The common hernia

It appears as a small bulge in the groin, gradually enlarging with time, though still painless. In the morning when you wake up it's not there, but when you get up and walk about, it appears. When you cough it is more prominent. This could be a hernia.

A hernia occurs when there is a weak point in the stomach wall and the abdominal contents bulge through this weak point beneath the skin. What could protrude may be just fat, soft tissue within the tummy or even bowel. The commonest site where these weak points occur is the groin. However it could occur in and around the belly button too. Sometimes a groin hernia as it enlarges can go into the scrotum.

Hernia is usually confined to adults. When there is a persisting congenital path where abdominal contents may go into the scrotum, a hernia could occur in infancy. A congenital defect in the tummy wall at the umbilicus or belly button in infancy could also result in a congenital umbilical hernia.

Other than a small umbilical hernia at the belly button in infants, all other types of hernia need surgical intervention. If the hernia is not attended to, with time, the bulging out contents can get attached to the structures outside the abdominal cavity and to each other and make a subsequent surgery more complicated.

If not surgically corrected, someday the hernia can get 'strangulated', which means that the blood supply to the contents of the hernia can get cut off. This is an emergency -- the bowel or the soft tissues can die and cause a site where bacteria gets multiplied releasing the toxic substances into the blood. If the bowel is involved, it could perforate and this condition is life-threatening. Thus intervention must be done before an emergency occurs.

Conservative methods are used only in debilitated patients where if the patient is subjected to surgery more serious complications could occur. With the recent advances in surgery, very few are not considered suitable for surgery.

The surgeon will give an early date for the operation. However, if the hernia spontaneously disappears or you can push it in without pain until it disappears, and it comes out when you strain or cough, it is unlikely to become an emergency all of a sudden. Therefore you don't need to go doctor shopping to get it done the very next day if you have got a date fixed for surgery in a few weeks.

Yet, if there is an emergency one cannot wait. If a hernia that used to spontaneously go in stays outside and gets swollen and red and there is sudden onset pain on the hernia, and it is painful to touch, you need to get to hospital as soon as possible. Surgery will be done as an emergency procedure once the diagnosis is made.

Usually surgery for a hernia is an elective or previously planned procedure. It could be done as a day case, meaning that you get admitted the same day and go home the same day. However, in our hospitals, usually the patient is admitted the previous evening.

The investigations that are needed are just basic blood counts and maybe a urine test. If the patient has a history suggestive of heart disease or other risk factors like advanced age, he may need an ECG. Diabetics need to keep a tab on their blood sugar levels, as wound healing could be impaired.

Before any surgery all the medications you are on will be reviewed by the doctor to avoid unnecessary complications. The patient should be prepared to reduce the risk factors that predispose him to hernia to prevent it recurring. Chronic cough should be treated. Constipation should also be addressed as straining at stools will strain the abdominal muscles and cause the hernia to recur. Smoking should also be stopped as it impairs wound healing and this could weaken the wound, causing the hernia to recur.

The patient will be anaesthetized so that he will not feel pain during the surgery. Most of the time groin hernias will be done using spinal anaesthesia, where an injection is given to make the area below the waist numb. It could be done under local anaesthesia, making only the site of the operation numb. However, in infants if the hernia occurs in the upper part of the tummy or around the belly button, usually general anaesthesia is used.

Once the patient recovers from anaesthesia after the surgery he will be sent to the ward. Provided he has no other complications he can usually go home the next day. Once the patient is fully awake, he can have clear fluids to drink and if he tolerates that without any vomiting he can have food also.

The patient can gradually get on with his routine life. If surgery is done under spinal anaesthesia, he will feel his legs are numb for a few hours. Once it wears off he can walk a little and go home the very next day. Light work is permitted but the pain might be a limiting factor. For instance, driving should be delayed until the patient can apply the brakes without feeling any pain.

Heavy exercise like cycling, lifting heavy weights that could strain you is ideally delayed two to three months. Patients can resume their sexual activities once the wounds are healed within two weeks or so.

Herniotomy now can be done as laparoscopic surgery or keyhole surgery. The recovery time is very short and the patients can resume their routines earlier than with the normal procedure. But this procedure is more time consuming and needs technical expertise.

If a patient feels severe pain that does not respond to pain killers, has fever, is unable to pass urine, or there is bleeding or swelling at the wound, he should seek medical attention. But problems following surgery are quite unlikely.