A hernia is a gap in the muscles and fascia of the abdominal wall through which the inner contents, small and/or large intestines, stomach, bladder etc, may protrude out beneath the skin. The patient notices a swelling, sometimes painful and often times not, that may disappear in the lying down position and increase with walking, standing or coughing.
There are several types of hernias. They are broadly divided into internal and external hernias. Internal hernias are not apparent on the outside and can be dangerous. They may occur from birth defects or after some bariatric procedures. As such, they will not be discussed any further here.
External hernias are far more common and vary in size and location. They may present at birth, in old age or any time in between. Both sexes are affected by this condition.
Seen very commonly, this is usually a swelling in the groin which appears on standing and reduces on lying down. Both females and males may suffer from inguinal hernias, though men tend to predominate. These may be tiny and even unnoticed by the patient, and progressively increase till they attain impressive sizes. In fully developed state, the scrotum may hang down till the thighs or knees!
This is also seen in the groin. It occurs more commonly in women, and often presents as an emergency with bowel obstruction (abdominal pain, severe vomiting, distension of the belly and inability to pass wind). While in an advanced state the bowel may become gangrenous and mandate a major open abdominal operation to remove it (laparotomy with bowel resection and anastomosis), it may lend itself very nicely to a laparoscopic of robotic procedure.
A hernia that appears after an abdominal surgery is known as incisional hernia. The location of the hernia depends upon the type of incision chosen for the primary surgery. The hernia occurs when the scar of the surgery becomes weak due to any reason and gives way.
About 20% of all open operations tend to become weak and result in hernias, These are typically bigger than the simple primary hernias, and may need special operations to give lasting and good results. This is often a major issue in the life of the patient and deserves special attention of a surgeon who is well versed in all forms of surgical treatment.
This term refers to a hernia of the navel. This is quite commonly seen in females, especially post pregnancy. Umbilical hernia is the most common cause of disfigurement of the navel. Though typically considered a minor matter by both patient and physician, they may be dangerous as they can get obstructed and need emergency operation. They are also often associated with weakness in the midline of the abdominal wall (diastasis recti or divarication of recti). This weakness may be a cause of recurrence in a simple repair. Any recurrence is liable to be a complex one and need more elaborate procedures that may fall under abdominal wall reconstruction.
This type of hernia is seen in the mid upper portion of the abdomen. Although usually small in size, they may be painful or large in a few individuals. Though a surgeon may typically make a single cut and fix the hernia that is obvious and problematic, this may not be what many experts would recommend. The midline linea alba is often weak and has several other small hernias that may be visible only after a CT scan of the abdomen. If not fixed, these hernias may develop further and present some years after the primary operation. This is the reason why many experts prefer to do keyhole approaches and place a large mesh after exposing all the defects in the line alba. Procedures like ventral TAPP and eTEP are increasingly used in such cases, though many factors are important in the choice of the operation.
A lumbar hernia occurs in the flank (towards the back). Though hernias at this site typically result from kidney surgeries, they may occur as primary hernias (the ones that occur without there having been a surgical scar at the site).
Lumbar hernias are uncommon and are nowadays treated with laparoscopic or robotic approaches. Placement of meshes from within the abdominal cavity (IPOM) is common, but not what many experts would recommend.
A Spigelian hernia occurs through a gap in the side of the six pack muscles (rectus abdominis). They are typically located in a zone somewhere below the level of the navel. The Spigelian hernia shows up as a bulge off centre, and the experienced surgeon recognises it immediately. A CT scan shows the hernia as one that is trapped between the muscle layers. The external oblique muscle is clearly present on top of the hernia. This type of hernia lends itself to a laparoscopic ventral TAPP very well.
When the stomach slides to the chest cavity through the diaphragm, it is called a sliding hiatus hernia. Reflux and heartburn are the most common symptoms. A paraesophageal hernia, the less common type, typically presents with vomiting, often resulting from gastric volvulus (a twist that threatens to cut off the blood supply of the organ and causes a crisis). Both these hernias (and a third hybrid type that involve both types) may be asymptomatic in many patients and be associated with obesity. They deserve careful evaluation and judicious management. Medical treatment is used for a lot of patients, but surgery is needed in handling the severely symptomatic cases. Surgery is almost always laparoscopic or robotic.
In many surgical cases, the surgeon brings out part of the large bowel or small bowel through a part of the abdominal wall. Examples include Hartmann operation for perforated diverticulitis, ileal conduit for radical cystectomy or terminal colostomy for low rectal cancer following the APR operation. These terms would be familiar only to the keen patient suffering from that particular problem and who has had a discussion with his/her surgeon about the treatment methods.
When the bowel escapes by the side of a segment of colon or ileum that is sometimes brought out as part of abdominal surgery, it is called a parastomal hernia. These hernias are notoriously difficult to treat, with very high recurrence rates. These are universally acknowledged as referral level cases to be done largely by abdominal wall specialists.
When the gap between two six pack muscles of the abdomen is more than 2 cm, the shape of the belly may be cylindrical. This is called diastasis recti. In severe cases, the patient may have functional problems with urination, defecation and may also have low back pain. The condition is typically seen following pregnancy. Obese men also tend to have upper abdominal diastasis. Surgical treatment depends on whether there is an associated hernia, whether there are symptoms and only where the gap is more than 3 cm. A variety of approaches are used in diastasis, including open abdominoplasty (especially if there is a pendulous apron of fat hanging down from the belly), laparoscopic or robotic approaches with various names and acronyms like SCOLA, REPA, eTEP, etc. The use of mesh is typical, but not mandatory. Each case is treated differently.
1. Swelling in the groin or abdominal wall which increases on prolonged standing, coughing,
sneezing or even a good laugh!
2. Pinching or dull aching pain in the swelling.
3. Constant pulling sensation inside the abdomen.
4. Constipation or difficulty in passing urin.
5. Gross abnormality the the shape of the belly or private parts lead to embarrassment.
Although majority of the hernias remains symptom free there is always a chance that the gut may get trapped in the defect, leading to a life-threatening condition called strangulation. This is merely one extreme example of when and why hernias need treatment. In many patients, they cause significant discomfort and mobility restrictions, leading to an overall poor quality of life. In most cases, hernias are operated to improve the QOL. Hernias often tend to be progressive in size and trouble-making potential, and are known to become huge. Such conditions are labelled as giant hernias or 'loss of domain' hernias. These are particularly dangerous and need speciality approaches. These should not be underestimated, as many patients have lost their lives in attempts at surgery in centres not equipped to tackle the complex patient or by surgeons not trained and experienced in this particular niche.
There are no magic pills for hernias! Surgery is the only way out to treat a hernia.
In groin hernias, a space underneath the muscles is created so as to allow the placement of a large piece of synthetic or biosynthetic mesh that stays permanently in place and prevents the hernia from recurring. That said, there is an increasing fashion of using meshes that may be partially or completely absorbed in a couple of years or so. If you wish to know about the utility of such products in your particular case, take it up with your surgeon.
In ventral and incisional hernias, the defect is closed with stitches after the contents are safely placed back into the abdominal cavity. An appropriately large mesh is placed under or over the abdominal muscles. This protects the repair.
At present, laparo-endoscopic (keyhole) approaches have made recovery very quick, safe and pain free, with minimal hospital stay. To a large extent, laparoscopic surgery has helped reduce the fear involved with open surgery, e.g. long cuts, prolonged and severe pain, delayed recovery, loss of work and wages. Using a mesh is the standard of care in most cases.
As the size of the hernia increases, or if it occurs as a recurrence, more elaborate reconstruction techniques are employed, These procedures may take a long time to complete in the operating theatre, But that is a necessary right of passage for the complex hernia patient on the way to recovery!
Among the various operations currently employed by experts for the complex or recurrent hernia, the following may be particularly relevant or important:
1. eTEP Rives-Stoppa/TAR
2. Open preperitoneal ventral hernia repair (Heniford operation)
3. Fasciotens
4. Open TAR
5. Abdominoplasty
6. RoboTAR
These are by no means the complete list of procedures for the patient with a troublesome hernia. There are many others that may be called upon depending on the situation.
It is the hallmark of a hernia expert to be facile with most approaches (if not all) and know when to use a procedure and when not to. It is very important for the patient to understand the pros and cons of the operation being considered for him/her and the alternatives thereto.
There is no better way to get past this than to have a frank conversation with your surgeon.