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Hernia Everything You Want to Know About It

Hernia Types, Symptoms, Causes, Diagnosis, Treatment, and Surgery

Hernia Everything You Want to Know About It

Hernia was founded in 1997 by Jean P. Chevrel with the purpose of promoting clinical studies and basic research as they apply to groin hernias and the abdominal wall . Since that time, a true revolution in the field of hernia studies has transformed the field from a ”simple” disease to one that is very specialized. While the majority of surgeries for primary inguinal and abdominal wall hernia are performed in hospitals worldwide, complex situations such as multi recurrences, complications, abdominal wall reconstructions and others are being studied and treated in specialist centers

A hernia usually develops between your chest and hips. In many cases, it causes no or very few symptoms, although you may notice a swelling or lump in your tummy (abdomen) or groin.

A hernia occurs when an organ pushes through an opening in the muscle or tissue that holds it in place. For example, the intestines may break through a weakened area in the abdominal wall.

An inguinal hernia occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially when you cough, bend over or lift a heavy object. However, many hernias do not cause pain.

An inguinal hernia isn’t necessarily dangerous. It doesn’t improve on its own, however, and can lead to life-threatening complications. Your doctor is likely to recommend surgery to fix an inguinal hernia that’s painful or enlarging. Inguinal hernia repair is a common surgical procedure.

What Is An Abdominal 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 enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. The pain can occur while resting or only during certain activities such as walking or running. Nearly all hernias have a potential risk of having their blood supply cut off (becoming strangulated).

When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted causing the decreased or total loss of blood supply to the protruding tissues. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen (which is transported by the blood).

What Are the Different Types of Abdominal Hernias?

Hernias of the abdominal and pelvic floor

  • Inguinal hernias are the most common of the abdominal hernias. The inguinal canal is an opening that allows the spermatic cord and testicle to descend from the abdomen into the scrotum as the fetus develops and matures. After the testicle descends, the opening is supposed to close tightly, but sometimes the muscles that attach to the pelvis leave a weakened area. If later in life there is a stress placed on that area, the weakened tissues can allow a portion of small bowel or omentum to slide through that opening, causing pain and producing a bulge. Inguinal hernias are less likely to occur in women because there is no need for an opening in the inguinal canal to allow for the migration and descent of testicles.
  • A femoral hernia may occur through the opening in the floor of the abdomen where there is space for the femoral artery and vein to pass from the abdomen into the upper leg. Because of their wider bone structure, femoral hernias tend to occur more frequently in women.
  • Obturator hernias are the least common hernia of the pelvic floor. These are mostly found in women who have had multiple pregnancies or who have lost significant weight. The hernia occurs through the obturator canal, another connection of the abdominal cavity to the leg, and contains the obturator artery, vein, and nerve.

Hernias of the anterior abdominal wall

The abdominal wall is made up of two sets of muscles on each side of the body that mirror each other. They include the rectus abdominus muscles, the internal obliques, the external obliques, and the transversalis.

  • When epigastric hernias occur in infants, they occur because of a weakness in the midline of the abdominal wall where the two rectus muscles join together between the breastbone and belly button. Sometimes this weakness does not become evident until later in adult life as it appears as a bulge in the upper abdomen. Pieces of bowel, fat, or omentum can become trapped in this type of hernia.
  • The belly button, or umbilicus, is where the umbilical cord attached the fetus to mother allowing blood circulation to the fetus. Umbilical hernias cause abnormal bulging in the belly button and are very common in newborns and often do not need treatment unless complications occur. Some umbilical hernias enlarge and may require repair later in life.
  • Spigelian hernias occur on the outside edges of the rectus abdominus muscle and are rare.
  • Incisional hernias occur as a complication of abdominal surgery, where the abdominal muscles are cut to allow the surgeon to enter the abdominal cavity to operate. Although the muscle is usually repaired, it becomes a relative area of weakness, potentially allowing abdominal organs to herniate through the incision.
  • Diastasis recti is not a true hernia but rather a weakening of the membrane where the two rectus abdominus muscles from the right and left come together. The diastasis causes a bulge in the midline. It is different than an epigastric hernia because, the diastasis does not trap bowel, fat, or other organs inside it.

Hernias of the diaphragm

  • Hiatal hernias occur when part of the stomach slides through the opening in the diaphragm where the esophagus passes from the chest into the abdomen.
  • A sliding hiatal hernia is the most common type and occurs when the lower esophagus and portions of the stomach slide through the diaphragm into the chest.
  • Paraesophageal hernias occur when only the stomach herniates into the chest alongside the esophagus. This can lead to serious complications of obstruction or the stomach twisting upon itself (volvulus).
  • Traumatic diaphragmatic hernias may occur due to major injury where blunt trauma weakens or tears the diaphragm muscle, allowing immediate or delayed herniation of abdominal organs into the chest cavity. This may also occur after penetrating trauma from a stab or gunshot wound. Usually these hernias involve the left diaphragm because the liver, located under the right diaphragm, tends to protect it from herniation of bowel.
  • Congenital diaphragmatic hernias are rare and are caused by failure of the diaphragm to completely form and close during fetal development. This can lead to failure of the lungs to fully mature, and it leads to decreased lung function if abdominal organs migrate into the chest.
  • The most common type is a Bochdalek hernia at the side edge of the diaphragm.
  • Morgagni hernias are even rarer and are a failure of the front of the diaphragm.

Symptoms of a Hernia

The signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen (an incarcerated strangulated hernia). Abdominal or pelvic pain can be part of the symptoms of many hernias.

Reducible hernia

  • It may appear as a new lump in the groin or other abdominal area.
  • It may ache but is not tender when touched.
  • Sometimes pain precedes the discovery of the lump.
  • The lump increases in size when standing or when abdominal pressure is increased (such as coughing).
  • It may be reduced (pushed back into the abdomen) unless very large.

Irreducible hernia

It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it.
Some may be chronic (occur over a long term) without pain.
An irreducible hernia is also known as an incarcerated hernia.
It can lead to strangulation (blood supply being cut off to tissue in the hernia).
Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.

Strangulated hernia

  • This is an irreducible hernia in which the entrapped intestine has its blood supply cut off.
  • Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).
  • The affected person may appear ill with or without fever.
  • This condition is a surgical emergency.

Hernia Causes

Hernias are caused by a combination of muscle weakness and strain. Depending on its cause, a hernia can develop quickly or over a long period of time.

Some common causes of muscle weakness or strain that can lead to a hernia include:

  • a congenital condition that occurs during development in the womb and is present from birth
  • aging
  • damage from an injury or surgery
  • chronic coughing or chronic obstructive pulmonary disorder (COPD)
  • strenuous exercise or lifting heavy weights
  • pregnancy, especially having multiple pregnancies
  • constipation, which causes you to strain when having a bowel movement
  • being overweight or obese
  • fluid in the abdomen, or ascites

There are also certain things that can increase your risk of developing a hernia. They include:

  • a personal or family history of hernias
  • being older
  • pregnancy
  • being overweight or obese
  • chronic constipation
  • chronic cough (likely due to the repetitive increase in abdominal pressure)
  • cystic fibrosis
  • smoking (leading to weakening of connective tissue)
  • being born prematurely or with a low birth weight

How Do Health Care Professionals Diagnose Abdominal Hernias?

For inguinal hernias, most patients notice a feeling of fullness or a lump in the groin area with pain and burning. Physical examination can usually confirm the diagnosis. Femoral or obturator hernias are more difficult to appreciate and symptoms of recurrent inguinal or pelvic pain without obvious physical findings may require a CT scan to reveal the diagnosis. Umbilical hernias are much easier to locate with the bulging of the belly button.

Hernias that are incarcerated or strangulated present a greater challenge since the potential complication of dead bowel increases the urgency. The health care professional seeks clues of obstruction, including a history of pain, nausea, vomiting, or fever. During a physical examination, a doctor may often discover that a patient has a markedly tender abdomen. These hernias are often exquisitely tender and firm. The exam may be enough to suspect incarceration or strangulation and require immediate consultation with a surgeon. Doctors may use X-rays or CT scans to confirm the diagnosis, depending upon the clinical situation.

Doctors may be able to diagnose hiatal hernias associated with GERD by learning a patient’s medical history during his or her physical exam. A chest X-ray can reveal part of the stomach within the chest. If there is concern about complications including esophageal inflammation (esophagitis), ulcers, or bleeding, a gastroenterologist may need to perform an endoscopy.

What Is the Treatment for Hernias?

Hernia treatment can be conservative (such as observation and support with trusses) if the hernia is not affecting your daily routine or does not cause severe pain. Curative treatment consists of surgery. Laparoscopic surgery has taken the place of traditional hernia surgery for some of the abdominal hernias. Herniorrhaphy is the surgical repair of a hernia.

Will You Need Surgery for a Hernia?

Surgical hernia repair is the ultimate treatment. The timing of treatment of a hernia and technique for treatment depends on whether it is reducible or irreducible and possibly strangulated.

Reducible hernia

  • In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.
  • If you have preexisting 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 complicated because of their 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.
  • The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place between the doctor and patient.

Irreducible hernia

  • All acutely irreducible hernias need emergency hernia repair because of the risk of strangulation.
  • An attempt to reduce (push back) the hernia will generally be made, often after giving 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, the development of dead (gangrenous) bowel is possible in as little as six hours.
  • In cases in which the hernia has been strangulated for an extended time, a surgeon will perform surgery to check whether the intestinal tissue has died and to repair the hernia.
  • In cases in which the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged from the hospital.

If a hernia that appears irreducible is finally reduced, it is important for a patient to consider a surgical correction. These hernias have a significantly higher risk of getting incarcerated again.

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