Hernia
Jan 27 , 2016 1 pm

Hernia    

What is Hernia? 
Hernia is a disease that occurs when internal organs (partial) move from the original position through the opening or push through the muscle or weakened fascia that moved from original position. It often appears in a new lump within its original membrane. Hernias are most common in small intestine. The word “Hernia” means rupture in Latin. Hernias can be categorized into several types according to the locations where the organs move to and their causes. Surgery is the most common treatment for this disease.
 

Each type of hernia is found in people of different sexes and ages, but can occurs in people of all races.

1. Inguinal hernia
This type of hernia is most common and occupies 75% of all types of hernia. It is found in men 25 times more than in women. When it is detected in men, people usually assumes it to move to the scrotum, which is not always correct. In fact, it is caused by the weak spot within abdominal wall and groin muscle, which is congenital. The symptoms will appear when the patients become adult or entering middle age. Some cases may be caused by the long period of coughing due to chronic bronchitis or emphysema. This type of hernia can be the cause of serious complications, for example, it can grow and press the femoral artery or lymph nodes. The more serious complication is the increasing pressure in the abdominal cavity that harms other organs.
 

 
2. Umbilical hernia
This type of hernia is usually congenital. Premature babies are more likely to develop this hernia. In general, after birth, the holes in the babies’ navels or umbilical cords will close naturally in every layers including skin layer, muscle layer and fascia layer will be formed. However, if the abdominal walls below the layer of the skin layer are not fully closed, part of the intestine might be able to push through the navel and cause this area to be swollen.
 




3. Hiatal hernia
There are two types of hiatal hernia.
- Sliding hiatal hernia
Part of the stomach and esophagus pushes through the hole in diaphragm (which is the opening that connects esophagus to abdominal cavity) into the chest.
- Paraesophageal hernia

Part of the stomach pushes up through the hole in diaphragm and lies next to the passage of esophagus.
Both types of hernia are caused by the loss of elasticity and flexibility in muscles and adhesive tissues of diaphragm due to aging. Other risk factor is abnormally high pressure in the abdominal cavity.
 


4. Femoral hernia
This type of hernia is relatively rare and mostly found in women. It is caused by small part of the intestine that is pushed through femoral canal, which is a hole below the groin. If this occurs, that part of intestine will become a lump near the lower groin. Other risk factor is increasing pressure in abdominal cavity.

5. Obturator hernia
Obturator hernia is a rare type of hernia which occurs mostly in women. It is caused by the part of intestine that moves through pelvic cavity. Women are more likely to develop this hernia because of the differences in pelvic anatomy.

6. Incisional hernia 

This hernia occurs through the place where previously surgical incision has been made. In some cases, even the incision wound in abdominal wall is healed, muscles and fascia tissues in such area might be weakened and part of the intestine might push through such area. However, the possibility to develop this type of hernia is considerably low with only about 2-10% of patients undergoing abdominal surgery.
 

 

In addition, increasing intra-abdominal pressure, which can be a risk factor of hernias as aforementioned, can be caused by;
- Being overweight; or
- Frequent heavy lifting; or
- Chronic cough; or
- Pulmonary emphysema; or
- Straining during defecation and urination on a regular basis; or
- Severe abdominal fluid retention; or
- Pregnancy etc.
 

What are the symptoms of hernia?
1. Dull pain as if something is bulging or pain around the affected area.
2. The lumps can be pushed in and out of the abdominal wall or groin and sometimes cannot move back to the former position on its own, which is the cause of pain around such area.

Is hernia dangerous?
In most cases, hernia is not usually a life-threatening disease but it can be annoying and be the cause of discomfort. However, it sometimes can be the cause of serious complications, for example, inguinal hernias which are not treated promptly can lead to severe infection. Therefore, if patients are diagnosed as having hernias, it is recommended that they should receive the treatment as soon as possible to avoid any possible complications.

Is hernia fatal?
As aforementioned, complications may occur in some cases. For example, when the patient develops inguinal hernia around the groin area and the part of intestine that pushed out through abdominal wall cannot move back its original position, which is called incarcerated hernia, that part of intestinal shall be obstructed and cause stomach pain, nausea and vomiting. Moreover, if it is not treated promptly, blood flow around the area shall be cut and some part of intestine shall begin to decay. Due to such decay, the risk of severe infection is also increased. 

How do physicians diagnose hernia?
Basically, physicians diagnose hernia by physical examination by checking the patients in various postures such as lying down, standing, and straining in bowel movement. The diagnosis of hernia is not difficult but it is important to confirm whether the hernia is incarcerated or there is the blockage of blood flow in incarcerated hernia by checking the symptoms and performing physical examination.If it is unclear whether the lump detected by physical examination is a hernia, ultrasound test may be used for further confirmation.In case that a hernia occurs in pelvis cavity, the lump might not be palpable but the physicians can tell from the symptoms that patients usually have frequent bowel obstruction. The diagnosis requires abdominal examination with CT scan.

As hiatal hernia hardly shows any symptoms, it is often detected coincidentally especially by lung x-ray, which will be shown in a form of shadow in the chest cavity. Barium swallow test or laparoscopic examination can be applied to confirm the indication. In some cases, it is accidentally detected by gastroscopy. For the patient with acid reflux symptom, the physicians might use laparoscopy examination to diagnose as well. 

 


How to treat Hernia?
Hernia requires surgical treatment to move part of intestine or other organs back into their original positions. After that, surgeons have to stitch the opening or reinforce the weakened tissues. 

1. Non-incarcerated Hernia: Surgical operation shall be scheduled when the patients have been diagnosed as having a hernia unless they are carrying any other diseases which surgical treatment is prohibited. Period of the time from diagnosis to the surgery depends on the risk of developing incarcerated hernia in each patient. If the hernia has high risk of incarcerated, such as immediate hernia, difficulties in moving back to original location, or the opening is small, the surgery must be done as soon as possible as it can develop into incarcerated hernia at anytime. 

2. Incarcerated Hernia: Primary treatment is to move the hernia back to its original location by having the patient lie flat, giving painkillers, muscle relaxants, sleeping pills and use fingers to push the hernia back to its original location. If success, the patient will be appointed for a surgery as soon as possible as the incarceration can occur again anytime. In case primary treatment fails, an emergency surgery is must be carried out otherwise the intestine will soon become strangulated and begin to decay.

3. Hernia patients with intestinal strangulation needs emergency surgery. From the time that intestine is strangulated, there are about 6 hours before the intestine will begin to decay until the part needs to be removed.

Although obturator hernia in pelvic cavity is not palpable, the patients should receive surgical treatment as well.

As well as paraesophageal hernia that the stomach can be incarcerated and strangulated, this type of hernia also requires prompt surgical treatment. 

For the patients with sliding hiatal hernia, if no symptom or only minor symptoms occur, the treatments can be medication treatment such as antacid, losing weight in overweight people, avoiding over eating, avoiding lying down immediately after eating, avoiding alcoholic drinks, tea, coffee, etc.. However, if the patients have severe or chronic symptoms that cannot be cured by medication treatment or the hernia is enlarged, surgical treatment may be required.

As the umbilical hernias diagnosed in infants may close on their own, the physicians can wait until about the age of 2 before considering whether the surgery is needed.

 

Standard Hernia Surgery (conventional)

The principle of conventional surgery is to tie the hernia sac and remove the sac, and strengthen the weakened abdominal wall to prevent recurrence by pulling neighboring tissues and stich them together. This kind of surgery is easy but gives a lot of stress to the tissues around stitched area, which cause postoperative pain that requires certain recovery period.

Laparoscopic Hernia Surgery

The surgery is to repair abdominal wall using laparoscope by making small incisions (ports) on the abdominal wall and to repair the hernia from within abdominal cavity as well as reinforce the surrounding area. Laparoscopic hernia surgery usually requires 3 small ports; 1 cm port for laparoscope and two 0.5 cm ports for other equipment. Then perform the removal surgery from the back of abdominal wall, which hernia hole can be seen clearly, cover the muscles with synthetic grate fixed using 3-4 pins. Generally, this technique is used in case of hernia on both sides of the groin or recurrence of hernia after standard surgery. However, the application in patients with unilateral hernia who never had surgery is increasing if requested by the patients. Laparoscopic surgery can reduce the chance of recurrence and cause less pain. Patients can return to their daily routine faster than conventional surgery.

Recovery after Hernia Surgery
Recovery period for patients who undergo hernia laparoscopic surgery or open surgery without any stressed tissues around the area is quite short. The patients are usually hospitalized for 2-3 days, and return to normal activities. Patients who undergo open surgery and have the tissues stitched together will have stressed tissues and require longer hospital stay and often needs another 5-7 days recovery period before returning to work.


How to take care of yourself after surgery?
1.Avoid jumping, lifting heavy objects and doing heavy exercise in the first 2 months.
2.Try not to strain during defecation or urination because abdominal pressure due to the  straining might relocate stitching or the grate and can be the cause of recurrence.

Complications after hernia surgery
Most of the complications after hernia surgery are not severe. For example, blood clot under the wound caused by bleeding from tiny blood vessels during operation, tissues infection, infections of the wound and the injuries of the adjacent organs such as the sperm duct, small nerves that receive sensation from the skin which shall be the cause of soreness or numbness on the patients’ leg.


Self-care and hernia prevention
Instructions for self-care and hernia preventions are as follows; 
1. Hernia patients waiting for a hernia surgery or patients who are unable to undergo surgery due to a serious illness such as severe heart disease, must be careful to avoid the risk of incarceration, such as lifting heavy objects or straining during defecation and urination. In addition, the patients can help minimizing hernia movement or expansion by wearing support garments or pants.
2. Patients after receiving surgical treatment could avoid the recurrence of hernia by losing weight overweight people or being careful not to become overweight, avoiding lifting heavy objects, avoid straining during defecation and urination on a regular basis.
3. Patients with hiatal hernia and acid reflux symptom should prevent the increasing of gastric acid in the stomach by avoiding alcoholic drinks, tea, coffee, soda, carbonated drinks and chocolate, spicy foods, greasy foods, trying not to eat large meal as well as refraining from having food later than 3 hours before bedtime and stop smoking. 

When should I see a physician?

You should visit the physician when;

1. Detect the lump inside the abdomen or groin by palpation. As mentioned previously in causes and symptoms of the hernias, the patient should see a physician for a diagnosis. 

2. Sudden pain occurs around the location of the hernia in the patients diagnosed as having a hernia and waiting for surgical treatment. The pain may be accompanied by nausea, vomiting or fever. The patients who have not been diagnosed, but have these symptoms  together with having a lump in the abdomen or groin area, should also see a physician for diagnosis as well.

Is doing sports a cause of hernia?

Some people claims that doing sports can cause the hernia, which it is not true. Running, jumping, or doing sports are not the cause of hernia, except some sports such as weight lifting or shot put in which the players have to strain their abs and cause the increasing pressure in the abdomen cavity. 

Is wearing tight underwear a cause hernia?       
Many people believes that wearing tight underwear can be the cause of hernia in men, so they wear the  boxers instead, which is incorrect. Wearing tight underwear does not increase the pressure in abdominal cavity and cause the hernia. Therefore, it is recommended to wear appropriate underwear which is not too tight or too loose. 

Can hernia recur after surgery? 
After the surgery of inguinal hernia around the groin, there are chances of hernia recurrence in the same side or in the other side of the groin. There are several causes of recurrence including the surgery has not been performed correctly, the treatment does not cover the risk factors or not completely eliminate all inducing factors such as smoking habit, patients’ frequent constipation which shall cause the strain during the defecation, untreated enlarged prostate. In addition, the weakened tissues, especially in the patients of old age, is also a major factor,.
If the first surgery is a conventional open surgery, repair surgery by laparoscopic technique will be advantages as open surgery causes lots of fibrosis which shall be formed in the front of abdominal wall and obstruct the vision in the repair surgery. Therefore, laparoscopic surgery which is performed from within abdomen cavity, will not be obstructed by fibrosis and repair surgery will be more accurate. However, the best way to prevent recurrence of hernia is to as well treat the inducing factors at the same time.   
 
Even though Hernia is not fatal, it is recommended not to overlook this disease. Everyone should better stay healthy and always checking for your own body abnormalities.