General Facts about Hernias

A hernia is a protrusion of a tissue, structure or part of an organ through the muscular tissue or the membrane by which it is normally contained. The hernia has three parts: the orifice through which it herniates, the hernial sac and its contents. 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. Although the term hernia can be used for bulges in other areas, it most often is used to describe hernias of the lower torso (abdominal wall hernias).

Hernias by themselves may be asymptomatic, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the hernia sac contents have their blood supply cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency. A hernia may be likened to a failure in the sidewall of a pneumatic tire. The tire’s inner tube behaves like the organ and the side wall like the body cavity wall providing the restraint. A weakness in the sidewall allows a bulge to develop, which can become a split, allowing the inner tube to protrude, and leading to the eventual failure of the tire.

Treatment of Hernias

It is generally advisable to repair hernias in a timely fashion in order to prevent complications such as organ dysfunction, gangrene and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired and recovery rarely requires long-term changes in lifestyle. Uncomplicated hernias are principally repaired by pushing back or "reducing" the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy).

If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary. Modern muscle reinforcement techniques involve synthetic materials (mesh prosthesis) that avoid over-stretching of already weakened tissue (as in older, but still useful methods). The mesh is placed over the defect, and sometimes staples are used to keep the mesh in place. Evidence suggests that this method has the lowest percentage of recurrences and the fastest recovery period. Increasingly, some repairs are performed through laparoscopes.

Many patients are managed through surgical daycare centers and are able to return to work within a week or two, while heavy activities are prohibited for a longer period. Patients who have their hernias repaired with mesh often recover in a number of days. Surgical complications have been estimated to be up to 10%, but most of them can be easily addressed. They include surgical site infections, nerve and blood vessel injuries, injury to nearby organs and hernia recurrence.

Self-Care at Home

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.

Medical Treatment

Treatment of a hernia 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 its 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.

• Irreducible hernia

All acutely irreducible hernias need emergency treatment because of the risk of strangulation. An attempt to reduce (push back) the hernia will generally be made, often with 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 6 hours. In cases where the hernia has been strangulated for an extended time, surgery is performed to check whether the intestine has died and to repair the hernia.

In cases where the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged. Because a hernia that was irreducible and is reduced has a dramatically increased risk of doing so again, you should therefore have surgical correction sooner rather than later.

Occasionally, the long-term irreducible hernia is not a surgical emergency. These hernias, having passed the test of time without signs of strangulation, may be repaired electively.

Causes of Hernias

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.

• Fluid in the abdominal cavity.

A family history of hernias can make you more likely to develop a hernia.

Symptoms of Hernias

The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—an incarcerated strangulated hernia.

Reducible hernia

• New lump in the groin or other abdominal wall area.

• May ache but is not tender when touched.

• Sometimes pain precedes the discovery of the lump.

• Lump increases in size when standing or when abdominal pressure is increased (such as coughing).

• May be reduced (pushed back into the abdomen) unless very large.

Irreducible hernia

• 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 long term without pain.

• Also known as incarcerated hernia.

• Can lead to strangulation.

• Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.

Strangulated hernia

• 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.

• It usually results in a surgical emergency.

• Not all strangulated hernias are irreducible.

Classification of Hernias

Hernias can be classified according to their anatomical location. Examples include:

• Abdominal hernias.

• Diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach).

• Pelvic hernias (for example, obturator hernia).

• Hernias of the nucleus pulposus of the intervertebral discs.

• Intracranial hernias.

Generally, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts and so on), is not advised. Exceptions are uncomplicated incisional hernias that arise shortly after the operation (should only be operated after a few months), or inoperable patients. It is essential that the hernia not be further irritated by carrying out strenuous labor.