Hernia

A hernia is a protrusion of an organ or fatty tissue through a weak spot in the tissues and muscles that surround the organ. It can occur in males and females, as well as children. It is more common in obese individuals. Hernias generally occur when a part of the intestine or the sac surrounding the abdominal contents (peritoneum) squeezes through a gap in the abdominal wall. The protruding part is known as the hernia sac and may contain part of the intestine, peritoneum or outer wall of the abdomen, stomach, and/or belly fat. It appears as a bulge and is usually visible from the outside.

Mentioned below are the common types of abdominal wall hernias:

• Inguinal (Groin) Hernia
  It is the most common form of a hernia occurring more frequently in males than in females. It involves the groin area where the skin of the thigh joins the abdominal crease (inguinal crease). An inguinal hernia can be direct or indirect. The direct and indirect hernias appear as a bulge in the inguinal area, slightly above the thigh. However, distinguishing between the two inguinal hernias is clinically important, as it helps in deciding the treatment plan.
• Indirect inguinal hernia
  It is a protrusion (herniation) of the contents of the abdomen through a structure called the deep ring into the inguinal canal. The hernial sac may pass through the inguinal canal and extend into the scrotum through the external ring. This path usually closes before birth but may fail to do so in some cases and become a possible site for the development of a hernia later in life. An indirect inguinal hernia may occur at any age and is one of the most common types of a hernia.
• Direct inguinal hernia
  It is an acquired type of a hernia. In a direct inguinal hernia (uncommon in children), the abdominal contents protrude through a weakness in the abdominal wall (typically the Hesselbach’s triangle) and exit through the superficial inguinal ring. A direct hernia may occasionally descend into the scrotum.
• Femoral Hernia 
  A femoral hernia is a protrusion of the abdominal contents through a structure in the thigh called the femoral canal. It causes a bulge just below the inguinal crease roughly in the centre of the upper leg. Women are prone than are men at a ratio of 2:1, which is doubled in mothers. Nevertheless, inguinal hernias are often found to occur more in women, followed by an incisional hernia, with a femoral hernia being the third common type. It mostly involves the right side more than the left side and involves both sides in about 15-20% women.
• Umbilical Hernia
  The umbilicus or the navel is the part of the body where the umbilical cord is attached at birth. The hernia of the umbilicus is common in children and in newborns in the form of a swelling in the navel (near the umbilicus). An umbilical hernia occurs due to incomplete closure of an opening in the abdominal wall muscles, which normally should close before birth. It can be further divided into three categories:
  • Umbilical hernia of a newborn.
  • Umbilical hernia of infants and children.
  • Umbilical hernia of adults (male: female, 1:5).
• Incisional Hernia
  It is also called ventral hernia or a postoperative hernia, which occurs due to a weak scar normally after any surgery of the abdomen. It is more common in females. Factors that lead to an incisional hernia are as follows:
  • Infection after surgeries for peritonitis (an inflammation of the peritoneum, the inner lining of the abdominal wall) or duodenal (an ulcer in a part of small bowel called duodenum) and others.
  • A site of past surgery (weak midline mainly after gynaecological surgeries).
  • Obesity along with reduced muscle strength.
  • Faulty technique while performing a surgery (faulty sutures).
  • Ascites (a collection of excess fluid in the abdomen) causing swelling of the abdomen, and persistent coughing after a surgery.
  • Wrong surgical incisions (mainly at sites where nerves are cut).
• Spigelian Hernia
  It is an interstitial hernia (pushing through the small spaces between the tissues) caused due to repeated pregnancies, obesity, advancing age, degeneration of the muscles, sudden strain due to coughing, picking up heavy objects among others. It occurs equally in males and females.
• Epigastric Hernia
  This is a hernia involving the epigastric region (the area above the navel and just below the breast bone of the rib cage). An epigastric hernia is usually composed of fatty tissue and rarely contains intestine. It is most common in muscular men and manual labourers. An epigastric hernia is often painless, but it can be painful to touch for some people. Most cases epigastric hernias are associated with peptic ulcer disease.
• Hiatal Hernia
  This is one of the general type of hernia encountered in people. The diaphragm (muscle sheet that separates the lung cavity and the abdominal cavity) has two openings: one for the food pipe and other for the aorta (a large blood vessel that carries blood from the heart to the rest of the body). When a part of the stomach is pushed upwards in either of the gaps, it leads to a hiatal hernia. It can accompany cases of stomach volvulus wherein the stomach attachment with the abdominal wall becomes loose leading to a change in the stomach position. It causes heartburn, pain, and vomiting in severe cases.
• Diaphragmatic Hernia
  This type of a hernia is usually caused due to a defect at birth in the diaphragm, which causes abdominal contents (eg, stomach, intestine, liver) to push through into the chest cavity.
• Lumbar Hernia
  Primary and secondary are the types of a lumbar hernia. Primary is extremely rare, and occurs due to an anatomical defect without any identifiable cause, whereas secondary appear due to a disease/surgery and is more common after kidney surgeries.

Some other types of hernias, such as a dual hernia, prevesical hernia, Littre’s hernia, Maydl’s hernia, and sliding hernia, are rarely seen.

The signs and symptoms of a hernia can vary widely, such as:

• It may appear as a painless lump to severely painful, swollen, tender protrusion of a body part, such as the abdomen or pelvis, which can or cannot be pushed back into the abdomen. Pain in the abdomen or pelvic region is a frequently occurring symptom of a hernia.
• Not all hernias cause problems. Occasionally, pain, a burning feeling, pressure, or a pulling sensation, especially during strenuous physical activities may be experienced. The cause of pain is the tense abdominal muscles.
• In a hiatal hernia, there may be dull aching pain over the upper abdomen especially on empty stomach. Vomiting may also occur if a hernia progresses and is left untreated. (Read more - Stomach pain causes and treatment)
• In an inguinal hernia, a bulge may develop in the groin. Sharp pain, burning sensation, or both can be felt if there is inflammation of the inguinal nerve. Nausea, vomiting, and fever can also occur if a hernia advances in case of strangulation of a dead bowel.
• An umbilical hernia in children occurs as a swelling in the umbilical region on crying. In adults, it appears as a swelling in the umbilical region, which increases with coughing or straining. Dragging pain is also present occasionally.
• Incisional hernias manifest as a discharge almost on the fourth postoperative day along the suture line as an early signal of development of an incisional hernia. A history of infection during surgery is also a sign. A bulge or swelling is seen in relation to the scar.

Causes

The factors that increase the risk of hernias include weak body tissues (abdominal muscles and associated connective tissue). Certain individuals have a weak connective tissue by birth, in others, it becomes weaker with age. A prolonged spell of illness or repeated surgeries can also weaken the tissues and muscles. Also, continuous strenuous physical activities or related conditions, which can increase the abdominal pressure, contribute to the formation or worsening of an already existing hernia. For example,

• Being obese results in an increased pressure in the abdomen.
• Sudden heavy lifting.
• Constant coughing.
• Strain during bowel movement and urination.
• Enlarged prostate.
• Poor nutrition.
• Undescended testes in males.
• Gynaecological surgeries in females or repeated pregnancies.
• Fluid collection in the abdomen.

Risk Factors

There are many risk factors associated with a hernia, such as

• Heredity (history of a hernia in the family).
• Smoking.
• Constipation.
• Playing sports or injury during playing sports.
• Obesity.
• Pulmonary conditions, including asthma and COPD.
• Pregnancy and labour.
• Ascites, surgery, steroids and drug abuse.

Whether and how hernias can be prevented depends on the type of a hernia. For example,

• To prevent incisional hernias, activities that cause excessive strain should be avoided. These include carrying heavy objects following a surgery, straining while passing stools, and excessive coughing. Emphasis should be on getting ample rest without undergoing undue stress.
• Since obesity and being overweight are risk factors for incisional hernias, it is best to keep your weight in check.
• Also, maintenance of proper hygiene and sterilising the area of the incision by regular dressings and follow-ups with the surgeon can help lower the risk of incisional hernias.
• Smoking should be completely stopped for better healing of surgical wounds, which also lowers the risk of incisional hernias.
• Diseases, such as diabetes, anaemia, and blood pressure (high/low), should be treated properly to ensure optimal wound healing. (Read more- High Blood Pressure treatment)
• Straining during bowel movements or urination should be avoided in case of inguinal hernias or incisional hernias; lifting of heavy objects should be done by bending the knees rather than bending the back directly. If possible, lifting very heavy weights should be avoided completely.

• A detailed physical examination by the doctor is usually sufficient to diagnose a hernia. Mostly, a hernial swelling is visible on standing straight. It can also be felt by directly placing your hand over it and bending down.
• Ultrasounds are useful in visualising femoral hernias, and X-rays may be advised if a bowel obstruction is suspected. Previously, a ‘herniagram’ was performed, but now it is discontinued due to its invasive nature.
• CT & MRI scan may be advised in certain cases.
• A barium meal study may be needed in certain cases where a dye containing a mineral called barium is consumed by the person. This dye can be visualized on an X-ray as it courses through the digestive tract showing any abnormalities in anatomy.
• Endoscopy is performed in case of a hiatal hernia to determine its extent and type, where a camera-fitted thin tube is passed into the stomach through the mouth to visualize internal defects and to diagnose a hiatal hernia.

Surgery

Surgery is the choice of treatment for hernias. It involves pushing back the contents of a hernia into the abdomen or removing it entirely and closing the gap with stitches. A mesh (synthetic or animal-derived) is used to support the weak tissues and muscles, which might have let the contents protrude through it.

Surgery can be performed in two ways: open or conventional surgery and minimally invasive or laparoscopic surgery. In an open surgery, a long and large cut is made at the site of a hernia and the weak muscles are repaired. In a laparoscopic or keyhole surgery, multiple small holes or cuts are made, and the surgery is performed using fine tube-like instruments. There is a camera fitted to help the surgeon get a detailed view on a monitor and to perform the necessary procedure.

In inguinal hernias, herniotomy, herniorrhaphy, or hernioplasty are the key procedures performed. Other variations of surgeries for inguinal hernias, such as Kuntz operation, Andrew’s imbrications, or Mcvay or Nyhus repair, can be performed, depending on the type of repair needed and will be decided by the surgeon. Many types of surgeries are done to manage different hernias.

Surgery is not always the only treatment option for hernias and may not be necessary if your hernia, irrespective of its type, is not causing any major health issues. Moreover, surgery is avoided in old people and in those who are seriously ill.

Medications

Occasionally, during a hiatal hernia, over-the-counter and other medications may be prescribed that help reduce stomach acid, thus relieving the discomfort and other symptoms that you might be experiencing. Some of these medicines are painkillers, H-2 receptor blockers that act against histamine, antacids and proton pump inhibitors (drugs that reduce the production of stomach acid).

Lifestyle management

Changes in the diet can often treat the symptoms of a hiatal hernia but will not cure it completely. A heavy meal in terms of the quality as well as the portion size should be avoided. A person should avoid lying down or perform strenuous physical activity after a meal. Hiatal hernia patients can reduce the acid reflux problem by avoiding spicy or sour foods that trigger the acid reflux. Also, avoid smoking until the symptoms persist. Body weight should be kept in check and measures should be taken to keep it in the normal range as per the person's height.

Some exercises may help strengthen the muscles around the hernia site, which may reduce some of the symptoms. However, over performing the exercises or doing it without the guidance of a qualified practitioner can increase the symptoms and even worsen the condition. Therefore, it is better to consult a physiotherapist and perform exercises under supervision.

If after undertaking all the necessary measures, the symptoms are not relieved then a surgery may be done to correct a hernia.

Prognosis

The outcome of hernial repairs is generally good if diagnosed and treated in a timely manner. The nature of the outcome depends on the type and size of a hernia along with reducing the number of factors that increase the risk of developing hernias.

Old age, a hernia that has been presenting from a very long time or has not been reduced back into the site of defect since a long time, are all risk factors for sudden complications like strangulation and intestinal obstruction. These are medical emergencies. Abdominal hernias generally do not recur in children, but they tend to recur in 10% of adults.

A timely diagnosis and surgery in early childhood help achieve excellent results.

Complications

Normally, there are not many complications encountered after a hernia surgery. However, if left untreated or improper surgical repair is done, it may lead to some serious complications, such as:

• Irreducibility.
• Obstructed hernia.
• Strangulated hernia.
• Inflamed hernia.
• Gangrene of the herniated part.
• Numbness at the surgical site.
• Rejection of the mesh that is used to treat a hernia.