The standard operation involves an incision about 8 cms in length through the skin and outer layer of abdominal wall muscle overlying the groin. The hernial sac and its contents are freed from the surrounding tissue and returned to the abdominal cavity.  The defect and surrounding weakness are then repaired using a single nylon sheet of mesh, which is stitched or stapled in place without tension. Older methods of surgical repair involved suturing the groin area under some tension, which led to a great deal of post operative pain, slow recovery, and a pretty high hernia recurrence rate as tight sutures will often cut through weak tissues with time. 

The new yardstick standard operation is a Lichtenstein tensionless mesh repair where a single sheet of mesh is carefully sutured deep to the first of the three layers of the groin. It was developed in 1987 and is still the standard although many variations and changes in surgery are evolving with differing types of mesh products.

My preferred method of open hernia surgical repair is to use a double layer of mesh, called a Prolene Hernia System, with reinforcing mesh being placed deep to all muscle layers and a second layer of connected mesh positioned, and fixed, in the standard position deep to the outer of the body’s three muscle layers.  I believe that this method reduces the already low risk of a hernia recurrence even further, and because of the method of its fixation, it leads to a shorter post operative recovery time.

There are several means of repairing hernias by open methods and every surgeon has their favourites.  The type of repair will also depend on the particular patient’s build, size of hernia and previous surgery.  Another method I sometimes use is called the Plug and Patch technique.

In many patients a light general anaesthetic together with a large volume of long acting local anaesthetic injected at the time of surgery will allow them to be discharged from hospital within a few hours of the surgery.  Oral analgesic tablets are given to use at home for a few days as required. Same Day surgery is the only method used in the United States, where hernias are commonly repaired under local anaesthetic and sedative tablets, rather than under a general anaesthetic. This is because U.S. insurance companies will not pay for an overnight hospital stay.

Some patients will remain in hospital overnight, as sometimes an injection of major narcotic is required or medication needed to stop post operative vomiting.  Pain relieving tablets taken orally are then usually sufficient. The occasional patient will be in hospital longer than one day, if there are other medical complications.

If same day surgery is your chosen method you will be given strong pain relieving tablets to take home and you may return to the hospital that night for an injection if you feel this is necessary.

Most patients will take oral pain relief medication for some days following surgery.

Sutures placed under the skin will be used and these do not have to be removed.

Day surgery offers a cost saving in that the cost of an overnight stay is more expensive.  Some health funds have no ‘co-payment’ for day cases and you should check with your health fund.

• You may undertake unrestricted activity.  Be guided by the discomfort in your wound. ‘Let your body do the talking’. 
• You cannot damage your operation.  The mesh used is stronger than your own body tissues and stitches or staples hold the mesh in place until it is incorporated into your tissues.  
• You may lift or strain as much as you wish, depending on how sore the wound is.
• Do not lie around in bed for long periods.  Get mobile quickly as recovery time is much reduced.
• Don’t drive for some days until you can easily manage as your insurance may be invalidated.
• Return to work when you feel able to do so.  You may return to any activity which is comfortable unless your employer tells you to stay away. 
• Modern methods of hernia repair with mesh are not the same as older methods.  Your recovery time is reduced by several weeks. Don’t believe what your neighbours or even nurses tell you about necessity to avoid physical activities.
• In general terms office workers could expect to return to work after two to three weeks but would still be somewhat sore and therefore limited in mobility.
• Most heavy manual workers can return to work after 3 to 4 weeks although earlier return is encouraged. Return to lighter duties before this is quite possible.

Operative and anaesthetic complications

Heart and chest problems can occur in the unfit after a general anaesthetic. These would include heart attacks, blood clots in the legs with spread to the lungs, both of which could be fatal.    Collapse of the lung bases with pneumonia after anaesthetic is possible, more likely to occur in the unfit or smokers. For the medically unfit some sort of light sedative anaesthetic with local anaesthetic or a spinal or epidural anaesthetic makes surgery much safer. 

Inability to pass urine    This is due to spasm of the bladder sphincter.  It may require a catheter or tube to be inserted into the bladder.  Occasionally a subsequent prostate operation can be required if the prostate gland is very large and urine cannot be passed.  It is usually preferable to have any necessary prostate surgery prior to embarking on an inguinal hernia repair.

Local Complications

Infection of the wound. This is not at all common and it presents some days after surgery with increasing swelling, redness and continuing throbbing pain.  It may require a small incision to be made under local anaesthetic to release any pus which has formed, and possibly antibiotics will be necessary.  Very rarely long term infection of the mesh can occur and this major problem can only be settled by an operation to remove the mesh. 

Discharge.  A small amount of clear fluid discharge from one end of the wound is usually related to irritation by the dissolving sutures and settles without any treatment apart from dressings.

Bruising and swelling.  The incision and scrotum may be discoloured or a little swollen or black and blue.  This is very common and is no cause for concern.  A firm swelling of blood will usually be reabsorbed over some weeks. Very rarely a very large collection of blood will require the wound to be drained.

Testicular blood supply.  A very small risk exists of damage occurring to the blood supply of the testicle.  This is much more likely (but still uncommon) if there has been previous hernia surgery in the area. Testicular blood supply damage in the literature is reported to occur in up 5% of cases where surgery is for a recurrent hernia.  Obviously this risk of damage is far less in experienced surgical hands but still may occur.   Loss of one testis is a major concern, loss of two testicles or of a sole testis is a total disaster.   

Damage to the Vas Deferens deferens   The vas is the tube carrying sperm from each testis.  Should both of these be damaged then infertility would result.  This is an extremely low risk as only a few cases have ever been reported.  The risks of sterility would of course be much higher if the patient had only one functioning testis. 

Damage to other structures   Adjacent large blood vessels can be damaged and require repair or even the bladder or bowel can be damaged rarely if an unusual hernia exists.  Damage is extremely rare.  It is remotely possible that bowel could subsequently become adherent to deeper positioned mesh with serious consequences of blockage or perforation and infection.

Trapping of nerves.  Several small nerves run right through the area of a hernia repair and in an isolated few cases a nerve can become pinched by a stitch, staple or scar tissue.  This can result in a very painful tender spot.  It may settle with time, with injections locally into the tender spot, or in rare cases with a further surgical exploration.          

Chronic Pain.   It is common to notice the odd twinge of minor discomfort in any area of the body which has undergone surgery, and this may occur for a few years after an operation.  Minor intermittent discomfort has been reported in up to 8% of patients who have undergone hernia surgery.  In some 1% of patients it can present as troublesome.  

Mesh Inguinodynia is one cause of this unexplained pain. It is felt that an unusual tissue inflammatory reaction can occur in isolated patients causing mesh to contract and constrict surrounding structures.  This can result in chronic pain, which may be felt in the testis, the groin, or both. Another rarer variety of this is where a vas deferens may be affected by inflammation around mesh resulting in pain on ejaculation.  Very rarely total removal of mesh and division of all nerves in the area can be required to cure severe chronic pain in the groin.

Recurrence of the hernia. In large series of hernia repairs by modern tensionless mesh repairs the chances of a recurrence has shown to be well under 1% over many years.  Older methods have all led to a lifetime recurrence rate of between 10 and 15%.  Difficult, very large, or recurrent hernias may require a substantially modified surgical procedure to reduce the risk of recurrence.