What is a Hernia?
Hernias are commonly referred to as “ruptures” or weaknesses in the abdominal wall. The most common sites are in the inguinal or groin area and around the umbilicus (navel). However, they can occur anywhere in the abdominal wall from the rib cage to the upper leg and pelvis. The focus here will be on the main types of hernia that are seen in the practice: inguinal, ventral and incisional.
Inguinal hernias in the groin are the most common type of hernia in men and women. They present most commonly as a bulge located just lateral and above the pubic area at the top of thigh above the groin crease. They can be painless or painful. Groin hernias are usually aggravated by activity, long periods of standing, straining, lifting, coughing or sneezing. They can be soft, but the ones that become incarcerated or trapped, can be firm. If the skin over the bulge is reddened, it may indicate that the tissue in the hernia may be strangulated (twisted with compromised blood supply) and this is an emergency. These hernias in men can be large enough to extend into the scrotum and can cause pain in the testicle on the side of the hernia. In women, inguinal hernias can cause swelling in the upper side of labia of the vagina. The femoral version of the groin hernia extends by the vein to the upper thigh and tends to incarcerate more often than other hernias. These are more common in older patients.
Ventral hernias, which include epigastric, umbilical and other more rare types of hernia, often present with the same symptoms as groin hernias. Incisional hernias are hernias that occur in a surgical scar. They are very common in incisions made around the navel for other procedures, such as laparoscopic procedures. Incisional hernias present with the same symptoms as other hernias, primarily a bulge with or without pain. Your primary care physician can be helpful in diagnosing a hernia and can order appropriate imaging if they are unsure if a hernia is present. Hiatal hernias are hernias that occur in the diaphragm on the left side, where the esophagus enters the abdomen.
Causes, Risk Factors & Prevention
Hernias occur in areas of the abdominal wall where there is potential for an anatomical weakness. We are connected to our mothers via blood vessels (the umbilical cord) that leave our body through the navel. That opening usually closes but later in life can reopen, leading to an umbilical hernia. In men, the testicles descend from their original location in the abdomen to the scrotum through the inguinal canal. This canal is an anatomical wonder, allowing the blood vessels and vas deferens to reach the testicle without being closed off. Hernias that occur along these structures are the most common type. Chronic coughing from asthma, lung conditions or smoking can increase the likelihood of a hernia occurring. Repeated straining to urinate or defecate (as a result of constipation) is a risk factor. Obesity makes hernias more likely to recur after repair and makes repair more challenging. It can also increase the risk of hernia formation. Surgical incisions in the abdominal wall can all develop hernias. There is no definitive way to prevent hernias but limiting heavy lifting, repetitive straining, coughing from smoking, and maintaining normal body weight can help.
Detection, Tests & Imaging
Most hernias are detected during a physical exam. Some hernias, such as a sports hernia, may only be diagnosed by history and symptoms. This type of hernia is a groin hernia and does not have a bulge that can be felt or seen. CT scans and ultrasound are helpful imaging techniques for diagnosing and locating a hernia. A CT scan can also help to determine if a hernia contains a part of the intestine and whether or not that intestine is obstructed. There is no blood test to determine if a hernia is present.
Most hernias require surgical repair. If patients are too ill for surgery or want to avoid an operation, trusses are devices that can be worn to keep a hernia from protruding. Surgical techniques for hernia repair are as varied as the surgeons doing them. In our practice, groin or inguinal hernias can be repaired open, laparoscopically or robotically.
Almost all repairs of groin hernias utilize mesh in the repair that is made of polypropylene, the same material used to make fishing line. We do not use the type of mesh that is part of class action lawsuits you see advertised on television. The mesh is usually implanted behind, around or more rarely, in front of the hernia defect. It becomes part of a strong scar, and because mesh repairs are usually done without tension, they have a lower risk of recurrence. Umbilical hernias are often repaired the first time with a permanent suture and mesh can be avoided.
Most hernia repairs can be accomplished in the outpatient setting as a one-day surgery. Most hernia repairs require general anesthesia. Sometimes, spinal anesthesia, as a block, can be utilized in groin or inguinal repairs. Some of the large incisional hernia repairs can require reconstruction of a majority of the abdominal wall. A 3 to 5 day stay in the hospital is not unusual in this situation.
For a majority of hernia repairs, there is complete recovery and return to full activity. Discomfort dictates the level of activity after hernia repair. There is no set weight limit that every physician follows. Most patients can return to lifting after repair if their job requires it. However, this will increase the risk of recurrence.
Antibiotics are given intravenously prior to the procedure in the operating room but are rarely continued at home after the procedure. After most repairs, there will be a postoperative visit in the office at 1-2 weeks postoperatively. For the more common repairs, the skin closure is usually made with an absorbable suture that will dissolve. For the larger repair, staples are commonly used for closure that will be removed around 7-10 days postoperatively. It is common for the subcutaneous tissue under the skin over a hernia repair to develop a prominent ridge or area of firmness. This is called a healing ridge and usually is completely resolved at 6-8 weeks postoperatively.
The first 2-3 days after the repair are typically associated with the most pain. The evening after the repair is usually not as bad due to local anesthesia injected into the tissues around the repair. This tends to keep you comfortable for most of the evening after the surgery. Rapid swelling, severe bruising and pain, purulent (pus) draining from the wound and a fever over 101 degrees should prompt you to call the office and report these symptoms. Soft bruising around the repair that develops over the first week after the surgery is very common and should not cause alarm. Difficulty urinating is a common problem after inguinal hernia repairs in men with prostate problems. Sitting in a warm bath or standing in a warm shower may help with urinating. If unable to urinate within about 6-8 hours of surgery, you should call the office or the physician on call. This may require a visit to the emergency room to have a catheter placed to drain the bladder until normal function returns. Every patient will receive specific instructions from the staff and/or the surgeon about recovery and activity after their repair.