Hernia | Dr Russell Manley | General Surgeon

What is a Hernia?

A hernia is a bulge or protrusion of an organ or fatty tissue through a weakened area in the muscle or connective tissue of the abdominal wall which encloses the abdominal organs.

A hernia can occur in children and adults. They can be born with them ( congenital), or acquired later in life. Hernias in newborns normally heal spontaneously within four years, but for others, hernia repair surgery is the standard treatment.

A hernia can develop in a variety of sites throughout the abdominal wall.

Types of Hernia

Many types of hernias are classified based on their anatomical location.

The common types of hernia include:

Inguinal: Part of the intestine protrudes through the lower abdominal muscle into the groin.

Femoral: Fat tissue or part of the intestine protrudes through the abdominal muscle beside the femoral artery present in the upper part of the thigh.

Incisional: Tissue protrudes through a previous surgical wound, which becomes structurally weak.

Umbilical: Fat tissue or part of the intestine protrudes through the abdominal muscle near the belly button.

Epigastric: Fat tissue or part of the intestine protrudes through the abdominal muscle above the belly button.

Hiatal/Paraesophageal: Part or all of the stomach and or other organs through the diaphragm into the thoracic cavity.

Symptoms

The symptoms depend on the type of hernia, its causes, and its severity. The main symptom is the appearance of a lump (a swollen area) in the region involved. The lump may be painless and only be felt on exertion such as lifting heavy objects, coughing, etc. Some hernias can cause pain during exertion. The lump may not be felt when the person is lying down; it becomes prominent on standing and particularly on straining. In rare instances hernias can become strangulated, interrupting blood supply to the herniated tissue or causing obstruction when involving the bowel.

Diagnosis

Doctors can usually diagnose a hernia by physical examination (for example: for inguinal hernia, a lump can be seen or felt in the groin).

There are multiple other causes of groin pain. Ultrasound, MRI and X-ray may be used to either define the hernia better or exclude other causes.

In some larger hernias, CT scans are arranged to help plan surgery and select the best technique to repair the hernia.

Treatment

After discussion, some patients with minimal symptoms may elect for a conservative or “watch and wait” approach.

Given a hernia is a mechanical defect and will not heal on its own, surgical repair is generally recommended for hernias that cause pain and other symptoms, and for irreducible hernias (structures cannot be returned to their normal locations) that are incarcerated or strangulated. Surgery aims at the closure and repair of the muscle wall through which the hernia protrudes.

The use of mesh in hernia repair is common practice in Australia. Mesh techniques have been shown to decrease recurrence rates. The mesh is usually synthetic (non-absorbable). Mesh is like any other medical device in that it has risks and benefits associated with use.

Hernia Repair

Open Surgery

Open surgery for abdominal wall hernias can be done either under general or local anaesthesia. Your surgeon makes as small an incision as possible (depending on the size of the hernia) to view and access the surgical site. Your surgeon pushes the part of the intestine, other organs or fatty tissue that protrudes back into its normal position and repairs the weakened muscle layer by sewing the edges of the healthy muscle wall together. A synthetic mesh is often placed and sewn over the weakened area to provide additional support and strength. The incision is closed after the procedure using dissolvable stitches.

Laparoscopy

Laparoscopy, also called keyhole surgery, is a less invasive surgical method that uses a device called a laparoscope (a small thin tube with a light and a tiny video camera connected to a television monitor), which helps visualize the internal organs during the operation.

The surgery is performed under general anaesthesia. The surgeon makes small incisions through which the laparoscope and other surgical instruments are inserted. Carbon dioxide is injected into a deeper layer of the abdominal wall with the aid of a balloon device, enabling your surgeon to create a space just outside of the abdominal cavity to visualize structures including the hernia contents itself. The contents are then reduced into their natural position and the defect is reinforced using a synthetic mesh by placing it over the weakened area.

This repair is known as a totally extraperitoneal repair (TEP). Other laparoscopic techniques involve entering the abdominal cavity and then incising the innermost layer (peritoneum) to visualize the hernia and complete the repair using synthetic mesh. The incision in the peritoneum is then closed. This repair is known as a transabdominal preperitoneal (TAPP) repair. Once the procedure is completed, the small abdominal incisions are closed with stitches or surgical tape.

Advantages of a laparoscopic procedure over the open surgical method include shorter hospital stay, smaller incisions, less postoperative pain, less risk of surgical site infection and faster recovery. You can resume normal activities in a few days.

There are specific individual circumstances where one technique will be more suitable than another and this, along with any other concerns would be discussed during a consultation.

Post-operative Care

Following surgery, you:

Can shower with the waterproof dressings applied.
Can go home the same day or day after the procedure.
Should avoid driving while taking pain killers as they induce drowsiness.
Can resume daily activities slowly while strenuous activities including lifting should be resumed only after your post-operative assessment with Dr Manley.
Use an ice pack on the wound to reduce pain, prevent swelling and lessen bloody discharge from the incision if present.