July 15, 2020 | 6:30-8:00PM | Hackensack University Medical Center
What Is a Hernia?
A hernia occurs when a body organ is pushed through a tear in the tissue or muscle that holds that organ in place. Hernias are a common condition in people of all ages.
Types of Hernias
- Inguinal: The most common type of hernia, inguinal hernias occur when a portion of the intestines push through a weakened area or tear in the lower abdominal wall, usually in the inguinal canal (groin area). Inguinal hernias account for more than 70 percent of all hernias. Men experience inguinal hernias 10 times more often than women.
- Hiatal: When part of the stomach pushes up through the diaphragm into the chest cavity, a hiatal hernia occurs. People over the age of 50 most commonly experience hiatal hernias. Hiatal hernias in children are usually a congenital birth defect. Hiatal hernias almost always cause gastroesophageal reflux (GERD).
- Ventral/Incisional: This type of hernia usually occurs after an abdominal surgery. The intestines may protrude through the incision, scar or surrounding tissue, which is weakened from surgery. A ventral hernia may occur at a past incision site, above the belly button (epigastric) or at another weak muscle site, usually the abdominal wall muscles.
- Femoral: Femoral hernias are very rare and occur when fatty tissue or part of the bowel pushes through a weak spot in the femoral canal into the groin at the top of the inner thigh. These hernias are more common in women than men due to the wider shape of the pelvis in women. Surgery is recommended right away due to risk of complications, such as bowel obstruction or bowel strangulation.
- Umbilical: Umbilical hernias usually occur in babies under six months old. In children, this is the only type of hernia that can heal on its own, usually by the age of one. Umbilical hernias can also occur in adults. The intestines push through the abdominal wall near the belly button.
- Internal hernia: Internal hernias are extremely rare, accounting for less than 1 percent of all hernias. This type of hernia occurs when the visceral contents (the internal organs in the abdominal cavity) are pushed through a tear in the peritoneal cavity. These hernias are contained inside the abdominal cavity.
Causes and Risk Factors
Muscle weakness and muscle strain are the two major factors contributing to hernias. Hernias may occur over a long period of time or suddenly. There are many causes of hernias due to muscle weakness, including:
- Straining on the toilet with constipation
- Carrying heavy loads
- Pushing heavy loads
- Persistent or chronic coughs
- Fluid retention in the abdomen
- Sudden weight gain
Other risk factors include a hereditary link, an undescended testicle, obesity, smoking and chronic conditions like cystic fibrosis that involve a persistent, heavy cough.
A bulge or lump is the most common symptom of a hernia. The hernia is more palpable and visible when standing up, bending down or coughing. Hernias do not always cause pain and usually are described as more of a discomfort. Pressure or a heavy feeling in the abdomen are usually present, as well as burning or aching where the bulge is located. Symptoms of a hiatal hernia include GERD, chest pain and difficulty swallowing.
Some hernias are asymptomatic (no symptoms) and may not be discovered until a medical exam is performed for an unrelated condition.
Complications of an untreated hernia can include:
- Intense pain
- Swollen and red skin over the hernia
- Restricted blood flow to the area, causing gray or blue skin tone
- Irreducible or incarcerated hernia (the bulge cannot be pushed back in) causing loss of blood supply to the intestinal tissue (also called strangulation)
- Tissue death (necrosis)
- Nausea and vomiting
Diagnosis includes a physical exam and patient history. Many hernias are visible and palpable upon exam. In some cases, other diagnostic tests may be ordered such as ultrasound, computerized tomography (CT) scan, urinalysis, blood tests, and an electrocardiogram (ECG) to determine heart problems that would be a risk factor for surgery.
Because most hernias are diagnosed based on a visual and physical examination, a misdiagnosis is possible. Even with an ultrasound, misdiagnoses can still occur. In questionable cases, a CT scan can assist in properly diagnosing a hernia. Hernias may also be misdiagnosed in women due to their higher prevalence in men. Also, hernias in women may be hidden internally, causing chronic intense groin or abdominal pain, which may be misdiagnosed as a different medical condition.
Nonsurgical hernia treatment
In adults with non-painful, reducible (can be pushed back in) hernias, “watchful waiting” is an option. Lifestyle changes such as medication, dietary changes, exercise, smoking cessation and weight loss may be recommended to ease symptoms.
Surgical hernia repair
There are two types of hernia repair surgery – open hernia repair and minimally Invasive hernia repair (laparoscopic and robotic). The type of surgery depends on the type of hernia being repaired; in some cases, a laparoscopic hernia repair is not an option, such as with strangulated intestines or infections.
In an open hernia repair, an incision is made near the hernia and a mesh is sewn over the muscle. Mesh is typically used for large hernia repairs and may reduce the risk of hernia recurrence. In an open repair, the muscle itself may also be sutured closed instead of using a mesh. The surgical site is closed using staples, sutures or surgical glue.
In laparoscopic/robotic hernia repair, several small incisions are made and tubes are inserted for instruments to pass through and sew in a mesh or sutures. The abdomen is filled with carbon dioxide gas to make the hernia more visible for the surgeon. This gas causes stomach bloating after hernia surgery, but resolves quickly. Like an open repair, a mesh or sutures or used to repair the hernia site.
If sharp abdominal pain and vomiting occur, the intestine may have slipped through the rupture and become strangulated. This is an emergency and immediate surgical treatment is required.
Robotic Hernia Surgery
At Advanced Laparoscopic Associates, we perform robotic hernia surgery on inguinal, ventral and incisional hernias. Robotic hernia repair carries a number of advantages over both traditional open and laparoscopic minimally invasive hernia repair.
Both laparoscopic and robotic hernia surgery involve the use of small tools, small incisions and flexible cameras. The difference is, in robotic hernia surgery, the surgeon controls a robotic arm from a console instead of using the surgical tools him- or herself.
The robotic arm has four hands and can be calibrated for incredibly fine movements. Another distinct advantage is the camera system, which can depict the surgical site in high-definition and three-dimensionally.
A clinical trial comparing open and robotic inguinal hernia repair found that patients who had robotic hernia surgery had shorter hospital stays and lower rates of post-surgical complications. Likewise, data from a national registry suggests that patients who have robotic ventral hernia repair also have shorter hospital stays and less risk of complications than those who have open ventral hernia repairs.
Recovery From Surgery
In most cases, patients can go home the same day after surgery. Complications or more complex repairs may require an overnight hospital stay and extend hernia surgery recovery time. Surgeons may use local or general anesthesia, depending on the type of surgery.
Drinking plenty of water is necessary for proper healing and avoiding constipation. Straining during a bowel movement should be avoided. Fiber or over-the-counter medications such as stool softeners can be added to the diet to help with constipation.
Postoperative urinary retention (PUR) is a post-surgical risk factor. Difficulty urinating after hernia surgery occurs in up to 22 percent of patients. Advanced age, history of benign prostatic hyperplasia (BPH, enlarged prostate) in men and bilateral repair are associated with PUR after inguinal hernia surgery.
Fatigue is common after surgery. Driving and drinking alcohol should be avoided for a couple of days, and will vary depending on your specific case. Lifting more than 10 pounds is prohibited for 4-6 weeks. Normal activity should be increased slowly, but walking every hour is encouraged to prevent blood clot formation.
Most people may return to work within two to three days if they feel able; however, the weight lifting restriction will still be in place and no strenuous activity should be performed. For more complex or recurrent hernia repairs, the lifting limit may be extended. Minimally invasive hernia repair recovery time may be shorter than open hernia surgery.
Scar healing occurs about four to six weeks after surgery and will continue to fade. Tight or rough clothing may irritate the incision site and should be avoided. Wound care instructions will be given to take home.
Mesh reduces the risk of a hernia recurrence. Obesity and wound complications increase the risk of recurrence, as do smoking and diabetes.
If you suspect you have a hernia or are interested in a surgical hernia repair, request an appointment today with one of our associates.