“Ask Dr. HKSH” – Hernia Surgery

Dr. CHAN Chi Wai, Angus

Specialist in General Surgery

Q1. What is hernia?

The most common symptom of hernia is protrusion of a subcutaneous lump when one stands up or when abdominal pressure increases such as straining with constipation, urine voiding, chronic cough or weight lifting. If the protrusion occurs in the groin area, it is called an inguinal hernia. When it occurs at the umbilical area, it is an umbilical hernia. If one has had surgery and the muscle has healed poorly, an incisional hernia may develop.

Hernia formation is primarily related to the structure of abdominal muscles. The central anterior abdomen consists of rectus abdominis, while the lateral abdominal muscles run obliquely. The groin area has a curved structure, making it the weakest structurally. When intra-abdominal pressure increases, a defect may develop in the muscle layer. The peritoneum then protrudes through this defect out of the abdominal cavity. Organs or tissues inside the abdomen, such as small intestine or omental fat, may protrude through this defect, forming a subcutaneous lump.

If the hernial orifice is too narrow and there is excessive protrusion of the small intestine or omental fat, the small intestine may become incarcerated, leading to strangulation and subsequent necrosis. One may experience pain and abdominal distension, or even develop intestinal obstruction. Emergency surgery is required.

Q2. I have had a hernia for many years without significant issues. Do I still need to seek medical attention?

Regarding the defect, if fat and small intestinal protrusion gets worse, the small intestine more likely gets trapped and can be dangerous. Surgical treatment is usually recommended.

Q3. How is a hernia treated?

As a structural problem, hernia cannot be treated with medication. It requires surgical management, including conventional surgery and minimally invasive surgery.

Common for inguinal hernia repair, conventional surgery involves an incision of approximately 5cm above the groin area. This incision is carried down through the skin and subcutaneous fat to the muscle layers, where the hernia defect is identified and repaired. To enhance repair, modern conventional surgery involves placing and suturing a surgical mesh over the muscle layer. This helps strengthen the muscular wall and reduce the risk of future recurrence.

For minimally invasive surgery to repair hernia, the major difference from conventional surgery is the use of much smaller incisions. The surgeon will make a 1-cm incision at the umbilicus, along with two additional 5mm incisions. Through these, the entire procedure is performed. The technique involves inserting a trocar into the space between the muscle layer and the peritoneum, then inflating with gas to expand it. This creates sufficient room to introduce other instruments and carry out the subsequent procedures. After entering this space, the surgeon will first pull the peritoneum back from the defect before securing a mesh in position over the hernia defect, thereby repairing the hernia. Upon completion of the surgery, the gas is released. The peritoneum then acts like a sandwich: the muscle layers and the peritoneum enclose and hold the mesh in place, which helps to reduce the risk of future recurrence.

Q4. How can two surgical approaches affect patients? Is there a difference in recovery time?

In conventional surgery, a 5-cm incision is made in the groin. It may cause pain when walking. Therefore, in terms of wound pain, this approach is generally associated with more discomfort than minimally invasive surgery, and patients may require a longer recovery period.

A mesh must also be sutured onto the muscle layer in conventional surgery. One may feel a pulling sensation while moving legs or engaging in exercises, which may cause discomfort for weeks. Therefore, after completion of conventional surgery, patients are often advised against any sports activities until several weeks later.

Since the mesh is sandwiched in place during minimally invasive surgery and thus requires no suturing, patients do not experience a pulling sensation. Located away from the groin, the incisions will not significantly affect one’s walking. The smaller incision also means that patients may only need to take pain medication for a few days. As for exercise, most patients can resume physical activity within two weeks.

Q5. Is minimally invasive surgery suitable for all patients?

Firstly, minimally invasive surgery must be performed under general anaesthesia, whereas conventional surgery can be conducted under local anaesthesia, regional anaesthesia, or general anaesthesia. General anaesthesia is necessary for minimally invasive surgery as it ensures the patient's abdominal muscles are completely relaxed. This allows the surgeon to insufflate gas into the abdominal cavity and create sufficient working space for the operation. If one is not suitable for general anaesthesia, minimally invasive surgery is not recommended.

As mentioned earlier, the surgical space lies between the muscle layer and the peritoneum. In case of adhesions between the peritoneum and the muscle layer due to previous abdominal surgery, and surgeon fails to safely separate these adhesions, minimally invasive surgery is not feasible. For example, minimally invasive surgery may not be suitable for hernia repair if one has had open prostate surgery or even robotic-assisted prostate surgery. This is because such procedures can cause the bladder to adhere closely to the outer muscle layer, making it not suitable for hernia repair via a minimally invasive approach.

Q6. Is there an age restriction for hernia repair surgery?

The risk associated with a hernia lies in the potential incarceration of the intestine. For children with a hernia, surgical repair is generally recommended. The timing of the surgery is determined by the child's overall health and developmental condition. For example, while immediate surgery is typically not advised for newborns, children aged one to two years may undergo operation if the health condition allows. 

For elderly patients, the decision depends on individual fitness. If one is deemed not suitable for surgery, conservative management is the only feasible option.