Hernia is the abnormal protrusion of an organ or tissue through a weak area in the muscle or other tissue that normally holds it in place. The term hernia is most commonly used to describe to the protrusion of the intestine through a weak area in the abdominal wall. Hernia is often referred to as a 'rupture'.
A separate condition, known as hiatus hernia, occurs when part of the stomach protrudes up through the natural opening for the oesophagus (gullet) - to pass from the chest through the abdomen. This problem is dealt with in the section on peptic ulcers.
If you have an inguinal hernia, the most common finding is in the swelling of the groin. The scrotum may als be enlarged. This lump will often be clearly visible beneath the skin. It may disappear when you lie down, and appear again if you cough, sneeze or strain on the toilet. Some hernias cause no pain at all, while others cause a dull aching sensation which is more pronounced during physical activity.
A strangulated hernia, which is a dangerous complication of the condition, is a medical emergency where a loop of bowel becomes trapped in the hernia defect. It generally causes intense abdominal pain and can be lethal. If dealth with quickly, complete recovery should follow.
A hernia can develop very gradually, over a period of years, or it may come on suddenly. Sometimes a hernia is present at birth.
Anyone can develop a hernia at any age - from the new-born to the very old. However, the following factors seem to increase the risk of abdominal hernia:
- Being male - 12 times more males than females develop groin hernias
- Previous abdominal surgery such as an appendoctomy or other abdominal injury
- A chronic cough, such as a smoker's cough
- Straining during bowel movements (because of constipation) or while urinating
- Straining to lift heavy objects
- Persistent sneezing, such as that caused by allergies
There are 70,000 hernia repair operations each year in the UK. It's a very common problem.
A hernia results from the protrusion of a part of the contents of the abdominal cavity (chiefly the intestines) through a weak point in the abdominal wall. The job of the abdominal wall (a sheet of muscle and tendon stretching from the ribs to the thighs) is to act as a kind of 'corset' supporting the tissue and organs within the abdomen and pelvis.
The abdominal wall has some natural weak spots - where the blood vessels serving the scrotum and leg pierce it and also in the umbilicus (navel) region. It can also be weakened by surgery, injury or any action that overstretches it or exerts undue pressure, like coughing or sneezing.
The pain and discomfort of an abdominal hernia come from the pressure of the abdominal contents upon the weak spot of the wall. Any movement causes additional pressure; that's why some hernia lumps are visible when you stand - because of the pressure exerted by gravity - and become invisible when you lie down. Such hernias are said to be 'reducible' and it is often possible to push them back inside the abdominal wall. Hernias that cause a constant bulge, whatever your position, are called non-reducible and these are the ones that are most prone to producing complications such as stangulation and obstruction and need prompt medical attention.
Over time, the abdominal contents will start to protrude even more, weakening the wall still further. In other words, hernia tends to be a progressive condition that worsens over time. Hernias do not get better on their own.
Doctors classify a hernia according to its position within the abdomen, as follows:
- Inguinal hernia. This is the most common form of hernia in men, accounting for around 94% of all cases. When a male's testicles descend into the scrotum, this causes a naturally weakened area of the abdominal wall, known as the internal ring. There are two kinds of inguinal hernia:
- In an 'indirect inguinal hernia' a portion of the intestine drops down into the internal ring and may extend down into the scrotum. An indirect inguinal hernia tends to occur as a result of an inherited weakness in the internal ring, or a weakness acquired in later life from, say, a groin injury.
- Less common is the 'direct inguinal hernia', which occurs near the internal ring, rather than within it. This usually occurs after age 40, as a result of ageing or injury.
- Epigastic hernia. This type of hernia results from a weakness in the muscles of the upper-middle section of the abdominal wall, above the navel. Men are three times more likely to have epigastric hernia than women.
- Umbilical hernia. The tissue around the navel is thinner than that in the rest of the abdominal wall, making this area prone to development of a hernia. Umbilical hernia can occur in babies, children and adults (see hernias in children).
- Femoral hernia. The area between the abdomen and thigh around the femoral artery is another site where a hernia may develop, although this one is far more common among women. A femoral hernia causes a bulge on the upper thigh.
- Incisional and stoma hernias. A surgical incision creates an area of weakness in the abdominal wall, where a hernia may develop. Incisional hernia sometimes occurs after, for instance, removal of the appendix. It is more likely to happen when the operation wound has become infected - a fairly common occurrence, in fact. Similarly, creation of a stoma (an artificial opening for the bowel, often done in treatment of colon cancer or other intestinal disease) strains the tissue in the surrounding area. Hernias following trauma or injury to the abdomen (e.g., following car crash) are relatively rare.
Multiple hernias, occurring at more than one site on the abdominal wall, may sometimes develop.
There is no sure way of preventing a hernia from developing, particularly if it results from an inherited weakness in the abdominal wall. However, avoiding certain risk factors may be helpful. For instance, if you have a smoker's cough, stop smoking; if you are prone to violent sneezing attacks because of hayfever, try to get some effective treatment from your doctor or chemist. Similarly, chronic constipation that causes you to strain on the toilet should be treated with a high-fibre diet or medical intervention.
If you suspect you have a hernia, you should always seek medical advice. A doctor should be able to tell whether you have a hernia or a some other problem by physical examination. Most cases should be treated by surgical repair as soon as possible after diagnosis - this removes the discomfort and pain associated with the condition, which could seriously affect your quality of life and, more importantly, prevents the development of a strangulated hernia, which is potentially life-threatening.
The only way of curing a hernia is by surgical repair. There are no drug treatments for the condition. The prospect of having an operation may seem daunting, especially if you have a reducible hernia which is not really causing much discomfort. However, remember that hernias do tend to get worse over time, and there is always a risk - however small - of developing the serious complication of a strangulated hernia. Hernia surgery is better carried out sooner, rather than later. However, it is important you discuss the different surgical options in detail with your doctor before coming to any decisions. Ask questions such as:
- What are the risks to me, in my current state of health, of having this operation?
- Will I need a local or a general anaesthetic?
- What does the operation actually involve? Ask the doctor to show you with a diagram if you are not sure
- What is the success rate of this operation? Are there any potential complications I should know about?
- How long will I have to stay in hospital?
- How long will I be off work?
- How long before I can get back to sports/making love/other relevant activities?
- Will there be much post-operative pain/discomfort?
- What kind of follow-up will be involved? Will I need to attend for outpatient appointments?
- What are the chances that my hernia will recur after surgical repair?
There are basically three types of hernia repair surgery:
Traditional hernia surgery
The traditional operation for hernia involves stitching and a general anaesthetic. The surgeon makes an incision in the abdominal wall around the hernia and first moves the hernia back into position within the abdominal cavity. The weak portion of the abdominal wall is then stitched back together.
More recent variations on this technique use patching the defect after it has been stitched up or maybe putting in a staple - the aim being to stop the weak section from opening up again. You may be admitted as a day case, or you may need to stay in hospital overnight, or even for a few days.
However it is done, this operation creates tension within the deep layers of the abdominal wall, which causes pain after the operation. The length of time the pain persists for and its intensity depend on the type of operation and how complex the hernia was to repair. You can generally expect degree of restriction in physical activity for some weeks after this kind of operation.
Now the most common form of hernia repair, this procedure is normally done under local anaesthetic. An incision is made over the site of the hernia and, as in the traditional method, the bulge is pushed back into place. The actual repair is done by placing a piece of fine, sterile mesh at the weak point of the abdominal wall. This is held firmly in place and the outer incision on the skin surface closed. The process only takes a few minutes.
Some surgeons still use some stitching in mesh repair, but it is possible to do the operation without stitching of the deeper layers of the abdominal wall. In this case no tension can develop within the muscle tissue. This means there is far less pain and discomfort than with traditional surgery. Since only a local anaesthetic is used, recovery time is much faster. Many patients can go home within an hour or so of the operation and an overnight stay is rarely needed. The mesh triggers a natural healing process. Sensing its presence, the surrounding muscle and tendon send out fibrous tissue which grows around and into the mesh. If you like, the mesh acts like the steel rods within reinforced concrete, strengthening the weak spot in the abdominal wall.
Sometimes known as keyhole surgery, the laparoscopic technique involves a repair of the hernia from inside the abdomen. Using either general or spinal anaesthesia, the surgeon makes a tiny incision near the hernia. Through this, miniature surgical instruments - including a video camera - are introduced and used to make the repair. The camera projects an image of the operation site onto a screen, which guides the surgeon's actions.
Because the incision is very small, there is less post-operative pain and faster healing than with the two 'open' techniques described above. However, in the hands of an inexperienced operator, laparoscopic techniques can cause damage to surrounding tissue because the surgeon has less control than with 'open' surgery. Laparoscopic repair for hernia has only really come into its own in the last few years but recent guidance from NICE (the National Institute for Clinical Excellence) says that it should be considered as an option alongside open surgery, depending on the exact nature of the hernia, the surgeon's experience in laparosopic surgery and the patient's ability to take general anaesthetic.
A surgical truss might be suggested if there has to be a wait for surgery or if, for some reason, surgery is not advisable. This is an elasticated belt which supports the abdomen and keeps the hernia from protruding. There is some evidence that wearing a truss weakens the muscles and restricts the circulation. There may have been some justification of their use in the past, when hernia repair was not so successful, but these days the patient needs to know why if his doctor recommends wearing one of these appliances.
After a hernia has been repaired, there is always a risk that it will recur. You can help prevent recurrence by keeping the abdominal wall strong and healthy. The following tips should help:
Â· Try to maintain a healthy weight Â· Exercise to tone the abdominal muscles Â· Get medical help for chronic constipation, allergies, or chronic cough Â· Eat high-fibre foods. There is an increased risk of deep-vein thrombosis (DVT) after a hernia operation so ask your surgeon about preventive measures such as wearing compression stockings.
Elective hernia repair has a high success rate, but the hernia may recur in between one to 20 per cent of cases. Recurrence is more likely with traditional surgery, but also depends upon the type of hernia and any complicating health factor. Mesh repair of a simple case of abdominal hernia is almost certain to last for life. Once a hernia has recurred it does, however, become progressively harder to repair on subsequent occasions.
British Hernia Centre
Web site: www.hernia.org
Tel: 0208 201 7000
Clinic specialising in mesh repair of hernia without stitches, running a comprehensive information website.
Hernia Resource Center
Web site: www.herniainfo.com
US-based site with information, quizzes and questions-and-answers.
Dr Susan Aldridge. Updated by malehealth for 2005 with thanks to Mr Satvinder Mudan, hernia specialist at the London Clinic.
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Page created on January 1st, 2005
Page updated on March 11th, 2010