What is a Hernia?
A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply.What are the different types of hernia?
Different types of abdominal-wall hernias include the following:
- Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis.
- Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age.
- Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age.
- Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally 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 roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to be evaluated by a health-care provider.
- Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).
- Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after
2%-10%of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.
- Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which is several inches to the side of the middle of the abdomen.
- Obturator hernia: This extremely rare abdominal hernia develops mostly 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 act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose.
- Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.
Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness.
- Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include
- heavy lifting,
- straining during a bowel movement or urination,
- chronic lung disease, and
- fluid in the abdominal cavity.
- A family history of hernias can make you more likely to develop a hernia
Hernia Symptoms and Signs
The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into the
abdomen (anincarcerated strangulated hernia).
- Reducible hernia
- It may appear as a new lump in the groin or other abdominal area.
- It may ache but is not tender when touched.
- Sometimes pain precedes the discovery of the lump.
- The lump increases in size when standing or when abdominal pressure is increased (such as coughing).
- It may be reduced (pushed back into the abdomen) unless very large.
- Irreducible hernia
- It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it.
- Some may be chronic (occur over a long term) without pain.
- An irreducible hernia is also known as an incarcerated hernia.
- It can lead to strangulation (blood supply being cut off to tissue in the hernia).
- Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.
- Strangulated hernia
- This is an irreducible hernia in which the entrapped intestine has its blood supply cut off.
- Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).
- The affected person may appear ill with or without fever.
- This condition is a surgical emergency.
If you have an obvious hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.
Surgery is the only treatment that can permanently fix a hernia. However, smaller hernias with no symptoms can sometimes be watched. Surgery may have more risk for patients with serious medical problems.
Surgery will usually be used for hernias that are getting larger or are painful. Surgery secures the weakened abdominal wall tissue (fascia) and will close any holes. Today, most hernias are closed with cloth patches to plug up the holes.
An umbilical hernia that fails to heal on its own by the time your child is 5 years old may be repaired.
Emergency surgery is sometimes needed. The sac containing the intestine or other tissue may become stuck in the hole in the abdominal wall. If it cannot be pushed back through, this can lead to a strangulated loop of intestine. If left untreated, this portion of the intestine dies because it loses its blood supply.
Instead of open surgery, some hernias can be repaired using a laparoscope (camera). The advantages of using a camera include small surgical cuts, faster recovery, and less pain after the procedure.
What is laparoscopic hernia repair surgery?
A number of factors have led to the development of a new method of repair called laparoscopic hernia repair. This technique is an extension of a traditional mesh repair method that was used in patients who had already experienced several hernia recurrences at the same site. Previously, this mesh repair approach had required a separate incision somewhat removed from the target area. However, with the progressive development of the instruments and techniques for laparoscopic surgery, the same procedure can now be done with several relatively small incisions. This allows the surgeon to enter the space behind the hernia defect and place the mesh with minimal injury to the surface of the abdomen. The advantages of this method include coverage of all the potential sites of groin hernia, which reduces the risks of recurrence while also decreasing the amount of postsurgical pain.
What about the use of a laser in hernia repair?
This is a relatively common question. It arises because, for a time, there were some surgeons marketing "laser hernia repair." While a laser may have been used to make the incision and to separate the tissues, the laser has no application in the repair of a hernia. It is impossible to perform the necessary structural repair with a laser, which functions essentially as a cutting tool. Hopes that somehow an incision made with a laser would significantly reduce pain have not been confirmed.
What kind of anesthesia is used for hernia surgery?
Most hernia repairs can be done with a variety of anesthetic methods. With modern general anesthetic techniques and monitoring, general anesthesia can be very safe. However the surgery can also be performed under local anesthesia or regional anesthetics, often using sedation medications at the same time to help relax the patient. The specific type of anesthetic for an individual patient is selected after careful evaluation of the patient's general health and individual concerns
The outcome is usually good with treatment. Recurrence is rare (1-3%).
In rare cases, inguinal hernia repair can damage structures involved in the function of a man's testicles.
Another risk of hernia surgery is nerve damage, which can lead to numbness in the groin area.
The biggest risk of hernia surgery is another hernia, which may occur years later.
- Use proper lifting techniques.
- Lose weight if you are overweight.
- Relieve or avoid constipation by eating plenty of fiber, drinking lots of fluid, going to the bathroom as soon as you have the urge, and exercising regularly.
- Men should see their doctor if they strain with urination. This may be a symptom of an enlarged prostate.
Call your doctor right away if:
- You have a painful hernia and the contents cannot be pushed back into the abdomen using gentle pressure
- You develop nausea, vomiting, or a fever along with a painful hernia
- You have a hernia that becomes red, purple, dark, or discolored
- You have groin pain, swelling, or a bulge
- You have a bulge or swelling in the groin or belly button, or that is associated with a previous surgical cut.