Abdominal wall hernia

What is a hernia?

A hernia is an abnormal protrusion of a viscus (e.g. part of the intestine) through its normal containing wall (e.g. the abdominal wall muscles).  They typically occur at natural sites of weakness (in the groin, at the umbilicus or through previous abdominal incisions).  They can occur spontaneously as the muscles weaken, or can be caused by anything that raises intra-abdominal pressure, such as lifting heavy objects, straining on the toilet, or persistent coughing.

A hernia can present as a lump that is noticed by the patient; this lump might disappear when lying flat (“reducible hernia”) or when is gently massaged back inside the abdomen.  The lump usually increases in size over time.  They can be painless, although it is common for the patient to complain of discomfort that increases during the day, or even severe pain.  If part of the bowel protrudes into the hernia and becomes stuck, it can restrict the blood supply to the bowel (“strangulated hernia”); this is a surgical emergency and a repair and sometimes a bowel resection are necessary immediately.  Because of the risk of strangulation, in addition to the symptoms of pain associated with a reducible hernia, surgery is indicated in most people.

What treatment options are there for a hernia?

It is possible to wear a support belt, known as a truss, to keep the hernia within the abdomen.  However, they tend to be somewhat uncomfortable and are not always effective.  Their use tends to be reserved for people who are not fit to undergo surgery.  For most people with a hernia, an operation to repair the defect is appropriate.

What does a hernia operation involve?

A hernia operation aims to repair the defect in the abdominal wall.  The contents of the hernia sac are returned to the abdominal cavity before a synthetic mesh is inserted.  There are a number of different ways in which this can be done, either using open surgery or laparoscopic (keyhole) techniques.  Open hernia repairs can be undertaken under local or general anaesthetic.  Laparoscopic hernia repair is undertaken under general anaesthetic.  Most hernia repairs are done as day cases.

What types of hernia are there?

1. Inguinal hernia

A hernia that occurs in the groin is called an inguinal hernia.  There is a natural weakness in the groin, known as the inguinal canal, which transmits the vessels that supply the testicle in men and a ligament in women.  They are the most common type of hernia and tend to be more prevalent in men.  There are essentially two different ways of repairing an inguinal hernia:
Open inguinal hernia repair
This is the more traditional method of repair and is still the gold standard.  An incision is made in the groin over where the bulge comes out, the hernia sac is returned to the abdomen and a mesh is sutured to reinforce the area.  The tissue layers and skin are then closed with dissolvable stitches.
Laparoscopic (keyhole) inguinal hernia repair
As opposed to open hernia surgery where the hernia is repaired from the outside of the abdominal cavity, laparoscopic repair reinforces the defect from within.  Three small cuts are made in the abdomen, through which a laparoscope (camera) and operating instruments are passed.  The hernia sac is pulled back into the abdomen before a mesh is inserted to reinforce the area.

2. Femoral hernia

A femoral hernia Occurs lower in the groin that an inguinal hernia.  They tend to be more common in women and have a higher risk of strangulation if left untreated.  They are usually repaired as an open operation through an incision in the groin, occasionally inserting mesh, although laparoscopic techniques can also be used.

3. Paraumbilical and Umbilical hernias

Hernias that occur near the umbilicus are called paraumbilical hernias; those that come directly though the navel are known as umbilical hernias.  It is common in childhood to have a protrusion at the navel, which normally closes over the first few years of life.  However, if the bulge does not go away repair will be necessary.  In adults, these hernias are acquired and, again, represent a natural weakness at this site.  They are more common in overweight patients. Adults who develop this type of hernia will need treatment, as it will not get better on its own.  Repair can be undertaken as an open or laparoscopic operation.  Your surgeon will be able to discuss this with you more.

4. Epigastric hernia

A hernia that occurs in the midline between the navel and the lower ribcage is called an epigastric hernia.  Sometimes they can be confused with a natural weakness where the muscles pull apart (“divarication of the rectus muscles”).  An epigastric hernia should be repaired, either open or keyhole, whereas surgery is usually not indicated for divarication.

5. Incisional hernia

As opposed to the hernias listed above that occur through natural weaknesses, incisional hernias result from a weakness in the abdominal wall caused by a previous scar or surgical wound that has not healed well.  They usually occur within two years of the surgery.  Incisional hernias vary in size and the treatment prescribed may also vary.  Open or laparoscopic techniques can be employed; the choice often being determined by the size of the hernia.  Large incisional hernias are usually best treated with open surgery, whilst laparoscopic surgery can give very good results for small to medium-sized hernias.   The main drawback with keyhole repair of a large incisional hernia is that a bulge can remain, which represents the hernia sac that is not removed during the operation, but rather has a mesh placed underneath it.  Your surgeon will advise you on which repair is most appropriate.

What are the risks of hernia surgery?

Hernia surgery is commonly performed and inherently safe.  However, there are specific complications and risks, which differ slightly depending on the type of hernia that is being repaired.  Essentially, there are risks of bleeding, infection (that can be serious if the mesh is involved and sometimes needs the mesh to be removed), chronic pain at the repair site, numbness around the area, and recurrence of the hernia.  Your surgeon will be able to inform you fully of the risks, as well as advising you on which type of repair is most appropriate.

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