What is it?
A hernia is a weakness in the muscles which form the front of the body wall. Usually, the bowel, and more rarely other organs, can push through this weak spot and create a bulge in the area. In your case the hernia is in the gristle between your breastbone and your tummy button. This is called the epigastrium. Sometimes there are more than one. It is usually caused by the body wall being weak from birth. Sometimes the body wall weakens with the passing of time. Sometimes the body is overstrained by coughing, heavy work or sport, etc. Hernias are very common and are easily treated. If left untreated they get bigger and cause pain. More dangerously, the bowel can sometimes get trapped in the weak spot of the muscles. This can cause a blockage of the bowel, which can eventually cause it to become strangulated. An emergency operation is then required to deal with the problem.
You can be given a local or a general anaesthetic. The choice depends partly on which you prefer, and partly on what your anaesthetist and surgeon think is best. The vast majority of operations for hernia repair are carried out under general anaesthetic. In some cases when the hernia is relatively small and your general medical condition does not allow you to tolerate the stress of a general anaesthetic, the operation can be done under local anaesthetic. Having a general anaesthetic means that you will be completely asleep during the operation. Having a local anaesthetic means that you will be awake during the operation, you will feel that something is being done at the area of the operation but will not feel pain. A cut is made into the skin overlying the hernia. The bulge is pushed back or is cut off. The weak part is mended/closed and strengthened, usually with strong stitches. Another alternative is to patch the weak spot with a piece of synthetic material. This is usually done when the tissues around the weak spot are not strong enough to be stitched up together with strong stitches or when the weak spot is so big that it is impossible to close it just by using stitches. The synthetic patch is placed on top of the weak spot and is stitched to the healthy tissues around it. Soon, a lot of scarred tissue develops above and under the patch which makes it very strong and doesn’t allow the hernia to come back again. The cut in the skin is then closed up.
Keyhole surgery for hernia repair is only carried out in some specialised centres and for selective cases. There is no clear evidence at the moment that it offers a significant advantage compared to the traditionally performed operations.
The operation can either be done as a daycase, which means that you come into hospital on the day of the operation and go home the same day, or as an inpatient case, which means spending one or two nights in hospital. Your doctor will have discussed with you which operation you will be having.
Simply waiting and seeing if you have more trouble is not a good idea. The hernia will always get worse. A support or a belt may be useful if the hernia is very big. It is a good idea if you do not like the idea of an operation, or if you are not fit enough for one. Keyhole operations for hernia repair are experimental.
Before the operation
Stop smoking and try to get your weight down if you are overweight. (See Healthy Living.) If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you.
On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible.. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks.
where you visit for an hour or two, a week or so before the operation for these checks.
After - In Hospital
A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. Do not make important decisions, drive a car, use machinery, or even boil a kettle during this time. The nurses will help you with everything you need until you are able to do things for yourself. Most patients have local anaesthetic injected into the wound (even if you have a general anaesthetic for the operation) to minimise the pain after the operation. Usually the wound is almost pain-free. There may be some discomfort on moving. Painkilling tablets should easily control this discomfort. Painkilling injections can be given. Ask for more if the pain is not well controlled or if it is getting worse.
It is important that you pass urine and empty your bladder within six hours of the operation. If you have difficulty, let the nurses know. The wound has a dressing which may show some staining with old blood after 24 hours. You can take the dressing off after 48 hours. There is no need for a dressing after this unless the wound is painful when rubbed by clothing. You can leave the wound without dressings after five days or so, when it is comfortable. There may be stitches or clips in the skin. They are usually removed 10 to 14 days after the operation. The wound may be held together with dissolvable stitches underneath the skin.
There may be some purple bruising around the wound which spreads downward by gravity and fades to a yellow colour after two to three days. This is expected and you should not worry. There may be some swelling of the surrounding skin which also improves in two to three days. After 7 to 10 days, slight crusts on the wound will fall off. Occasionally minor matchhead-sized blebs (blisters) form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so.
After - At Home
Make sure you are going home by car with your relative or friend. Go to bed. Take two painkiller tablets every six hours to control any pain. The next morning you should be able to get out of bed quite easily despite some discomfort. You will not do the wound any harm. The exercise is good for you. The second day after the operation, you should be able to spend most of your time out of bed in reasonable comfort. You should be able to walk 50 yards slowly.
By the end of a week the wound should be nearly pain-free. You can wash but try to keep the wound area dry until the stitches/clips come out. If there are only dissolvable stitches under the skin, try to keep the wound dry for a week.. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or take a bath as often as you want. You are likely to feel very tired and need rests two to three times a day for a week or more. You will gradually improve. By the time a month has passed you will be able to return completely to your usual level of activity. At first discomfort in the wound will prevent you from harming yourself by lifting things that are too heavy. After one month you can lift as much as you used to lift before you had the operation. There is no value in trying to speed the recovery of the wound by special exercises before the month is out. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 10 days. You can restart sexual relations within a week or two, when the wound is comfortable enough. You should be able to return to a light job after about two weeks and any heavy job within four to six weeks.
If you have this operation under general anaesthetic, there is a very small risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will bring the risk for such complications very close to zero.
Complications are rare and seldom serious. If you think that all is not well, please let the doctors and the nurses know.
Bruising and swelling may be troublesome, particularly if the hernia is large. The swelling may take four to six weeks to settle down. Serious bleeding that might require another operation to stop it happens in less than 1% of cases.
Infection happens in 1 to 2% of cases and usually settles down with antibiotics in a week or two. The infection can cause more trouble in situations where the hernia was repaired with a synthetic patch. The patch is a foreign body and if it gets infected it makes it difficult to control the infection with the antibiotics. If this happens, you may require antibiotics for a longer period of time and, very rarely, you might need another operation to remove the patch. In this case, you will most probably need another operation in the future to repair the hernia again.
Extremely rarely (1 in 2000 cases) the bowel or other organs of the abdomen can be damaged during the operation and if this occurs you will need another operation to fix the problem.
Aches and twinges may be felt in the wound for up to six months. About 1 to 2% of patients experience some pain for longer than this (chronic incisional pain) and if this happens the doctors will discuss with you the best way to deal with the problem.
Overall, the chances of the hernia coming back again is about 1 in 100. This can go up to 2 to 3% if the hernia was very big or the patient’s tissues are not very healthy and they are not healing well, for example if the patient is elderly or diabetic.
The operation should not be underestimated, but practically all patients are back to their normal duties within one month. These notes will help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.
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