Hernia

Introduction

A hernia is the protrusion of an organ or the lining of an organ through the wall of the cavity (commonly abdomen) that normally contains it. The common contents are part of intestine or abdominal fat tissue, lined by a thin membrane which will form hernial sac. It will usually appear when there is increase in the abdominal pressure and will dissappear when lying down. This phenomenon is called ‘reducible’.

Type Hernia

  1. Inguinal hernia: Occurs in groin. Seventy five percent of abdominal hernias are of this type. It occurs 25 times more common in male than in female. Inguinal hernias are divided into 2 types; direct and indirect. Both can be differentiated  based on their origins eventhough the swelling may look the same. It is important to recognize which type of inguinal hernia in the clinical diagnosis.
    • Indirect inguinal hernia: This occurs when a portion of the intestine slips through the inguinal canal via the internal opening of the inguinal canal. This canal was once going through by testes from within the abdomen into the scrotum during fetal development. It usually closes around the time of birth, however in this situation it remains open. It can happen in all ages. Sometimes the hernial sac can protrude into the scrotum.
    • Direct inguinal hernia: It occurs when hernia contents push through a weak spot in the abdominal area which is relatively thin. It does not extend into the scrotum. Unlike Indirect Inguinal Hernia, Direct Inguinal Hernia tends to occur in the middle aged and elderly people when abdominal wall becomes weaker as the age increases.
  2. Femoral Hernia: Femoral canal is the passage where femoral artery, vein and nerve exit from abdomen into femoral area. Usually this canal is tight and compact, but it can become loose and expanded which will allow abdominal contents to protrude out through it. Femoral hernia causes swelling at the mid thigh just below the inguinal fold. Commonly occurs in female and tends to become irreducible where it cannot be pushed in.
  3. Incisional hernia: Abdominal surgery may result in changes in the abdominal wall architecture especially along the incised area. This area will become weak and will cause hernia to occur. It happens in 2-10% of abdominal surgery.

Causes of Hernia

Hernia in the elderly could be caused by patent inguinal canal, defect in the abdominal wall or weakness in the abdominal wall for some reasons.

Any condition or situation which causes increase pressure  in the abdominal cavity would contribute into hernia formation or would cause hernia to be worsen. Examples;

  • Obesity,
  • Lifting heavy weight,
  • Cough,
  • Strain ing during urination or defecation
  • Chronic lung disease and
  • Ascites – Fluid collection in the abdominal cavity.

Sign, Symptoms and Hernia Complications

Signs and sympoms of hernia may vary. It could be mild where one presents with a swelling which is usually not painful, appears during standing or coughing or straining and dissappears when lying down or pushed back with hand. Other may present with severe features like painful swelling to some extent cannot be touched, hence cannot be pushed back into the abdomen or irreducible, skin may look red or blackish and patient may develop fever. This is due to hernia contents such as intestine has received reduced blood supply as its blood vessels may be compressed usually at the hernia opening. This is called srangulated hernia.

  • Reducible hernia
    • It can appear as a new swelling at the groin or at other abdominal area.
    • One may feel mild dull pain but usually touching the swelling will not cause pain.
    • Swelling will appear or increase in size when standing or when there is increase in the abdominal pressure (eg. coughing).
    • It can be pushed back into the abdomen (reducible).
  • Irreducible hernia
    • It appears as a swelling which may be mildly painful, initially able to appear and dissappear (reducible), later on it can go into abdomen by itself or  be pushed into by hand.
    • Some may become chronic when the swelling is not reducible for quite sometime especially if it is not painful, the patient does not bother to seek treatment.
    • It may worsen and become strangulated hernia.
  • Strangulated hernia
    • Commonly begins as an irreducible hernia then later got obstructed and strangulated at the hernia opening causing compression to the blood vessels, eventually  will compromise the blood supply to the intestine in the hernia sac.
    • Usually patient will have severe pain when swelling is touched or pressed. There will be signs and symptoms of intestinal obstruction (such as nausea, vomiting and abdominal distension).
    • Patient may develop fever and looked very ill.
    • This condition is an emergency/surgical emergency. Urgent surgery has to be done.

Treatment

Home care

In general all hernia should be operated unless patient is not fit for surgery due to certain other health problems.

Avoid activities that can cause increase in the abdominal pressure such as coughing, lifting heavy object or straining which will make hernia becomes worst. Someone who has cough need to seek treatment. Someone who has to strain during urination or defecation should go for examination by doctor to ascertain  the cause. It may be caused by constipation or  enlargment of the prostate which need to be treated.

Medical Treatment

Depend on wether  it is reducible or irreducible and possibility of strangulation..

  • Reducible hernia
    • Generally all hernia need to be operated to avoid possibility of complicating to strangulation.
    • If surgery cannot be done due to other medical reasons, surgery will not be carried out or be postponed and doctor needs to examine patient periodically.
    • There are conditions doctor will not operate due to nature of hernia.
      • There is hernia with wide opening and the risk of strangulation is very low and there is a  situation where surgery to close this wide opening is very complicated.
    • Treatment may be different for each hernia and doctor will discuss with patient the method of  treatment including the risks and benefits if surgery  is done or not.
  • Irreducible hernia
    • All irreducible hernia needs emergency treatment due to risk of strangulation.
    • Attempt to reduce the hernia can be done and facilitated by the use of painkiller and muscle relaxant.
      • If the hernia contents include intestine, there is a risk of strangulation which will compromise blood supply to the intestine.  If the blood supply is totally cut off, the intestinal tissue will die (become gangrenous) in 6 hours.
      • If the strangulation occurs beyond that duration, surgery   is done to assess the severity and extension of intestinal tissue damage and to repair the hernia.
      • If the duration of irreducible hernia is short and the strangulation is satisfactorily excluded, patient may be disharged from ward once hernia has been reduced.
    • Since this hernia has a tendency to become irreducible again, it is better to do surgery earlier than usual.

Occasionally hernia has been irreducible for quite sometime and becoming chronic. Patient does not feel pain and there are no signs of intestinal obstruction, in this case, surgery can be done electively.

Last Review : 26 April 2012
Writer : Dr. Mohd Daud Che Yusof
Reviewed : Dr. Sanidah binti Md. Ali