Hernia

A hernia is a condition where intraabdominal contents (usually intestine or fat) prolapse through a hernia “gate”, causing it to bulge out of the area in question.

Types

• External hernias (visible externally)
  • Inguinal hernia – herniation through the inguinal canal
  • Incisional hernia – herniation through the abdominal wall
  • Umbilical hernia – herniation through the umbilicus
• Internal hernias
  • Diaphragmatic hernia (a congenital condition, covered in paediatrics)
  • Hiatal hernia
  • Hernia into the compartments of the peritoneum

Etiology

The cause for any abdominal hernia is the same: increased intraabdominal pressure. This can be caused by:

• Obesity
• Heavy lifting
• Heavy coughing (chronic lung disease)
• Constipation

A family history of hernia is also a risk factor.

Clinical relevance

Most hernias are not dangerous, but cosmetically bothersome to the patient. However, in some cases dangerous complications may occur, most notably bowel incarceration or strangulation.

When examining a hernia, it’s important to note:

• The size
• Whether it’s reducible or not (may be pushed back into the abdomen)
• The size of the hernia gate
• The content of the hernia
• The complaint of the patient

Irreducible hernias can lead to bowel incarceration, in which case it’s known as an incarcerated hernia. The incarcerated bowel will be obstructed, causing bowel obstruction. In some cases, incarcerated bowel may also be cut off from its blood supply, which is called strangulated hernia. This causes severe pain due to the ischaemia and necrosis.

Treatment

Both incarcerated hernia and strangulated hernia are surgical emergencies. In case of incarcerated hernia without strangulation we try manual reduction first. If that doesn’t work, the patient needs emergency surgery. If reduction does work, the patient should receive surgery during the same hospital admission (but not urgently). If the patient has strangulated hernia, they need emergency surgery anyway; manual reduction is not tried.

Emergency surgery for incarcerated and strangulated hernia is usually performed open. If performed within 6 hours from the onset of symptoms, bowel loss may be prevented.

Other hernias are mostly cosmetic issues and may be treated with elective surgery if the patient wishes and there are no contraindications.

With hernia surgery, the hernia is first reduced and then the hernia gate is reinforced to prevent herniation from re-occurring. Reinforcement may be with a synthetic mesh or by using the patient’s own tissues as reinforcement.

If the risk for surgery is too high, conservative treatment should be used.‎