What is a hernia?
A hernia is a weakness or defect in the connective tissues of the abdominal wall that allows a protrusion of fatty tissue or internal organs through the defect appearing as a bulge beneath the skin. A hernia may gradually increase in size over time getting larger and larger while interfering with daily activities.In some cases, hernia surgery may be needed. There are several types of hernias based on the location.
What causes a hernia?
A hernia may occur on the background of a weakness in the tissues of the abdominal wall formed during development as a fetus or from prior injury. Predisposing factors includes aging, pregnancy, obesity and chronic straining. The hernia is often precipitated by periods of straining of the abdominal muscles as occurs during heavy lifting, pushing or pulling, coughing, sneezing, constipation, or difficult urination.
What are the symptoms?
A hernia typically presents as a bulge beneath the skin in the area of the defect in the abdominal wall. There is often a dull ache associated with the hernia that may precede the appearance of a bulge. The hernia is often reducible meaning that the bulge can be pushed back inside the abdomen or may return inside the abdomen when lying down.
The contents of the hernia can sometimes become trapped outside the abdomen creating a condition called an incarcerated hernia. This may be associated with moderate to severe pain. If the intestine is trapped outside the abdomen in the hernia then this can cause a bowel obstruction resulting in nausea and vomiting in addition to pain.
Trapping of the hernia may progress to a condition known as a strangulated hernia if there is compromise of the blood flow to contents of the hernia. This can result in death of the contained tissues such as the intestine. This is associated with severe pain and is an emergency.
A hiatal hernia occurs when a part of the stomach protrudes through a weakness in the diaphragm into the chest cavity. The weakness may be congenital, acquired after injury, or resulting from predisposing factors such as chronic straining, pregnancy or obesity.In some cases hiatal hernia surgery is necessary.
Hiatal hernias typically produce symptoms in older women. The symptoms are characteristic of acid reflux and can include any of the following:
• Repeated heartburn
• Regurgitation of food
• Chest pain
The diagnostic work-up of a hiatal hernia requires specialized testing including a barium swallow to visualize the esophagus using a special x-ray called fluoroscopy, an upper endoscopy to visualize the lining of the esophagus and stomach, and ph measurements of the esophagus.Other specialized tests are sometimes useful.
Initial treatment consist of conservative measures such as:
• Avoidance of large meals before lying down
• Smaller meals
• Elevation of the head of the bed
• Stopping smoking
• Avoidance of alcohol
• Avoidance of caffeine
• Avoidance of constricting clothing
• Weight loss
In addition to the above conservative measures, medications that suppress acid production have proven very useful in managing the symptoms. Antacids, H2 blockers such as Zantac or Pepcid, and proton pump inhibitors such as omeprazole are often used in the treatment plan.
Hiatal hernia surgery is indicated if the symptoms cannot be controlled or if there is a complication from the hiatal hernia. The surgical procedure performed consists of a laparoscopic approach to bringing the stomach out of the chest and back into the abdomen, repair of the weakness in the diaphragm (the hiatus), and wrapping a part of the upper stomach around the esophagus to control the symptoms and prevent recurrence. Patients are generally in the hospital for 1-2 nights and benefit from a quicker recovery with less pain using the laparoscopic approach.
What is the treatment of a hernia?
The treatment is based on the features of the hernia, its impact on your quality of life, and your general state of health. Treatment options may include observation, use of a supportive device, or surgery. Surgery is the only way to fix a hernia. In some cases emergency surgery is required. The treatment option that is right for you will be based on a discussion between you and your surgeon.
Types of Hernias
Dr Shashank Shah and Team works with all types of hernias. Learn more about the kinds of hernias you may be experiencing and the hernia repair procedures offered at LOC.
Inguinal (Groin) Hernia
An inguinal hernia typically occurs as a bulge in the groin. It is more frequent in men than in women. In men, depending on the type of inguinal hernia it may descend into the scrotum.
A femoral hernia usually occurs at the upper aspect of the inner thigh in women.
An umbilical hernia occurs at the navel or “belly button”.
An incisional hernia occurs at the site of a previous surgery. This type of hernia is usually caused by the injury to the tissues from the previous surgery.
These are types of hernias that arise at the front of the abdominal wall. They include incisional, epgastric (located below the sternum or “breast bone”), and spigelian hernias (located off the midline towards the side of the abdomen).
This is a term often used to describe a type of hernia that is complicated to treat. This may include recurrent hernias, giant hernias, or hernias with associated fistulas or infections, among others.
Hernia Repair Procedures
Surgery is the definitive treatment for a hernia.
Indications for hernia repair surgery include:
- Symptomatic Hernia – a hernia creating symptoms of discomfort, pain or interfering with activities of daily living.
- Incarcerated Hernia – a hernia trapped outside the abdominal wall and cannot be returned back inside the abdominal cavity.
- Bowel Obstruction – a hernia causing a blockage of the intestines requires surgical repair.
- Strangulated Hernia – a hernia that has compromised blood supply of the contents. There is a high risk of death of the tissues such as intestines that are contained in the strangulated hernia. This requires emergency surgery.
The laparoscopic repair uses small incisions on the abdominal wall through which the instruments are placed into the abdominal cavity. The abdomen is filled with air and the repair is guided by use of a camera. The hernia contents are brought back into the abdominal cavity and a mesh is secured in place to cover the hernia defect from the inside. The mesh helps to prevent its recurrence.
The laparoscopic repair has the advantages of quicker recovery, less pain, and less risk of infection.
The open repair is the traditional approach to hernia repair surgery with an incision made over the area of the hernia. The contents are returned back into the abdominal cavity and the sac is removed. Depending on factors such as the location and the size of the hernia, a mesh is often used to cover the area of the hernia defect. Otherwise the defect is closed with sutures.
The open approach is commonly used for very large hernias or those that are complicated by factors such as bowel obstruction, infection, incarceration, strangulation, or recurrences.
Use of Mesh
A mesh is a supporting structure used to give strength to the hernia repair. It is used to cover the defect and reduce tension in the repair. Tension, otherwise, can lead to recurrence of the hernia.
The mesh is made of synthetic material such as polypropylene or polyester. Alternatively, the mesh may be a biologic graft derived from animal tissue. The biologic grafts are often used if there is great concern for an infection as they tend to be resistant to infections.
Choice of Repair
The decisions regarding the laparoscopic vs. open approach hernia repair surgery and regarding use of mesh vs. no mesh will be individualized based on the characteristics of the hernia and the discussion you have with your surgeon.