An inguinal hernia is when soft tissue protrudes through a weak spot in the abdominal wall. These hernias are the most common reason men undergo surgery. (Getty Images)
Abdominal wall hernias are common abnormalities that exist in up to 10% of the population.
While they can be present at any age, including in infants, the likelihood of occurrence increases with maturity. A hernia is one of the major causes for work loss and disability. While surgery is normally a cure, in some instances, life-threatening complications may lead to death.
Hernias develop when an internal structure, such as the bowel, pushes through a weak gap in the abdominal wall musculature and forms a saclike structure. This bulge is usually apparent externally. The location and the size of the abnormality determine whether symptoms will develop.
Today, treatments vary based on the scale and severity of the hernia. Some are closely monitored and may not require any therapy. For those that are larger, have significant symptoms and potentially may become strangulated, surgery is the only option.
The most common types are:
Inguinal: Approximately 75% of abdominal hernias appear near the groin where a portion of the intestine or fat presses through the inguinal canal. Men are more often affected than women. Because of the potential risk of blood flow interruption to the bowel stuck outside the abdomen, most inguinal hernias need to be repaired.
Umbilical: These arise at a weak point in the abdominal wall near the navel; a segment of bowel protrudes through the defect creating a hernia sac. The affliction more frequently occurs in infants, but usually resolves by age three or four; if it does not clear up, surgery may be needed. Umbilical hernias can also occur in adults secondary to being overweight, chronic coughing or constipation and pregnancy. If symptomatic, treatment will usually be necessary.
Incisional: When tissue presses into a scar site from previous surgery, a hernia may develop. They are relatively common, vary in size and can occur weeks, months or years after an operation. They do not resolve spontaneously.
Femoral: Presenting in the groin region, intestine protrudes into the femoral canal forming a hernia. They mainly afflict older women, are less frequent than inguinal hernias and prone to complications. After being diagnosed, surgery is ordinarily advised.
Epigastric: Located in an opening of the muscles or tendons in the upper abdomen, these hernias are small and often without symptoms. When discovered, surgical treatment is recommended.
Spigelian: These comparatively rare hernias form in the midst of abdominal muscle fibers. They are equally prevalent in males and females and more likely arising in later life. The diagnosis can be difficult because spigelians tend to be small and produce symptoms that may mimic other abdominal complaints. Since they are inclined to have complications, removal is usually suggested.
Abdominal wall hernias are classified as to when they occur:
Hernias are also grouped on their ability to be either “reduced” manually by pushing the hernia sac back into the abdomen or “non-reducible” where the pouch containing intestine cannot be manipulated. The latter situation can be life threatening. The hernia may become “strangulated” or “incarcerated” with the blood supply to the bowel cut off. An emergency operation is required to prevent gangrene.
Abdominal wall hernias do not always produce dramatic symptoms.
In young children, increased irritability may be the only manifestation. In adults, exercise, coughing or straining while lifting may generate an ache or burning pain. For the clinically dangerous strangulated hernia, marked discomfort is associated with a toxic appearance of the afflicted individual.
Because most hernias are visible and can be felt, the diagnosis is principally made on a doctor’s physical exam. If there is uncertainty, particularly in the presence of unexplained symptoms, imaging procedures such as ultrasound, CT or MRI may be indicated.
Hernias have plagued humanity for millennia.
The first accounts were in ancient Egypt. In one tomb, there is a depiction of a man’s inguinal hernia being reduced. The ancient Greeks named the condition “hernios,” meaning bud or offshoot. During these eras different devices and some primitive operative techniques were used. A simple repair meant castration; strangulation was a death sentence.
It wasn’t until the anatomical discoveries in the Renaissance that hernia treatments began; the additional knowledge did not initially improve the outcomes. After the introduction of anesthesia and aseptic techniques in the 19th century, new surgical methods emerged. A turning point took place in the 1930s with the utilization of prosthetic mesh in the repair process.
Today, treatments vary based on the scale and severity of the hernia. Some are closely monitored and may not require any therapy. For those that are larger, have significant symptoms and potentially may become strangulated, surgery is the only option.
The operative procedure entails either pushing the hernia back into the abdominal cavity or removing the sac and closing the abdominal wall gap with stitches. Mesh is placed over the affected area to prevent reoccurrence.
There are two types of surgical techniques currently used:
Both techniques can correct all types of hernias. Which one to utilize in a particular scenario is based upon the surgeon’s evaluation, clinical circumstances and the patient’s preference.
A truss or belt was popular in the past to keep the hernia pouch in place and ease discomfort. Although it may provide temporarily relief, these devices are no longer recommended because they fail to treat the underlying hernia and can cause pressure ulcers.
The risk of acquiring an abdominal wall hernia can be lessened by maintaining a healthy weight, eating well to thwart constipation, avoiding heavy lifting and quitting smoking. But if one does develop, modern surgery can provide relief.
Stolz is a retired physician and author of “Medicine from Cave Dwellers to Millennials.”