A hernia is a weakness that develops in certain anatomical regions of the body. The weakness is usually located in the inguinal (groin areas) or at the umbilicus (belly button). A hernia in these areas may be congenital (from birth) or acquired later on in life (from lifting or straining). A hernia is not a mass or a tumor, but just a protruding weakness through the different muscle layers of the abdominal wall.

This weakness allows the pressure from inside the abdominal cavity to push out, creating a bulge - much like a bubble bulging through a weak spot on an inner tube. This bulge can be occupied by intra-abdominal fat or intestines. Most natural hernias occur in the groin and umbilical area.

Here you can see what a hernia looks like once the skin has been opened at surgery. The red bulge in the middle of the picture is the hernia sac. The metal instruments are called retractors and are used during surgery to hold the incision open so that the surgeon can obtain a better view of the operative field.

How Common is a Hernia?

The National Center for Health Statistics estimates that about 5 million people in the United States have an abdominal hernia. Only a fraction of these people seek treatment. It is generally thought that 3% of the general population will have or develop some type of abdominal wall hernia. Hernias are five times more common in males. The most common hernia in either sex is the inguinal (groin) variety. A different type of hernia, the femoral hernia is more common in females. Congenital hernias (from birth) are noticed early on in development (normally younger than 1 year old). Approximately 700,000 hernia repairs are done each year in the U.S

What Causes a Hernia?

When the hernia defect is congenital, it is secondary to a structure that causes a weakness in the abdominal wall at birth. This would explain inguinal hernias in children (a weakness created when the testicle pushes through the abdominal wall during development), and also umbilical hernias (where the umbilical cord leaves the body-belly button). A hernia that develops later in life may not have an exact cause. A lot of questions are raised whether these hernias later in life are just weaknesses from birth and are eventually noticed. Medical histories obtained from some young patients can tell you exactly when the hernia developed. Histories usually incriminate work related physical stress as the cause. Chronic increased intra-abdominal pressure may play a role in hernia formation. Prolonged coughing, prostate problems, bowel irregularity and other medical conditions may predispose us to hernia development. A common property of all hernias is that once they are present, they are permanent until surgically repaired

Signs and Symptoms

A hernia usually first becomes noticeable as a bulge somewhere in the abdomen or pelvic area or in the scrotum for men. If the bulge is reducible, it may enlarge when the person is standing and become smaller when he or she lies down. Hernias can also occur without symptoms and are commonly identified during a routine physical exam. The patient may point to a bulge, often without pain. Pain can be produced when the bulge is pushed in (reduced). A classic history is that the hernia will disappear at night (the hernia will disappear because the person lies on their back and gravity causes the hernia to be reduced). Symptoms such as pain located below the hernia, groin numbness and burning, and thigh pain are frequent complaints. Occasionally people can notice changes in their bowel habits because the hernias contain large segments of the small bowel or colon. Intermittent abdominal pain and cramping can be seen if the hernia contents get obstructed or twisted.

Older men can have a hernia that has been present for many years. These hernias can extend down from the groin and involve the scrotum and testicle. If the bulge in the groin or umbilical region cannot be pushed back in, pain is almost always present (an incarcerated hernia). An incarcerated hernia is usually an emergency, and in most cases requires surgery. In some cases these incarcerated hernias can be reduced with sedation and pain medications, but still should be surgically repaired. If a hernia is incarcerated for an extended period of time, the hernia contents will become strangulated. In a strangulated hernia, the contents of the hernia sack may not be viable. This type of complication would result in a much larger operation and is one of the main reasons that hernias are repaired prophylactically.

Common Types of Hernias

• The inguinal hernia, or groin hernia, is the most common type of hernia defect - affecting about 2% of men in the United States. During development, a male's testicles descend into the scrotum. This causes a naturally weakened area in the wall of the abdomen, called the internal ring. This weakened area makes men more susceptible to a hernia at this location. The intestine drops down into the internal ring and can extend down into the scrotum in men or to the outer folds of the vagina in women.The inguinal hernia can be classified as direct or indirect. This distinction is based on some anatomical landmarks in the area of the groin. The two types are not easily differentiated preoperatively, and always have similar symptoms and physical findings. This hernia is seen in both children and adults.

• Another natural area of weakness in the abdomen is the umbilicus (belly button) which, like the internal ring, is made up of tissue that is thinner than that in the rest of the abdomen. This is another area where a hernia is often seen. Patients can present at any age, the weakness is always at the umbilicus. Physical exam shows a rounded bulge at the umbilical region (out belly button). This hernia is also seen in adults and children.

• This is a weakness created at the site of a previous incision. This hernia can vary in size and location. An incisional hernia can be the largest type of hernia defect, and sometimes can be very difficult to repair. Etiology of the incisional hernia is related to surgical technique, infection stresses in the postoperative period, and general health of the patient.

• This is a weakness at the exit site of the large arteries of the legs. As they exit the abdomen, a natural site of weakness is created. This hernia is most common in women and is often hard to detect.

Treatment

Hernias may be approached in three different ways: expectantly, nonoperatively, or by surgical repair.

Expectant treatment is based on the idea that the hernia will repair itself. This type of repair is not realistic. The only time expectant treatment may work is with a small congenital umbilical hernia. These hernias may spontaneously regress and need no repair (up to age 4). No treatment of hernias may be reasonable in the very old or sick people. A patient always has the option of not undergoing treatment, but he or she should understand that the hernia may become worse and that there is a risk of intestinal strangulation.

Nonoperative treatment of a hernia involves the use of some type of external device to push the hernia in. These devices are called trusses. Trusses are worn around the waist and act by pushing in on the defect. These devices are rarely successful. Trusses were once popular, but now are rarely seen.

Surgery is currently the treatment for all hernias. Many different techniques have been developed over the years. These techniques are based on the simple idea of closing the defect that is present and strengthening that area so the hernia will not recur. Recently the surgical approach has concentrated on the tension free repair and the laparoscopic techniques. Tension free repairs are based on the idea that a hernia repair should not be under tension. Tension is thought to be one of the main reasons for a hernia to recur. Lichtenstein pioneered the idea of the tension free repair using synthetic mesh. Other physicians and institutions have developed similar surgical techniques, all based on the tension free hypothesis.

I use the Prolene Hernia System from Ethicon. This synthetic patch allows for a double layer of reinforcement of the abdominal wall and a tension free repair. The work in developing this repair was pioneered by Dr. Gilbert at the Hernia Institute of Florida. Results are excellent with low recurrence rates. Most patients' experience less postoperative pain, are done under local, and always as an outpatient. Most patients can return to normal activities within two weeks.

Laparoscopic hernia repairs have grown in popularity over the last several years. This technique is used almost exclusively in inguinal hernia. The laparoscopic approach places a synthetic patch behind the defect, creates smaller incisions, and has a similar time period for return to normal activities. Drawbacks to this repair are the higher equipment costs, longer operating times, and demands of the surgical technique. Umbilical hernia repairs are done with a similar tension free approach. The main idea behind the repair is to reinforce the umbilical defect, and repair the abdominal wall. These repairs can easily be done with a local anesthesia in an outpatient setting.

How Dangerous is the Surgery?

Risks involved in hernia repairs, whether open or laparoscopic are few. Bleeding and infection are the most frequently seen complication, and occurs in less than 1% of cases. Infection rates are not changed with the use of preoperative antibiotics. Injury to the intestines, spermatic cord, testis, or local cutaneous nerves is almost never seen. Some postoperative discomfort is always expected, but is less with tension free repairs. Men may experience some scrotal swelling and bruising.

Recovery After Surgery

The postoperative recovery of the hernia repair patient has changed in the past five years. Restrictions in activity are not as strict, and return to work is anticipated much earlier. Patients are all done as outpatients as long as their medical history permits. Patients return to most of their normal activities within a few days. Work restrictions have decreased with the use of the new techniques of repair. Most patients can return to work within 10-14 days after surgery. Patients may shower in two days, and drive when they are not taking pain pills.

Summary

Hernia formation can affect people of all ages and is a common medical condition. Repair of an uncomplicated hernia prevents the possibility of greater complications in the future. Techniques of repair are forever changing, and the newest tension free repairs have the best results.

Copyright:

Geoffrey Wilcox M.D.
301 Ohio River Blvd.
Edgeworth Commons
Sewickley Pa 15143

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