Dr Tariq Jagnarine
Hernia is a common problem. It causes a localized bulge in the abdomen or groin. It can often be harmless and pain-free, but at times it can bring discomfort and pain.
They are usually straightforward to diagnose, simply by feeling and looking for the bulge. Treatment is a choice between watchful waiting and corrective surgery, either via an open or keyhole operation. Inguinal hernia surgery is more common in childhood and old age, while the likelihood of femoral hernia surgery increases throughout life.
A hernia occurs when there is a weakness or hole in the peritoneum, the muscular wall that usually keeps abdominal organs in place. This defect in the peritoneum allows organs and tissues to push through, or herniate, producing a bulge. The lump may disappear when the person lies down, and sometimes it can be pushed back into. Coughing may make it reappear.
TYPES
Hernias can commonly be found in the following areas:
• Groin: a femoral hernia creates a bulge just below the groin. This is more common in women. An inguinal hernia is more common in men. It is a bulge in the groin that may reach the scrotum.
• The upper part of the stomach: a hiatal or hiatus hernia is caused by the upper part of the stomach pushing out of the abdominal cavity and into the chest cavity through an opening in the diaphragm.
• Belly button: a bulge in this region is produced by an umbilical or periumbilical hernia.
• Surgical scar: past abdominal surgery can lead to an incisional hernia through the scar.
CAUSES
Apart from an incisional hernia (a complication of abdominal surgery), in most cases, there is no obvious reason for a hernia to occur. The risk of hernia increases with age and occurs more commonly in men than in women.
A hernia can be congenital (present at birth) or develop in children who have a weakness in their abdominal wall.
Activities and medical problems that increase pressure on the abdominal wall can lead to a hernia. These include:
• Being overweight or obese straining on the toilet (due to long-term constipation, for example)
• Persistent cough
• Cystic fibrosis
• enlarged prostate.
• Straining to urinate
• Abdominal fluid
• Lifting heavy items
• Peritoneal dialysis
• Poor nutrition
• Smoking
• Physical exertion
• Undescended testicles
SYMPTOMS
In many cases, a hernia is no more than a painless swelling that presents no problems and needs no immediate medical attention. A hernia may, however, be the cause of discomfort and pain, with symptoms often becoming worse when standing, straining, or lifting heavy items. Most people who notice increasing swelling or soreness eventually see a doctor.
In some cases, a hernia needs immediate surgery, for instance, when part of the gut becomes obstructed or strangulated by an inguinal hernia.
Immediate medical attention should be sought if an inguinal hernia produces acute abdominal complaints such as pain, nausea, vomiting, the bulge cannot be pushed back into the abdomen.
The swelling, in these cases, is typically firm and tender and cannot be pushed back up into the abdomen.
A hiatal hernia can produce symptoms of acid reflux, such as heartburn, which is caused by stomach acid getting into the esophagus.
TREATMENT
For a hernia without symptoms, the usual course of action is to watch and wait, but this can be risky for certain types of hernia, such as femoral hernias. Within 2 years of a femoral hernia being diagnosed, 40 percent result in bowel strangulation.
It remains unclear whether non-emergency surgery is worthwhile for hernia repair in cases of an inguinal hernia without symptoms that can be pushed back into the abdomen.
The American College of Surgeons and some other medical bodies consider elective surgery unnecessary in such cases, recommending instead a course of watchful waiting.
Others recommend surgical repair to remove the risk of later strangulation of the gut, a complication where blood supply is cut off to an area of tissue, which requires an emergency procedure.
These health authorities consider an earlier, routine operation preferable to a riskier emergency procedure.
A 2014 systematic review of 20 years of data on conventional open hernia repair (herniorrhaphy) and laparoscopic hernia repair (herniorrhaphy) in infants and children found that laparoscopic surgery is faster than open surgery for bilateral hernias, but that there is no significant difference in operating time for unilateral inguinal hernia repair. The rate of recurrence is similar for both types of procedures, but complications, such as wound infection, are more likely with open surgery, especially in infants.
