Inguinal Hernia Surgery: Treatment, Procedure, Risks, Recovery

Inguinal Hernia Surgery is a surgical procedure done to repair a hernia in the groin (area of the hip between the stomach and thigh). A hernia is a bulge in the abdominal wall caused by a weak area. An inguinal hernia is a type of hernia in the groin. This can be present since birth (indirect inguinal hernia) or develop later in life due to the weakening of the abdominal muscles (direct inguinal hernia).

Anatomy and Physiology Inguinal Region

The inguinal region, also known as the groin of the body is the area where the upper thighs meet the lowest part of the abdomen. Normally, the abdomen and groin are separated by a wall of muscle and tissue. The only wall openings are small tunnels called the inguinal and femoral canals. The inguinal canal comprises a floor, anterior wall, posterior wall, and roof. 

1. Roof: formed by muscles: internal oblique, transversus abdominis
2. Anterior: formed by aponeuroses: internal oblique, external oblique
3. Floor: formed by ligaments: inguinal ligament, lacunar ligament
4. Posterior: formed by tendon and transversalis fascia

Generally, In males, these canals allow the spermatic cord and ilioinguinal nerve to pass between the abdomen and the groin area. Whereas in females, these canals allow round ligament of the uterus and ilioinguinal nerve to pass between the two regions.

Inguinal hernia surgery is mainly considered when the patient has the following types of hernia. 

1. Direct Inguinal Hernia: This type of inguinal hernia penetrates directly through the wall of the inguinal canal. This generally occurs in adults over time.
2. Indirect Inguinal Hernia: This type of inguinal hernia enters the inguinal canal through the top. This usually occurs in newborn babies as a birth defect.
3. Strangulated Hernia: A type of hernia in which the contents of the hernia are ischemic due to a compromised blood supply.

A doctor may recommend inguinal hernia surgery to a patient if he/she experiences:

1. Swelling in the scrotum (the sac-like structure holding the male testicles)
2. Pain in the groin area which  gets aggravated while coughing, exercising, or lifting any object
3. A bulge in the groin (the area where the upper thigh and the lower abdomen connect)
4. Weakness or pressure in the groin area.

Inguinal hernia surgery involves repairing the posterior (rear) wall of the inguinal canal. The procedure is generally performed under anaesthesia (local or general) based on the severity of the hernia. The procedure usually takes 30 to 45 minutes to complete depending on the patient’s age, other comorbidities and the severity of the condition. The following steps are involved in the procedure:

1. The patient will be administered anaesthesia (local, regional or general). The type of anaesthesia will be decided by the doctor/surgeon based on the results of the pre-anaesthesia evaluation of the patient.
2. The surgeon will then check the vital measures of the patient such as the heart rate, oxygen concentration, and blood pressure throughout the procedure.
3. The surgical area will also be cleaned using an antiseptic solution.
4. Once the patient is stable after administering the anaesthesia, the surgeon conducts the procedure.
5. Surgery for repairing an inguinal hernia can be performed in three ways:
   1. Open surgery:
      1. Local anaesthesia or a regional anaesthetic is commonly used during open inguinal hernia surgery. It is injected into the spine. In some cases, general anaesthesia may be given.
      2. The surgeon will make a single incision of 6 to 8 centimetres over the hernia.
      3. Following this, the surgeon will place the fatty lump of tissue or bowel loop back inside the incision site.
      4. The surgeon will implant a mesh at the weak area where the hernia developed to strengthen the abdominal wall.
      5. The surgeon will use stitches to close the surgical site after the repair is done.
      6. In the case of strangulated hernia, the damaged part of the bowel may be removed, followed by joining the two healthy ends of the bowel.
      7. Open surgery is preferred in the case of larger hernias. 
   2. Laparoscopic surgery:
      1. During this surgery, the patient will be placed under general anaesthesia.
      2. Instead of a single big incision, the surgeon will create 3 to 5 small incisions in the lower abdomen during the surgery.
      3. The surgeon will insert a laparoscope (a narrow tube with a tiny video camera attached to it through one of the incisions.
      4. Other incisions will be used to insert the instruments to repair the hernia.
      5. The surgeon will then use a piece of mesh to seal and strengthen the abdominal wall.
   3. Robotic surgery:
      1. It is performed in a similar way as laparoscopic surgery. 
      2. In robotic surgery, the surgeon will sit at a console in the operating room and control the surgical instruments from there. 
      3. Robotic surgery is a newer technique and can be utilised to repair some minor hernias and rebuild the abdominal wall.
6. Once the surgery is performed, the patient is taken to a recovery room. Here the patient is monitored until his or her health condition becomes stable.

Before undergoing inguinal hernia surgery, the doctor/surgeon will discuss and prepare the patient for the surgery. These steps often involve:

Before Inguinal Hernia Surgery

Before undergoing the inguinal hernia procedure, the doctor will:

1. Recommend pre-operative examinations/investigations that include physical examination, blood tests, and other tests that may be required to ensure if the patient is healthy enough to endure the anaesthetic procedure.
2. Advise the patient to stop certain medications such as aspirin and salicylate-containing painkillers at least a week before the surgery, as they can increase the risk of bleeding.
3. Advise the patient to fast starting from midnight before the surgery.
4. Advise the patient to take specific medications on the day of surgery and take them only with a sip of water.
5. Ask the patient to sleep well the night before the surgery.
6. Ask the patient to plan for someone to drive home after the surgery. The patient will be unable to drive or get home on his/her own due to the anaesthesia and pain medication.

On the day of Inguinal Hernia Surgery

1. The patient must reach the hospital before the scheduled time for the surgery.
2. The patient will be asked to sign a consent form. 
3. The patient will be instructed to remove his/her street clothes and jewellery and wear a hospital gown.
4. If necessary, any pre-operative medications will be administered, and the vitals will be checked and documented.
5. A nurse will place an intravenous catheter in the patient’s hand or forearm, and then general anaesthesia will be administered.
6. The patient will be shifted to the operation theatre for the procedure.

A patient who has undergone an inguinal hernia surgery can expect the following after the surgery:

The recovery process at the hospital

1. After the surgery, the patient will be moved to a recovery room where the vitals (heart rate, blood pressure, respiratory rate) and urine output will be constantly monitored. 
2. If the patient experiences post-anaesthesia difficulties such as severe nausea, vomiting, or unable to pass urine, he/she may be admitted to the hospital for the night.
3. If the patient was given general anaesthesia, the coordination and reasoning might be compromised for a brief period. So, the patient must avoid driving, alcohol, and making big decisions for 48 hours after the surgery.
4. The surgical site will be sore and uncomfortable after the operation. Painkillers will be provided to the patient to help deal with the pain.
5. The patient will only be discharged from the hospital when the condition of the patient stabilises.
6. The patient would be able to go home on the same day if he/she were administered a local anaesthetic.

Recovery process/expectation after hospital discharge

1. All the instructions provided by the doctor must follow at home.
2. The patient must:
   1. Increase the activity level gradually to avoid clot formation.
   2. Avoid heavy lifting and intense activities for 4 to 6 weeks.
   3. Drink plenty of fluids and eat a high-fibre diet to reduce the chances of constipation. Constipation might create pain around the wound if the patient strain during bowel movement.
   4. Avoid wearing tight-fitting clothes as they can rub against the incision site and hamper the healing process.
   5. Wash the hands before and after the patient touches the incision site.
   6. Follow the surgeon’s recommendations when it comes to changing the bandages.

First follow-up appointment

1. The first follow-up appointment with the doctor will usually be scheduled within 2 weeks after the surgery.
2. During the follow-up, the doctor will do a thorough check-up of the surgical site to check for the recovery process.
3. The doctor might also change the medication or advise the patient to continue with the previous medication for some more time, depending on the condition and recovery of the surgical area.
4. The doctor will advise the patient for further timely follow-ups as well.

Inguinal hernia surgery is a safe procedure as it helps relieve the symptoms of a hernia and improve the quality of life of an individual. Below mentioned are some of the benefits of inguinal hernia surgery.

1. Remove any bulge or lump
2. Prevent complications
3. Help reduce pain and discomfort
4. A quicker return to work and a shorter recovery time (days instead of weeks)

Like any other surgical procedure, inguinal hernia surgery also has risks and complications associated with it. These include:

1. Infection
2. Bleeding
3. Blood clots
4. Breathing problems
5. Allergic reactions to anaesthesia, other medications, or materials used during surgery.
6. Damage to other blood vessels or organs
7. Damage to the nerves
8. Damage to the testicles if a blood vessel connected to them is harmed
9. Long-term pain in the cut area
10. Return of the hernia

When is consultation with the doctor needed?

A patient must contact the doctor/surgeon right away if he/she experiences any of the following symptoms: 

1. Bleeding from the incision site
2. Foul-smelling discharge from the incision site
3. A temperature greater than 38°C for an extended period 
4. Increased abdominal swelling or discomfort that isn’t alleviated by painkillers
5. Consistent nausea or vomiting, as well as chills
6. Increasing redness around the incisions 
7. Continuous coughing or shortness of breath 
8. Inability to pass urine

Delaying surgery for an inguinal hernia can lead to the following complications:

1. Incarcerated hernia: When herniated tissue becomes stuck and cannot be easily pushed back into place, it is called an incarcerated hernia.
2. Strangulated hernia: If left untreated, an incarcerated hernia can turn into a strangulated hernia. The intestine’s blood flow can be severed, resulting in ‘strangulation’. This is a life-threatening medical condition.

The cost of inguinal hernia surgery ranges from ₹35,000 to ₹1,20,000. The cost varies based on the following factors:

1. Age of the patient
2. Type of the procedure done
3. Technique and equipment used
4. The medical condition of the patient
5. The type of hospital facility availed - individual room or shared.