Today I took the husband of a friend who doesn’t drive for a hernia procedure. Dropped him off around 8:15 a.m., and they called me at 10:45 a.m., saying he would be ready to go in half an hour. When I had my colonoscopy, they wouldn’t let me drive either. Plus, you were not allowed to call Uber, Lyft, etc. or a taxi. The surgical center where the hernia procedure was done had the same rules. Guess they really don’t want to be held liable for anyone still under the influence of a powerful anesthetic. I have not personally had any experience with a hernia — so far — but I remember my nephew having hernia surgery as a baby. As an adult or a baby, I’m sure the experience is not very pleasant. Let’s find out more about it.
According to Wikipedia, a hernia is the abnormal exit of tissue or an organ — such as the bowel — through the wall of the cavity in which it normally resides. Various types of hernias can occur; most commonly involve the abdomen and, specifically, the groin. Groin hernias are most commonly of the inguinal type but may also be femoral. Other types of hernias include hiatus, incisional and umbilical hernias. Symptoms are present in about 66% of people with groin hernias. This may include pain or discomfort in the lower abdomen, especially with coughing, exercise, or urinating or defecating. Often, it gets worse throughout the day and improves when lying down. A bulge may appear at the site of hernia, that becomes larger when bending down. Groin hernias occur more often on the right than left side. The main concern is bowel strangulation, where the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness in the area. Hiatus or hiatal hernias often result in heartburn but may also cause chest pain or pain while eating.
Risk factors for the development of a hernia include smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease and previous open appendectomy, among others. Predisposition to hernias is genetic and occurs more often in certain families. Deleterious mutations causing predisposition to hernias seem to have dominant inheritance, especially for men. It is unclear if groin hernias are associated with heavy lifting. Hernias can often be diagnosed based on signs and symptoms. Occasionally, medical imaging is used to confirm the diagnosis or rule out other possible causes. The diagnosis of hiatus hernias is often by endoscopy.
Groin hernias that do not cause symptoms in males do not need to be repaired. Repair, however, is generally recommended in women due to the higher rate of femoral hernias, which have more complications. If strangulation occurs, immediate surgery is required. Repair may be done by open surgery or laparoscopic surgery. Open surgery has the benefit of possibly being done under local anesthesia rather than general anesthesia. Laparoscopic surgery generally has less pain following the procedure. A hiatus hernia may be treated with lifestyle changes such as raising the head of the bed, weight loss and adjusting eating habits. The medications H2 blockers or proton pump inhibitors may help. If the symptoms do not improve with medications, a surgery known as laparoscopic Nissen fundoplication may be an option.
About 27% of males and 3% of females develop a groin hernia at some point in their lives. Inguinal, femoral and abdominal hernias were present in 18.5 million people and resulted in 59,800 deaths in 2015. Groin hernias occur most often before the age of 1 and after the age of 50. It is not known how commonly hiatus hernias occur, with estimates in North America varying from 10% to 80%. The first known description of a hernia dates back to at least 1550 BC, in the Ebers Papyrus from Egypt.
Signs and symptoms
By far the most common hernias develop in the abdomen when a weakness in the abdominal wall evolves into a localized hole or "defect" through which adipose tissue or abdominal organs covered with peritoneum may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatus hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.
Hernias may or may not present with either pain at the site, a visible or palpable lump or in some cases, more vague symptoms resulting from pressure on an organ that has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.
Hernias are caused by a disruption or opening in the fascia or fibrous tissue which forms the abdominal wall. It is possible for the bulge associated with a hernia to come and go, but the defect in the tissue will persist.
Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.
Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation (loss of blood supply), obstruction (kinking of intestine) or both. Strangulated hernias are always painful, and pain is followed by tenderness. Nausea, vomiting or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge, in this case, may turn red, purple or dark and pink.
In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT can show with precision the anatomic site of the hernia sac, the contents of the sac and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.
Complications
Complications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localized swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed.
A surgically treated hernia can lead to complications such as inguinodynia, while an untreated hernia may be complicated by:
- Inflammation.
- Obstruction of any lumen, such as bowel obstruction in intestinal hernias.
- Hydrocele of the hernial sac.
- Hemorrhage.
- Autoimmune problems.
- Irreducibility or Incarceration in which it cannot be reduced or pushed back into place, at
least not without very much external effort. In intestinal hernias, this also substantially
increases the risk of bowel obstruction and strangulation.
Causes
Causes of hiatus hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen and incorrect posture.
Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination — constipation, enlarged prostate, chronic lung disease and fluid in the abdominal cavity.
Also, if muscles are weakened due to poor nutrition, smoking and overexertion, hernias are more likely to occur.
The physiological school of thought contends that in the case of inguinal hernia, the above-mentioned are only an anatomical symptom of the underlying physiological cause. It contends that the risk of hernia is due to a physiological difference between patients who suffer hernia and those who do not, namely the presence of aponeurotic extensions from the transversus abdominis aponeurotic arch.
Abdominal wall hernia may occur due to trauma. If this type of hernia is due to blunt trauma, it is an emergency condition and could be associated with various solid organs and hollow viscus injuries.
Diagnosis – inguinal
By far the most common hernias — up to 75% of all abdominal hernias — are inguinal hernias, which are further divided into the more common indirect inguinal hernia, in which the inguinal canal is entered via a congenital weakness at its entrance — the internal inguinal ring and the direct inguinal hernia type where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. In some selected cases, they may require surgery. There are special cases in which the hernia may contain both direct and indirect hernia simultaneously pantaloon hernia, or — though very rare — may contain simultaneous indirect hernias.
Pantaloon hernia or saddle bag hernia is a combined direct and indirect hernia when the hernial sac protrudes on either side of the inferior epigastric vessels.
Diagnosis – femoral
Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type — especially when ascending cephalad — however, they generally appear more rounded, and in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.
A Cooper's hernia is a femoral hernia with two sacs, the first being in the femoral canal and the second passing through a defect in the superficial fascia and appearing almost immediately beneath the skin.
Diagnosis – umbilical
They involve protrusion of intra-abdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. Umbilical hernias in adults are largely acquired and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may be a contributing factor.
Diagnosis – incisional
An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue. These occur in about 13% of people at two years following surgery.
Diagnosis – Diaphragmatic
Higher in the abdomen, an internal "diaphragmatic hernia" results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.
A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach — esophageal hiatus — serves as a functional "defect," allowing part of the stomach to periodically "herniate" into the chest. Hiatus hernias may be either "sliding," in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding — also known as para-esophageal — in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.
A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2,000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral in Bochdalek's triangle, resulting in Bochdalek's hernia or anteromedial-retrosternal in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia or Morgagni's hernia.
Other hernias
Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with "visceral hernias," where the herniating tissue arises within the abdominal cavity.
Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:
- Abdominal wall hernias
- Epigastric hernia: a type of hernia that causes fat to push through a weakened area in the walls of the abdomen. It may develop in the epigastrium — upper, central part of the
abdomen. Epigastric hernias are more common in adults and usually appear above the
umbilical region of the abdomen. It is a common condition that is usually asymptomatic
although sometimes their unusual clinical presentation can present a diagnostic
dilemma for the clinician. Unlike the benign diastasis recti, epigastric hernia may trap fat
and other tissues inside the opening of the hernia, causing pain and tissue damage. It is
usually present at birth and may appear and disappear only when the patient is doing an
activity that creates abdominal pressure, pushing to have bowel movements or crying.
- Spigelian hernia: the type of ventral hernia where aponeurotic fascia pushes through a
hole in the junction of the linea semilunaris and the arcuate line creating a bulge. It
appears in the abdomen lower quadrant between an area of dense fibrous tissue and
abdominal wall muscles causing a Spigelian aponeurosis.
It is the protuberance of omentum, adipose or bowel in that weak space between the stomach muscles that, ultimately, pushes the intestines or superficial fatty tissue through a hole causing a defect. As a result, it creates the movement of an organ or a loop of intestine in the weakened body space that it is not supposed to be in. It is at this separation or aponeurosis in the ventral abdominal region that herniation most commonly occurs.
Spigelian hernias are rare compared to other types of hernias because they do not develop under abdominal layers of fat but between fascia tissue that connects to muscle. The Spigelian hernia is generally smaller in diameter, typically measuring 1–2 cm., and the risk of tissue becoming strangulated is high.
- Amyand's hernia: a rare form of an
inguinal hernia — less than 1% of
inguinal hernias — which occurs when
the appendix is included in the hernial
sac and becomes incarcerated.
The condition is an eponymous disease
Amyand (1660–1740), who performed
the first successful appendectomy in
1735.
Most of the cases are diagnosed intraoperatively and a preoperative diagnosis is rarely
made in such cases. Management should be individualized according to appendix's
inflammation stage, presence of abdominal sepsis and comorbidity factors. The decision
should be based on factors such as the patient's age, the size and anatomy of the
appendix, and in case of appendicitis, standard appendectomy and herniorrhaphy without a
mesh should be the standard of care.
Amyand's hernia is commonly misdiagnosed as an ordinary incarcerated hernia. Symptoms
mimicking appendicitis may occur. Treatment consists of a combination of appendectomy
and hernia repair. The inflammatory status of the appendix determines the type of hernia
repair and the surgical approach. Incidental appendicectomy in the case of a normal
appendix is not favored.
- Brain herniation, a potentially deadly side
effect of very high pressure within the
skull that occurs when a part of the brain
is squeezed across structures within the
skull. The brain can shift across such
structures as the falx cerebri, the
tentorium cerebelli and even through the
foramen magnum — the hole in the base
of the skull through which the spinal
cord connects with the brain. Herniation
can be caused by a number of factors
that cause a mass effect and increase
intracranial pressure. These include
- Broad ligament hernia
- Double indirect hernia: an indirect inguinal hernia with two hernia sacs, without a
concomitant direct hernia component, as seen in a pantaloon hernia.
- Hiatus hernia: a type of hernia in which abdominal organs — typically the stomach — slip
through the diaphragm into the middle compartment of the chest. This may result in
gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms
such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include
trouble swallowing and chest pains. Complications may include iron deficiency anemia,
- Littre's hernia: a hernia involving a Meckel's diverticulum, a slight bulge in the small
intestine present at birth and a vestigial remnant of the omphalomesenteric duct — also
called the vitelline duct or yolk stalk. It is named after the French anatomist Alexis Littré
(1658–1726).
- Lumbar hernia: a hernia in the lumbar
region (not to be confused with a lumbar
disc hernia), contains the following
entities:
- Petit's hernia: a hernia that protrudes
through the lumbar triangle aka
Petit's triangle. This triangle lies in the
posterolateral abdominal wall and is
bounded anteriorly by the free margin
of external oblique muscle, posteriorly
by the latissimus dorsi and inferiorly
by the iliac crest. The neck — the spot
where the hernia protrudes into the
opening — is large, and therefore, this
hernia has a lower risk of strangulating than some other hernias. It is named after French surgeon Jean Louis Petit (1674–1750).
- Grynfeltt's hernia: a herniation of abdominal contents through the back, specifically
through the superior lumbar triangle or Grynfeltt-Lesshaft triangle, which is defined by
the quadratus lumborum muscle, twelfth rib and internal oblique muscle. It is named
after physician Joseph Grynfeltt (1840–1913).: a hernia that protrudes through the
lumbar triangle aka Petit's triangle. This triangle lies in the posterolateral abdominal wall
and is bounded anteriorly by the free margin of external oblique muscle, posteriorly by
the latissimus dorsi and inferiorly by the iliac crest. The neck — the spot where the
hernia protrudes into the opening — is large, and therefore, this hernia has a lower risk
of strangulating than some other hernias. It is named after French surgeon Jean Louis
Petit (1674–1750).
- Grynfeltt's hernia: a herniation of abdominal contents through the back, specifically
through the superior lumbar triangle or Grynfeltt-Lesshaft triangle, which is defined by
the quadratus lumborum muscle, twelfth rib and internal oblique muscle. It is named
after physician Joseph Grynfeltt (1840–1913).
- Maydl's hernia: a rare type of hernia and may be lethal if undiagnosed. The hernial sac
contains two loops of bowel with another loop of bowel being intra-abdominal. A loop of
bowel in the form of “W” lies in the hernial sac, and the center portion of the “W” loop may
become strangulated, either alone or in combination with the bowel in the hernial sac. It is
more often seen in men, and predominantly on the right side. Maydl's hernia should be
suspected in patients with large incarcerated herniae and in patients with evidence of intra-
abdominal strangulation or peritonitis. Postural or manual reduction of the hernia is contra-
indicated as it may result in non-viable bowel being missed. It is named after Czech
surgeon Karel Maydl.
- Obturator hernia: a rare type of hernia of the pelvic floor in which pelvic or abdominal
contents protrudes through the obturator foramen. Because of differences in anatomy, it is
much more common in women, especially multiparous and older women who have recently
lost much weight. The diagnosis is often made intraoperatively after presenting with bowel
- Parastomal hernias, which is when tissue protrudes adjacent to a stoma tract.
- Paraumbilical hernia: a hole in the
connective tissue of the abdominal wall
in the midline with close approximation to
the umbilicus. If the hole is large enough,
there can be protrusion of the abdominal
contents, including omental fat and/or
bowel. These defects are usually
congenital and are not noticed until they
slowly enlarge over an individual's
lifetime and abdominal contents herniate
through the hole creating either pain or a
visible lump on the abdominal wall. If
abdominal contents get incarcerated or stuck in the hole this can cause pain. If the
abdominal contents become strangulated by losing their blood supply from pinching or
twisting, those tissue will die. If it is omental fat, this will cause pain and could potentially
lead to an infection. If the strangulated contents are bowel, then in addition to pain the
individual will develop a bowel obstruction. And if the dead bowel is not surgically removed
in an emergent fashion, the condition could be fatal.
- Perineal hernia: a hernia involving the perineum (pelvic floor). The hernia may contain fluid,
dogs, and other mammals, and often appears as a sudden swelling to one side (sometimes
both sides) of the anus.
A common cause of perineal hernia is surgery involving the perineum. Perineal hernia can be caused also by excessive straining to defecate. Other causes include prostate or urinary disease, constipation, anal sac disease (in dogs), and diarrhea[citation needed]. Atrophy of the levator ani muscle and disease of the pudendal nerve may also contribute to a perineal hernia.
- Richter's hernia: occurs when the antimesenteric wall of the intestine protrudes through a
defect in the abdominal wall. This is distinct from other types of abdominal hernias in that
only one intestinal wall protrudes through the defect, such that the lumen of the intestine is
incompletely contained in the defect, while the rest remains in the peritoneal cavity. If such a
herniation becomes necrotic and is subsequently reduced during hernia repair, perforation
and peritonitis may result. A Richter's hernia can result in strangulation and necrosis in the
absence of intestinal obstruction. It is a relatively rare but dangerous type of hernia.
Richter's hernia has also been noted in laparoscopic port-sites, usually when the fascia is
not closed for ports larger than 10 mm. A high index of suspicion is required in the post-
operative period as this sinister problem can closely mimic more benign complications like
port-site haematomas. Treatment is resection and anastomosis. Mortality increases with
delay in surgical intervention. It is named after German surgeon August Gottlieb Richter
(1742–1812).
- Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other
words, the organ is part of the hernia sac. The colon and the urinary bladder are often
involved. The term also frequently refers to sliding hernias of the stomach.
- Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an
uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of
hernia is only a rare cause of sciatic neuralgia.
- Sports hernia: Athletic pubalgia, also
called sports hernia, core injury, hockey
hernia, hockey groin, Gilmore's groin or
groin disruption is a medical condition of
the pubic joint affecting athletes. It is a
syndrome characterized by chronic groin
pain in athletes and a dilated superficial
ring of the inguinal canal. Football and
ice hockey players are affected most
frequently. Both recreational and
professional athletes may be affected.
- Tibialis anterior hernia: can present as a bulge in the shins. Pain on rest, walking or during
exercise may occur. The bulge can typically not be present unless pressure or flexing of the
leg occurs.
- Velpeau hernia: a hernia in the groin in front of the femoral blood vessels.
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