Incisional hernia repair

Definition

Incisional hernia repair is a surgical procedure performed to correct an incisional hernia. An incisional hernia, also called a ventral hernia, is a bulge or protrusion that occurs near or directly along a prior abdominal surgical incision. The surgical repair procedure is also known as incisional or ventral herniorrhaphy.

Purpose

Incisional hernia repair is performed to correct a weakened area that has developed in the scarred muscle tissue around a prior abdominal surgical incision, occurring as a result of tension (pulling in opposite directions) created when the incision was closed with sutures, or by any other condition that increases abdominal pressure or interferes with proper healing.

Demographics

Because incisional hernias can occur at the site of any type of abdominal surgery previously performed on a wide range of individuals, there is no outstanding profile of an individual most likely to have an incisional hernia. Men, women, and children of all ages and ethnic backgrounds may develop an incisional hernia after abdominal surgery. Incisional hernia occurs more commonly among adults than among children.

Description

An incisional hernia can develop in the scar tissue around any surgery performed in the abdominal area, from the breastbone down to the groin. Depending upon the location of the hernia, internal organs may press through the weakened abdominal wall. The rate of incisional hernia occurrence can be as high as 13%

with some abdominal surgeries. These hernias may occur after large surgeries such as intestinal or vascular (heart, arteries, and veins) surgery, or after smaller surgeries such as an appendectomy or a laparoscopy , which typically requires a small incision at the navel. Incisional hernias themselves can be very small or large and complex, involving growth along the scar tissue of a large incision. They may develop months after the surgery or years after, usually because of inadequate healing or excessive pressure on an abdominal wall scar. The factors that increase the risk of incisional hernia are conditions that increase strain on the abdominal wall, such as obesity, advanced age, malnutrition, poor metabolism (digestion and assimilation of essential nutrients), pregnancy, dialysis, excess fluid retention, and either infection or hematoma (bleeding under the skin) after a prior surgery.

Tension created when sutures are used to close a surgical wound may also be responsible for developing an incisional hernia. Tension is known to influence poor healing conditions because of related swelling and wound separation. Tension and abdominal pressure are greater in people who are overweight, creating greater risk of developing incisional hernias following any abdominal surgery, including surgery for a prior inguinal (groin) hernia. People who have been treated with steroids or chemotherapy are also at greater risk for developing incisional hernias because of the affect these drugs have on the healing process.

The first symptom a person may have with an incisional hernia is pain, with or without a bulge in the abdomen at or near the site of the original surgery. Incisional hernias can increase in size and gradually produce more noticeable symptoms. Incisional hernias may or may not require surgical treatment.

The effectiveness of surgical repair of an incisional hernia depends in part on reducing or eliminating tension at the surgical wound. The tension-free method used by many medical centers and preferred by surgeons who specialize in hernia repair involves the permanent placement of surgical (prosthetic) steel or polypropylene mesh patches well beyond the edges of the weakened area of the abdominal wall. The mesh is sewn to the area, bridging the hole or weakened area beneath it. As the area heals, the mesh becomes firmly integrated into the inner abdominal wall membrane (peritoneum) that protects the organs of the abdomen. This method creates little or no tension and has a lower rate of hernia recurrence, as well as a faster recovery with less pain. Incisional hernias recur more frequently when staples are used rather than sutures to secure mesh to the abdominal wall. Autogenous tissue (skin from the patient's own body) has also been used for this type of repair.

Two surgical approaches are used to treat incisional hernias: either a laporoscopic incisional herniorrhaphy, which uses small incisions and a tube-like instrument with a camera attached to its tip; or a conventional open repair procedure, which accesses the hernia through a larger abdominal incision. Open procedures are necessary if the intestines have become trapped in the hernia (incarceration) or the trapped intestine has become twisted and its blood supply cut off (strangulation). Extremely obese patients may also require an open procedure because deeper layers of fatty tissue will have to be removed from the abdominal wall. Mesh may be used with both types of surgical access.

Minimally invasive laporoscopic surgery has been shown to have advantages over conventional open procedures, including:

• reduced hospital stays
• reduced postoperative pain
• reduced wound complications
• reduced recovery time

Surgical procedure

In both open and laparoscopic procedures, the patient lies on the operating table, either flat on the back or on the side, depending on the location of the hernia. General anesthesia is usually given, though some patients may have local or regional anesthesia, depending on the location of the hernia and complexity of the repair. A catheter may be inserted into the bladder to remove urine and decompress the bladder. If the hernia is near the stomach, a gastric (nose or mouth to stomach) tube may be inserted to decompress the stomach.

In an open procedure, an incision is made just large enough to remove fat and scar tissue from the abdominal wall near the hernia. The outside edges of the weakened hernial area are defined and excess tissue removed from within the area. Mesh is then applied so that it overlaps the weakened area by several inches (centimeters) in all directions. Non-absorbable sutures (the kind that must be removed by the doctor) are placed into the full thickness of the abdominal wall. The sutures are tied down and knotted.

In the less-invasive laparoscopic procedure, two or three small incisions will be made to access the hernia site—the laparoscope is inserted in one incision and surgical instruments in the others to remove tissue and place the mesh in the same fashion as in an open procedure. Significantly less abdominal wall tissue is removed in laparoscopic repair. The surgeon views the entire procedure on a video monitor to guide the placement and suturing of mesh.

Diagnosis/Preparation

Diagnosis

Reviewing the patient's symptoms and medical history are the first steps in diagnosing an incisional hernia. All prior surgeries will be discussed. The doctor will ask how much pain the patient is experiencing, when it was first noticed, and how it has progressed. The doctor will palpate (touch) the area, looking for any abnormal bulging or mass, and may ask the patient to cough or strain in order to see and feel the hernia more easily. To confirm the presence of the hernia, an ultrasound examination or other scan such as computed tomography (CT) may be performed. Scans will allow the doctor to visualize the hernia and to make sure that the bulge is not another type of abdominal mass such as a tumor or enlarged lymph gland. The doctor will be able to determine the size of the defect and whether or not surgery is an appropriate way to treat it. A referral to a surgeon will be made if the doctor believes that medical treatment will not effectively correct the incisional hernia.

Preparation

Many months before the surgery, the patient's doctor may advise weight loss to help reduce the risks of surgery and to improve the surgical results. Control of diabetes and smoking cessation are also recommended for a better surgical result. Close to the time of the scheduled surgery, the patient will have standard preoperative blood and urine tests, an electrocardiogram, and a chest x ray to make sure that heart and lungs and major organ systems are functioning well. A week or so before surgery, medications may be discontinued, especially aspirin or anticoagulant (blood-thinning) drugs. Starting the night before surgery, patients must not eat or drink anything. Once in the hospital, a tube may be placed into a vein in the arm (intravenous line) to deliver fluid and medication during surgery. The patient will be given a preoperative injection of antibiotics before the procedure. A sedative may be given to relax the patient.

Aftercare

Immediately after surgery, the patient will be observed in a recovery area for several hours, for monitoring of body temperature, pulse, blood pressure, and heart function, as well as observation of the surgical wound for undue bleeding or swelling. Patients will usually be discharged on the day of the surgery; only more complex hernias such as those with incarcerated or strangulated intestines will require overnight hospitalization. Some patients may have prolonged suture-site pain, which may be treated with pain medication or anti-inflammatory drugs. Antibiotics may be prescribed to help prevent postoperative infection.

Once the patient is home, the hernia repair site must be kept clean, and any sign of swelling or redness reported to the surgeon. Patients should also report a fever or any abdominal pain. Outer sutures may have to be removed by the surgeon in a follow-up visit about a week after surgery. Activities may be limited to non-strenuous movement for up to two weeks, depending on the type of surgery performed. To allow proper healing of muscle tissue, hernia repair patients should avoid heavy lifting for at least six to eight weeks after surgery, or longer as advised.

Risks

Long-term complications seldom occur after incisional hernia repair. Short-term risks are greater with obese patients or those who have had multiple earlier operations or the prior placement of mesh patches. The risk of complications has been shown to be about 13%. The risk of recurrence and repeat surgery is as high as 52%, particularly with open procedures or those using staples rather than sutures for wound closure. Some of the factors that cause incisional hernias to occur in the first place, such as obesity and nutritional disorders, will persist in certain patients and encourage the development of a second incisional hernia and repeat surgery. Each subsequent time, the surgery will become more difficult and the risk of complications greater. Postoperative infection is higher with open procedures than with laparoscopic procedures.

Postoperative complications may include:

• fluid buildup at the site of mesh placement, sometimes requiring aspiration (draining off)
• postoperative bleeding, though seldom enough to require repeat surgery
• prolonged suture pain, treated with pain medication or anti-inflammatory drugs
• intestinal injury
• nerve injury
• fever, usually related to surgical wound infection
• intra-abdominal (within the abdominal wall) abscess
• urinary retention
• respiratory distress

Normal results

Good outcomes are expected with incisional hernia repair, particularly with the laparoscopic method. Patients will usually go home the day of surgery and can expect a one- to two-week recovery period at home, and then a return to normal activities. The American College of Surgeons reports that recurrence rates after the first repair of an incisional hernia range from 25–52%. Recurrence is more frequent when conventional surgical wound closure with standard sutures (stitches) is used. Recurrence after open procedures has been shown to be less likely when mesh is used, although complications, especially infection, have been shown to increase because of the larger abdominal incisions. Laparoscopy with mesh has shown rates of recurrence as low as 3.4%, with fewer complications as well.

Morbidity and mortality rates

Deaths are not reported resulting directly from the performance of herniorrhaphy for incisional hernia.

Alternatives

The alternatives to first-time and recurrent incisional hernia repair begin with preventive measures such as:

• Losing weight; maintaining suitable weight for age and height.
• Strengthening abdominal muscles through regular moderate exercise such as walking, tai chi, yoga, or stretching exercises and gentle aerobics.
• Reducing abdominal pressure by avoiding constipation and the buildup of excess body fluids, achieved by adopting a high-fiber, low-salt diet.
• Learning to lift heavy objects in a safe, low-strain way using arm and leg muscles.
• Controlling diabetes and poor metabolism with regular medical care and dietary changes as recommended.
• Eating a healthy, balanced diet of whole foods, high in essential nutrients, including whole grains, fruits and vegetables, limited meat and dairy, and eliminating prepared and refined foods.

See also Femoral hernia repair; Inguinal hernia repair.

Resources

books

Maddern, Guy J. Hernia Repair: Open vs. Laparoscopic Approaches. London: Churchill Livingstone, 1997.

organizations

American College of Surgeons (ACS), Office of Public Information. 633 North Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5000. <http://www.facs.org>.

The National Digestive Diseases Information Clearinghouse (NIDDK). 2 Information Way, Bethesda, MD 20892-3570. <http://www.niddk.nih.gov/health/digest/nddic.htm>.

other

"Focus on Men's Health: Hernia." January 2003. MedicineNet Home. <http://www.medicinenet.com>.

Incisional and Ventral Hernias (Patient Information). Central Montgomery Medical Center, Outpatient Surgery Department. 2100 N. Broad Street, Lansdale, PA 19446. (215) 368-1122.

L. Lee Culvert

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Incisional hernia repair is performed in a hospital operating room or a one-day surgical center by a general surgeon who may specialize in hernia repair procedures.

QUESTIONS TO ASK THE DOCTOR

• What procedure will be performed to correct my hernia?
• What is your experience with this procedure? How often do you perform this procedure?
• Why must I have the surgery?
• What are my options if I do not have the surgery?
• How can I expect to feel after surgery?
• What are the risks involved in having this surgery?
• How quickly will I recover? When can I return to school or work?
• What are my chances of having this type of hernia again?
• What can I do to avoid getting this type of hernia again?

Hernia

Definition

A hernia is the protrusion of an organ through the structure or muscle that usually contains it.

Description

There are many different types of hernias in children. The most common are direct inguinal hernias, indirect inguinal hernias, and umbilical hernias. A direct inguinal hernia occurs when a small section of bowel herniates, or protrudes, through the groin muscle. Indirect inguinal hernia occurs when part of the bowel protrudes through the muscles of the groin into a sac left over from fetal development. An umbilical hernia occurs when a portion of the bowel protrudes through a small defect in the abdominal wall muscle near where the umbilical cord attaches to the baby's abdomen. More serious defects involving herniation of abdominal contents outside the infant's body are omphalocele and gastroschisis. These are not a result of an organ protruding through weakened muscle tissue but rather are a result of a much larger defect of the muscles of the abdomen that causes the internal organs to develop outside the body. Omphalocele and gastroschisis are considered abdominal wall defects and are not called hernias.

While an umbilical hernia usually resolves spontaneously as the abdominal muscles grow and requires no further treatment, in children with direct and indirect inguinal hernia, surgery is almost always required to prevent the herniated bowel from becoming incarcerated or strangulated. When an inguinal hernia is incarcerated, the bowel becomes swollen and trapped outside the body. If the hernia remains incarcerated for too long, strangulation can occur. In strangulation, the blood supply to the section of bowel that has herniated is cut off, and the tissue begins to die. When this happens, the intestines cannot function properly and are said to be obstructed. If the bowel perforates, or develops a hole in it, emergency surgery is required to repair the intestine and prevent infection.

A more severe, but less common, hernia is a diaphragmatic hernia. This occurs inside the body when the diaphragm, the large muscle that separates the abdominal cavity from the chest cavity, fails to develop fully. In children with diaphragmatic hernia, the contents of the abdomen protrude into the chest cavity. These children may have difficulty breathing. During fetal development the presence of abdominal organs in the fetal chest cavity prevents the lungs from growing normally. A diaphragmatic hernia can occur as an isolated defect or as part of a more complex syndrome. Children with diaphragmatic hernias are usually very ill and require immediate treatment after birth. Some of these children have other defects such as cardiac anomalies, chromosomal abnormalities, kidney and genital anomalies, and neural tube defects, such as spina bifida .

Demographics

Estimates of the true incidence of inguinal hernias vary, but they may affect 1–5 percent of all births in the United States. International rates appear to be similar. Males are more than seven times more likely to have an inguinal hernia than females, and premature infants are more likely than full term infants to have inguinal hernias and to have incarcerated hernias. While inguinal hernias seem to affect all racial groups at the same rate, umbilical hernias occur more frequently in African Americans.

Diaphragmatic hernias occur in approximately one in every 3,000 births. These hernias do not seem to affect any race or nationality more than another.

Causes and symptoms

A direct inguinal hernia is caused when the muscles of the floor of the groin area are weak and allow the bowel to press through. An indirect inguinal hernia is caused when remnants of early fetal genital development stay within the body after this development is complete. In early fetal development male and female genitalia are identical. At around the seventh week of gestation, the gonads (sex organs) begin to change, or differentiate, into the characteristic genitalia of males and females. Males develop testes, and females develop ovaries. During this process, in some fetuses, a small sac may form near the genitalia. Most often the opening to this sac, called the processus vaginalis, closes. However, in children with inguinal hernia, this sac remains patent, or open, becoming a container into which bowels may be herniated.

The main symptom of inguinal hernias (both direct and indirect) in infants is an obvious bulge in the groin in the inguinoscrotal region (near the scrotum) in boys and in the inguinolabial (near the labia) in girls. The bulge may or may not be painful. It will usually appear after straining or crying and then disappear after a period of time. If the hernia has incarcerated, the infant will be in obvious pain , appearing fussy, crying, and refusing to eat. The skin over the hernia may be discolored and swollen.

Umbilical hernia is caused by a small defect in the muscles of the abdominal wall. These hernias are usually small and have no symptoms other than a small protrusion near the base of the umbilical cord.

Like inguinal hernias, diaphragmatic hernias are caused early in fetal development. The structures that form the diaphragm do not properly form, allowing the contents of the lower abdomen to migrate up near the heart and lungs. The increased pressure these organs place on the lungs causes the lungs to remain small and underdeveloped. When the infant is born and must breathe air, the lungs are not able to work properly.

Children with diaphragmatic hernia have the following symptoms immediately after birth: breathing difficulty, a bluish skin color (cyanosis), rapid breathing, rapid heat rate, and asymmetrical chests—one side is not the same size as the other. These infants are often critically ill and are be placed on a ventilator—a machine to help them breath. Because the lungs have not had enough room to grow and are small, doctors must stabilize the baby's breathing before the hernia can be repaired.

When to call the doctor

If a small child, especially an infant, has a bulge in the abdominal or groin area, the child's pediatrician should be consulted. If the child is in severe pain, and the skin is discolored or swollen, medical help should be sought immediately.

Diagnosis

Umbilical and inguinal hernias are diagnosed by physical examination. For some children with inguinal hernia, a laparoscopic examination may be performed. A laparoscopy is an exploratory surgical procedure in which the doctor makes an incision and inserts a small tube connected to a camera to view the herniated area. This procedure is used most often in patients who have already had one hernia repair to see if the hernia has returned in a new location.

Diaphragmatic hernia may be diagnosed while the fetus is still in the womb using prenatal ultrasonography. After birth, physical symptoms of respiratory distress, cyanosis, and chest asymmetry can indicate the presence of a diaphragmatic hernia. In children with less severe diaphragmatic hernias, the diagnosis may be made later in childhood if the child develops intestinal obstructions . An x ray showing bowel loops within the chest cavity confirms the diagnosis.

Treatment

Umbilical hernia is generally a benign condition that will resolve spontaneously as the muscles of the abdomen grow. No treatment is usually required. For children in whom the umbilical hernia does not resolve, surgery is not usually performed until after the age of five. The only treatment necessary is observation of the hernia during routine physical examinations.

The standard treatment for inguinal hernias is a surgical repair called herniorrhaphy. Unlike umbilical hernias, inguinal hernias do not resolve spontaneously. Because of the risk of incarceration and strangulation, most doctors prefer to repair these hernias as soon after the initial diagnosis as possible. Herniorrhaphies are performed as an outpatient procedure in otherwise healthy full-term infants and children.

Prior to repair surgery, parents may be taught how to apply pressure to the hernia, thereby reducing it temporarily and preventing incarceration. If the hernia has already become incarcerated, the doctor will attempt to force the hernia out of the sac and back into the body manually. This process is called manual reduction. With the child on his back, the doctor will use his fingers to press the hernia back into the body. If successful, manual reduction relieves the child's pain and prevents strangulation until surgery can be scheduled. Repair surgery is usually performed within 72 hours. If an incarcerated hernia is not reducible, surgery must be performed much sooner to prevent strangulation. If strangulation occurs, emergency surgery is the only treatment.

Treatment for diaphragmatic hernia involves treatment of the other accompanying health issues. First and foremost, the infant's respiratory distress must be addressed. Most newborns with diaphragmatic hernias require intubation and ventilation. A tube is inserted through the mouth into the throat, and breathing is assisted by a ventilation machine. A feeding tube may be inserted through the nose and into the stomach to insure the infant receives sufficient nutrition . After the infant is stabilized, surgery to repair the hernia is performed. In diaphragmatic hernia repair surgery, the herniated abdominal organs are forced back into their proper position within the abdomen. If the bowels are injured or malrotated, this will be repaired, and the hole in the diaphragm is sewn closed and patched, if necessary, with surgical mesh.

Prognosis

If diagnosed early in childhood, the prognosis for children who have had a surgically repaired inguinal hernia is excellent. Occasionally there are complications associated with inguinal hernias including death, but these are rare, occurring most often in children who were diagnosed later in childhood or whose hernias were strangulated.

The prognosis for children with diaphragmatic hernia depends on the extent of the defects of the lungs and the impact of the treatments necessary to save their lives. Children with diaphragmatic hernias have an increased incidence of chromic lung disease. These children also have an increased risk for slow growth and development. The survival rate of these children is also related to the other anomalies these children may have. If the diaphragmatic hernia is part of a syndrome, the other birth defects may be life threatening. The survival rate after surgical repair of a diaphragmatic hernia is 60–80 percent.

Prevention

The exact cause of umbilical hernias, inguinal hernias, and diaphragmatic hernias is as of 2004 unknown. Until a cause is discovered, no prevention is available.

Parental concerns

Prior to surgery, parents of a child with an inguinal hernia can be taught to apply pressure to the hernia, preventing incarceration. Parents should be aware of the circumstances under which to seek immediate medical attention for their child.

KEY TERMS

Herniorrhaphy —Surgical repair of a hernia.

Incarcerated hernia —A hernia of the bowel that can not return to its normal place without manipulation or surgery.

Laparoscopy —A surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube (laparoscope) is inserted. This allows the doctor to examine abdominal and pelvic organs. Other small incisions can be mad to insert instruments to perform procedures. Laparoscopy is done to diagnose conditions or to perform certain types of surgeries.

Reducible hernia —A hernia that can be gently pushed back into place or that disappears when the person lies down.

Strangulated hernia —A hernia that is so tightly incarcerated outside the abdominal wall that the intestine is blocked and the blood supply to that part of the intestine is cut off.

Ultrasonography —A medical test in which sound waves are directed against internal structures in the body. As sound waves bounce off the internal structure, they create an image on a video screen. Ultrasonography is often used to diagnose fetal abnormalities, gallstones, heart defects, and tumors. Also called ultrasound imaging.

See also Abdominal wall defects.

Resources

BOOKS

Hernia Repair: Medical Dictionary, Bibliography, and Annotated Research Guide to Internet Research. San Diego, CA: Icon Group International, 2004.

LeBlanc, Karl, et al. Laproscopic Hernia Surgery: An Operative Guide. Oxford, UK: Oxford University Press, 2003.

Official Patient's Sourcebook on Inguinal Hernia. San Diego, CA: Icon Group International, 2002.

Parker, James, et al. Hernia: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet Research. Boulder, CO: netLibrary, 2003.

Rudolph, Colin D., and Abraham M. Rudolph, eds. Rudolph's Pediatrics, 21st ed. New York: McGraw-Hill, 2003, pp. 24–34, 36.

WEB SITES

Hebra, Audre. "Pediatric Hernias." eMedicine, August 2, 2004. Available online at <www.emedicine.com/ped/topic2559.htm> (accessed November 21, 2004).

Lewis, Nicola and Philip L. Glick. "Diaphragmatic Hernias." eMedicine, October 8, 2004. Available online at <www.emedicine.com/ped/topic2937.htm> (accessed November 21, 2004).

Deborah L. Nurmi, MS

Umbilical hernia repair

Definition

An umbilical hernia repair is a surgical procedure performed to fix a weakness in the abdominal wall or to close an opening near the umbilicus (navel) that has allowed abdominal contents to protrude. The abdominal contents may or may not be contained within a membrane or sac. The medical name for a hernia repair is herniorraphy.

Purpose

Umbilical hernias are usually repaired either to relieve discomfort or to prevent complications. It is not always necessary to fix an umbilical hernia. If the person is not in pain, the hernia is often not repaired. Complications may develop if pressure inside the abdomen resulting from daily activity pushes the abdominal contents further through the opening. They may then become twisted or strangulated. Strangulation is a condition in which the circulation to a section of the intestine (or other part of the body) is cut off by compression or constriction; it can cause extreme pain. If the strangulation persists, the tissue can die from lack of blood supply and lead to an infection.

Demographics

An umbilical hernia can occur in both men and women, and can occur at any age, although it is often present at birth. Umbilical hernias are found in about 20% of newborns, especially in premature infants. Umbilical hernias are more common in male than in female infants; with regard to race, they are eight times more common in African Americans than in Caucasians or Hispanics. While umbilical hernia is not a genetically determined condition, it tends to run in families. In the adult population, umbilical hernias are more common in overweight persons with weak abdominal muscles, and in women who are either pregnant or have borne many children. People with liver disease or fluid in the abdominal cavity are also at higher risk of developing an umbilical hernia.

Description

Repair of an abdominal hernia involves a cut, or incision, in the umbilical area. Most herniorrhaphies take about two hours to complete. After the patient has been given a sedative, the anesthesiologist will administer a local, spinal, or general anesthetic. The type of anesthesia used depends on the patient's age, general health, and complexity of the procedure. The incision is usually made underneath the belly button. The herniated tissues are isolated and pushed back inside the abdominal cavity. A hernia repair may be done using traditional open surgery or with a laparoscope. A laparoscopic procedure is performed through a few very small incisions. The hole in the abdominal wall may be closed with sutures, or by the use of a fine sterile surgical mesh. The mesh provides additional strength. Some surgeons may choose to use the mesh when repairing a larger hernia. A hernia repair done with a mesh insert is called a tension-free procedure because the surgeon does not have to put tension on the layer of muscle tissue in order to bring the edges of the hole together.

Diagnosis/Preparation

Diagnosis

In children, umbilical hernias are often diagnosed at birth, usually when the doctor feels a lump in the area around the belly button. The hernia may also be diagnosed if the child is crying from pain, because the crying will increase the pressure inside the abdomen and make the hernia more noticeable.

Umbilical hernias in adults occur more often in pregnant women and obese persons with weak stomach muscles. They may develop gradually without producing any discomfort, but the patient may see a bulge in the abdomen while bathing or getting dressed. Other patients consult their doctor because they have felt the tissues in the abdomen suddenly give way when they are having a bowel movement. In an office examination, the patient may be asked to lie down, lift the head, and cough. This action increases pressure inside the abdomen and causes the hernia to bulge outward.

A hernia that has become incarcerated or strangulated is a medical emergency. Its symptoms include:

• nausea
• vomiting
• abdominal swelling or distension
• pale complexion
• weakness or dizziness
• extreme pain

When a hernia is present at birth, some surgeons may opt for a "wait and see" approach, as umbilical hernias in children often close by themselves with time. If the hernia has not closed by the time the child is three or four years old, then surgery is usually considered. If the hernia is very large, surgery may be recommended.

Repair of an umbilical hernia in an adult is usually considered elective surgery . The patient's surgeon may recommend the procedure, however, on the grounds that hernias in adults do not close by themselves and tend to grow larger over time.

Preparation

Adults scheduled for a herniorraphy are given standard blood tests and a urinalysis . They should not eat breakfast on the morning of the procedure, and they should wear loose-fitting, comfortable clothing that they can easily pull on after the surgery without straining their abdomen.

Aftercare

Aftercare will depend in part on the invasiveness of the surgery, whether laparoscopic or open; the type of anesthesia; the patient's age; and his or her general medical condition. Immediately after the procedure, the person will be taken to the recovery area of the surgical center, where nurses will monitor the patient for signs of excessive bleeding, infection, uncontrolled pain, or shock. Hernia repairs are usually performed on an outpatient basis, which means that the patient can expect to go home within a few hours of the surgery. Adult patients, however, should arrange to have a friend or relative drive them home. If possible, someone should stay with them for the first night.

The nurses will provide the patient with instructions on incision care . The specific instructions will depend on the type of surgery and the way in which the incision was closed. Sometimes a see-through dressing is placed on the wound that the patient can remove about three days after the procedure. It may be necessary to keep the dressing dry until some healing has taken place. Very small incisions may be closed with Steri-strips rather than sutures.

Risks

There are surgical and anesthesia-related risks with all surgical procedures. The primary surgical risks include bleeding and infection. Anesthesia-related risks include reactions to the specific anesthetic agents that are used; interactions with over-the-counter and herbal preparations; and respiratory problems. The greatest risk associated with umbilical hernia is missing the diagnosis. Additional risks include the formation of scar tissue and recurrence of the hernia.

Normal results

Umbilical hernia repair is usually considered an uncomplicated procedure with a relatively short recovery period. A study reported in the December 2002 issue of the American Journal of Surgery found that patients who had laparoscopic surgery with the use of a surgical mesh had fewer complications and reoccurrences of a hernia than those with the traditional open surgery. However, laparoscopic surgery took somewhat longer to perform, possibly because the laparoscopic approach is often used for larger repairs.

Morbidity and mortality rates

In general, there are few complications with hernia repair in children. The most serious complication is surgical injury to the bladder or intestine; fortunately, this complication is very rare—about one in 1000 patients. The recurrence rate is between 1% and 5%; recurrence is more likely in patients with very large hernias. The rate of infection is less than 1%. In the adult population, a November 2001 study reported in the American Journal of Surgery found a 5% mortality in elderly patients undergoing emergency hernia repairs.

Alternatives

There are no medical or surgical alternatives to an umbilical hernia repair other than watchful waiting. Since umbilical hernias present at birth often close on their own, intervention can often be delayed until the child is several years old. There is some risk that the hernia will enlarge, however, which increases the risk of incarceration or strangulation.

Resources

books

"Congenital Anomalies: Gastrointestinal Defects." Section 19, Chapter 261 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Delvin, David. Coping with a Hernia. London, UK: Sheldon Press, 1998.

periodicals

Manthey, David, MD. "Hernias." eMedicine, June 22, 2001 [June 6, 2003]. <www.emedicine.com/EMERG/topic251.htm>.

Wright, B.E., et al. "Is Laparoscopic Umbilical Hernia Repair with Mesh a Reasonable Alternative to Conventional Repair?" American Journal of Surgery 184 (December 2002): 505-508.

organizations

American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000. <www.aafp.org>. E-mail: fp@aafp.org

American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. (847) 434-4000; FAX: (847) 434-8000. <www.aap.org>. E-mail: kidsdoc @aap.org

American College of Surgeons. 633 North St. Clair Street, Chicago, IL 60611-3231. (312) 202-5000; FAX: (312) 202-5001. <www.facs.org>.

other

American College of Surgeons. About Hernia Repair. <www.facs.org/public_info/operation/hernrep.pdf>.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

This procedure is performed by a general surgeon or a pediatric surgeon. It is usually performed on an outpatient, or ambulatory, basis in a hospital. After a few hours of recovery in the surgical center, the patient is able to return home.

QUESTIONS TO ASK THE DOCTOR

• How soon can my child return to normal activities?
• How soon can I return to work and my other normal activities?
• When can I drive?
• What should I do to take care of the incision?
• How many times have you performed this surgery?
• What kinds of complications are there to this procedure?
• What kinds of complications have your patients experienced?

Hernia

Definition

Hernia is a general term used to describe a bulge or protrusion of an organ through the structure or muscle that usually contains it.

Description

There are many different types of hernias. The most familiar type are those that occur in the abdomen, in which part of the intestines protrude through the abdominal wall. This may occur in different areas and, depending on the location, the hernia is given a different name.

An inguinal hernia appears as a bulge in the groin and may come and go depending on the position of the person or their level of physical activity. It can occur with or without pain. In men, the protrusion may descend into the scrotum. Inguinal hernias account for 80% of all hernias and are more common in men.

Femoral hernias are similar to inguinal hernias but appear as a bulge slightly lower. They are more common in women due to the strain of pregnancy.

A ventral hernia is also called an incisional hernia because it generally occurs as a bulge in the abdomen at the site of an old surgical scar. It is caused by thinning or stretching of the scar tissue, and occurs more frequently in people who are obese or pregnant.

An umbilical hernia appears as a soft bulge at the navel (umbilicus). It is caused by a weakening of the area or an imperfect closure of the area in infants. This type of hernia is more common in women due to pregnancy, and in Chinese and black infants. Some umbilical hernias in infants disappear without treatment within the first year.

A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the muscle that separates the chest from the abdomen (the diaphragm). This type of hernia occurs more often in women than in men, and it is treated differently from other types of hernias.

Causes and symptoms

Most hernias result from a weakness in the abdominal wall that either develops or that an infant is born with (congenital). Any increase in pressure in the abdomen, such as coughing, straining, heavy lifting, or pregnancy, can be a considered causative factor in developing an abdominal hernia. Obesity or recent excessive weight loss, as well as aging and previous surgery, are also risk factors.

Most abdominal hernias appear suddenly when the abdominal muscles are strained. The person may feel tenderness, a slight burning sensation, or a feeling of heaviness in the bulge. It may be possible for the person to push the hernia back into place with gentle pressure, or the hernia may disappear by itself when the person reclines. Being able to push the hernia back is called reducing it. On the other hand, some hernias cannot be pushed back into place, and are termed incarcerated or irreducible.

A hiatal hernia may also be caused by obesity, pregnancy, aging, or previous surgery. About 50% of all people with hiatal hernias do not have any symptoms. If symptoms exist they will include heartburn, usually 30-60 minutes following a meal. There may be some mid chest pain due to gastric acid from the stomach being pushed up into the esophagus. The pain and heartburn are usually worse when lying down. Frequent belching and feelings of abdominal fullness may also be present.

Diagnosis

Generally, abdominal hernias need to be seen and felt to be diagnosed. Usually the hernia will increase in size with an increase in abdominal pressure, so the doctor may ask the person to cough while he or she feels the area. Once a diagnosis of an abdominal hernia is made, the doctor will usually send the person to a surgeon for a consultation. Surgery provides the only cure for a hernia through the abdominal wall.

With a hiatal hernia, the diagnosis is based on the symptoms reported by the person. The doctor may then order tests to confirm the diagnosis. If a barium swallow is ordered, the person drinks a chalky white barium solution, which will help any protrusion through the diaphragm show up on the x ray that follows. Currently, a diagnosis of hiatal hernia is more frequently made by endoscopy. This procedure is done by a gastroenterologist (a specialist in digestive diseases). During an endoscopy the person is given an intravenous sedative and a small tube is inserted through the mouth, then into the esophagus and stomach where the doctor can visualize the hernia. The procedure takes about 30 minutes and usually causes no discomfort. It is done on an outpatient basis.

Treatment

Once an abdominal hernia occurs it tends to increase in size. Some patients with abdominal hernias wait and watch for a while prior to choosing surgery. In these cases, they must avoid strenuous physical activity such as heavy lifting or straining with constipation. They may also wear a truss, which is a support worn like a belt to keep a small hernia from protruding. People can tell if their hernia is getting worse if they develop severe constant pain, nausea and vomiting, or if the bulge does not return to normal when lying down or when they try to gently push it back in place. In these cases they should consult with their doctor immediately. But, ultimately, surgery is the treatment in almost all cases.

There are risks to not repairing a hernia surgically. Left untreated, a hernia may become incarcerated, which means it can no longer be reduced or pushed back into place. With an incarcerated hernia the intestines become trapped outside the abdomen. This could lead to a blockage in the intestine. If it is severe enough it may cut off the blood supply to the intestine and part of the intestine might actually die.

When the blood supply is cut off, the hernia is termed "strangulated." Because of the risk of tissue death (necrosis) and gangrene, and because the hernia can block food from moving through the bowel, a strangulated hernia is a medical emergency requiring immediate surgery. Repairing a hernia before it becomes incarcerated or strangulated is much safer than waiting until complications develop.

Surgical repair of a hernia is called a herniorrhaphy. The surgeon will push the bulging part of the intestine back into place and sew the overlying muscle back together. When the muscle is not strong enough, the surgeon may reinforce it with a synthetic mesh.

Surgery can be done on an outpatient basis. It usually takes 30 minutes in children and 60 minutes in adults. It can be done under either local or general anesthesia and is frequently done with a laparoscope. In this type of surgery, a tube that allows visualization of the abdominal cavity is inserted through a small puncture wound. Several small punctures are made to allow surgical instruments to be inserted. This type of surgery avoids a larger incision.

A hiatal hernia is treated differently. Medical treatment is preferred. Treatments include:

• avoiding reclining after meals
• avoiding spicy foods, acidic foods, alcohol, and tobacco
• eating small, frequent, bland meals
• eating a high-fiber diet.

There are also several types of medications that help to manage the symptoms of a hiatal hernia. Antacids are used to neutralize gastric acid and decrease heartburn. Drugs that reduce the amount of acid produced in the stomach (H2 blockers) are also used. This class of drugs includes famotidine (sold under the name Pepcid), cimetidine (Tagamet), and ranitidine (Zantac). Omeprazole (Prilosec) is not an H2 blocker, but is another drug that suppresses gastric acid secretion and is used for hiatal hernias. Another option may be metoclopramide (Reglan), a drug that increases the tone of the muscle around the esophagus and causes the stomach to empty more quickly.

Alternative treatment

There are alternative therapies for hiatal hernia. Visceral manipulation, done by a trained therapist, can help replace the stomach to its proper positioning. Other options in addition to H2 blockers are available to help regulate stomach acid production and balance. One of them, deglycyrrhizinated licorice (DGL), helps balance stomach acid by improving the protective substances that line the stomach and intestines and by improving blood supply to these tissues. DGL does not interrupt the normal function of stomach acid.

As with traditional therapy, dietary modifications are important. Small, frequent meals will keep pressure down on the esophageal sphincter. Also, raising the head of the bed several inches with blocks or books can help with both the quality and quantity of sleep.

Prognosis

Abdominal hernias generally do not recur in children but can recur in up to 10% of adult patients. Surgery is considered the only cure, and the prognosis is excellent if the hernia is corrected before it becomes strangulated.

Hiatal hernias are treated successfully with medication and diet modifications 85% of the time. The prognosis remains excellent even if surgery is required in adults who are in otherwise good health.

Prevention

Some hernias can be prevented by maintaining a reasonable weight, avoiding heavy lifting and constipation, and following a moderate exercise program to maintain good abdominal muscle tone.

Resources

BOOKS

Bare, Brenda G., and Suzanne C. Smeltzer. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 8th ed. Philadelphia: Lippincott-Raven Publishers, 1996.

KEY TERMS

Endoscopy— A diagnostic procedure in which a tube is inserted through the mouth, into the esophagus and stomach. It is used to visualize various digestive disorders, including hiatal hernias.

Herniorrhaphy— Surgical repair of a hernia.

Incarcerated hernia— A hernia that can not be reduced, or pushed back into place inside the intestinal wall.

Reducible hernia— A hernia that can be gently pushed back into place or that disappears when the person lies down.

Strangulated hernia— A hernia that is so tightly incarcerated outside the abdominal wall that the intestine is blocked and the blood supply to that part of the intestine is cut off.

Hernia Repair

Definition

Hernia repair is a surgical procedure to return an organ that protrudes through a weak area of muscle to its original position.

Purpose

Hernias occur when a weakness in the wall of the abdomen allows an organ, usually the intestines, to bulge out of place. Hernias may result from a genetic predisposition toward this weakness. They can also be the result of weakening the muscle through improper exercise or poor lifting techniques. Both children and adults get hernias. Some are painful, while others are not.

There are three levels of hernias. An uncomplicated hernia is one where the intestines bulge into the peritoneum (the membrane lining the abdomen), but they can still be manipulated back into the body (although they don't stay in place without corrective surgery). This is termed a reducible hernia.

If the intestines bulge through the hernia defect and become trapped, this is called an incarcerated hernia. If the blood supply to an incarcerated hernia is shut off, the hernia is called a strangulated hernia. Strangulated hernias can result in gangrene.

Both incarcerated and strangulated hernias are medical emergencies and require emergency surgery to correct. For this reason, doctors generally recommend the repair of an uncomplicated hernia, even if it causes no discomfort to the patient.

Precautions

Hernia repair can be performed under local, regional, or general anesthesia. The choice depends on the age and health of the patient and the type of hernia. Generally hernia repair is very safe surgery, but—as with any surgery—the risk of complications increases if the patient smokes, is obese, is very young or very old, uses alcohol heavily, or uses illicit drugs.

Description

Hernia repairs are performed in a hospital or outpatient surgical facility by a general surgeon. Depending on the patient's age, health, and the type of hernia, patients may be able to go home the same day or may remain hospitalized for up to three to five days.

There are two types of hernia repair. A herniorrhaphy is used for simpler hernias. The intestines are returned to their proper place and the defect in the abdominal wall is mended. A hernioplasty is used for larger hernias. In this procedure, plastic or steel mesh is added to the abdominal wall to repair and reinforce the weak spot.

There are five kinds of common hernia repairs. They are named for the part of the body closest to the hernia, or bulge.

Femoral hernia repair

This procedure repairs a hernia that occurs in the groin where the thigh meets the abdomen. It is called a femoral hernia repair because it is near the spot where the femoral artery and vein pass from the leg into the trunk of the body. Sometimes this type of hernia creates a noticeable bulge.

An incision is made in the groin area. The tissues are separated from the hernia sac, and the intestines are returned to the abdomen. The area is often reinforced with webbing before it is sewn shut. The skin is closed with sutures or metal clips that can be removed in about one week.

Inguinal hernia repair

Inguinal hernia repair closes a weakness in the abdominal wall that is near the inguinal canal, the spot where the testes descend from the body into the scrotum. This type of hernia occurs in about two percent of adult males.

An incision is made in the abdomen, then the hernia is located and repaired. The surgeon must be alert not to injure the spermatic cord, the testes, or the blood supply to the testes. If the hernia is small, it is simply repaired. If it is large, the area is reinforced with mesh to prevent a recurrence. External skin sutures can be removed in about a week. Patients should not resume sexual activity until being cleared by their doctor.

Umbilical hernia repair

This procedure repairs a hernia that occurs when the intestines bulge through the abdomen wall near the navel. Umbilical hernias are most common in infants.

An incision is made near the navel. The hernia is located and the intestines are returned to the abdomen. The peritoneum is closed, then the large abdominal muscle is pulled over the weak spot in such a way as to reinforce the area. External sutures or skin clips can be removed in about 10 days.

Incisional hernia repair

Incisional hernias occur most frequently at the site of a scar from earlier abdominal surgery. Once again, the abdomen is opened and the intestines returned to their proper place. The area is reinforced with mesh, and the abdominal wall is reconstructed to prevent another hernia from developing. External sutures can be removed in about a week.

Hiatal hernia

A hiatal hernia repair is slightly different from the other hernias described here, because it corrects a weakness or opening in the diaphragm, the muscle that separates the chest cavity from the abdominal cavity. This surgery is done to prevent the stomach from shifting up into the chest cavity and to prevent the stomach from spilling gastric juices into the esophagus, causing pain and scarring.

An incision is made in the abdomen or chest, and the hole or weakness in the diaphragm is located and repaired. The top of the stomach is wrapped around the bottom of the esophagus, and they are sutured together to hold the stomach in place. Sometimes the vagus nerve is cut in order to decrease the amount of acid the stomach produces. External sutures can be removed in about one week. This type of hernia repair often requires a longer hospital stay than the other types, although techniques are being improved that reduce invasiveness of the surgery and the length of the hospital stay.

Preparation

Before the operation, the patient will have blood and urine collected for testing. X rays are taken of the affected area. In a hiatal hernia, an endoscopy (a visual inspection of the organs) is done.

Patients should meet with the anesthesiologist before the operation to discuss any medications or conditions that might affect the administration of anesthesia. Patients may be asked to temporarily discontinue certain medications. The day of the operation, patients should not eat or drink anything. They may be given an enema to clear the bowels.

Aftercare

Patients should eat a clear liquid diet until the gastrointestinal tract begins functioning again. Normally this is a short period of time. After that, they are free to eat a healthy, well-balanced diet of their choice. They may bathe normally, using a gentle, unscented soap. An antibiotic ointment may be prescribed for the incision. After the operation, a hard ridge will form along the incision line. With time, this ridge softens and becomes less noticeable. Patients who remain in the hospital will have blood drawn for follow-up studies.

Patients should begin easy activities, such as walking, as soon as they are comfortable, but should avoid strenuous exercise for four to six weeks, and especially avoid heavy lifting. Learning and practicing proper lifting techniques is an important part of patient education after the operation. Patients may be given a laxative or stool softener so that they will not strain to have bowel movements. They should discuss with their doctor when to resume driving and sexual activity.

Risks

As with any surgery, there exists the possibility of excessive bleeding and infection after the surgery. In inguinal and femoral hernia repair, a slight risk of damage to the testicles or their blood supply exists for male patients. Accidental damage may be caused to the intestinal tract, but generally complications are few.

Normal results

The outcome of surgery depends on the age and health of the patient and on the type of hernia. Although most hernias can be repaired without complications, hernias recur in 10-20% of people who have had hernia surgery.

Resources

OTHER

"Hernia Repair." ThriveOnline. 〈http://thriveonline.oxygen.com〉.

KEY TERMS

Endoscopy— A procedure in which an instrument containing a camera is inserted into the gastrointestinal tract so that the doctor can visually inspect the gastrointestinal system.

Gangrene— Death and decay of body tissue because the blood supply is cut off. Tissues that have died in this way must be surgically removed.

Peritoneum— The transparent membrane lining the abdominal cavity that holds organs such as the intestines in place.

hernia A hernia is where a part of the abdominal content protrudes or bulges through an abnormal opening in the inner layers of the wall of the abdomen. The hernial ‘sac’ usually contains either fatty tissue or a loop of intestine. Some common types are groin, umbilical, and incisional hernias.

Groin hernias

There are two types of groin hernia, inguinal or femoral, the former being far more common and making up 98% of all groin hernias. Inguinal hernias are common in newborn boys, where they arise as a result of a ‘canal’ normally present in the embryo between the inside of the abdomen and the scrotum, which fails to close. They are also common in adult life and increase in frequency as one grows older. Inguinal hernias are approximately twenty times more common in men than women, while, interestingly, femoral hernias are more common in women.

Usually a groin hernia presents with a lump in the groin, felt all the time or only when straining. It often causes a dull ache that is worse with activity. The lump may get bigger with coughing or straining and shrink or disappear with lying down. Not all hernias are easily felt, however. When the contents can be pushed back into the abdomen the hernia is said to be ‘reducible’ — and ‘irreducible’ if not.

Surgeons have been treating and repairing hernias for over 3000 years, with varying degrees of success. The Mummy of Pharaoh Merneptah (nineteenth dynasty, 1224–14 bc) showed a large wound in the groin, with the scrotum separated from the body indicating that crude surgery had been performed on an inguinal hernia that had passed down into the scrotum. Nowadays many hernia repairs are performed worldwide each year, some 80 000 in the UK alone. The repair is usually performed by reinforcing the defect with stitches or a plastic mesh, often as a day case procedure, using either a local or a general anaesthetic.

While most hernias are usually just troublesome, on rare occasions they enlarge quickly with a sudden intense pain and part of the bowel gets trapped and becomes blocked. This intestinal obstruction is an emergency situation and requires surgery to free the trapped piece of bowel or to excise it if irretrievably damaged by ‘strangulation’ of its blood supply.

Umbilical hernias

Up to a fifth of babies are born with a bulge through a defect at the site of the umbilical cord. The majority will close by themselves and they only occasionally need surgical repair if the hernia becomes excessively large or inflamed, or if it is still present by the age of about four. Adults also develop hernias in the region of the umbilicus (paraumbilical). These are often associated with obesity, can be uncomfortable, and may become irreducible. Again they are usually repaired as a day case or overnight stay procedure.

Incisional hernias

These occur months or years after abdominal surgery and are common after such procedures as large bowel surgery in either sex, or hysterectomy in women. They are more common in obese patients or following a postoperative wound infection. They may become very large and unsightly. Rarely they may cause the bowel to obstruct and require emergency surgery. Nowadays they are usually repaired with a large piece of mesh, as there is a high recurrence rate after a sutured repair.

S. G. Taylor, and P. J. O'Dwyer

hernia protrusion of an internal organ or part of an organ through the wall of a body cavity. The hernia is enclosed by a sac formed by the lining of the cavity. It results from a weakness or rupture in the wall, usually where there is already a natural weakness. A hernia may be present at birth or acquired later in life after heavy strain on the musculature. Structurally weak points, e.g., where various blood vessels, nerves, and ducts enter or leave a body cavity, occur in areas such as the lower abdomen, the diaphragm, and the region around the navel. If the protruding structure is caught in the muscular aperture of the wall, the result is a strangulation of the part, or an incarcerated hernia. Prompt medical attention must be received or loss of blood and eventual gangrene may result. A small hernia usually bulges spontaneously under exercise and strain and recedes into the cavity when the subject relaxes. A truss or external pad held against the weak spot may be used to control a hernia. However, surgery is usually recommended, even for a mild hernia, since it may eventually enlarge.

hernia (her-niă) n. the protrusion of an organ or tissue out of the body cavity in which it normally lies. diaphragmatic h. the protrusion of an abdominal organ through the diaphragm into the chest cavity. femoral h. the protrusion of part of the bowel at the top of the thigh, through the point at which the femoral artery passes from the abdomen to the thigh. hiatus h. the most common type of diaphragmatic hernia, in which the stomach passes partly or completely into the chest cavity through the oesophageal opening. This hernia may be associated with gastro-oesophageal reflux. incarcerated h. a hernia that is swollen and fixed within its sac. inguinal h. (or rupture) the protrusion of a sac of peritoneum, containing fat or part of the bowel, through the lower abdominal wall. irreducible h. a hernia that cannot be returned to its normal site. strangulated h. a hernia that is cut off from its blood supply, becoming painful and eventually gangrenous. umbilical h. see exomphalos.

HERNIA

DEFINITION

Hernia is a general term for a bulge or protrusion of an organ through a part of the body in which it is usually contained.

DESCRIPTION

There are many different kinds of hernias. The most familiar are those that occur in the abdomen. In this type of hernia, a part of the intestines protrudes (sticks out) through the wall of the abdomen. An abdominal hernia can occur in different areas. The name given to the hernia depends on the location in which it occurs. Some examples of abdominal hernias are the following:

• An inguinal (pronounced IN-gwin-null) hernia appears in the groin. It may come and go depending on various factors, such as the amount of physical activity. Inguinal hernias account for 80 percent of all hernias. They are more common in men.
• Femoral (pronounced FEH-muh-rull) hernias are similar to inguinal hernias, but they occur lower in the body. They are more common in women, and commonly occur during pregnancy.
• A ventral hernia is also called an incisional hernia. The name reflects the fact that it often occurs at the location of an old surgical scar (incision). A ventral hernia is caused by the stretching of scar tissue. It occurs most commonly in pregnant women and people who are obese (excessively over-weight, see obesity entry).
• An umbilical hernia occurs at the navel. Umbilical hernias are common among infants. They occur when the naval area does not close up properly after birth. Some umbilical hernias clear up by themselves within the first year.
• A hiatal (pronounced hi-ATE-ul) hernia is different from other abdominal hernias. It cannot be seen from outside the body. In a hiatal hernia, the stomach bulges upward into the diaphragm. The diaphragm is a muscle that separates the chest from the abdomen. Hiatal hernias are more common in women than in men.

CAUSES

Most hernias develop at weak spots in the abdominal wall. The weakness may be present at birth, or it may develop later in life for a variety of reasons. Any unusual pressure on the abdomen can cause a hernia to develop. Some examples of the causes of hernias are:

• Heavy lifting
• Unusually severe coughing
• Pregnancy
• Obesity or sudden and excessive weight loss
• Aging
• Previous surgical procedures

SYMPTOMS

A person can sometimes feel a hernia as it develops. There may be tenderness or a slight burning sensation in the area where the hernia is developing. Sometimes a person can push the hernia back into place. In other cases, the hernia may just disappear by itself. In still other cases, the hernia cannot be pushed back into place easily.

About half of the people with hiatal hernias have no symptoms. Those who do have symptoms are likely to experience heartburn. Heartburn is caused when stomach acid is pushed back into the esophagus (pronounced ee-SAH-fuh-guss). The esophagus is the tube that leads from the windpipe to the stomach. Heartburn may also be accompanied by chest pain. These symptoms are worse when a person is lying down.

DIAGNOSIS

Hernias are fairly easy to diagnose. A doctor can usually feel the hernia simply by touching it. The doctor may ask the patient to cough. The extra pressure caused by coughing will make the hernia stick out even more, making it even easier to feel.

A hiatal hernia is more difficult to diagnose. The first clue often comes from symptoms described by the patient, such as heartburn and chest pain after eating. A barium swallow can also be used to diagnose a hiatal hernia. A barium swallow is a procedure in which a patient swallows a chalky white substance containing barium. An X ray is then taken of the patient's digestive system. A hiatal hernia shows up as a protrusion into the diaphragm.

Hiatal hernias can also be diagnosed by endoscopy (pronounced en-DOS-kuh-pee). Endoscopy is a procedure in which a small tube is inserted through the mouth, then into the esophagus and stomach to allow the doctor to see the hernia. A hiatal hernia can actually be seen by this method.

TREATMENT

Once an abdominal hernia occurs, it tends to increase in size. Some patients with an abdominal hernia decide not to seek treatment right away. They may try to keep the hernia under control with a truss. A truss is a support garment worn like a belt. It helps keep the hernia from protruding. People with hernias must avoid strenuous activity, such as heavy lifting or straining themselves.

Constant pain, nausea, and vomiting are signs that the hernia has become worse. The patient may notice that the hernia can no longer be pushed back into place. In such cases, medical help should be sought. Surgery will probably be necessary.

The surgical treatment for hernia is relatively simple. The hernia is pushed back into the abdominal cavity. The muscle lying on top of the hernia is then sewed back into place. If necessary, additional support may be added to keep the hernia in place.

If a hernia is not treated, severe complications can result. Part of the intestine can become trapped outside the muscles of the abdomen. A blockage in the intestine may develop. In the worst cases, this blockage can cut off the blood supply to the intestine. Part of the intestine may actually die.

A hiatal hernia is treated differently. Surgery is recommended only as a last resort. Instead, changes in the patient's lifestyle are recommended. Some of these changes are:

• Avoiding lying down after meals
• Avoiding spicy or acidic foods, alcohol, and tobacco
• Eating small, frequent, bland meals
• Eating a high-fiber diet

Several medications can also help relieve the symptoms of a hiatal hernia. For example, antacids are used to neutralize stomach acid and decrease heartburn. Drugs are also available to reduce the amount of stomach acid produced. A third option is a group of drugs that makes the muscles around the esophagus work more efficiently. The stomach empties faster and there is less chance of heartburn.

Alternative Treatment

Alternative practitioners often recommend changes similar to those listed above. In the case of a hiatal hernia, they may also suggest the use of visceral manipulation. Visceral manipulation is a method for returning the stomach to its proper position. Natural products are sometimes recommended for hiatal hernias too. For example, the natural product called deglycyrrhizinated licorice is thought to help reduce the effects of stomach acid.

PROGNOSIS

Abdominal hernias usually do not reoccur in children. They do reappear, however, in about 10 percent of adults. Surgery is considered the only cure. The prognosis will be excellent if the patient does not seek medical help too late.

Hiatal hernias are treated successfully with medication and changes in diet about 85 percent of the time. The prognosis remains good even if surgery is required to repair the hernia.

PREVENTION

Some hernias can be prevented by following some simple rules, such as:

• Maintain a reasonable weight.
• Avoid heavy lifting.
• Follow a program of moderate exercise.

FOR MORE INFORMATION

Books

Delvin, David. Coping with a Hernia. Sterling, VA: Capital Books Inc., 1998.

Hernia

Hernia Means Rupture

Do Children Get Hernias?

Resource

A hernia is the protrusion of an organ through an abnormal opening in the tissue that normally encloses it.

KEYWORDS

for searching the Internet and other reference sources

Digestive system

Gastrointestinal tract

Hernia Means Rupture

The word hernia, in Latin, means rupture. A hernia refers to an opening, or separation, in the muscle, tissue, or membrane that normally holds an organ in place. This opening allows the organ to poke through the hole. Hernias may be caused by muscular weakness, heavy lifting, straining, illness, obesity, or pregnancy.

Hernias commonly occur in the groin, where they are called inguinal (ING-gwi-nal) hernias; in the belly button (umbilical hernias); in the chest, where they are called hiatal (hi-AY-tal) hernias; and in the abdomen (abdominal hernias).

Inguinal hernias

The wall of the abdomen is made of thick muscle, but holes exist normally in certain places, such as the groin, through which structures such as blood vessels pass. Hernias usually occur when the intestines push out against these built-in weaknesses. Hernias may be dangerous if the protruding piece of intestine gets trapped and twisted, thus obstructing the flow of food and fluid through the intestine, and sometimes stopping blood supply to that part of the intestine.

Inguinal hernias are the most common type and are often visible as large lumps. Some people with inguinal hernias do not feel anything,

whereas others feel severe pain. The only way to fix this type of hernia is to repair it surgically, using stitches or mesh to close up the hole. Without surgery, an inguinal hernia will usually just keep getting bigger over time.

Hiatal hernias

Another common type of hernia is a hiatal hernia. The esophagus, or food pipe, passes to the stomach through a gap in the diaphragm* called the hiatus (hi-AY-tus). A hiatal hernia occurs when the stomach pokes above the diaphragm into the chest. There are no visible bulges, but people have symptoms such as heartburn. Hiatal hernias do not necessarily require surgery. Often, lifestyle changes such as losing weight and avoiding smoking, drinking alcohol, and eating hot, spicy foods can make the symptoms go away.

* diaphragm

(DY-a-fram) is the muscle that separates the chest and abdominal cavities. It is the chief muscle used in breathing.

Umbilical hernias

Umbilical hernias are common in children. One out of five babies has one, but this type usually heals by itself.

Abdominal hernias

Abdominal, or intra-abdominal, hernias occur more rarely, when an organ in the abdomen pokes through membranes that normally hold it in place.

Do Children Get Hernias?

Karen loved taking care of her baby brother. One day when she was changing his diaper, she noticed he had a plum-sized bump along the inside of his thigh where it met his torso (his groin). When he cried, it got bigger, like a small balloon being blown up. It looked pretty strange, but he did not seem to be in any pain. Karen’s parents took him to the doctor, who said the baby had an inguinal hernia.

The doctor explained that up to 5 percent of healthy babies are born with inguinal hernias, and 80 to 90 percent of children with this type of hernia are boys. These hernias occur because certain openings do not close after birth the way they should, allowing the intestine to bulge out of the hole. The doctor scheduled an operation so that he could surgically repair the baby’s hernia, but he assured Karen’s parents that the surgery was a safe and common procedure.

Babies also sometimes have umbilical hernias, but these usually heal on their own without surgery.

See also

Resource

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) posts fact sheets about inguinal hernia and hiatal hernia at its website.

Fact sheet about inguinal hernia may be found at URL http://www.niddk.nih.gov/health/digest/summary/inhernia/inhernia.htm

Fact sheet about hiatal hernia and its relation to gastroesophageal reflux may be found at URL http://www.niddk.nih.gov/health/digest/pubs/heartbrn/heartbrn.htm

her·ni·a / ˈhərnēə/ • n. (pl. -ni·as or -ni·ae / -nēˌē/ ) a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it (often involving the intestine at a weak point in the abdominal wall). DERIVATIVES: her·ni·al adj.

hernia Protrusion of an organ, or part of an organ, through its enclosing wall or connective tissue. Common hernias are a protrusion of an intestinal loop through the umbilicus (umbilical hernia), or protrusion of part of the stomach or oesophagus into the chest cavity (hiatus hernia).

hernia XIV. — L.

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