Hernia: Everything a Patient Should Know

Definition: A hernia is defined as the protrusion of the contents of a body cavity out of the area where they are normally contained into another. These contents, usually portions of abdominal organs, intestines or abdominal adipose (fat) tissue, are anatomically enclosed in the membranous abdominal cavity that lines the abdominal region.

Classification of Hernias: There are many methods by which hernias are classified. The four general classifications are according to anatomy, reducibility, path taken and part affected.

Anatomical Classification of Hernias: This classification is based upon the site where the hernia is present. Some of the following are examples of anatomical hernias:

1. Umbilical hernia is one which protrudes through the umbilical area at the navel, ordinarily called belly button. This is the only hernia which heals itself. It may be present at birth in babies but normally heals it self in the first few months after birth.
2. Inguinal hernia is one in which abdominal contents protrude the inguinal canal. It can be on either side of the body. These form about 80 % of all hernias. More common in men than is women.
3. Femoral hernia is one in which there is a protrusion of a loop of the intestine through a weakening in the abdominal wall. The weakening in the abdominal wall is generally located in the groin near the thigh. These are more common in women than in men. Other hernias based on anatomical classification include inguinal, and femoral hernias.
4. Epigastric hernia is one in which abdominal contents protrude in the midline of the abdomen between the breast bone and the umbilicus (navel).
5. Hiatus Hernia is one which occurs at the opening of the diaphragm into the oesophagus where it attaches to the stomach. In some patients the muscle around the opening becomes weak or is congenitally weak. Hence the uppermost part of the patient’s stomach may protrude through the diaphragm into the thoracic cavity. Most hernias of this type do not cause any symptoms the patient will not be able to see a bulge on the outside. If the patient becomes symptomatic then he might complain of heartburn, indigestion, and chest discomfort. Hiatal hernias are most frequently managed with medication and diet changes. Surgery may be needed in some cases.

There are other anatomical hernias but they are beyond the scope of this article and will not be discussed here.

Classification according to Patho physiology. As already stated hernias occur where there is congenital weakness in a membrane which holds and organ in anatomically. When the membrane becomes weak then the organ contained within it begins to protrude out. Initially, the opening is small and generally the protruding organ can be put back.

Reducible hernias: When a hernia can be gently guided back into the cavity where it belongs then is said to be reducible. In the initial stages the “opening” in the membrane is usually small and when the patient sits or lies down the hernia may become reduced naturally and the patient does not feel any discomfort.

Irreducible hernias: are sometimes called strangulated hernias. Strangulation is said to occur when the protruding organ cannot be guided back into the cavity where it belongs. When strangulation occurs then the blood supply to the protruding part, generally intestines, is impaired or completely cut off. A strangulated hernia is a medical surgical emergency. If the blood supply is completely cut off the gangrenous and ensuing sepsis may be fatal to the patient.

Incisional Hernias: These may be reducible or irreducible. Incisional are the end product of poor healing of a previous operation. The first sign of an Incisional hernia developing is redness around the surgical site soon after the operation. When this happens it is important to notify the surgeon so that the patient may be followed up regularly.

Causes of Hernias

Hernias do not develop suddenly. Most of the time hernias are caused by a combination of environmental and physical stress factors. They usually take a long time to develop. Contrary of common wisdom hernias are common in babies, toddlers and teens. The underlying cause is generally some congenital weakness. In these situations even minor straining can result in a hernia. Common causes include the following:

1. Gross and Morbid Obesity commonly cause hernias. Mild Obesity can also cause a hernia.
2. Lifting heavy weights can cause hernias.
3. Straining which is related to constipation can produce this condition.
4. Persistent strong coughing and/or sneezing are known to cause hernias.
5. Some women develop hernias during pregnancy.

Prevention of Hernias

As a rule there are no specific things you can do to prevent a hernia. However the following life style changes may be helpful.

1. Stay healthy: Maintain the right weight for your age, sex, body type and activity.
2. Reduce weight if you are obese: Eat a healthy diet and generally keep fit by exercising regularly. Seek the help of a dietitian, doctor or a Registered Nurse if needed.
3. Prevent constipation by exercising and eating diet rich in fibers.
4. Lift weights cautiously: Do not lift weights which are too heavy. If one has to lift something that is very heavy then the use of leg muscles is advocated rather than waist or abdominal muscles.
5. When sick see a doctor so that allergies and cough can be controlled.
6. Smoking causes persistent cough and increases the risk of developing a hernia. Give up smoking.

Treatment and Management of Hernias

Most patients need and should consider surgical repair of hernias. However, for patients who are not fit for surgery trusses can be tailor made to contain the organ and prevent the hernia from getting worse and strangulating.

The patient should see a doctor as soon as possible. If a hernia becomes strangulated the consequences could be fatal. Seeing a doctor is of utmost importance even if there are no symptoms or the protrusion is minimal. Generally, a registered doctor would recommend herniorrhaphy. This is a technical way of saying, “repairing the hernia”.

Herniorraphy is of Two Basic Types:

1. conventional surgery: This involves an abdominal incision under general anaesthesia. During this procedure the protruding tissues are either removed (excised) or pushed back into the abdomen. Finally, the abdominal wall is repaired and strengthened. Some surgeons use a taflon graft to do this. Other surgeons sew the abdominal wall. This results in strengthened by bringing the surrounding muscles over it and in closer proximity. Taflon is a special type of mesh, like a cloth which is placed in the weakened section of the abdominal wall.
2. Laparoscopic surgery: This procedure is also done under general anaesthesia. The surgeon uses a long metal viewing tube inserted through a tiny incision. The rest of the procedure is much the same as described above. However, with this type of surgery the patient is able to go home sooner and able to return to work sooner.

ACS reports that over half a million people undergo hernia surgery each year.

Risks Associated With Repairing of a Hernia

Modern surgical interventions have reduced risks associated with surgery. However, some degrees of risks persist. However, when agreeing to a procedure the patient and surgeon must evaluate the risk to benefit ratio in each situation. The patient must not be subjected to excessive risks. The following are some of the common risks.

1. Dysuria: After this procedure many patients experience difficulty passing urine. This may occur if there is bladder sphincter spasm.
2. Testicular swelling: This may occur in male patients because of the proximity of the abdominal organs.
3. Wound infection. This may occur due to primary or secondary sources of infection.
4. Primary, secondary or reactionary bleeding may occur: Proper post operative care and management will help minimize this risk.
5. Scar formation: Following healing the patient may be left with a scar.
6. If the patient had laparoscopic surgery then a hernia may develop in the area through which the instrument was passed.
7. Risk of the formation of a new Incisional hernia is real and cannot be ruled out.
8. Postoperative chest infections and other complications like DVT, PE and non-healing of wound may occur.
9. For a full list of possible post operative complications see my article at Healthmad.com

Wound Management: Each patient has a wound which needs careful looking after and management. It is normal to have small amounts of bleeding post operatively. The dressing must be changed every second or third day.

Return to normal activity: This will take a few months and is contingent upon the size of the wound and comorbidities but light duties can generally be commenced about one week later. The surgeon will advice the patient on when he can return to work.

Eating and Drinking: Most patients can start to eat and drink normally upon discharge from hospital. Post operatively, in most hospitals, nurses will generally guide the patient on when to resume eating. Nausea and vomiting are common postoperatively and the nurse will, if prescribed, give the patient an antiematic.

Pain management: This is an essential part of post operative care and the Registered Nurse will give you pain controlling medications as necessary.

Discharge and Follow up care. If there are no complications and the patient had open excision surgery he may have to stay in hospital until the sutures are removed. If the surgery was keyhole and there were no other complications then he may be discharged home the same or next day. Follow up appointment is usually set for the following week and monthly after that.

The patient’s general practitioner will be notified about the operation and any follow up care.

This article is for educational purposes only and should not be used for diagnostic, treatment or management purposes.