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Hernia

Overview

A hernia is the abnormal protrusion of a tissue or an organ through an opening or a site of weakness in the cavity wall where it is usually contained. For example, intestines can come out through a defect in the abdominal wall in a direct inguinal hernia. Most commonly, hernias appear as a bulge on the surface of the abdomen, in the upper thigh and groin area. Very small hernias may only occur on coughing or bending forwards. Hernias could be different depending on their location, like inguinal hernia, femoral hernia, umbilical hernia, epigastric hernia, hiatal hernia, etc. Most hernias cause only mild symptoms unless they are complicated by obstruction or strangulation. When the contents inside the trapped intestine are blocked and can not move forwards, it is called obstruction of a hernia. Such a hernia must be treated to relieve intestinal obstruction. Strangulation of a hernia refers to the entrapment and constriction of the contents to the extent of cessation of blood supply, causing the tissue’s death. Strangulation is a medical emergency and must be treated to prevent the death of the intestine. 

Causes

Hernias usually result from increased abdominal pressure or a weakness in the wall that is resulted from several other reasons. It may also be congenital, developed in the womb, and present at birth. The causes of a hernia are;

  • Lifting weight for a prolonged period in an occupation or otherwise. 
  • Doing strenuous exercises involving heavy weight lifting. 
  • Chronic coughing 
  • Chronic Constipation
  • Obesity
  • Sudden weight gain
  • Weakening of a wall due to previous surgeries
  • Multiple pregnancies in women also weaken the walls

Types

Some common types of hernia are described below;

  • Inguinal hernias: They are the most common types of hernia. They contain the intestines that push through the abdominal wall or descend in the inguinal canal. The inguinal canal serves as a passage for the spermatic cord in males and broad ligament in females and is found in the groin. They are of two types; direct inguinal hernia and indirect inguinal hernia. They are more common in males.
  • Diaphragmatic hernias: They are inside the body and are caused by weakness in the diaphragm through which the part of the stomach slides up and down in between the chest and abdomen. They are of two types; sliding hiatal hernia, para-esophageal hernia. 
  • Incisional hernia: They appear at the site of incisions made by previous surgery.
  • Umbilical hernia: They appear at the region of the umbilicus or navel and are mostly found in babies.  
  • Epigastric hernia: It appears at the upper abdomen in the midline.
  • Femoral hernia: It occurs in the femoral canal, which is present at the top part of your inner thigh. They're more common in females. 

Risk Factors

Following are risk factors of hernia 

  • Low birth weight babies or those born prematurely 
  • COPD
  • cystic fibrosis 
  • Pregnancy
  • Chronic constipation
  • Smoking 
  • Obesity
  • Family history of hernias

Epidemiology

Abdominal wall hernias occur with a prevalence of 1.7% for all ages and 4% for those over 45 years. 75% of abdominal wall hernias are Inguinal hernias with a lifetime risk of 3 % in women and 27% in men. Hernias are more prevalent in males (67.27%) than females (32.72%). The male to female ratio is 3:1.

Signs And Symptoms

Signs and symptoms of hernias depend on their type, their contents, and the degree of severity. In most cases, hernias may have no symptoms. However, there may be specific symptoms such as heartburn, trouble swallowing, and chest pain in some types, such as in Hiatal hernias. Often, patients are unaware of having hernias; they usually turn up as incidental findings while undergoing a routine physical examination. Inguinal hernias may cause discomfort, pain, pressure, or dragging sensation at the site. Men can feel pain and swelling in the scrotum as the contents of the hernia are descended in the scrotum. Obstructed hernia presents with constipation, vomiting, nausea, inability to pass gas. A strangulated hernia may present with vomiting, fever, inability to pass gas or stool, pain, and redness of the hernia bulge. 

Differential Diagnosis

The conditions that may mimic the signs and symptoms of a hernia are;

  • Lymphadenopathy 
  • Lymphoma 
  • Metastatic neoplasm 
  • Hydrocele 
  • Epididymitis
  • Testicular torsion 
  • Hematoma 
  • Abscess
  • Femoral artery aneurysm 
  • Undescended testes 
  • Lipoma

Diagnosis

History and physical examination still prove to be the best way to diagnose hernias. Your doctor will take a detailed history, and you will be asked about the first time you noticed the bulge and the activity that made the bulge appear. If you are experiencing any other symptoms, you may be asked about your lifestyle, occupation, physical activity, history of smoking, or previous surgery, and a family history of hernia. The doctor will then proceed with the physical examination. He will feel a bulge in the abdominal or groin area that may get larger when you are asked to stand, cough, or strain. This test is used to look for a positive cough impulse or a negative cough impulse, which is a specific diagnostic test of a hernia. In a strangulated hernia, the bulge appears red or purple, accompanied by pain. All of the following tests may aid in diagnosing the condition.

  • Ultrasound of abdomen.
  • CT scan of the abdomen
  • MRI scan of the abdomen
  • X-Ray of the abdomen.
  • Endoscopy

Treatment

Surgery is the definitive treatment for a hernia. Before performing surgery, some conservative treatments can be tried, like wearing a truss, a special belt to support the hernia. You would be advised to watch for changes such as appearance or worsening of pain and discomfort. 

The doctor will determine the necessity and type of surgery based on several factors like the type, contents, severity of a hernia, patient's overall health, and preference. 

The hernia repair is called hernioplasty and can be performed by open surgery or laparoscopic (minimally invasive ) surgery and robotic repair. In open surgery, the surgeon makes a single incision, and the bulging hernia is either removed or pushed back into the body. A mesh can be applied at the place of the hernia to provide extra support. In laparoscopic surgery, the surgeon makes multiple small incisions, through which a thin, lighted tube is inserted with a camera to see, and instruments are used to repair the hernia. 

Medications

Medicines have a limited role, and they may be prescribed only for symptomatic relief. 

  • Proton pump inhibitors for hiatal hernia
  • Antacids
  • Painkiller (Tylenol, Acetaminophen Advil, Aleve)

Prognosis

Hernias do not go away on their own. The only way to effectively treat hernia is through surgical repair. However, they reappear in 10 percent of adults. If diagnosed early, the prognosis of surgically repaired hernias is excellent. Recovery time of hernias repaired by surgery may take 4 to 6 weeks after surgery. The patient is advised not to lift heavy objects, but they can return to light daily activities.