HERNIA Our body is designed to have passageways and cavities to help things travel from one part to the other, such as food (esophagus traveling through diaphragm), blood, arteries and veins (traveling through inguinal canals and femoral canals), and also umbilical artery and vein (traveling through the belly button when we are a fetus), nerves or other items. A hernia is a hole in the body that has gotten either too large or is a new hole that has developed due to a weakness in a part of the body. When a hernia develops, organs in other parts of our body can push through the hole and strangle, resulting in pain and discomfort. Sometimes the strangling can be severe enough to kill tissue, resulting dying off of the choked contents, perforation, abscess, infection, and possibly even death. Hernias, unfortunately, do not get smaller with time. They can only get bigger. Hernias should be considered for surgical repair to help prevent such problems. Repair usually involves stitches to help close the hole down, and often mesh is needed to patch the weak area strongly. Typical areas include: UMBILICAL HERNIA. An umbilical hernia is a hernia that results from a natural weakness in the anterior abdominal wall at the belly button. This is the remnant where the umbilical artery and veins flowed from mother to fetus to help give nutrients and exchange waste before baby is born. INGUINAL HERNIA. An inguinal hernia is formed from a natural weakness down in the groin. There is a natural opening in the abdominal wall that allows the testicles in men to travel from their original location near the kidneys inside the abdomen until eventually going through the abdominal all to reside down into the scrotal sac. As the testicles migrate downward, they take its blood supply with it along with the sperm tube or vas deferens. Eventually the hole tightens down but it cannot completely close or the blood supply to the testicles would be cut off; therefore, this is a natural weakness point. Because the abdominal contents rest on the groin, the openings (internal and external rings of the inguinal canal) can dilate up or a weak area can form near there, resulting in a hernia. As a result, the inner lining of the abdomen (peritoneum) can travel along this increased opening creating a hernia sac that allows abdominal contents, such as fat, intestine, bladder, or other organs to herniate into the canal and perhaps even out into the groin and scrotum. Although women do not have testicles, their body development is somewhat similar in that a natural weakening is created there for the labia to be anchored to the abdomen. Also nearby is the natural opening that allows the major artery veins and nerves that travel to the thigh and legs to come from the abdomen, called the femoral canal. Sometimes this area can dilate up and as well abdominal contents can herniate. When herniation results, the analogy of a baby sticking its head through the crib rails where INCISIONAL HERNIAS Sometimes in order to do surgery the abdominal wall needs to be completely cut through and at the end of surgery stitches are used to help close the abdomen together. Unfortunately, sometimes complete healing does not take place and the closure can break down or this naturally weak area can loosen up and a hernia can form. There are certain risk factors for developing hernias. Being immunosuppressed, taking steroids or other immunosuppressive medications can slow wound healing will result in weakened healing tissue and gives increased risk for herniation. Smoking decreases the amount of oxygen delivered to the incision or wound, slowing and weakening the healing process and increasing the risk of infections. Wound infections can also weaken the ultimate healing process. Repeated incisions in the same spot can result in weaker or slower healing. Increased physical strain such as chronic coughing from bronchitis or recurrent pneumonias; increased abdominal straining from conditions such as prostate problems or chronic constipation can increase abdominal pressure and result in increased herniations of the abdominal wall. Jobs involving a lot of heavy lifting or heavy physical activity can also increase abdominal strain and increase risk or help exacerbate symptoms of a hernia. TREATMENTS FOR HERNIA Treatments for hernia involve surgical closure. Surgery involves freeing off scar tissue around the hernia, identifying and either reducing or removing a hernia sac, resection of any contents that may be choked off or stuck, and then closing the hernia down. If the hernia is small, as in most umbilical hernias, it can be closed with a few large stitches to help get the tissues to reapproximate, provided the tissue around the hernia is of good quality. In most other hernias, such as groin hernias and incisional hernias, tissue around the hole or hernia is too weak to provide a good long-term solution to do closure. Therefore, mesh is used, which is usually a pliable, thin sheet of plastic material the consistency of a screen door with small holes allowing healing tissue to intertwine and incorporate into the mesh. Some mesh is designed to have smooth surfaces to help prevent adhesions to bowel if mesh repairs are done on the inner layers of the abdomen. Stitches or tacks are often used to help hold the mesh in place to make sure it does not move or migrate and this helps reduce hernia recurrence. Smaller hernias such as umbilical or groin hernias can be performed in an outpatient procedure where deep sedation or brief general anesthesia can be used to help keep the patient comfortable as surgery is done to repair the hernia. Patients are monitored for a few hours, then discharged home with pain medications and instructions. Larger hernias, such as incisional hernias often require a hospital stay of a few days to up to a week in order to have adequate pain control and ensure good bowel function before discharge. INGUINAL HERNIA There are different approaches to fixing an inguinal hernia. The traditional way is to use a small open incision on the groin a few inches long to help open up the inguinal canal, which resides within the muscle layers of the abdominal wall. Once the roof of this canal is opened up, the cords are inspected and any lead points such as a hernia sac are dissected or freed off the cord structures and reduced back into the abdomen. The weak area is identified and is usually patched close with mesh and stitches. The roof of the canal is closed back up and the skin is closed. In a laparoscopic hernia repair, three small incisions are made near the belly button and a balloon or other instrument is used to dissect in the abdominal wall just behind the major washboard muscle of the abdomen (rectus) to get down to the level of where the groin canal is. The inner lining or peritoneum is followed to look for any lead points or hernia sacs going into the weak area of the abdomen. They are dissected off the cord structures and reduced back into the abdomen. A piece of mesh is laid on as a patch to help seal the hole shut and help prevent abdominal contents from reherniating back into the weakened hernia site. Sometimes tacks or stitches are used to help hold the mesh in place. Sometimes the mesh can be safely tucked into the abdomen like a letter in an envelope and tacks or stitches can be avoided. Both procedures are done on an outpatient basis. Risks of the procedure include: BRUISING. This is usually temporary and there can be a moderate area of the lower abdomen and/or genitals, it wades away in a manner of days to weeks. Sometimes blood can form in a pocket or in a prior hernia cavity resulting in a hematoma. Typically these areas are almost giving the sensation that the hernia persists. These hematomas will resolve over weeks. INFECTION A THE SKIN OR INFECTION OF THE MESH. Antibiotics are given preoperatively to minimize this risk as well as doing the operation in the operating room under sterile conditions. Certain health conditions do increase the risk for infection (diabetes, smoking, immunosuppression, on steroids, history of prior infections, etc.) but attempts are made to minimize this risk. PAIN at the incision, genitals as well as the inner thigh close to where surgery is performed. Good surgical technique helps minimize this risk and often local anesthetic is used to help decrease tenderness and soreness after surgery. Unfortunately, this is a sensitive area of the abdomen. Good pain control and low impact activity for several weeks is essential to avoid any exacerbations of pain. Reoperations for hernias that have recurred despite prior repair also increase the risk of postoperative pain. TESTICULAR INJURY Care is made to avoid any injury to the blood vessels to the testicles in mean or other important structures. While a rare occurrence, there have been instances where blood supply to the testicles has been compromised and the testicle on the same side of the hernia repair had to be removed. Fortunately this is extremely rare, but the risk is not completely zero. PROBLEMS WITH URINATION can occur and a catheter needs to be placed in the bladder to help it empty better. Under rare instances, the catheter needs to be left in place for a few days until bladder tone can return and the patient can urinate on their own. Patients with prostate problems tend to have an increased risk of this. INCISIONAL HERNIAS Incisional hernias require general anesthesia. Approaches are either through a traditional open approach or a laparoscopic approach. An open approach involves going through the skin to the prior abdominal incision to help free all the adhesions and tissues around the weakened area and either use stitches or most likely a piece of mesh to help patch the hole closed. Mesh is usually laid just right over or just deep to the hole, stitches are placed to connect the mesh and the tough layer of the abdomen (the fascia) to help patch the weakened area closed. Laparoscopic approach involves using small incisions away from the hernia and freeing adhesions inside the abdominal cavity and laying a special mesh to patch the hernia closed. The rough side is placed up against the abdominal wall, and the side facing the inner contents of the abdomen is smooth to avoid any scarring to the intestines or abdominal contents. Stitches are placed and brought out through the skin to help hold the mesh in place and often a spiral tacker is used to keep the edge of the mesh flat and not curl, exposing the rough surface to bowel contents. Recovery after most incisional hernia repairs requires hospitalization to ensure that pain control is adequate. Usually the patient receives intravenous pain medications and quickly switch over to pain pills. Bowel function is monitored as well to make sure the intestines are working adequately by discharge. Patients stay sometimes only overnight to as much as a week, depending how extensive dissection and surgery was needed. Most people leave in 2-3 days. To read more about Hernia Repair, click here. Use Acrobat Reader to Open PDF Files

Regional Surgical Specialists 2006