Hernia

Hernias can have serious complications if not treated.

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. The pain can occur while resting or only during certain activities such as walking or running. Nearly all hernias 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 causing the decreased or total loss of blood supply to the protruding tissues. 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).

Common 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 and can cause pain that is difficult to distinguish from testicle pain. 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 middle of the upper leg. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated (cutting off blood supply). 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 professional.
• Umbilical hernia: These common hernias (10%-30%) are often noted in a child at birth as a protrusion at the belly button (the umbilicus). An umbilical hernia is caused when an opening in the child's 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 when a child is 2 to 4 years of age. 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). They usually do not cause abdominal pain.
• Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness through 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 lateral to 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.
• Hiatal hernia: This type of hernia occurs when part of the stomach pushes through the diaphragm. The diaphragm normally has a small opening for the esophagus. This opening can become the place where part of the stomach pushes through. Small hiatal hernias can be asymptomatic (cause no symptoms), while larger ones can cause pain and heartburn.
• Diaphragmatic hernia: This is usually a birth defect causing an opening in the diaphragm, which allows abdominal content to push through into the chest cavity.

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
  • obesity,
  • heavy lifting,
  • coughing,
  • 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.

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 (an incarcerated strangulated hernia). Abdominal or pelvic pain can be part of the symptoms of many hernias.

• 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.

All newly discovered hernias or symptoms that suggest you might have a hernia should prompt a visit to the doctor. Hernias, even those that ache, if they are not tender and easy to reduce (pushed back into the abdomen), are not necessarily surgical emergencies, but all have the potential to become serious. Referral to a surgeon should generally be made so that the need for surgery can be established and the procedure can be performed as an elective surgery and avoid the risk of emergency surgery should your hernia become irreducible or strangulated.

If you find a new, painful, tender, and irreducible lump, it's possible you may have an irreducible hernia, and you should have it checked in an emergency setting. If you already have a hernia and it suddenly becomes painful, tender, and irreducible, you should also go to the emergency department. Strangulation of intestine within the hernia sac can lead to gangrenous (dead) bowel in as little as six hours. Not all irreducible hernias are strangulated, but they need to be evaluated.

Your primary care doctor will be able to diagnose and initially treat many hernias. Definitive treatment will usually require surgery. Depending on the location of the hernia, the hernia repair will usually be performed by a general surgeon.

If you have an obvious hernia, the health care professional may not require any other tests (if you are healthy otherwise) to make a diagnosis. 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. X-rays (often CT scans) can assist in the diagnosis or evaluating the extent of the hernia.

Hernia treatment can be conservative (such as observation and support with trusses) if the hernia is not affecting your daily routine or does not cause severe pain. Curative treatment consists of surgery. Laparoscopic surgery has taken the place of traditional hernia surgery for some of the abdominal hernias. Herniorrhaphy is the surgical repair of a hernia.

Surgical hernia repair is the ultimate treatment. The timing of treatment of a hernia and technique for treatment depends on whether it is reducible or irreducible and possibly strangulated.

• Reducible hernia
  • In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.
  • If you have preexisting medical conditions that would make surgery unsafe, your doctor may not repair your hernia but will watch it closely.
  • Rarely, your doctor may advise against surgery because of the special condition of your hernia.
    • Some hernias have or develop very large openings in the abdominal wall, and closing the opening is complicated because of their large size.
    • These kinds of hernias may be treated without surgery, perhaps using abdominal binders.
    • Some doctors feel that the hernias with large openings have a very low risk of strangulation.
  • The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place between the doctor and patient.
• Irreducible hernia
  • All acutely irreducible hernias need emergency hernia repair because of the risk of strangulation.
  • An attempt to reduce (push back) the hernia will generally be made, often after giving medicine for pain and muscle relaxation.
  • If unsuccessful, emergency surgery is needed.
  • If successful, however, 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 (gangrenous) bowel is possible in as little as six hours.
    • In cases in which the hernia has been strangulated for an extended time, a surgeon will perform surgery to check whether the intestinal tissue has died and to repair the hernia.
    • In cases in which the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged from the hospital.
• If a hernia that appears irreducible is finally reduced, it is important for a patient to consider a surgical correction. These hernias have a significantly higher risk of getting incarcerated again.

• Risk of strangulation: In considering when to have a reducible hernia surgically repaired, it is important for a patient to know the risk of strangulation.
  • The risk varies with the location and size of the hernia and the length of time it has been present.
  • In general, hernias with large sac contents with a relatively small opening are more likely to become strangulated.
  • Hernias that have been present for many years may become irreducible.
• Operative complications: Complication rates vary according to whether the surgery was elective or emergent, the hernia size and location, as well as the techniques used (open surgery or laparoscopic)
• Most complications occur over the short term and are easily treatable.
  • The hernia that comes back after initial surgical repair can be repaired by the same or an alternate method.
  • Complications of hernia repair include
    • recurrence (most common),
    • urinary retention,
    • wound infection,
    • fluid build-up in scrotum (called hydrocele formation),
    • scrotal hematoma (bruise), and
    • testicular damage on the affected side (rare).

To lower the risk of a hernia becoming irreducible or strangulated, the sooner a reducible hernia is repaired the better.

In general, all hernias should be repaired unless severe preexisting medical conditions make surgery unsafe. The possible exception to this is a hernia with a large opening. Trusses and surgical belts or bindings may be helpful in holding back the protrusion of selected hernias when surgery is not possible or must be delayed. However, they should never be used in the case of femoral hernias.

Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size.

You can do little to prevent areas of the abdominal wall from being or becoming weak, which can potentially become a site for a hernia. Modifying your behavior and weight loss can help prevent worsening of the hernia.