Causes of hernia Hernia occurs due to weakness or defect in the abdominal wall. The wall of the abdomen has areas which are potentially weak. Hernia develops at these weak areas due to continuous strain on the abdominal wall because of heavy exercises, persistent coughs, injury or after straining for urination or passing stools. Areas of weakness or defects in the abdominal wall may be natural or develop after an operation, injury or as a result of aging.
People at risk for developing Hernia Both men and women can get a hernia. Hernia can occur in a newborn child or develop over time. Many diseases cause an increase in intra-abdominal pressure and predispose to development of hernia. For example liver disease with ascites, constipation and chronic intestinal obstruction due to cancers, chronic coughs and chronic obstructive pulmonary disease, straining for micturition due to benign prostatic hypertrophy etc. Similarly pregnancy and abdominal operations cause stretching and weakening of abdominal wall and predispose to hernia.
Common types of hernia: There are different kinds of hernia which are managed based on similar basic surgical principles. The common types of hernia are inguinal hernia, femoral hernia, incisional hernia [ Ventral hernia], epigastric hernia, umbilical hernia, lumbar hernia, diaphragmatic hernia [ through the diaphragm], hiatus hernia and internal hernias.
Symptoms: Hernias cause a protrusion or swelling underneath the skin, in the abdomen or groin particularly on straining during urination, during straining for passing stools, or while lifting a heavy object. Sometimes there may be a sharp pain, a dull aching sensation or a feeling of fullness at the site of hernia. The complain will increase gradually and most patients develop complications sooner or later. If the hernia cannot be pushed back it may lead to dangerous complications. It often means that a part of the intestine has got trapped in the hernia. In such cases intestinal obstruction or strangulation or gangrene of the intestines can occur. When these complications occur the hernia becomes painful and the patient experiences abdominal pain, distension of abdomen and vomiting. Such complications require an urgent emergency surgery to save life. In internal hernias the intestines may protrude through a narrow orifice inside the abdomen and no swelling is visible to the patient. The patient only has complains of pain and vomiting.
Why hernia should be operated: Hernia patients are advised surgery for two main reasons.
[1] To relieve symptoms associated with hernia.
[2] The complications of hernia are adhesion formation, obstruction of intestines and strangulation with gangrene of bowels. All these are dangerous complications and pose significant risk for the patient. Hernia surgery is advised to prevent these life threatening complications.
Preoperative evaluation and preparation: Before undergoing any surgery a few tests are required to evaluate your fitness, risks and plan for anesthesia and operation. You need to have a few simple blood tests. Additional tests such as an x-ray of the chest, abdomen, ECG or ultrasonography of abdomen may also be needed. Imaging is important for detecting nonpalpable, unsuspected hernias, internal hernia and diaphragmatic hernias. Imaging with MRI or Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. Imaging also offers clear detail of the abdominal wall allowing planning of hernia surgery accurately.
Anesthesia: Generally, one of the following three forms of anesthesia is used:
[1] Local anesthesia: is suitable for many patients. This involves injection of a local anesthetic medicine at the site of operation. A sedative is also sometimes given to make the patient sleepy during the operation. The advantage of using local anesthesia is that the patient is usually able to go home the same day. This is also very useful in patients with medical illnesses like hypertension, heart disease, asthma, bronchitis or other major illness in whom a general or spinal anesthesia may be contraindicated.
[2] Spinal anesthesia: In this the lower part of the body is made numb by an injection given in the back. The patient has to remain in hospital for a day after spinal anesthesia.
[3] General anesthesia: The patient remains asleep during the operation under influence of anesthetic drugs. The patient has to remain in hospital for a day after general anesthesia. Patients who are anxious prefer to have general or a spinal anesthesia rather than local anesthesia.
Choices for operation: There are two types of operations widely accepted for repairing a hernia, the conventional open mesh hernioplasty and the laparoscopic hernia repair. The area of muscle weakness or defect in the abdominal wall is reinforced with a synthetic mesh. In both open and laparoscopic mesh hernioplasty a piece of surgical mesh is placed over the hernia defect and held in place with sutures or small surgical staples. In the past two decades, hernia surgery has gone through several advancements. With ample evidence that the use of mesh is associated with a reduced rate of recurrence, and with the availability of a variety of prosthetic meshes for the reinforcement of the defect or weakening of the abdominal wall, most surgeons now preferably perform tension free mesh repair.
Choice of mesh used for hernia repair: Although the use of traditional microporous or heavyweight polypropylene meshes in the last 2 decades have reduced the incidence of recurrence after hernia surgery to less than 1%, a major concern has been the formation of a rigid scar plate causing patient discomfort and chronic pain, impairing quality of life. More than 50% of patients with large mesh prosthesis in the abdominal wall complain of paresthesia, palpable stiff edges of the mesh, and physical restriction of abdominal wall mobility. The new light-weight, composite meshes offer a combination of thinner filament size, larger pore size, reduced mass, and a percentage of absorbable material. Thus, there is less foreign body implanted, the scar tissue has greater flexibility (with almost physiologic abdominal wall mobility), there are fewer patient complaints, and the patient's quality of life is better. For laparoscopic repair of incisional hernias multilayered proceed surgical mesh or dual mesh are used which are still more costly.
Open versus Laparoscopic mesh hernioplasty: In traditional open surgery an incision large enough to perform the surgery is given. Laparoscopic surgery is also known as minimally invasive surgery and requires one or more small incisions [5mm to 10 mm] for the camera and instruments to be inserted. The operation is then performed under telescopic image guidance seen on a monitor. Only after a thorough clinical evaluation your surgeon determines whether laparoscopic hernia repair is right for you. Any one procedure may not be best for all patients.
For inguinal and femoral hernias the Lichtenstein open tension-free mesh hernioplasty, performed under local anesthesia, is a time tested, safe, economical, quick and easy to perform operation. In addition, it carries fewer complications and has become the gold standard in open tension-free hernioplasties. The technical feasibility of open mesh hernioplasty in even the most complicated hernias and the excellent results achieved with the Lichtenstein repair has been evaluated in large series and this method has become popular among surgeons all around the world.
Laparoscopic inguinal hernia surgery is feasible in expert hands, but the learning curve for laparoscopic hernia repair is long (200-250 cases), the severity of complications is greater, detailed analyses of cost effectiveness are lacking, and long-term recurrence rates are not known. The role of laparoscopic inguinal hernia repair in treatment of an uncomplicated, unilateral hernia is still unresolved. Laparoscopic hernia surgery may not be technically feasible in very large size, irreducible or sliding hernias and the success of a laparoscopic surgery depends more on the surgeon's experience. However laparoscopic inguinal hernioplasty may offer specific benefits in some situations, such as recurrent hernia after conventional anterior open hernioplasty, bilateral hernias, and patients undergoing laparoscopy for other clean operative procedures. The cost of the laparoscopic operation is higher than the open procedure because of the specialized equipment and larger size of mesh used.
While open surgery is the preferred treatment for most patients with large incisional hernias [ventral hernia], laparoscopic surgery may be feasible in smaller incisional hernias and umbilical hernias.
Postoperative care: Patient is asked to rest for few hours. He or she may be discharged on the same day on a day care basis. Early mobilization is the key to rapid convalescence. If general or regional anesthesia is used, the patient may be hospitalized for few days. There is some pain in the postoperative period, and suitable analgesics should be prescribed. The dressing is removed on the fifth postoperative day, and stitches are removed on seventh postoperative day. Light work can be resumed after a week and heavier jobs after 6 weeks. With the routine use of mesh for hernia surgery recurrence rate has come down to less than 1%. Although some recurrences occur early cases may be reported many years later. A thorough clinical evaluation, high degree of suspicion and a diligent follow up for a long period is advised to keep track of recurrences. Patients with chronic pain, postoperative neuralgia, paresthesias, neurapraxia, or hyperasthesia for more than 6 months after surgery should be referred for further evaluation.
