Hernia: Types, Causes and Treatment

How do you know if you have a hernia?

A hernia is an abnormality (disease) in which the intra-abdominal organs protrude from an abnormal opening in the abdominal wall. The cause of protrusion is the increased intra-abdominal pressure due to lifting heavy weights, coughing/ sneezing, straining due to constipation, or passing urine.

The name of the hernia is derived from the abnormal opening of the abdominal wall.

Inguinal hernia passes through the inguinal openings in the groin through which the testicular cord passes namely deep and superficial inguinal rings.

An umbilical hernia happens to pass through the weakened area of the umbilical scar.

An incisional hernia is a name given to a protrusion from a surgical site - an area where a cut was made in the abdomen for surgery and stitched back causing weakness at that site of the abdominal wall.

The structures which protrude out of the abnormal opening are abdominal organs which are present near the opening or are more mobile-like omentum (a fatty apron of the intestines), small intestine, large intestine, fat of the inner lining of the abdominal wall.

Not Just a Bulge

A hernia is seen as a lump or a bulge on the abdomen which appears on coughing or standing up and goes inside or reduces on lying down or pushing gently with the hand.

The size of the hernia or the bulge as seen by the patient increases gradually or slowly over the years to become larger and larger.

The other symptoms associated with a hernia is pain over the swelling and a dragging sensation in the abdomen. The pain increases as the hernia becomes larger or whenever a complication of obstruction or strangulation of hernia occurs. 

Inguinal/Umbilical/Incisional Hernia

Inguinal hernias occur in the groin.

The groin swelling which is initially small gradually increases in size becoming larger and larger gradually.

The swelling which is seen initially in the lower part of the abdomen just away from the midline on one or both sides, increases in size to go down into the scrotum and when large, sometimes becomes so huge that they hang down to mid-thigh or even lower. 

In such large inguinal hernias, most of the abdominal structures lie in the hernial sac in the scrotum.

Umbilical hernias occur both in neonatal and in later life.

A few of the neonatal umbilical hernias close / heal spontaneously but the larger ones and those which don’t close by itself require to be operated. 

Umbilical hernias and hernias which occur around the umbilicus are called para-umbilical hernias and are especially frequent in the obese patients as the layer of fat in the abdominal wall muscles creates weak points through which hernia protrudes out. The intra-abdominal pressure of obese patients is also much higher because of increased fat-laden omentum and other organs.

An epigastric hernia is a name given to those hernias which occur in the midline from umbilicus upwards till the bony structure of the chest. These hernias usually contain the intra-abdominal fat and cause considerable pain due to the ligamentous structure of the midline causing injury to the protruding fat on movement.

Incisional Hernia occurs through previous surgery scar and is of very common occurrence.

The incision to operate inside the abdomen and closure of the same causes damage to muscle, ligament, nerves and blood supply to the affected areas,

The healing which occurs is jeopardised leading to the formation of a weak scar and this area is prone to producing a hernia. 

Incisional hernias can form soon after the surgery to many years later due to repeated push by the raised intra-abdominal pressure. 

What Causes Hernia?

Many of the inguinal and umbilical hernias are congenital i.e. present at birth. 

Inguinal hernias at birth and neonates are the most common surgical disease in childhood. The inguinal canal through which the testis, which is intra-abdominal in early foetus descend down to the scrotum and the peritoneal sac gets obliterated, does not get obliterated in these patients and remains patent leading to the formation of inguinal hernia at birth or later in life.

If the sac is thin then only fluid can pass through it from the abdomen to the scrotum. This collection of the fluid in the scrotum is called congenital hydrocoele.

However, if the sac is big, intestines and other intra-abdominal organs also descend down into the scrotum called a congenital inguinal hernia. 

Some of these patent sacs are not obvious at birth but cause the formation of an inguinal hernia in later life.

Most other causative factors for the formation of hernias is raised intra-abdominal pressure.

Whenever we cough/sneeze, strain while passing stools and urine or lift heavy weights or strenuous work, the intra-abdominal pressure rises causing any weak spots in the abdominal wall to become hernia. 

Patients having chronic cough, asthma, chronic bronchitis are candidates for the formation of hernia and also a much higher incidence of recurrence after surgery.

Patients of chronic constipation and people habituated to pushing excessively during defecation are also candidates for hernia formation. 

Patients of enlarged prostate and stricture of the urethra (narrowing of the tube through the urine passes out) who strain to pass urine also fall in the same category.

The weakness of the musculature of the abdominal wall is also a very important factor in the causation of hernia esp. in old age, People leading a sedentary life and not exercising, strokes leading to paralysis of the abdominal musculature and obese patients with fat infiltrating the abdominal wall.

Raised Intra-abdominal pressure in pregnancy, Ascites (collection of fluid in the abdomen), Large Ovarian Cysts and large bulky tumours are important contributing factors.

Complications of Hernia

Hernias are liable to cause complications.

When a complication would occur is difficult to predict but as the hernia increases in size and when you can feel or detect small intestine as a content in the hernial sac, the chances of a complication occurring are very high.

It is said that complications in hernia are like a demon's sword hanging over your head which can fall anytime and kill you.

Irreducible Hernia

It's a term given to a hernia in which the contents which used to come out on coughing and standing up and reduce on lying down and pushing do no more go inside but remain out like a bulge or swelling. This complication happens because the hernial opening through which the contents pass is small and large parts have been pushed through it during a sudden increase in intra-abdominal pressure or a large increase in pressure over an extended time period.

Obstructed Hernia

The opening of the hernia being small causes compression of the structures which pass through leading to obstruction of the lumen of the intestine and also compression of the blood supply. 

If the lumen of the small or large intestine is obstructed partially or fully, it is called obstructed hernia and indicates an emergency situation requiring surgery.

Strangulated Hernia

If the blood supply is also obstructed, the contents which have passed through the tight rim of the hernia die out and require immediate surgery called a strangulated hernia.

In a strangulated hernia every hour counts and delay by a few hours, the intestine becomes black and gangrenous and has to be excised/removed and it is a life-threatening complication. 

You may have carried a hernia for a number of years but when a complication occurs it doesn’t give you more than a few hours to get operated. Any delay is life-threatening. 

More people die due to preventable hernia complication than due to cancers.

The larger the hernia and the smaller the opening, the more the likelihood of complications.

Hernias may cause mild pain, dragging sensation and a bulge but once an obstruction or strangulation occurs the size of the bulge increases and there is severe pain in the swelling and in the abdomen with vomiting and abdomen gets distended (swelling of the abdomen).

Hence it’s recommended that hernias should be operated on as soon as it is detected and not wait for a complication to occur and put your life at risk.

Manipal Hospital Dwarka is the best hospital for hernias in Delhi having the best doctors who work together to provide the highest level of patient care. For the best hernia treatment in Delhi consult the best cancer hospital near you.

 

Dr. Muneendra Gupta

Consultant - Department Of Minimal Access Surgery

Manipal Hospitals, Dwarka, Delhi

 

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