Hernia

• Symptoms of a hernia include pain or discomfort and a localized swelling somewhere on the surface of the abdomen or in the groin area.
• There are many different types of hernias.
• Serious complications from a hernia result from the trapping of tissues in the hernia (incarceration), which can result in the damage or death of the tissue.
• Hernia repair and the treatment of hernia complications require surgery.
• Lumps and swelling in the abdominal area should be examined by a doctor.

A hernia is a general term that refers to a bulge or protrusion of a body tissue or organ through the structure that normally contains it. For example, brain tissue can herniate as can discs in the spine. A common herniation in people is an abdominal herniation. The following article will discuss these hernias.

An abdominal hernia is an opening or weakness in the muscular structure of the wall of the abdomen. The peritoneum (lining of the abdominal cavity) protrudes through the opening and this defect causes a bulging of the abdominal wall. This bulging is usually more noticeable when the abdominal muscles are tightened, thereby increasing the pressure in the abdomen. Any activities that increase intra-abdominal pressure can worsen a hernia; examples of such activities are lifting, coughing, or even straining to urinate or have a bowel movement. Imagine a barrel with a hole in its side and a balloon that is blown up inside the barrel. Part of the inflated balloon would bulge out through the hole. The balloon going through the hole is like the tissues of the abdomen bulging through a hernia.

When the lining protrudes it can contain intra-abdominal contents such as the intestines and omentum (the layer of fat that covers abdominal organs). Serious complications from a hernia can result from the trapping of tissues in the hernia -- a process called incarceration. Trapped or incarcerated tissues may have their blood supply cut off, leading to damage or death of the tissue. The treatment of an incarceration usually involves surgery.

About 10% of the population will have an abdominal hernia during their lifetime. The hernias may occur in infants, children, and adults -- both in males and females. However, the majority of abdominal hernias occur in males.

The most common location for hernias is the groin (or inguinal) area. There are several reasons for this tendency. First, there is a natural anatomical weakness in the groin region which results from incomplete muscle coverage. Second, the upright position of human posture results in a greater force that pushes toward the bottom of the abdomen, thereby increasing the stress on these weaker tissues. The combination of these factors over time breaks down the support tissues, enlarging any preexisting hole, or leads to a tear, resulting in a new hole.

Several different types of hernia may occur, and frequently coexist, in the groin area. These include indirect, direct, and femoral hernias, which are defined by the location of the opening of the hernia from the abdomen to the groin. Another type of hernia, called a ventral hernia, occurs in the midline of the abdomen, usually above the navel (umbilicus). Hernias can also occur within the navel (umbilical hernia).

Symptoms of a hernia include pain or discomfort and a localized swelling somewhere on the surface of the abdomen or in the groin area. A hernia can also be painless and only appear as a bulging. The pain may be intermittent or constant and the swelling may decrease or be absent, depending on the amount of pressure in the abdomen. Constant, intense pain at a bulge site may indicate a medical emergency and should be evaluated immediately by a doctor.

Epigastric, umbilical, incisional, lumbar, internal, inguinal, hiatal, and Spigelian hernias all occur at different sites of the abdomen in areas that are prone to anatomical or structural weakness. With the exception of internal hernias (within the abdomen), these hernias are commonly recognized as a lump or swelling and are often associated with pain or discomfort at the site. Internal hernias can be extremely difficult to diagnose until the intestine (bowel) has become trapped and obstructed because there is usually no external evidence of a lump.

A hernia repair requires surgery. There are several different procedures that can be used for fixing any specific type of hernia. In the open surgical approach, following appropriate anesthesia and sterilization of the surgical site, an incision is made over the area of the hernia and carried down carefully through the sequential tissue layers. The goal is to separate away all the normal tissue and define the margins of the hole or weakness. Once this has been achieved, the hole is then closed, usually by some combination of suture and a plastic mesh. When a repair is done by suture alone, the edges of the defect are pulled together, much like sewing a hole together in a piece of cloth. One of the possible complications of this approach is that it can put excessive strain on the surrounding tissues through which the sutures are passed. Over time, with normal bodily exertion, this strain can lead to the tearing of these stressed tissues and the formation of another hernia. The frequency of such recurrent hernias, especially in the groin region, has led to the development of many different methods of suturing the deep tissue layers in an attempt to provide better results.

In order to provide a secure repair and avoid the stress on the adjacent tissue caused by pulling the hole closed, an alternative technique was developed which bridges the hole or weakness with a piece of plastic-like mesh or screen material. The mesh is a permanent material and, when sewn to the margins of the defect, it allows the body's normal healing process to incorporate it into the local structures. Hernia repair with mesh has proved to be a very effective means of repair.

After the hernia repair is completed, the overlying tissues and skin are surgically closed, usually with absorbable sutures. More and more of hernia repairs are now being done using laparoscopic techniques (see below).

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 may have 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.

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. There has been no evidence that incisions by lasers will decrease pain or decrease healing time.

Most hernia repairs can be done with a variety of anesthetic methods. With modern general anesthetic techniques and monitoring, general anesthesia is 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.

Unfortunately, exercising to improve a hernia is likely to aggravate the condition. The hernia exists because of a localized absence of muscle and supporting structure. Exercise can strengthen the surrounding muscles, thereby worsening the localized weakness and increasing the pressures inside the abdomen. The result is that more tissue can be forced through the defect and enlarge the hernia.

Most of the factors that lead to the development of hernias are beyond the control of the individual. Some of those factors are inherited and develop as the individual grows. The arrangement of the local tissues and their thickness and strength may greatly affect the relative risk of developing a hernia over a lifetime. However, that risk can be increased by failure to use good body mechanics when lifting, poor abdominal support posture, smoking and weight-control problems.

Since genetics dictate inherited features and structure, there is a significant risk of inheriting the anatomical features that may predispose to a hernia. There may also be inherited factors that result in tissue weakness, which ultimately allows the deterioration of the supporting structures and leads to the formation of a hernia. However, this does not necessarily imply that the offspring of an individual with a hernia will ultimately develop the problem. However, some infants are born with congenital defects that lead to hernia development.

Groin hernias are somewhat more likely to develop on both sides. This is probably because the structural elements develop symmetrically, and the stresses on the body that occur over time are similar on both sides. When a patient becomes aware of a groin swelling on one side, examination by a doctor will often identify a small hernia on the opposite side.

In general, hernias that are at risk for complications, that cause pain, or that limit activity should be repaired. If they are not repaired, there is a risk that an emergency surgical procedure may be required at a later date.

Sometimes, a hernia can be temporarily controlled by wearing a belt-like device that applies external compression, which pushes the tissues back into the abdomen and holds them there. This device is called a truss. The truss must be carefully applied on a daily basis. It should only be used for selected situations following careful evaluation by a doctor.

Not all lumps or swellings on the abdominal wall or in the groin are hernias. People should have such lumps or swellings examined by a doctor. Other possible causes include benign or malignant tumors or enlarged lymph nodes. These problems require entirely different types of evaluation and treatments; self-diagnosis may be incorrect and delay needed treatments.