Patients with hernias are commonly encountered in surgical clinics. This disease is susceptible to complications, and always needs an operation for cure. This article explains how hernias occur, and how they should be treated.
The commonest hernia is the inguinal, or groin, hernia. A tough layer of tissue, called the fascia transversalis, surrounds the abdominal organs. There is a small hole in the fascia transversalis, called the "internal inguinal ring". If this hole enlarges, the intestines may herniate through the internal inguinal ring. The protruded intestines lie under the skin, and are visible externally as a bulge in the groin. Herniated intestines lie under the skin in a sort of bag, the "hernia sac".
Inguinal hernias are far commoner in males than in females. They occur because of an inborn weakness in the abdominal wall, although they do not always present at birth. Hernias are more common in children with undescended testes. Hernias are also somewhat more common in patients who have large tumours, large collections of fluid in the abdomen, or who have to strain hard such as in chronic constipation or chronic cough.
Patients with hernias complain that "something slips out of the abdomen" when they stand or cough. They become aware of an uncomfortable bulge in the groin, which is nothing but intestines that have slipped out of the abdomen. It is nearly always possible to reduce the intestines back into the abdominal cavity by lying down or by exerting pressure with the hand. Hernias are often somewhat painful. Over time the size of the hernia gets larger. There is obviously very little space available for the herniated intestines, and they tend to get compressed. Occasionally, the herniated intestines can be so severely compressed that the passage of food through them becomes obstructed. In fact, hernia is among the commonest causes of obstruction of the intestines . This is a life-threatening condition, and needs emergency treatment. Since a hernia causes discomfort, and can have life-threatening complications, treatment is always needed. The only effective treatment is by operation.
Operation is usually done under general anesthetic (ie the patient is made unconscious). However it is possible to make the operative area numb with anesthetic injections and operate while the patient is awake. At operation the herniated intestines are pushed back into the abdominal cavity. Ther hernia sac becomes empty, and is tied off. In children this is the only step needed. In adults however the internal inguinal ring (the hole in the fascia transversalis) needs to be narrowed and strengthened. A complex series of stitches is applied for this. In some patients, a mesh made of synthetic material is applied around the internal ring.
Surgery through a laparoscope. These days many operations are being performed through small incisions, using an thin telescope (the laparoscope) and special instruments. Laparoscopic surgery, already the method of choice for gall bladder surgery, is now gradually becoming established for hernia repairs as well. Non-laparoscopic repairs are also called "open" operations. After laparoscopic repair pain is less than after the open operation, and patients usually return to work earlier. Pain after laparoscopy is about 50% less than after open surgery, and return to work is 10-20% earlier in time. However pain is rarely severe in either type of operation. Disadvantages of laparoscopic repair are increased costs, and some complications. Average costs of surgery are Rs 10,000-20,000, and in any given hospital laparoscopic surgery is roughly twice as expensive as open surgery. Complications of laparoscopic surgery are rare. However, because the abdomen is entered, these can be more serious. In contrast since open repair is an entirely external operation, serious complications are almost unheard of. Recurrence rates are marginally higher after laparoscopic surgery. Results after laparoscopic hernia repair are very dependent upon the surgeon's experience. Overall there is little to choose between the two types of procedure. In patients who have bilateral hernias, or are undergoing repair for a recurrent hernia, laparoscopic repair is better than open repair. For first time hernias the advantages of laparoscopy are not marked, and in the average case it is probably safer to opt for the open repair. The very highly skilled laparoscopist can achieve results as good as, or even better than those achieved by surgeons performing a competent open repair.
After surgery patients can walk on the same day, and can usually be discharged in 12-24 hours, and return to work in 4-5 days, or more if the job is strenuous. The most common complication after surgery is difficulty in passage of urine. If the patient practises passing urine into a urinal while lying down, he will find it easier to do so after the operation. A swelling in the scrotum occurs in many patients, and resolves spontaneously. Infection in the operative site can rarely occur. Patients should take a bath before surgery to decrease the risk of infection.
Recurrence. Hernias can and do recur. Recurrence of hernia may occur in 1-5% of patients. Most recurrences occur in the first 2 years.
There is no effective nonoperative treatment for hernias. A "truss" or hernia support is available, and should probably never be used as it tends to cause more harm than good.
Patients with a hernia should take a normal diet. It is advisable to avoid constipation, therefore a high-fiber diet (plenty of vegetables, salads etc) should help.
If you have a hernia, consult a doctor.
http://www.hernia.org/ and http://www.hernia.org/faq.html: an extremely informative site, great detail, links sometimes take time to open. They have an amusing (but not so useful) "interactive" site on hernia. FAQs.
http://www.american-hernia.com/: another very good site. Worth a visit
www.shouldice.com: the Shouldice Clinic is probably the most famous of all hernia clinics
http://www.surgeries.com/hernia.shtml: also recommended
Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a
practising surgeon attached to Dharamshila Cancer
Hospital, Sir Ganga Ram Hospital and to Noida Medicare
Center. Formerly Professor of Surgery, Himalayan
Institute of Medical Sciences, Dehradun, Dr Sood has a
special interest in gastrointestinal surgery. He has had
an active academic career, has published several papers
in national and international journals, and is the Editor
(with Dr Anurag Krishna) of a widely acclaimed book
titled Surgical Diseases in Tropical Countries.
Last revised: May 10, 2000