Hernia
By Dr. Sreekrishnakumar A. Vasu, MS in General Surgery
Introduction
Hernia is a protrusion of the contents of a body cavity where they are normally contained. Although the term hernia can be used for bulges in other areas, it is most often used to describe hernias of the abdominal wall.
Abdominal wall hernias are very common, particularly among men. Hernia operation is one of the common surgeries performed all over the world. Hernias are usually named for the area in which they occur.
Hernias are usually asymptomatic in the beginning, but nearly all have a potential risk of having their blood supply out off (becoming strangulated) which makes it a surgical emergency.
Different types of abdominal wall hernias
Inguinal (groin) hernia: Inguinal hernia makes up to 75% of all abdominal wall hernias and is 25 times more often seen in males than females. These hernias are of two types – direct or indirect. Both occur in the groin area where the skin of the thigh joins the lower abdomen (the inguinal crease), but they have slightly different origins. Both of these direct and indirect hernia, however is important clinically for the operating surgeon, so that he can decide about the surgical procedure as a part of treatment.
Femoral hernia: The Femoral Canal is the path through which femoral artery, vein and nerve leave the abdominal cavity to the the thigh. Although a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in the mid thigh area. This usually occurs in the females and more prone complications like irreducibility (can’t be pushed back) and strangulation (blood supply becomes cut off)
Unbilical hernia:
The incidence of this hernia is 10% to 30%. Many babies have a small umbilical hernia as protrusion at the belly button (umbilicus). This is because the opening for the umbilical cord blood vessels does not close before birth. If small (less than half inch), this type of hernia usually closes gradually by age 2 years. Even if the area is closed at birth, umbilical hernia can appear later in life because this spot may remain a weaker place in the abdominal wall.
Incisional hernia:
Abdominal surgery for any other diseases can cause a flaw in the abdominal wall. This may result in localized defect through which a hernia may develop. This occurs after 2-10% of all abdominal surgeries. Incisional hernias are notorious for recurrence after surgical repair.
Epigastric hernia:
Occurs between the navel and the lower part of the rib cage in the midline of the abdomen. This hernia usually contains fatty tissue and often painless and will not be able to push back in the beginning itself.
Spigelian hernia:
This is a rare type of hernia which occurs along the edge of the rectus abdominus muscle in the middle of the abdomen.
Obturator hernia:
This is extremely rare more seen in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge, but can cause bowel obstruction, which usually causes nausea and vomiting. Because of lack of bulging, this hernia is very difficult to diagnose.
Casues of hernia
Some of this abdominal wall hernia can be present at birth (congenital), others develop later in life. These hernias involve existing openings in the abdominal cavity or areas of abdominal wall weakness.
Any condition which increases the pressure inside the abdominal cavity can contribute to the formation or can worsen the hernia. It includes:
- Obesity
- Heavy lifting
- Cough
- Straining during defecation or urination
- Prolonged standing
- Excess fluid inside abdominal cavity (ascites)
- A family history of hernia can make you to develop a hernia
Symptoms of hernia
Signs and symptoms of hernia can range from a painless lump to painful profusion that is unable to push back into the abdomen.
Reducible hernia
It appears as a lump in the groin or other abdominal wall area
It may cause mild pain but usually not tender when pressed
Some time mild pain may be the starting symptoms
The lump increase in size when standing or during coughing
It can be pushed back into abdomen.
Irreducible hernia
It may present as a painful enlargement of a previously reducible hernia that cannot be returned into abdominal cavity.
Some may be persisting for long time (chronic) without pain
It is also called incarcerated hernia.
It can lead to strangulation (when blood supply to the contents is cut off)
Signs and symptoms of bowel obstruction may occur such as nausea and vomiting.
Strangulated hernia
It is an irreducible hernia in which the blood supply to its content is cut off.
Pain is always present
The patient may have fever and he feels more tired.
It is a surgical emergency.
When to consult a doctor
Any symptoms suggest you might have a hernia should prompt a visit to the doctor. Hernias which are easily reducible do not require emergency surgery, but any time it can become serious. Consultation with a surgeon will help you to understand the need for surgery and the procedure can be performed as an elective surgery, so that you can avoid the risk of emergency operation.
If you find a new, painful, non compressible lump, it is possible you may have an irreducible hernia, and you should have it checked with the doctor. If you already have a hernia and it suddenly becomes painful and irreducible, you should attend emergency department. Strangulation (cut off blood supply) of the intestine within the hernia sac can lead to gangrenous bowel (non viable bowel), which can happen within a time period of 6 hrs. All irreducible hernias may not be strangulated, but they need to be evaluated.
Examination and tests
If there is a definite hernia, the doctor may not suggest any other tests. If you have any symptoms of hernia (dull ache in groin or other area with lifting or straining but without an obvious lump), the doctor can feel the area while coughing or standing. This action may make the hernia able to felt. If you have an inguinal hernia, the doctor will feel for the possible path way and look for a hernia by inverting the skin of the scrotum with his finger.
Treatment of hernia
In general, all hernias should be repaired unless if there is any danger in undergoing the surgery due to pre existing medical conditions. In case of hernia with a large opening the operation is not necessary. ‘Trusses and surgical belts or bindings’ may be helpful in holding back the protrusion of selected hernias when surgery is not possible. However, they should never be used in case of femoral hernias.
Avoid activities that increase intra abdominal pressure (lifting, coughing or straining) that may cause the hernia to increase in size.
Medical treatment
Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.
Reducible hernia
In general, all hernias should be repaired to avoid complications in the future.
If you have pre existing medical conditions that would make surgery unsafe, repair of hernia should be delayed.
Rarely, doctors may advise against surgery because of the special condition of your hernia.
Some hernias have very large opening in the abdominal wall, and closing, opening is complicated because of its large size.
These hernias may be treated using abdominal binders.
Surgery for these hernias not necessary as the chance of strangulation is low.
The treatment of every hernia is individualized and its risks and benefits should be discussed.
Irreducible hernia
All acutely irreducible hernias need emergency treatment because of the risk of strangulation.
An attempt to reduce (push back) the hernia will be made after giving medicine for pain and muscle relaxation.
If unsuccessful, emergency surgery needed.
If successful, treatment depends on the length of the time that the hernia was irreducible.
If the intestinal contents of the hernia had the blood supply cut off, the development of dead bowel is possible in as little as six hours.
In case where the hernia has been strangulated for an extended time, the surgery is performed to check whether the intestinal tissue has died and to repair the hernia.
In case where the length of time that hernia was irreducible was short and gangrenous bowel is not suspected, emergency surgery is not necessary.
A hernia that was irreducible and got reduced now has an increased risk of doing so again, you should therefore have surgical correction sooner rather than later.
Occasionally, the long term irreducible hernia is not surgical emergency. These hernias, having passed the test time without signs of strangulation, may be repaired electively.
Follow-up
To lower the risk of recurrence, you have to have adequate rest after the surgical repair, as suggested by your doctor. If any medical problems (cough, constipation etc.) develop during the post surgical period, it should be treated in time with the help of your doctor.
Prevention
You can do little to prevent areas of abdominal wall from being weak, which can potentially become a site for a hernia.
Summary
Hernia is a very common condition which needs treatment in time.
Hernia operation is one of the common surgeries all over the world.
Risk of strangulation is the main reason for surgery in all hernias
Operative complications
Approximately less than 10% of the people undergoing hernia surgery will have any of the following complications. These are short term and usually treatable. Recurrence of hernia after the initial surgery can be repaired by the same or an alternate method.
Complications include
Recurrence (less than 2%).
Urinary retention.
Wound infection
Fluid buildup in Scrotum (Hydrocele).
Scrotal haemafoma (bruise).
Testicular damage on the affected side (rare).
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