Consultant Surgeon & Surgical Director
Gilmore Groin and Hernia Clinic
108 Harley Street
Stop Press: Women Get Hernias Too!
As hernias are much more common in men than in women (for reasons I shall explain later) it is not surprising that some people think that women don’t get them at all. But, of course, they still can.
What is a Hernia?
Let’s talk Inguinal (groin) hernias
Inguinal (groin) hernias are the commonest type in both men and women. These are the classical hernias that appear as a lump in the groin.
Sometimes there is a period of aching in the groin before the lump appears but often there are no symptoms at all, apart from the lump itself.
Often the lump is not present in the morning but appears as the day goes on. It usually disappears when you lie down (we say it is “reducible”).
In both men and women, the gonads (testicles and ovaries) begin their development at the back of the abdomen. In women the ovaries stay inside the tummy, but in men the testicles move through the muscles of the abdominal wall (the inguinal canal) so that they lie outside of the body (usually). They take with them a collection of nerves and blood vessels, as well as layers of connective tissue (fascia) and the vas deferens (the whole lot being called the spermatic cord). This means that in men the inguinal canal is much bigger than in women and it causes a potential weakness through which hernias can occur (in women there is a small structure called the “round ligament of the uterus” that goes through the inguinal canal, but this is much smaller and so the weakness is much less).
Direct & Indirect Inguinal (groin) hernias:
Technically there are two types of inguinal hernia, called “direct” and “indirect”. The later tends to slide down the cord (or the round ligament) and reduce upwards and backwards. The former poke straight through and go straight back. In practice both are repaired in a similar way. Whilst in some cases there is a particular episode that results in a hernia (carrying something heavy or straining, for example), it is likely that most hernias occur because of the combination of the muscular weakness and a general, genetic, predisposition, and were always going to happen at some point.
Repairing Inguinal (groin) hernias
Most inguinal hernias will be operated on at some point (we say “repaired”) but, unless they are becoming increasingly painful, there is not usually any rush. People, understandably, worry about “strangulated” hernias, where the bowel can get stuck, but this is extremely rare. In terms of surgery there are basically two choices: a laparoscopic repair, or an “open” repair.
A laparoscopic operation involves using small telescopes to pull the hernia back (reduce it) and place a plastic mesh behind the muscles of the abdominal wall. It is often described as “minimally invasive surgery”, but, in fact, although the individual incisions can be quite small, the area that is operated on is around 3 times larger, and the volume 9 times larger, than with an open approach. So it is actually a bigger operation on the inside and it always uses a plastic mesh which, some feel, can contribute to chronic pain after the operation.
- Open operation:
An open operation can actually be done through quite a small incision (4-5cm, which is similar to the total size of the number of the small incisions needed for a laparoscopic repair) and it can also be done with just stitches (a “Shouldice” type repair), although many surgeons do still use a mesh patch, or sometimes a smaller “plug” (which seems not to have as high an incidence of post-operative chronic pain). Any operation is a compromise between stopping the hernia coming back (recurrence) and keeping possible complications as low as possible. The use of a small plug, along with stiches to strengthen the muscles is a good combination (“open mesh plug repair with muscular reconstruction”). After an operation it is possible to start gentle exercises after 3-4 days and most people are back to normal in a couple of weeks.
Despite the suggestion that laparoscopic repair gets people back to work more quickly and has a lower recurrence rate, this almost certainly isn’t the case. In addition, laparoscopic surgery has many more potential complications (although all rare).
The next common hernia in the groin area in women is the femoral hernia.
The lump with a femoral hernia is lower down, in the groin crease, and it is often more difficult to reduce and so they tend to be more uncomfortable and will usually end up being repaired. As with inguinal hernias there is a potential weakness (the femoral canal) just next to the main blood vessels that go into the leg (the femoral artery and vein). In women the pelvis is wider in this area, so the canal is bigger, and it is this anatomical difference that leads to the higher number of femoral hernias in women. Having children can make the pelvis more flexible and they are more common in women who have children. Quite a few of then actually get diagnoses during pregnancy as, particularly in later pregnancy, hormones are produced that make the pelvis more flexible.
Repairing Femoral hernias
The operation is usually “open and can be done through a smaller and lower scar than with a inguinal hernia. Often a small plug is placed in the femoral canal and a small number of stitches used to close the canal. Women get back to normal quite quickly after this procedure as it is a smaller operation that an inguinal hernia repair.
The third sort of common hernia is the “umbilical” hernia that causes a lump near the navel (belly button). Once again, it’s all to do with anatomy! The umbilicus is the scar from the umbilical cord so there is no muscle here. This makes the area weaker and more prone to a hernia. Many babies have a small umbilical hernia at birth, but these will almost always heal themselves by 2 years old. In adults they are probably slightly more common in women than men and account for 10% of all hernia operations. Being overweight certainly adds to the chance of getting one (and of it coming back after an operation), but many slim people get them too. Most umbilical hernias are small and cause no problems.
Repairing Umbilical hernias
These may never need an operation. If they are bigger or causing symptoms, then surgery is appropriate. As with other types of hernia it can be done laparoscopically or open. As many umbilical hernias are quite small, they can easily be repaired with a small incision just above or below the umbilicus and a small number of strong stitches used to repair the hole. It is possible to put a mesh on the front of the muscles if the hole is quite big. As before, the laparoscopic technique will always use a mesh, and in this case, it is place on the inside of the abdomen to seal the hole, after the hernia has been reduced. Umbilical hernias recur more frequently than groin hernias (5-10%, compared with 1-3 %).
Just as a final aside, many people, as they get older, and many women, particularly after having children, develop a condition called “divarication of the rectus muscles”. This causes a swelling running down the middle of the abdomen, from just underneath the breast bone to the umbilicus. It is particularly noticeable with straining or exercise. This happens because the rectus muscles (the ones that give you a “six pack”) have got weak or stretched and no longer meet tightly. This allows everything to bulge out. It is not a hernia and generally nothing needs to be done. Exercises focusing on the “transversus layer of muscle” can reduce it or stop it from progressing, but once you have got it, you are stuck with it to some degree. Whilst it is, technically, possible to repair it, this would involve opening up the entire abdomen an pulling it together, a big operation. In rare cases if this is done it is often combined with an abdominoplasty (a “tummy tuck”).
So, ladies, look out for hernias, because you can bet them too, but be reassured that they are not as common and are usually easily fixed!