Hernia

Hernia

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 often 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 usually are harmless, 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.

Different types of abdominal wall hernias include the following:

Inguinal Hernia:

Making up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into 2 different types, direct and indirect. Both occur in the area of where the skin crease at the top of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal crease. Distinguishing between the direct and indirect hernia, however, is not that important because both are treated the same.

Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during prebirth development. It descends from the abdomen into the scrotum. This pathway normally closes before birth but remains a possible place for a hernia. Sometimes the hernial sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age but becomes more common as people age.

Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in a place where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia almost always occurs in the middle-aged and elderly because their abdominal walls weaken as they age.

Femoral Hernia:

The femoral canal is the way that the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal. A femoral hernia causes a bulge below the inguinal crease in roughly the middle of the thigh. Rare and usually occurring in women, femoral hernias are particularly at risk of becoming irreducible and strangulated.

Umbilical Hernia:

These common hernias (10-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn’t close completely. If small (less than three quarters of an inch) this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot remains a weaker place in the abdominal wall. Umbilical hernias most often appear later in elderly people and middle-aged women who have had children.
Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall that must heal on its own. This flaw can create an area of weakness where a hernia may develop. This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. After surgical repair, incisional hernias have a high rate of returning (20-45%).

Spigelian Hernia:

This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.

Obturator Hernia:

This extremely rare abdominal hernia happens mostly in women. This hernia protrudes from the pelvic cavity through an opening in your pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting.

Epigastric Hernia:

Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Causes

Although one type of abdominal hernia can be present at birth (umbilical hernia), the others happen 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.
  
  
  

  - 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.

Hernia Symptoms

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—possibly a strangulated hernia.

• Asymptomatic 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
  
  - Usually painful enlargement of a previous 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 where the entrapped intestine has its blood supply cut off
  
  - Pain always present followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting)
  
  - You may appear ill with or without fever
  
  - Surgical emergency
  
  - All strangulated hernias are irreducible (but all irreducible hernias are not strangulated)

When to Seek Medical Care

All newly discovered hernias or symptoms that suggest you might have a hernia should prompt a visit to the doctor. Hernias, even those that ache, if they are not tender and easy to reduce (push back into the abdomen), are not surgical emergencies, but all have the potential to become serious. Referral to a surgeon should generally be made so that you can have surgery by choice (called elective surgery) and avoid the risk of emergency surgery should your hernia become irreducible or strangulated.

If you find a new, painful, tender, and irreducible lump, it’s possible you may have an irreducible hernia, and you should have it checked in an emergency setting. If you already have a hernia and it suddenly becomes painful, tender, and irreducible, you should also go to the emergency department. Strangulation (cut off blood supply) of intestine within the hernia sac can lead to gangrenous (dead) bowel in as little as 6 hours. Not all irreducible hernias are strangulated, but all cases of strangulation are irreducible hernias.

Exams and Tests

If you have an obvious hernia, the doctor will not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you may have an indirect inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

Medical Treatment

Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.

Reducible

In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.

If you have pre-existing 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 not possible 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 and that surgery is not needed if you are relatively symptom free.

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

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, 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 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 becomes irreducible has a dramatically increased risk of doing so again, if you have had an irreducible hernia, you should have surgery 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.

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