Hernias

What is a hernia?

A hernia is where bowel or fat pushes through a weak spot in the deep strong (fascia) layers of the abdominal wall. There are natural “weak spots” in the abdominal wall that are prone to developing hernias. These are commonly in the groin (inguinal and femoral) and the belly button (umbilicus). Previous surgery can also weaken the abdominal wall leading to a hernia (incisional).

There are various terms that are used to describe a hernia:

Reducible

A reducible hernia can be pushed back in. This is often easier to do when lying down and commonly comes back out again when standing or coughing

Irreducible or incarcerated

This is where the hernia is out and can not be pushed back in. This is not necessarily an emergency, particularly if the hernia just contains fat.

Strangulated

This is an emergency. If the hernia is irreducible and contains bowel there is a risk that the blood supply can be compromised. Strangulated hernias are typically very painful and will result in a bowel obstruction. If there is any concern about a strangulated hernia, urgent medical care is advised.

What are the common types of hernias?

Inguinal hernia

An inguinal hernia is the most common type of hernia and is more frequent in males. The inguinal canal is a longitudinal space within the muscles of the abdominal wall just above the groin. In males it contains all the structures that go to and from the testes and in females it contains the round ligament which connects to the uterus. Males are more likely to have a weakness at this point as the testes descend through the inguinal canal during development.

There are two types of inguinal hernias - indirect and direct. An indirect hernia is where the “weak spot” is at the deep ring, which is where all the structures to and from the testes (spermatic cord) traverses. A direct hernia is a weakness directly through one of the muscles just medial to the deep ring. The distinction between the two is at times for academic purposes as both are treated with the same operation and sometimes occur together.

Femoral Hernia

A femoral hernia is slightly lower down in the groin than an inguinal hernia and occurs next to the main blood vessels travelling in to the leg. Femoral hernias are more commonly seen in females. Most femoral hernias are recommended to undergo surgery as they have a higher risk of emergency complications if left untreated.

Umbilical and Paraumbilical hernia

We all have a natural “weak spot” at the belly button (umbilicus). Hernias can be directly through the middle of the belly button creating an “outy” (umbilical hernia), or pushing off to one side creating a crescent shape umbilicus (paraumbilical). These hernias commonly just have a small amount of fat within them, though can occasionally involve bowel.

Epigastric hernia

An epigastric hernia can occur anywhere from the xiphisternum (bottom of the ribs) to the belly button (umbilicus). We all have a “weak spot” here where the two rectus muscles are joined together.

Incisional hernia

Any incision in the abdominal wall can weaken over time and create a hernia. The most common incision that leads to a hernia is in the midline (straight up and down the middle). Incisional hernias can range from very small (<1cm) to very large (>20cm). The repair of an incisional hernia can be very different depending on the size of the hernia.

What symptoms does a hernia cause?

The most common symptom of a hernia is a visible bulge. This is typically worse when standing and disappears when lying down.

Hernias at times can be painful, which is typically exacerbated by heavy lifting and exercise.

Less commonly a hernia can cause a complication such as a bowel obstruction or strangulation (see above). This is an emergency situation and requires urgent care.

What investigations are required?

Often nothing! Hernias are usually diagnosed on examination alone. If there is any doubt about the diagnosis or if it is a complex hernia, a scan may be required. This will usually be either an ultrasound or CT scan depending on the site of the hernia.

How is a hernia repaired?

A hernia will never disappear on it’s own. It will usually either stay the same or slowly increase in size over time.

The surgical repair of a hernia varies depending on the size and location. Small umbilical or epigastric hernias can sometimes be repaired with sutures. All other hernias will usually be repaired and reinforced with mesh. This significantly reduces the recurrence rate of the hernia.

In general terms there are two methods for repairing hernias, open or laparoscopic (keyhole). Both have their advantages and disadvantages. The choice of operation will be discussed with you during your consultation.

Is mesh safe?

YES! This is a very common question that we are asked, particularly with the recent attention with regards to use of mesh for gynaecological prolapse repair. Mesh has been used for hernia repairs for many decades and has proven to be safe. For most hernias a simple suture repair without mesh has an unacceptably high recurrence rate. This rate is significantly reduced with the use of mesh.

Mesh is an inert substance that your body will not “reject”. The mesh is designed to promote scarring (fibrosis) which is ultimately what provides the long term strength of the repair. There are various types of meshes that can be used and tailored to the specific operation.