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General Surgery

Hernia

Hernia is an opening formed by the lining of the abdominal cavity. Abdominal wall hernia occurs when the contents of the intestine bulges out of the abdominal wall. Hernias are developed at birth (congenital) or may appear later (acquired).

Hernias may be present at birth and occurs when the lining around the abdominal organs, fails to close before birth. Hernia may also result if the connective tissue degenerates in the abdominal wall due to which, pressure builds up in the abdominal wall leading to a bulge in the abdomen. Some of the other factors that worsen hernia are chronic cough, obesity, constipation, pregnancy, poor nutrition, smoking and stretching or straining abdominal muscles while lifting heavy objects.

Hernia Types

There are different types of hernias based on their location. The most common types are listed below.

Symptoms

Some of the commonly observed symptoms include abdominal pain, bulge in the abdominal area, severe groin pain which increases on coughing or lifting heavy things, burning, gurgling sensation, nausea and vomiting.

Your physician can confirm the presence of hernia by performing physical examination. The size of hernia increases on coughing, bending, lifting, or straining. Rarely ultrasound may be needed to look for hernia.

Treatment

Surgery is the only treatment and is usually performed for hernias that enlarge in size due to increased intra-abdominal pressure causing intestinal obstruction and restricted blood supply which may lead to death of bowel tissues.

A hernia repair is usually performed as an outpatient surgery with no overnight stay in the hospital. The operation may be performed as an “open” or “keyhole” (laparoscopic) surgery.

Your surgeon will decide which procedure is suitable for the repair and performs with your consent.

In open hernia repair, a large incision is made on the groin (abdomen) and the bulge is pushed back into place. Laparoscopic hernia surgery is a surgical procedure in which a laparoscope (telescope) is inserted into the abdomen through a small incision. The laparoscope is a small fibre-optic viewing instrument made up of a tiny lens, light source and video camera.

  • Hernioplasty- This type of procedure is done if the abdominal wall is completely ruptured and damaged. A synthetic mesh is used which is stitched along with the abdominal wall to provide support.
  • Herniorrhaphy: This method is done if the abdominal wall is torn and causes leakage of the intestinal contents. Your surgeon opens the wall and pushes the content back into the abdomen and the torn tissue is stitched.

Open surgery

This surgery is performed under general or a local anaesthesia and single large incision is made on the groin area and hernioplasty or herniorrhaphy is performed.

Laparoscopic or Keyhole surgery: This surgery is performed under general anaesthesia and several small incisions are made around the abdomen. Through one of the incision, a laparoscope a small, fibre-optic tube with a tiny camera is inserted. Through the other incisions, surgical instruments are inserted and hernioplasty and herniorrhaphy is performed.

Carbon dioxide (CO2) is put into the abdomen through a special needle that is inserted just below the navel. This gas helps to separate the organs inside the abdominal cavity, making it easier for the physician to see the reproductive organs during laparoscopy. The gas is evacuated at the end of the procedure.

As common with other surgeries, hernia surgery is also associated with certain complications such as local discomfort and stiffness, infection, damage to nerves and blood vessels, bruising, blood clots, wound irritation and urinary retention.

Inguinal Hernia

Inguinal hernia is a condition where a part of the intestine protrudes out of the abdomen through a tear in the abdominal wall. Inguinal hernias most commonly develop in the area between the abdomen and thighs, in the area of inguinal ring. Inguinal hernias affect people of all ages and are more common in men compared to women.

Inguinal hernias are of two types:

  • Indirect inguinal hernias – Indirect inguinal hernia often affects premature infants and is caused because of non-closure of inguinal canal and is a congenital disorder.
  • Direct inguinal hernias – Direct inguinal hernia is common in adult males and is caused because of degeneration of tissues in abdominal muscles.

Inguinal hernias cause discomfort and sharp pain which may be worsened with increased activity and relieved on rest. Patients may also experience burning or gurgling sensation at the site of hernia.

Femoral Hernia

Femoral hernia appears as a bulge in the upper thigh, is a loop of intestine, or another part of the abdominal contents, that has been forced out of the abdomen through a channel called the “femoral canal”(a tube-shaped passage at the top of the front of the thigh). It most commonly develops in women due to the wider pelvic region and also in older people.

Femoral hernias may be congenital or develop later in life. Certain factors such as chronic constipation, obesity, and stressful urination because of enlarged prostate may increase the risk of hernias. Patients with femoral hernias may have a bulge in upper thigh area and may have symptoms such as abdominal pain, nausea and vomiting, and discomfort on standing or lifting heavy objects.

Hiatus Hernia

Normally, the stomach is completely below the diaphragm. In individuals with hiatus hernia part of the stomach slides through the diaphragm, the muscular sheet that separates the lungs and chest from the abdomen, and protrudes into chest cavity. Hiatal hernia is more common and affects people of all ages.

Hiatal hernias are of two types:

  • Sliding hiatal hernia – The top portion of stomach slides up and down through the diaphragm with increased pressure on abdominal cavity
  • Fixed Hiatal hernia – The top portion of stomach moves up into the chest cavity and does not slide down into normal position.

Obesity, chronic cough, chronic constipation, smoking, and hereditary factors increases the risk of developing hiatal hernias. Hiatal hernia may not cause any symptoms but patients may experience chest pain, heart burn, belching, and hiccups.

Incisional Hernia

It occurs through a scar of any previous surgical incision made in the abdomen and usually develops after many years of surgery. Incisional hernias are small and only the peritoneum or tissue layer lining the abdominal cavity protrudes out. Incisional hernias are more common in obese individuals and in pregnant women. Risk is more in those who had multiple surgeries earlier and those who perform activities that impart more stress of abdomen.

Patients may experience pain and discomfort and there is always a risk of recurrence.

Umbilical Hernia

Umbilical hernia is a small bulge around the umbilicus (belly button). An umbilical hernia in an infant is caused by the incomplete closure of the muscles around the Umbilicus. Smaller umbilical hernias often require no treatment and get closed by the age of 2 however larger umbilical hernias may necessitate the surgical treatment. Umbilical hernias may also develop later in life during pregnancy. Conditions such as mucopolysaccharide storage diseases, Beckwith Wieldemann syndrome, and Down syndrome may increase the risk of umbilical hernias.

The bulge in umbilical hernia will be soft and bulges may appear when the baby cries or sits up.

Recurrent Hernia

Recurrent hernias as the name implies recur at the same site of earlier hernia. Recurrence is more common in obese individuals and those who had multiple surgeries earlier. Recurrence is more common with incisional hernias because the risk factors such as obesity may persist and cause recurrence.

Surgery is the best approach for recurrent hernias however the difficulty or complications increase on subsequent repairs. Recurrent hernias can be repaired with open surgery or laparoscopic surgeries and the chances on infections are minimal with laparoscopic approach. Certain preventive measures such as treating chronic cough before treating hernias, avoiding smoking, avoiding strain on abdomen during bowel movement, and avoiding lifting of heavy objects may help in preventing recurrence.

Mesh & Hernia Repairs

Surgery is the best approach for hernia treatment. Various surgical techniques are used to treat hernias and it is recommended that using ‘tension free’ repair method is beneficial preferably with incisional hernias. Also surgery is recommended for recurrent hernias. In treating larger hernias surgeons use a synthetic material called ‘mesh’ to close the defect or hole. The mesh minimizes the tension at surgical wound and prevents recurrence. Mesh used in surgery also provides support to the weakened abdominal walls. These meshes are available in various sizes and shapes so as to meet the requirements.

Surgeons place this mesh either below of above the defect in the abdominal wall and will be held in place with sutures. This mesh provides support for the growth of new tissue and this tissue incorporates the mesh into surrounding area.