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Inguinal hernia repair

Professor Andrew Kingsnorth describes the possible complications that can follow the health service's most common surgical operation

Professor Andrew Kingsnorth describes the possible complications that can follow the health service's most common surgical operation

Inguinal hernia repair is the most commonly performed general surgical operation, with approximately 105,000 repairs being undertaken per year in the NHS. Mesh hernia repair (the Lichtenstein operation) is now almost universally used and is the operation recommended by NICE.

Laparoscopic repair in uncomplicated unilateral primary inguinal hernia is not indicated unless it is carried out by a recognised laparoscopic expert in a unit regularly undertaking this procedure. Patients receiving laparoscopic repair for uncomplicated unilateral inguinal hernias do not experience significantly less pain, faster recovery or earlier return to activities. However, there is a benefit in patients with bilateral and recurrent hernias and in appropriate centres, laparoscopic repair can be carried out for these indications.

The majority of patients will be receiving their inguinal hernia repair in a day-case centre with same-day discharge. The majority will receive general anaesthesia although local anaesthesia is superior in surgeons trained to perform this technique and results in faster return to 'street readiness'.

The key recommendations postoperatively are that return to normal activities is rapid and should occur within one week, return to work can occur as soon as two weeks, and return to all activities and sport within four weeks. Many patients exceed these time limits and return to activities and work much earlier.

Analgesia
Even if the procedure is performed under general anaesthesia, the inguinal wound will have been infiltrated with long-acting local anaesthesia, resulting in good pain relief for several hours.

Regular analgesia usually consisting of a codeine-based drug and an NSAID and several days supply will have been prescribed. The patient should be advised to take these analgesics for the first few days to pre-empt the onset of groin pain and allowing freedom of movement.

The patient should have been advised that there will be discomfort when rising from a sitting position to standing, coughing, sneezing and bending and climbing stairs.

They should be encouraged to take analgesics to counter the symptoms. Oedema around the wound occurs and may coexist with some slight bruising. In addition a slight ooze of blood from the wound is not uncommon and the patient should be reassured that this is not a complication. Mild pinkness around the wound is normal but if this becomes red and associated with a tense painful swelling it may indicate infection, for which the patient should seek advice by phoning the hospital or seeing the GP.

Resuming normal gentle activity the day after surgery while taking regular mild analgesics will result in a fully mobile patient experiencing mild pain that scores no more than 2 on a scale of 1-10. This pain may be exacerbated slightly by exertion but should be no greater. The wound will be covered by an opaque dressing and this should not be removed unless there is severe discomfort or reddening observed around the edges.

After day one, more strenuous activities, including lifting and straining, are encouraged but analgesics should be continued if necessary until day three or four when they can be discontinued. At this time the dressing can be removed, and bathing and showering encouraged without a dressing.

At this time more strenuous activities can be undertaken and by one week patients can carry out relatively normal physical activity, apart from strenuous sports and heavy lifting.

The wound
Slight bleeding from the wound is not uncommon because the absorbable subcuticular suture used may have punctured a minor dermal capillary, resulting in limited bleeding which stains the dressing.

More substantial bleeding may indicate bleeding from a small artery in the skin wound or from a deeper structure and the dressing should be removed to check the source of the bleed. If a wound haematoma with marked swelling of the wound and purplish discolouration is apparent this requires surgical review.

Wound infection will not become apparent until day three or four when reddening, swelling and pain in the wound is apparent because of cellulitis. Suppuration with an exudate of pus may occur later and, if it does, the patient should be referred to the surgical unit.

Mild genital oedema affecting the penis and scrotum is not uncommon and may take several days to settle down. If this oedema is excessive surgical review may be required.

Occasional immediate recurrence of the hernia may occur because of technical failure but recurrences generally do not appear for several months.Minor wound problems such as bleeding, oedema or pain can usually be managed by reassurance and encouragement to take analgesics.

Large haematomas, purulent wound discharges, excessive pain or scrotal swelling should be managed by contact with the hospital either through a specialist care nurse or the surgical admissions unit and early reassessment by the surgical team. It is reasonable to treat mild wound cellulitis with oral antibiotics as this will usually settle down spontaneously without any surgical intervention.

Patients with wound complications or severe pain will often wish to be reassessed by the surgical team who performed the operation. These patients should be sent to the surgical assessment unit early to see whether surgical intervention is indicated, or whether the complication can be managed conservatively or observed for a period as an inpatient.

There are no hard and fast rules and returning to work is very much left up to the individual and the type of work undertaken. However, excessive time off work should not be encouraged and as a guide those undertaking sedentary work (light, supervisory/clerical) may return to work within one to two weeks. Those undertaking minimal lifting can probably return after two to three weeks and only those with heavy labour-intensive jobs will require three to four weeks off work.

Only those developing complications will require longer periods off work and full activities.

Return to normal home activity is encouraged the day after surgery and this is the key to a speedy recovery and good pain control. Patients should be encouraged to lift and strain, allowing their wound discomfort to guide them as to what is acceptable. If the patient is relatively pain free, driving can be resumed within a few days.

Resumption of sporting activities is encouraged approximately two to four weeks after surgery although this should be delayed for more strenuous and contact sports such as rugby, squash and climbing.The tension-free mesh hernioplasty (Lichtenstein operation), if performed under local anaesthesia as a day case, has greatly accelerated the times for recovery. The previous advice that patients should be off normal activities and work for six weeks after inguinal hernia repair is no longer necessary.

Professor Andrew Kingsnorth is a consultant surgeon and professor of surgery at the Peninsula Medical School, Derriford Hospital, Plymouth
Competing interests
None declared

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