A hernia is a hole in the abdominal muscles through which abdominal contents, usually fat but sometimes intestines, can protrude.
In many cases, hernias cause no or very few symptoms – in fact, some people do not suffer from the condition’s archetypal bulge appearing on their abdomens. However, others notice a swelling or lump, particularly when coughing, sneezing or straining and some people feel pain or an ache around the lump. When laying down, the protruding part can often drop back and disappear so there is nothing to see or feel.
Although 1 in 10 people will suffer from a hernia, the most common type, called the inguinal hernia, or groin hernia, mainly affects men. It occurs when fatty tissue or a part of the bowel pokes through into the groin at the top of the inner thigh.
Most of these hernias are thought to result from ageing because the muscles surrounding the abdomen become weaker as we get older. However, hernias can develop as a result of any factor that weakens the tissues of the abdominal wall such as our genes and smoking or even a long-term cough and sustained heavy lifting, which increase the pressure within the abdomen.
The University of Michigan has also reported that obesity can increase the risk of developing abdominal wall hernias because being overweight increases the pressure on the abdominal muscles. It has been suggested that obesity can lead to the development of multiple hernias in the muscle wall and a higher likelihood of recurrence after surgery.
Once diagnosed, treatment options should be discussed with a patient. However, it is generally considered that the only curative treatment is surgery. In fact, the surgical repair of groin hernias is one of the most common procedures undertaken by the NHS. The procedure involves returning the tissue or part of the bowel back to its original location and it can be performed as open or keyhole surgery.
Although the British Hernia Society states that problems after straightforward groin hernia repair are very rare, the clinical negligence team at Penningtons Manches is seeing an increase in enquiries concerning the diagnosis and management of hernias as well as poor surgical outcomes.
Enquiries often relate to the information provided to patients on available treatment options and the risks and benefits of surgery. Some clients have concerns over complications arising from delays in surgical treatment following diagnosis. Hernias can become larger over time, which can make surgery more complex. Delaying surgery also increases the risk of strangulation, which is a life-threatening complication where the hernia becomes trapped in the abdominal wall, threatening blood supply to the tissue. This requires emergency treatment. Emergency surgery increases the risk of further hernias; the procedure is often more complicated than standard repair and is associated with a mortality rate that is seven times higher than elective operations.
There has also been recent criticism regarding poor surgical outcomes. In September 2018, the BBC’s Victoria Derbyshire programme reported on the most common treatment for hernias in England which involves a doctor pushing bulging tissue back into the body and covering it with a piece of surgical mesh. The programme has reported that up to 170,000 patients who have had hernia mesh implants in England in the past six years could face complications as the suspected complication rate of hernia mesh operations is estimated as being as high as between 12 and 30%. The adverse effects are reported to include chronic pain causing people to struggle to walk, sleep and continue with their normal lives – some have said that the pain has left them feeling suicidal.
Given that mesh surgery has been used for hernia repairs since the 1990s, there are concerns that the total number who have faced, and are facing, complications is much higher. In fact, the group of MPs now investigating the use of mesh have said that this may be “another scandal”.
Criticism is being directed against NHS trusts for failing to have a consistent policy for guidelines on treatment or follow-up with patients; manufacturers who are under no obligation to follow up on problems and also the regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), whose job it is to ensure medical devices are safe It is continuing to stand by the use of mesh for hernia operations and told the BBC that it had ‘not had any evidence which would lead us to alter our stance on surgical mesh for hernia repairs or other surgical procedures for which they are used’.
Although the British Hernia Society has also encouraged clinicians not to change their current practice, it has reminded them of the requirement of obtaining patients’ informed consent which should include discussions about surgery vs no surgery, mesh vs no mesh as well as the provision of information sheets being available prior to surgery.
The concerns over hernia mesh have come to light after it emerged that more than 800 women are taking legal action against the NHS over the use of vaginal mesh implants. Dr Suzy Elneil, a consultant urogynaecologist who participated in the campaign to halt the use of vaginal mesh, has estimated that treating those experiencing complications with hernia mesh could cost a minimum of £25,000 per patient to cover the removal of the mesh, a further operation to treat the hernia and follow-up care.
Emma McCheyne, a senior associate in Penningtons Manches’ clinical negligence team, comments: "We are seeing a rising number of enquiries from clients who are concerned about various aspects of their hernia treatment from diagnosis through to surgery and poor outcomes. Sadly many of these poor outcomes could have been avoided if appropriate advice and timely treatment had been offered. The impact can be significant, affecting an individual’s day-to-day quality of life and ability to work, as well as giving rise to a potentially increased risk of future complications and treatment needs.”