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Hernias

  • Types of Hernias

    What is a hernia?

    A hernia is a bulge caused by tissue pushing through the wall of muscle that’s holding it in. Most hernias are abdominal hernias. This means they happen in the belly and groin areas. You may have a hernia if you can feel a soft lump in your belly or groin or in a scar where you had surgery in the past. The lump may go away when you press on it or lie down. It may be painful, especially when you cough, bend over, or lift something heavy. Weakness in the abdominal wall could also result from surgical scars (incisional hernias) or following laparoscopy (port site hernias), or around stomas (when the bowel is brought on to the skin) (parastomal hernias). Hernias are generally repaired in order to avoid the life-threatening complication of strangulation i.e. entrapment of a knuckle of bowel in the defect, causing it to lose its blood supply. Types of hernias include:

    • Inguinal hernia.
    • Femoral hernia.
    • Umbilical hernia.
    • Incisional hernia.
    • Epigastric hernia.
    • Hiatal hernia.

    There are two ways that a hernia repair can be carried out. These are laparoscopic or minimally invasive surgery, or open surgery.

    Keyhole (laparoscopic) surgery (for groin hernias)

    The advantage of key hole or minimally invasive surgery is that hernias in both groins can be operated on simultaneously; period of recovery is smaller and incidence of chronic pain is much less compared to an open repair. In the traditional open repair, if one has hernias in both groins, usually one side would be operated on at one time and the other side needs an operation later when the operated side has healed up. The laparoscopic technique is also useful when a hernia has recurred after a previous open repair.However, one sided hernias can also be repaired by this minimally invasive technique. The principles of hernia repair by minimally invasive surgery are similar to open repair and a non absorbable mesh is used to strengthen the area, and to avoid recurrence (hernia coming back). Some hernias (e.g. large inguinal hernias going into the scrotum, incarcerated or strangulated hernias) are not suitable for the laparoscopic approach.

    You will usually be able to go home on the same day, but some people stay in hospital overnight if they have other medical problems or if they live alone.

    Open surgery

    The surgeon makes an approximately 5cm cut in your groin. The inguinal canal (the channel near your bowel) is opened to return the fatty lump or loop of bowel to your abdomen, where it should be.The wall of your abdomen is strengthened by fixing a patch of unabsorbable mesh to it.In an emergency situation, if the hernia has become trapped (strangulated) and part of the bowel damaged, the affected segment may need to be removed and the two ends of healthy bowel rejoined. This is a bigger operation and you may need to stay in hospital for four to five days.

  • Femoral Hernias

    Femoral hernias occur in the groin – the small area of the lower abdomen on each side, just above the line separating the abdomen and the legs.They are relatively uncommon (they account for 2% of all hernias and 6% of all groin hernias, the other 94% are inguinal), more likely to occur in women than in men (70% of femoral hernias occur in women, probably because of their wider pelvis making the femoral canal slightly larger) and are often confused with inguinal hernias by both patients and doctors.Almost half of all femoral hernias first come to light as emergencies.

    What are the signs?

    A small swelling very low down next to the groin skin crease; sometimes just below the crease so the swelling seems to be at the top of the thigh.

    What are the symptoms?

    Often very little, perhaps a bit of an ache. This is why they tend to be so ‘dangerous’ – there are often no symptoms until they strangulate. If strangulation occurs the lump becomes hard and tender. A femoral hernia that gets stuck or ‘incarcerated’, on the way to strangulation, can cause severe local and abdominal pain, nausea and vomiting. If a loop or knuckle of intestine is within the hernia sac it requires immediate, emergency surgery.The estimated time for bowel viability (survival) is about 8-12 hours.

    Why is strangulation common?

    The reason so many femoral hernias come to light as emergencies is probably that the femoral canal, through which the hernia appears, is narrow with most of its entrance (the femoral ring) rigid and unyielding.

    What should I do?

    Femoral hernias should be repaired early and not left until they become a problem. Not all doctors realise how important this is.

    What operation?

    The goal of surgery is to close off the femoral canal. Before mesh arrived on the scene this was done with stitches, stitching the front and back of the opening together. The problem is that there is not much ‘give’ here, trying to sew two rigid structures to each other. The result can be both painful and not very reliable. Our preferred method is to place a soft mesh cone plug in the femoral canal. This sits in the femoral canal where it remains, stopping anything going through. This can be done with local anaesthesia through a short cosmetically-placed incision just above the groin crease.

  • Hiatus Hernias

    The diaphragm is the part of the body that is affected by a hiatal or hiatus hernia. A hiatal hernia is where part of the upper stomach pushes through the diaphragm at this usually snug point. Part of the stomach can “herniate” at this “hiatus” if the opening is weakened.

    Causes and risk factors for a hiatal hernia:

    Experts do not fully understand all of the causes of the weaknesses that result in hiatal hernias.A hiatal hernia is thought to be caused by pressure pushing up on the diaphragm.

    There may be inherited genetic factors that make some people more at risk from pressure.

    Symptoms of a hiatal hernia:

    The stomach bulging up as a hiatal hernia often gives no symptoms. It is often detected only by chance in people who have a scan for another reason.The symptoms of a hiatal hernia are caused by acid coming up from the stomach.Acid going up from the stomach can cause heartburn. Heartburn tends to worsen in relation to different foods and drinks or happens when lying down and bending over, especially when done soon after eating. It can produce a bad taste in the back of the throat, as well as bloating and belching.If the heartburn symptom in particular becomes a regular problem, people have acid reflux. If acid reflux happens too regularly for too long, this can progress to gastroesophageal reflux disease (GERD).The risk of a hiatal hernia related to obesity means that tackling obesity could prevent it, or at least help with controlling symptoms. Other known causes and risk factors are not preventable. In all cases when there are symptoms, these can be managed.For any hiatal hernia, changes to eating and drinking can help. Dietary tips to help against hiatal hernias producing heartburn symptoms include:

    • Reducing total meal sizes
    • Reducing portions
    • Not having so many of the foods that trigger more acid to be pushed up

    The timing of eating and drinking can be a factor because mealtimes affect when acid can flow back into the esophagus.People should have meals 3 hours of more before lying down to bed. Real problems with acid might be helped by raising the head end of the mattress so that the bed slopes slightly toward the feet.

    Medical options:

    If a hiatal hernia is causing enough of a problem with acid reflux, doctors may prescribe a drug to reduce stomach acid and heartburn symptoms. Treatments to relieve symptoms are also available over the counter without prescription.

    Surgery:

    Only rarely do hiatal hernias need surgery in hospital under general anesthesia:

    • People who develop long-term, severe reflux problems may consider an operation if lifestyle and medical treatments do not work.
    • If part of the stomach squeezes through the diaphragm into such a bulge that it loses healthy blood supply, surgery becomes important.

    The operations for hiatal hernias are done through a large open incision or a few keyhole cuts. The procedure, called laparoscopic Nissen fundoplication is one of the most regularly performed to treat sliding hiatal hernias.

    • Pull the stomach back down

    Tighten the diaphragm around the esophagus to stop the hernia bulge

  • Incisional Hernias

    An Incisional Hernia is a hernia that occurs through a previously made incision in the abdominal wall, ie the scar left from a previous surgical operation. The incision will have been made in order to get to an internal organ such as the appendix, or a caesarian section. So an Incisional hernia is not the same as a Recurrent Hernia.After that previous operation, the surgeon will have had to close the layers of the abdominal wall with stitches. Sometimes this closure simply comes apart, fails to heal properly in the first place or just comes apart with time.

    How common are they?

    Remarkably common. It is estimated that at least 12-15% of abdominal operations lead to an incisional hernia.Historically, and even today, the success rate for repairing them is quite poor with a high incidence of complications and failure. In some reports from other surgeons 50-60% of incisional repairs have failed within 2 years.

    Are incisional hernias dangerous?

    As with all hernias, if the hernia strangualates, i.e. the hernia contents (the intestine) get trapped and lose their blood supply, which is very dangerous.

    Can or should I leave it?

    If you do, it will almost certainly enlarge. It will just get bigger and probably become more and more unsightly and uncomfortable.

    Do I have any non-surgical options?

    Wear a corset or belt. Not ideal, can cause additional problems and it is difficult to find a good one.

    What is the best way of repairing it?

    We have extensive experience in this area and today most hernia surgeons agree: a) using mesh gives the best results.

    1. open or keyhole repairs are both good (when performed by expert specialists) and which to use depends on the hernia, the intended result, the patient, and the surgeon. The type of repair should be tailored to the individual case and by an expert
    2. the layer of the abdominal wall in which the mesh is placed is a really important factor

    Is mesh always used?

    It should be. Sutured repairs have a really high failure rate. Biological meshes are unproven, and there are few long-term results available. So far in the majority of cases, when the mesh dissolves, the hernia returns.

    How good is the keyhole repair?

    It depends who does it. It does not bring the edges of the hole together, so if there is a really wide gap the result may be disappointing, with quite a big bulge remaining. However, in the hands of experts specialising in this method of hernia repair, the results can be good.

  • Inguinal Hernias

    What Is an Inguinal Hernia?

    An inguinal hernia occurs in the groin area when fatty or intestinal tissues push through the inguinal canal. The inguinal canal resides at the base of the abdomen. Both men and woman have an inguinal canal. In men, the testes usually descend through this canal shortly before birth. In women, the canal is the location for the uterine ligament. If you have a hernia in this passage, it results in a protruding bulge that may be painful during movement.

    Symptoms of Inguinal Hernia

    These types of hernias are most noticeable by their appearance. They cause bulges along the pubic or groin areas that can increase in size when you stand up or cough. This type of hernia may be painful or sensitive to the touch. Other symptoms may include: pain when coughing, exercising, or bending over, burning sensations, a heavy or full sensation in the groin, swelling of the scrotum in men.

    Causes and Risk Factors of Inguinal Hernia:

    There isn’t one cause for this type of hernia, but weak spots within the abdominal and groin muscles are thought to be a major contributor. Extra pressure on this area of the body can eventually cause a hernia. Examples of risk factors include: heredity, personal history of hernias, being male, premature birth, obesity, pregnancy, chronic cough, frequent constipation, frequently standing for long periods of time

    Types of Inguinal Hernias:

    Inguinal hernias can be either indirect or direct. An indirect inguinal hernia is the most common type. A direct inguinal hernia most often occurs in adults. The popular belief is that weakening muscles during adulthood lead to a direct inguinal hernia. Inguinal hernias can also be incarcerated or strangulated. An incarcerated inguinal hernia happens when tissue becomes stuck in the groin and can’t go back. Strangulated hernias are lifethreatening and require emergency medical care.

    Diagnosis of an Inguinal Hernia

    A doctor can easily push these hernias back into your abdomen when you are lying down. Your doctor can make this determination during a physical exam. During the exam, your doctor will ask you to cough while standing so they can check the hernia when it’s at its largest.

    Treating Inguinal Hernias

    Surgery is the primary treatment for inguinal hernias. It’s a very common operation and a highly successful procedure when done by a well-trained surgeon. Your doctor will recommend either herniorrhaphy (“open” repair) or laparoscopic surgery (done through a small scope). Open repair involves making an incision into the groin and returning the abdominal tissues to the abdomen and repairing the abdominal wall defect. Laparoscopy uses several short incisions rather than a single, longer incision.

    Prevention and Outlook of Inguinal Hernias

    Although you can’t prevent genetic defects that may cause hernias, it’s possible to lessen the severity of hernias by: maintaining a healthy weight, eating a high-fiber diet,not smoking, avoiding heavy lifting. Early treatment can help cure inguinal hernias.

  • Paediatric Hernias

    Hernias in Children:

    1.  Groin or Inguinal Hernias

    A paediatric inguinal hernia can occur at any age, but the peak incidence is during infancy and early childhood with 80-90% occurring in boys. About 3-5% of healthy, full-term babies may be born with an inguinal hernia and one third of infancy and childhood hernias appear in the first 6 months of life. In premature infants the incidence of inguinal hernia is substantially increased, up to 30%. In just over 10% of cases, other members of the family have also had a hernia at birth or in infancy.

    Symptoms:

    A hernia in an infant or a child will be seen as a bulge or a swelling in the groin. In boys the swelling might be seen in the scrotum. In many cases the swelling may only be seen during crying or straining. Inguinal hernias in children are prone to get stuck, i.e. the lump does not go away when the child relaxes. This is called incarceration. However, an incarcerated or irreducible hernia  should be seen by a doctor urgently. In an acute situation, the child or infant should be admitted to hospital and given some pain relief and sedation. Initial attempts are made by the doctors to gently negotiate the hernia back inside. If the hernia does not go back, or the child is ill, the irreducible hernia should be operated upon urgently as it may contain intestine that is in danger of strangulating.  Strangulation is extremely serious and must be avoided at all costs.

    The Operation

    The surgery is carried out under general anaesthetic. A small incision is made in the groin and the hernia sac is found. In children and babies it is sufficient to remove the hernia sac. The hole in the abdominal muscle does not usually need to be repaired, i.e. does not need stitching or mesh.The incision in the skin is usually closed with dissolving stitches.

    Strangulated hernias can prove fatal. At best they can be extremely painful and are surgical emergencies. That means they require urgent professional attention.

    2.  Umbilical Hernia (the navel)

    This is one of the most common paediatric surgical conditions affecting 1 in 5 of all children. Umbilical hernias are more common in premature babies and children with Down’s Syndrome and there is a slight familial tendency. They appear as a bulge at the umbilicus (the navel), which can vary from the size of a pea up to the size of a small plum. They are not usually painful and are much more obvious when the child cries or strains.

    Do they need an operation if they are not treated?

    There is a general agreement that most infantile umbilical hernias will eventually close spontaneously, though experts disagree over what period of time. Probably 80-90% of umbilical hernias will have closed by the time the child is 3, but the larger ones may be present up to 11 years before finally closing. Umbilical hernias present after puberty will probably not close spontaneously. In the case of infantile umbilical hernias, problems rarely occur, so that surgery is rarely required. However the presence of pain in the hernia, particularly if associated with vomiting or constipation, requires an urgent surgical opinion and possible operation. NEVER ignore signs of pain or distress or any bulge in an infant or child.

  • Stoma Hernias

    A hernia is a weakness or split in the muscle wall of the abdomen which allows the abdominal contents (usually some part of the intestine) to bulge out. Stomas pose an additional problem. When a stoma is brought out to the surface of the abdomen it must pass through the muscles of the abdominal wall, thus a potential site of weakness is immediately created.  Factors that can contribute to causing a stoma hernia to occur include coughing, being overweight or having developed an infection in the wound at the time the stoma was made. The development of a stoma hernia is often a gradual phenomenon, with the area next to the stoma stretching and becoming weaker with the passage of time.  Stoma hernias are rarely painful, but are usually uncomfortable and can become extremely inconvenient. They may make it difficult to attach a bag properly and sometimes their sheer size is an embarrassment as they can be seen beneath clothes. Although a rare complication, the intestine can sometimes become trapped or kinked within the hernia and become obstructed. Even more seriously the intestine may then lose its blood supply. This is very painful and requires emergency surgery to untwist the intestine and prevent the strangulated part of the bowel from being irreversibly damaged. Regardless of inconvenience or pain, hernias are defects in the abdominal wall and should not be ignored simply because they might not hurt. This is probably true with small hernias in people who are very elderly and infirm or people for whom an anaesthetic would be dangerous.

    Repair of stoma hernias – The usual approach

    If symptoms are severe enough, the hernia is repaired. The repair of a stoma hernia requires that the abdominal wall tissue is made to fit back snugly around the stoma, leaving no weakness. There are two options. One can move the stoma to a new site on the abdomen, or one can try to repair the hernia around the stoma, leaving the stoma where it is.

    A more modern approach

    Whether one chooses to leave the stoma at its original site or to move it, we feel that the hernia itself should be repaired with mesh over and beyond the weakened area to reinforce the whole weakened muscle structure. This is an improvement over the original stitching method and our technique usually enables us to avoid the more major procedure of re-siting the stoma. This use of mesh, rather than stitches, serves to avoid future recurrences, which happen when the stitches used with other methods are pulled away from the tissue. Whilst there can be no guarantee of the permanence of any stoma hernia repair, it is felt that this technique offers the least risk of recurrence.

  • Umbilical Hernias

    What is an umbilical hernia?

    An umbilical hernia occurs when part of the bowel or fatty tissue pokes through an area near the belly button. Umbilical hernias are common in young infants.  An umbilical hernia looks like a lump in the navel, which might become more obvious when the baby is laughing, crying, going to the toilet, or coughing. When the child is lying down or relaxed, the lump may shrink.  In the majority of cases, an infant’s umbilical hernia closes on its own by the age of 12 months. If the hernia is still there by the time the child is  4 years old, a doctor may recommend surgery. Umbilical hernias might also develop in adults, especially if they are very overweight, lifting heavy objects, or have a persistent cough.

    Symptoms of an umbilical hernia

    There may be a soft bulge/swelling near the umbilicus (navel). The bulge is usually more noticeable if the baby cries, laughs, coughs, or strains. Pain – in children and infants, umbilical hernias are not usually painful. However, adults may feel pain or discomfort if the hernia is large.

    When to see a doctor:

    • The bulge becomes painful, the infant/adult vomits (and there is a bulge).
    • The bulge swells up more, the bulge becomes discoloured.
    • You used to be able to reduce the hernia (i.e. push the bulge flat against the abdomen), but now it cannot be reduced without significant pain/tenderness

    Diagnosis of an umbilical hernia:

    A doctor will be able to diagnose an umbilical hernia during a physical examination. He/she may also be able to determine what is protruding – what is caught in the hernia sac.

    Treatments for umbilical hernia:

    Surgery may be ordered if:

    • The hernia grows after the child is 1-2 years old
    • The bulge is still there by the age of 4
    • If the intestines are within the hernial sac, preventing or reducing the movement of the intestines (called peristalsis)
    • If the hernia becomes trapped

    Adults – surgery is usually recommended, to prevent potential complications, especially if the hernia grows or starts to hurt.

    Surgery

    Umbilical surgery is a quick procedure. Umbilical hernia surgery is a small, quick operation to push the bulge back into place and to make the abdominal wall stronger. In most cases, the patient will be able to go home on the same day. The surgeon makes an incision at the base of the belly button and pushes either the fatty lump or bowel back into the abdomen. Muscle layers are stitched over the weak area in the abdomen wall, effectively strengthening it.

    Complications of an umbilical hernia

    Umbilical hernia complications are very rare in children. If the protrusion becomes incarcerated (trapped) and cannot be pushed back into the abdominal cavity, the primary concern is that the intestines might lose some of its blood supply and become damaged. If the blood supply is completely cut off, there is a risk of gangrene and life-threatening infection. Incarceration is rare in adults, but even rarer in children.