Hernia

Definition

A hernia is a protrusion of any viscus (i.e. abdominal organ) from its proper cavity. A hernia can lead to an incarcerated and often obstructed (i.e blocked) bowel or a strangulated bowel with a compromised blood supply.

Epidemiology

  •  There are 1 million abdominal wall hernia’s repaired per year – Inguinal hernia repairs equate to 770,000
  •  25% of males & 2% of females have inguinal hernias in their lifetimes, which is the most common type of hernia
  •  75% of all hernias are groin related with 2/3rd indirect & 1/3rd direct
  •  Indirect inguinal hernias are the most common hernias in M & F
  •  Incisional and ventral hernias account for 10% of all hernias
  •  Only 3% of hernias are femoral hernias
  •  The incidence of inguinal hernias in children ranges up to 4.4%, while umbilical hernias occur in approx 1 in every 6 children
  •  90% of inguinal hernia repair occur in males
  •  Femoral hernias occur almost exclusively in women
  •  Indirect hernias usually occur in 1st year of life
  •  Indirect hernias occur more frequently in premature vs term infants
  •  Direct hernias occur in older patients
  •  Umbilical hernias are 8 x common in black vs white infants
  •  Most umbilical hernias close spontaneously within the 1st year of life
  •  Epigastric hernia – 0.5-10%, M:F=3:1, 30-50 yr
  •  Spigelian hernia –M:F=4:3, 40-70 yr

Anatomy of Abdominal Wall Hernias

  • D = Direct inguinal
  • E = Epigastric
  • F = Femoral
  • I = Indirect inguinal
  • P = Paraumbilical
  • S = Spigelian
  • U = Umbilical

Anatomy of Abdominal Wall Hernias 

  • 1 = Monro’s line (U & ASIS)
  • 2 = Spigelian Aponeurosis
  • 3 = Interspinal line (b/w ASIS)
  • 4 = Umbilical plan
  • 5 = Spigelian hernia belt

Causes

  • Increased pressure within the abdomen
  • A pre-existing weak spot in the abdominal wall
  • A combination of increased pressure within the abdomen and a pre-existing weak spot in the abdominal wall
  • Straining during bowel movements or urination
  • Heavy lifting
  • Fluid in the abdomen (ascites)
  • Pregnancy
  • Excess weight
  • Chronic coughing or sneezing

Men are more likely to have an inherent weakness along the inguinal canal because of the way males develop before birth. In male babies, the testicles form within the abdomen and then move down the inguinal canal into the scrotum. Shortly after birth, the inguinal canal closes almost completely — leaving just enough room for the spermatic cord to pass through but not enough to allow the testicles to move back into the abdomen. Sometimes, the canal doesn’t close properly, leaving a weakened area.

In female babies, there’s less chance that the inguinal canal won’t close after birth. Weaknesses can also occur in the abdominal wall later in life, especially after an injury or a surgical operation in the abdominal cavity. Whether or not you have a pre-existing weakness, extra pressure in your abdomen from straining, heavy lifting, pregnancy or excess weight can cause a hernia.

Risk factors

Risk factors for an inguinal hernia include:

  • Being male: You’re far more likely to develop an inguinal hernia if you’re male. Also, the vast majority of newborns and children who develop inguinal hernias are boys.
  • Family history: Your risk of inguinal hernia increases if you have a close relative, such as a parent or sibling, who has the condition.
  • Certain medical conditions: People who have cystic fibrosis, a life-threatening condition that causes severe lung damage and often a chronic cough, are more likely to develop an inguinal hernia.
  • Chronic cough: A chronic cough, such as from smoking, increases your risk of inguinal hernia.
  • Chronic constipation: Straining during bowel movements is a common cause of inguinal hernias.
  • Excess weight: Being moderately to severely overweight puts extra pressure on your abdomen.
  • Pregnancy: This can both weaken the abdominal muscles and cause increased pressure inside your abdomen.
  • Certain occupations: Having a job that requires standing for long periods or doing heavy physical labor increases your risk of developing an inguinal hernia.
  • Premature birth: Infants who are born early are more likely to have inguinal hernias.
  • History of hernias: If you’ve had one inguinal hernia, it’s much more likely that you’ll eventually develop another — usually on the opposite side.

Signs and Symptoms

Asymptomatic Hernia

  • Swelling or fullness at the hernia site
  • Aching sensation (radiates into the area of the hernia)
  • No true pain or tenderness upon examination
  • Enlarges with increasing intra-abdominal pressure and/or standing

Symptomatic Hernia

  • A burning, gurgling or aching sensation at the bulge
  • Pain or discomfort in your groin, especially when bending over, coughing or lifting
  • A heavy or dragging sensation in your groin
  • Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum

Incarcerated Hernia

  • Painful enlargement of a previous hernia or defect
  • Cannot be manipulated (either spontaneously or manually) through the fascial defect
  • Nausea, vomiting, and symptoms of bowel obstruction (possible)

Strangulated Hernia

  • Patients have symptoms of an incarcerated hernia
  • Systemic toxicity secondary to ischemic bowel is possible
  • Strangulation is probable if pain and tenderness of an incarcerated hernia persist after reduction
  • Suspect an alternative diagnosis in patients who have a substantial amount of pain without evidence of incarceration or strangulation

Site-specific findings

With femoral hernia, medial thigh pain and groin pain are possible. Incisional hernias at sites of prior abdominal surgery are usually asymptomatic. Patients present with a bulge at the site. The bulge may become larger upon standing or with increasing intra-abdominal pressure.

Diagnosis

Imaging studies

  • Imaging studies are not required in the normal workup of a hernia
  • Ultrasonography can be used in differentiating masses in the groin or abdominal wall or in differentiating testicular sources of swelling.
  • Flat and upright abdominal films to diagnose a small bowel obstruction (in case of obstructed hernia)
  • CT scanning or ultrasonography may be necessary if a good examination cannot be obtained, because of the patient’s body habitus, or in order to diagnose a spigelian or obturator hernia. Spigelian hernia is a rare form of abdominal wall hernia that occurs through a defect in the spigelian fascia, which is defined by the lateral edge of the rectus muscle at the semilunar line (costal arch to the pubic tubercle).

Management

Surgical Consultation

  • Concern regarding the bulge
  • Pain over the hernia
  • Inability to reduce the hernia

Open Hernia Repair

In this procedure the surgeon makes an incision in your groin and pushes the protruding omentum or intestine back into your abdomen. The surgeon then sews together the weakened or torn muscle. The weak area often is reinforced and supported with a synthetic mesh (hernioplasty). After the surgery, you’ll be encouraged to move about as soon as possible, but it may be four to six weeks before you’re fully able to resume your normal activities.

Laparoscopic Hernia Repair

In this minimally invasive procedure, the surgeon operates through several small incisions in your abdomen. A small tube equipped with a tiny camera (laparoscope) is inserted into one incision. Guided by the camera, the surgeon inserts tiny instruments through another incision to repair the hernia using synthetic mesh.

Most people who have laparoscopic repair experience less discomfort and scarring after surgery and a quicker return to normal activities. Laparoscopy may be a good choice for people whose hernias recur after traditional hernia surgery because it allows the surgeon to avoid scar tissue from the earlier repair. Laparoscopy also may be a good choice for people with hernias on both sides of the body (bilateral inguinal hernias).

Some studies indicate that a laparoscopic repair may have an increased risk of complications and of recurrence following surgery. These risks can be reduced if the procedure is performed by a surgeon with extensive experience in laparoscopic hernia repairs.

Laparoscopic hernia repair may not be for you if:

  • You have a very large hernia
  • Your intestine is pushed down into the scrotum
  • You’ve had previous pelvic surgery, such as prostate surgery (prostatectomy), multiple Caesarian sections, bladder surgery etc
  • You can’t receive general anesthesia

Complications of Laparoscopic Hernia Repair

  • Wound infection
  • Haematoma/Seroma
  • Urinary retention
  • Infected mesh
  • Fistula
  • Transection of vas
  • Dysejaculation syndrome
  • Ischaemic orchitis and testicular atrophy
  • Neuralgia – short live or chronic
  • Recurrence
  • Respiratory complications
  • DVT and pulmonary embolism
  • Bladder or Bowel injury
  • Major vascular injuries

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