Assessing the risk of strangulation in a hernia

Today, I want to talk about the 5 characteristics of a hernia that your surgeon will want to know so that they can assess whether a hernia is at risk of strangulation.

Generally speaking, the risk of strangulation of a hernia is quite low. Only one in a hundred hernias becomes strangulated. But even then, it's still a considerable risk and a threat to a person's life. So, it is important to be able to assess the risk of strangulation.

1. Reducibility: The first thing that your surgeon will want to know is whether or not you are able to push that hernia back in. The technical word for that is reducibility. If your hernia is reducible, (i.e. you are able to push it back in), then that means the hernia is at a lower risk of strangulation than one that you can’t reduce. Some hernias are reducible as soon as a person lies flat while other hernias require a bit of manipulation to push back in. Some hernias cannot be reduced at all back into the abdomen. These are known as incarcerated hernias and are at most risk of strangulation.

2. Location: The second thing that your surgeon will want to know is where the hernia actually is. Femoral hernias (a type of groin hernia) have the highest risk of strangulation compared to other hernia locations because of the size of the hernia hole and the inflexibility of the tissue around it. Inguinal and umbilical hernias carry an intermediate risk of strangulation, whereas incisional hernias (which arise from surgical scars) tend to have a lower risk of strangulation, particularly if the hole (defect) underlying the hernia is large.

3. Severity of symptoms: The third consideration that the surgeon will want to assess is the degree of symptoms that the hernia is causing. The more severe the symptoms arising from a hernia, the more likely it is to become strangulated. So if you're experiencing more and more pain with the hernia or developing digestive symptoms associated with it like increasing difficulty in opening your bowels, or periodic bloating then these might be early signs that the hernia is about to strangulate. Please note that severe bowel symptoms might be an indication of bowel obstruction. This is another complication of hernias and is considered a medical emergency which requires immediate surgical attention.

4. Previous hernia complications: The fourth thing that your surgeon will want to know is the history of this hernia and if it has caused trouble in the past or not. If you have previously presented to A&E with bowel symptoms or an irreducible hernia, requiring surgical attention to push the hernia back in and resolve the symptoms, then this is a sign that the hernia is likely to develop further complications in the near future, including strangulation. Remember never to trust a hernia that has caused problems in the past.

5. Size: The fifth and final thing that a surgeon will want to understand is the size of the hernia and the size of the underlying hole (or defect) from which the hernia arises. In inguinal and umbilical hernias, there is a correlation between the size of the hernia and its potential to become strangulated. Interestingly, the size of an incisional hernia does not dictate its potential for strangulation, but rather, the size of the underlying defect from which the hernia arises is more important. The bigger the defect, the easier it is for an incisional hernia to bulge out and go back in again without risk of strangulation. In summary, the risk of strangulation in inguinal and umbilical hernias increases with the size of the hernia, while the risk of strangulation in incisional hernias is greater with smaller defects.

Remember, always consult a specialist if you have any concern about a hernia.

Keyhole versus open surgery for groin hernias

If you have a groin hernia, and you have decided with your surgeon that the best way forward is to surgically repair this, then one of the crucial steps is to agree on the way it's going to be repaired.

There are two ways to surgically repair a groin hernia:

1)            Open conventional surgery

2)            Keyhole surgery

Briefly explained, the open conventional approach is where a cut is made, just above the skin fold in the groin, approximately 6-7cm in length to access and repair the hernia. With keyhole surgery, 3 small incisions are made in the tummy, measuring between 5-15mm, and then keyhole instruments are inserted through these holes to access and repair the hernia.

So which of these 2 approaches is better?

That's not an easy question to answer, but I'll address 3 important factors that help to determine which of the two techniques is best for you.

1)      Your general health

Keyhole surgery can only be done through a general anaesthetic whereas open surgery can be performed through a general or local anaesthetic. So, if you're not fit for a general anaesthetic, then you may only be offered open surgery to repair the hernia.

2)      Surgeon’s experience

Some surgeons are more comfortable performing the repair through the open approach. Others are more comfortable with the keyhole approach, and some are comfortable with either technique, so is it important that the surgeon chooses an approach that they are comfortable doing.

3)      Outcomes

Lets explore some of the main differences in results between keyhole and open surgery. If we look at the risk of complications after the operation, we'll find that no study has identified any difference between the two approaches. Equally when it comes to the success of the operation and the potential for the hernia coming back in the future, again, no study has found one or the other technique to be superior.

But there are some areas where differences in outcomes have been shown between the two techniques. Some studies have shown that keyhole surgery reduces the risk of long term pain after hernia repair. That isn't surprising considering that there are 3 nerves that you'll have to identify and preserve when you repair a hernia through the open approach. When it comes to keyhole surgery, there are nerves that a surgeon should avoid, but these are a bit further out of the way, and can be avoided with relatively less effort.

The other difference that studies have shown is the recovery time after the procedure. Keyhole surgery offers a slightly quicker recovery rate in comparison to open surgery.

You also have to look at other considerations, for example, where the wound is going to be placed. If you're planning to sit for a prolonged period of time shortly after surgery (e.g. as a driver or passenger on a long trip, or if you wish to return early to your office job), you may want to consider not having a wound in the groin but rather in a higher location.

I always argue that keyhole surgery avoids creating a wound in the groin, which is a slightly more contaminated area, but there hasn't actually been any evidence to show that infection rates are higher with open repair in comparison to keyhole surgery.

So there are lots of factors to consider when deciding between keyhole and open surgery, but the important thing is to discuss these options with your surgeon so that you can both agree the best way forward for you.

Reducing the risk of hernia recurrence

Patients sometimes ask me what it is they can do to improve chances of their hernia operation being successful. i.e. reducing the chances of hernia recurrence and failure. I would divide these factors into two: things that patients can do before the operation and things that they can do after.

The two most important things that patients can do before surgery are weight loss and reducing (or quitting) the consumption of tobacco products. These are factors that have been found in the past to be associated with hernia recurrence. The more tobacco products a patient uses and the more excess weight that they put on, the higher the likelihood of wound complications after surgery, and the higher the risk of hernia recurrence.

In terms of the things that patients can do after surgery, I would advise patients to take it easy in the first couple of days or so after surgery, but that's mainly because of the discomfort that patients can be in after the operation. But generally speaking, if the patient is comfortable performing an activity or a manoeuvre, then it's absolutely fine to perform that. For example, getting out of bed, standing up, sitting down, walking, carrying light objects (in the early days), driving, and even cycling (after a week or two) after the operation should be absolutely fine if the patient does not complain of pain. But obviously, if the patient feels discomfort or pain when performing a certain activity or manoeuvre, then that is a warning signal from the body and my advice is to take a step back and not continue with that activity, but maybe repeat it again in a week or two.

So these are the factors that I believe a patient can look out for and potentially modify to improve their chances of a successful hernia operation.

Do all groin hernia need to be surgically repaired?

We know that surgery is the only proven treatment to repair a hernia but is surgery the right option for everyone? For most people, it is. But like most things in life, there are exceptions to this rule.

For example, if a patient has serious underlying health problems, then surgery might not be the right treatment for them. But even in those situations, one option is to have the operation done under a local anaesthetic.

Another reason is if the person doesn't want to have an operation which can be the case if the hernia isn't bothering them too much or if they haven't noticed it at all, for example, with an incidental or an occult hernia. Even with more noticeable hernias. sometimes a patient just doesn't want to have an operation.

It is perfectly acceptable in these situations for the surgeon and patient to agree to ‘watch and wait’. In other words, to keep an eye on the hernia and not have it surgically repaired at that time.

But it's important to mention that for every three people who decide not to have an operation immediately and to go down the watch and wait, route, two will need an operation within five years’ time because of worsening of symptoms or a change in circumstances.

So that's really important to bear in mind when deciding whether you want to have an operation to repair a hernia or whether you want to wait and see.

How does a groin hernia present?

Groin hernias affect many people, particularly men. In fact, one in four men will develop a groin hernia in their lifetime.

The most common sign of a groin hernia is as a lump or a swelling in the groin. It is often this noticeable bulge that prompts a person to seek medical advice. Hernia lumps can range from barely detectable to quite large. These lumps may either appear when you're standing up and then disappear when you lie flat. Sometimes, they only show up when you cough, and you may be able to push them back in. But there are also cases where the swelling is always present, even when lying down and can be difficult to push back in.

The other symptom that a hernia can cause is pain around the groin or sometimes just an abnormal sensation in that area, like a dragging feeling or general discomfort in that area. Many sensory nerves pass across the groin so it’s no surprise that groin hernias can stimulate these nerves, causing sensory symptoms like pain. A person can present with these abnormal sensation in the groin, either with or without a lump. If you have a hernia that can’t be felt through a clinical examination, this is called an occult hernia. Your doctor might request a scan for you to confirm the diagnosis.

Occasionally, a hernia in the groin may go unnoticed, causing no symptoms at all. This is called an incidental hernia and is often detected during a scan performed for an unrelated reason.

It is also important to mention that, although uncommon, a hernia can cause the bowel inside it to twist or lose its blood supply which can cause extreme pain and symptoms of bowel blockage like vomiting or stomach swelling. This complication happens in about one in 100 of patients with an inguinal hernia (the commonest type of groin hernia) and is more likely to happen in large hernia lumps that can't be easily pushed back in, or in femoral hernias (a different type of groin hernia, more common in women).

So to summarize: groin hernias can present with a visible swelling, pain or abnormal sensation in the groin. In some cases, they may even present with no symptoms at all and are discovered incidentally during an unrelated scan. Bear in mind that, whilst uncommon, hernias can also lead to bowel complications which require emergency treatment so early assessment is important.

Regardless of how a groin hernia presents or is diagnosed, it is important to have it checked by a specialist who can guide you on the next steps of management.