General Surgery - Hernias
A hernia is a defect in the deep layer of the anterior abdominal wall which can cause the intraabdominal organs to “push through” to just under the skin. Without surgical intervention, these hernias can cause abdominal pain, vomiting, and in the worst case scenario, organ death. We fix these defects using either minimally invasive or traditional techniques, depending on each individual situation. There are several types of hernias: inguinal, umbilical, ventral, and incisional to name a few.
Inguinal hernia
There are two types of inguinal hernias, an indirect and direct inguinal hernia.
- An indirect hernia occurs when a portion of intestine or intraabdominal fat passes down the inguinal canal alongside the spermatic cord where the testis descends into the scrotum. Indirect inguinal hernias are usually caused by a congenital defect which occurs as a weakness in the inguinal canal manifesting after injury, pregnancy, or aging.
- A direct hernia occurs when an intestinal loop or intraabdominal fat pushes through a weakness in the lower abdominal wall. Direct inguinal hernias may appear following an episode of heavy lifting, pregnancy, exercising, persistent coughing, straining while urinating or defecating, or by gaining a lot of weight.
Inguinal hernias are further classified by how they present clinically.
- In a reducible hernia, the hernia can be manipulated back into the abdominal cavity through the defect.
- In an incarcenated hernia, the hernia can't be put back into place without surgery because of swelling of the hernia contents or "sticking" of the hernia to the surrounding tissues.
- A strangulated hernia is the most dangerous type. The contents within the hernia becomes twisted or swollen. When this occurs, normal blood flow to the intestinal loop becomes compromised resulting in death of whatever is within the hernia. Immediate surgery is needed in this type of hernia.
Individuals with a hernia may experience the following symptoms:
- A lump or swelling under the skin in the groin area
- A sharp, sudden pain in the groin or scrotum regions
- Abdominal cramping, pain, or bloating
- Pain in the groin while standing or moving
There are two surgical approaches available for the treatment of inguinal hernias - the traditional open surgical repair or a laparoscopic repair.
- An open repair of an inguinal hernia is the most common type of treatment. This procedure can be done under general, spinal, or local anesthesia. An open repair requires an incision in the groin directly over the hernia (lump). The hernia is manipulated back into the abdominal cavity and the abdominal wall defect is repaired with a synthetic material or "mesh" to prevent recurrence of ther hernia. This mesh is placed over the defect to serve as a scaffolding on which scar tissue will grow.
- A laparoscopic hernia repair is done only under general anesthesia and involves three much smaller incisions than that used in an open technique. These incisions are placed around the navel. The abdominal cavity is inflated with carbon dioxide and a laparoscope (a fiber-optic narrow camera with a light on the end) and other instruments are inserted through the incisions. Using a monitor the surgeon pulls the herniated tissue back into place and staples a patch over the opening from the inside.
Recovery time after a repair of a hernia can vary, depending upon the extent of the repair and if there is strangulation of the intestine. In general, full recovery can be expected within four to six weeks. There are certain restrictions that have to be followed after a repair of an inguinal hernia to ensure a successful and complete recovery and to prevent a recurrence. Some restrictions are avoidance of strenuous activity, no heavy lifting/pushing/pulling, and minimal straining on urination or defecation.
Umbilical, ventral, and incisional hernias
These hernias are different from inguinal hernias as they present as a lump in areas of the abdominal wall aside from the groin. These hernias occur because of weaknesses through the strongest layer of the abdominal wall, or "fascial layer". There are several natural weaknesses of the fascial layer other than the groin area such as at the umbilicus (navel) and the midline of the wall. Weakness of the fascia can also be created, as when any incision is made through the fascia from previous surgery.
Just as in inguinal hernias, these hernias can become incarcerated or strangulated which are surgical emergencies. Repair for these hernias can be done open or laparoscopic, depending upon each individual case. Recovery time is similar to that of inguinal hernias.
Summary
Hernias occur because of either congenital or acquired defects of the abdominal wall. Without surgical intervention, they can grow larger and have the continued risk of becoming incarcerated or stranglated. There are open and laparoscopic approaches to repairing these, each with it's own advantage and disadvantage. With a combined approach to healing on both the surgeon's and patient's part, a repair of a hernia can be uneventful with a minimal chance of recurring.
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University Surgical Consultants