominal open surgery, it may not be possible to perform your surgery laparoscopically.

• FEMORAL HERNIAS
• Majority of these are repaired during an emergency presentation and require open surgery. A bowel resection may be required.
• However, if you have a femoral hernia repaired electively, this may be repaired laparoscopically or by open technique.

• UMBILICAL HERNIAS
• These are normally repaired open as the open incision is small and the excess skin can be tucked down nicely using the open technique. By laparoscopic methods, the excess skin 'flaps in the breeze' and often this space will then fill with serous fluid leading to a seroma.

• OTHER HERNIAS
• Most hernias can be repaired by minimally invasive laparoscopic techniques. It is important to ask your surgeon which approach is more appropriate.

SHOULD I HAVE A MESH?
• Mesh reduces the risk of recurrence by 50-75% at 2 years. 
• There is also a lower risk of chronic pain with mesh repair.

RISK OF HERNIA REPAIR
• The risk of recurrence is approximately 3-10%
• There is also a risk of wound or mesh infection / urinary retention / urinary tract infection / chronic pain / general risks from anaesthetic / surgery.
• If the mesh becomes infected, it may need to be removed.
• For inguinal and femoral hernia repairs, there is also a risk of:
• Ischaemic orchitis which usually results in testicular atrophy. Orchiectomy is rarely necessary. The risk of this is minimized by avoiding unnecessary dissection within the spermatic cord.
• Nerve injury - neuroma or entrapment of ilioinguinal or genitofemoral nerve. The risk of this is less with laparoscopic surgery compared to open. With the laparoscopic technique, it is important to avoid tacking the mesh down onto the nerves in the 'triangle of gloom'.

WHAT SPECIFIC POST-OPERATIVE INSTRUCTIONS ARE THERE POST HERNIA REPAIR?
• Post-operative pain may last for 1-2 weeks. You should take 2 weeks off work and not drive while on strong pain relief, usually for 2 weeks.
• You should not lift anything heavy for 6 weeks. If returning to work, you should be on light duties, and should not recommence heavy lifting until 6 weeks post-operatively.
• You will be given strong analgesia and prophylactic antibiotics for the first week.
• Paracetamol and NSAIDS are often useful to help with analgesia.
• You should be reviewed post-operatively in the rooms in 2 weeks.
• The dressings should be left intact for at least 5 days. If the dressing gets wet, it is important to clean the wound and replace the dressing.
• After 5 days, the dressings may be removed.
• There may be some bruising around the wound. With inguinal and femoral hernia repairs, there may be bruising near the genitalia. Males may get bruising around the base of penis and scrotum.
• If you get any fevers, severe abdominal pain or redness around the wound, please book an earlier appointment for review or advise the patient to go to the emergency department for assessment.
This material is general information only and should not replace medical advice or instructions given by the health professional. No action or inaction should be taken based solely on the contents provided on this information fact sheet. 
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