Hernia
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What is Hernia
A hernia is a weakness or opening in the abdominal wall, that often results in bulging out of fat or an organ such as intestine, which then occupies space under the skin. The opening in the abdominal wall through which the fat or organs protrude is called the Hernia defect.
Hernia can affect anybody – going by statistics one-in-ten of us will have hernia at some point in our lives. It is found in both sexes, can occur at any age and sometimes infants may be born with it.
Surgery for hernia is one of the most commonly performed operations worldwide with millions of cases being treated every year.
Treatment of Hernia
The definitive treatment of hernia is a surgery. With a lot of hernias remaining asymptomatic for long, an obvious question that can arise in one’s mind is, ‘ What if I leave my hernia untreated?’ Well, the general consensus within the medical fraternity is that ‘All hernias should be repaired unless severe pre-existing medical conditions make surgery unsafe’. Many patients, especially those having a smaller, asymptomatic hernia who are anxious of undergoing a surgery still choose to stay away from a surgical treatment. However it should be borne in mind that.
- An asymptomatic hernia usually causes pain and discomfort with time. Also, in those with mild existing symptoms, the symptoms usually worsen with time.
- In case you delay a surgical treatment, the hernia will most likely increase with time, making a future repair technically more difficult.
- The earlier the repair, the smaller the hernia and the lesser the trauma from surgery. Typically, a more rapid recovery is achieved after surgery for a smaller hernia.
- The possibility of strangulation always looms large. It is usually more common with the smaller hernias and you certainly do not want it while you are on a vacation in some remote place or before an important event like a wedding.
Thus, a wise decision would be to find a hernia specialist and get the hernia repaired as soon as possible. A useful rule of thumb is that once you are sure you have a hernia, it is best to have it treated as early as possible and as well as possible.
UNDERSTANDING THE BASICS OF A HERNIA SURGERY
 The goal of a hernia surgery is to repair the weak tissue in the abdominal wall and seal the defect so that fat or intestines cannot push through it again. Depending upon the surgical approach used, there are two types of repairs; Open repair and Laparoscopic ( keyhole ) repair. In an Open surgery, a single long incision ( cut ) is made in the area of the hernia. The herniated organs are pushed back in place and the area is then sutured back with/without placing a mesh to strengthen the weak area of the abdomen. The basic principles of a Laparoscopic repair remain the same, the only significant difference being that instead of a single long cut, several small ( 3-5 ) nicks are made each being about a centimetre long. A laparoscopic repair is done under general anaesthesia and carries more benefits like a quicker recovery, lesser post-operative pain and lower infection rate. However, a laparoscopic repair may not be possible if you have a large hernia or you can’t receive general anaesthesia. It is best to leave the decision to your doctor who will be in a better position to decide which approach would benefit you more depending upon various factors like location/type/severity of hernia as well as your medical history.
I. Inguinal Herina Repair Surgery
- Primary Muscular Repair aka Shouldice’s Repair
This method involves pushing back the herniated organs and sewing the abdominal wall tissues back together with the help of sutures. However, the abdominal muscles are constantly under tension after the suturing and hence may potentially give way once again in the future. Hence, this procedure has a high recurrence rate. - Simple Prolene Mesh Repair aka Leichenstein’s Repair
In this ‘tension-free’ repair, a Polypropylene mesh is used to seal the defect so that the tension that the muscles are under in a Shouldice’s repair is avoided. The procedure is usually done under local anaesthesia and needs 24-48 hour hospitalisation. Although the procedure is time tested, safe and economical, there are chances of post-operative groin pain ( Inguinodynia ) due to nerve entrapment. - Laparoscopic Repair ( TEP and TAPP Repair )
In these procedures done under general anaesthesia, a Polypropylene mesh is placed on the inner side of the abdominal wall ( posterior compartment ). However, these are technically much more difficult procedures with a recurrence rate of 8-15%. Hospitalisation time needed is 24-48 hours. - 3-D Mesh Hernia Repair
This is the most advanced and preferred technique for inguinal hernia repair. It is a simple and promising method which covers the hernia defect from 3 sides- above, below and centre. It is a tension-free repair in which a Polypropylene mesh is used.
Advantages- Negligible recurrence rate
- No risk of chronic groin pain as no stitches are taken to fix the mesh.
- It is a very short procedure requiring about 15-20 minutes
- Day care procedure with a short hospital stay of about 12 hours.
II. Femoral Hernia Repair surgery
     A Femoral hernia repair surgery can be done either as an open surgery or a laparoscopic ( keyhole ) surgery. In the open surgery a single long incision/cut is made whereas in a laparoscopic surgery about 3 small nicks are made. In either of the surgeries, the surgeon reduces the hernia by pushing the fatty tissues/loop of bowel back into the abdomen. This is followed by securing the femoral canal with a mesh to repair the weak spot which let the hernia through.
Both open and keyhole surgeries are safe and effective, although there is lesser pain and a faster recovery after a keyhole surgery. The choice of which technique to use depends upon your general health and the expertise of the operating surgeon.
III. Umbilical Hernia Repair Surgery
Umbilical hernia in adults is becoming fairly common due to increasing incidence of obesity and laparoscopy ( Port-site hernia ). A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. Although quite popular because of less post-operative pain and early recovery, the cosmetic outcome of this procedure is not good as some amount of bulge remains post-operatively. - 3-D Mesh repair
Most of the above methods involve removing the umbilicus, but at Healing Hands Clinic we ensure that umbilicus is preserved by adopting a modified 3-D umbilical hernia repair. In this procedure, the defect is closed from the anterior as well as posterior aspect. The umbilicus is repositioned to achieve an excellent cosmetic outcome. It is a day care procedure which means you will be discharged from the hospital the same day. The recurrence rate is almost negligible.
IV. Epigastric & Incisional Hernia Repair
Umbilical hernia in adults is becoming fairly common due to increasing incidence of obesity and laparoscopy ( Port-site hernia ). A repair may be done in either if the following ways:
- Primary Muscular Repair
This method involves reducing the hernia and sewing the abdominal muscles back together with the help of sutures ( surgical thread ). However, this method has a high recurrence rate due to absence of mesh. - Prolene Mesh Repair
In this method, a Polypropylene mesh is placed over the defect. However, following this procedure, there are high chances of collection of pus at the operation site which makes it an unfavourable choice. - Laparoscopic Repair
Done under general anaesthesia, 4 incisions of 1 cm each are taken. The defect is closed from the posterior aspect with a mesh. - Octomesh Repair
In this innovative method, a specially designed Polypropylene mesh implant called Octomesh is used. As the name suggests, the Octomesh has 8 integrated radiating arms ( tentacles ) which are simply tunnelled through the muscles of the abdominal wall. These arms are held securely in place by friction. The most striking advantage of an Octomesh repair is that it is a sutureless ( no internal stitching ) with negligible recurrence rate. The absence of sutures also reduces the post-operative pain and chances of pus collection.
Understanding The Mechanism of Hernia
To choose the right treatment, it is of utmost importance that you understand what exactly hernia is. The abdominal wall which consists of the abdominal muscles and tendons, holds the abdominal contents in place. These abdominal contents consist of fat and various organs especially the intestines. The abdominal wall envelopes these contents like a corset. If there is any weakness or opening in this wall, the corset like effect is lost and it gives way to the abdominal contents causing them to protrude through the defect. This bulging of the fat/organs is what we call the hernia, which is usually visible as a swelling under the skin. This mechanism is similar to what happens with a bulge in a damaged tyre, where the inner tube, normally contained by the hard rubber of the tire extends out through a thin or weakened space.
Why do Hernia occur ?
- Any condition that increases the pressure of the abdominal cavity over a prolonged period of time may become a cause for hernia eg. Obesity, chronic cough, heavy lifting, chronic constipation leading to straining during bowel movement.
- Family history of hernia makes one more likely to get it.
- Some hernias may be present at birth
- Idiopathic, which means the cause is not known.
Symptoms of Hernia
- A hernia may first appear as a new lump or bulge in the groin or in the abdominal area. There may be an associated dull ache but usually it is not painful on touch. The lump increases in size on standing, coughing and may be pushed back/disappear on lying down.
- A small painless hernia if left untreated, usually increases in size.
- Occasionally, the hernia may become irreducible i.e. it cannot return to the abdominal cavity on lying down or with manual pushing. At this stage it also becomes painful.
- Sometimes the loop of bowel that has herniated becomes obstructed. This can cause extreme pain, nausea, vomiting, constipation and needs immediate treatment.
- At times the hernia becomes ‘strangulated’ ( explained further below ) in which the person appears ill with/without fever, nausea, vomiting and extreme pain even to touch. This condition is life threatening and thus a surgical emergency.
What is a Strangulated Hernia ?
If a loop of intestine or omentum becomes trapped in the weak point in the abdominal wall ( hernia defect ) through which it has herniated, it can obstruct the bowel leading to severe pain, nausea, vomiting and inability to have a bowel movement or pass gas. This is called an Incarcerated hernia. An Incarcerated hernia may cut off blood supply to the trapped intestine. This condition is called Strangulation and it can cause rapid death of that part of the bowel tissue. Any dead tissue within the body can turn extremely hostile very quickly and start releasing toxins in the blood stream which causes Septicaemia ( blood poisoning ) and in turn death, if not treated immediately and aggressively. Strangulation most commonly occurs with the smaller hernias, as the larger ones tend to slide in and out easily and are at a lesser risk of being clamped shut by the muscle opening ( hernia defect ).
Diagnosis of Hernia
The diagnosis of hernia is usually a clinical one, which means that your doctor will go through a history of your symptoms followed by a brief physical examination. During this check up she/he may feel the area of bulge by raising your abdominal pressure ( this is done by making you stand/cough ), as this manoeuvre makes the hernia more obvious. In case you have an inguinal hernia, the doctor will feel for the potential pathway by examining along your scrotum.To summarise, in vast majority of cases where there is an obvious swelling in the groin/abdominal area, which increases in size on standing, straining or coughing, a clinical diagnosis of hernia is made and NO TESTS are needed. More challenging diagnoses are best performed by hernia specialists
TYPES OF HERNIA
Listed below is a concise description of some of the common hernias. Although there are other types too, they are quite rare and beyond the scope of this piece of information.
- INGUINAL HERNIA
This is the commonest type of hernia that occurs in the groin area at the top of the inner thigh. Commonly found in men, it is associated with ageing and repeated strain on the abdomen. An inguinal hernia or its repair should not be taken lightly because neglect in either of the situations can impair blood supply to the testicles, since the blood vessels that supply the testicles pass through the areas where this hernia occurs. Impaired blood supply may cause death of the testicular tissue requiring its removal. - FEMORAL HERNIA
Found more commonly in women, this also occurs in the groin area, just above the line separating the abdomen and the legs. A femoral hernia should not be neglected as it has high chances of strangulation, which is a medical emergency. In fact almost half of femoral hernias first come to light as emergencies. Thus femoral hernias should be repaired at the earliest, before the complications ensue.
- UMBILICAL HERNIA
It occurs when fat or a part of the bowel bulges through the abdomen near the belly button. It is found in babies when the opening in the abdomen through which the umbilical cord passes doesn’t seal properly after birth. It is also found in adults due to repeated strain on the abdomen. - EPIGASTRIC HERNIA
It occurs in the midline of the abdomen, in the area between the naval and the lower part of the breastbone ( sternum ). This hernia always occurs in the midline because it comes out between the two rectus muscles of the abdomen that meet in the midline. Although the lump may sometimes appear off the midline, the defect/opening is always in the midline. It may be found in infants too because of congenital weakness in the midline of the abdominal wall. - INCISIONAL HERNIA
It occurs at the site of a previous abdominal surgery for another cause, during which the abdominal muscles were cut open to allow the surgeon to enter the abdominal cavity to operate. Although the muscle is sutured ( stitched ) during closure, it becomes a relative area of weakness, potentially allowing abdominal organs to herniate through the incision line.
