A hernia is an abnormal defect in the abdominal wall through which tissue or an internal organ may protrude. Typically, a hernia will present itself as a bulge, which may or may not be associated with pain or discomfort. Once a hernia develops, it will never repair itself and, therefore, surgery usually becomes indicated. A hernia repair involves closing the abnormal defect so that no further tissue may protrude through the opening. This essentially eliminates the risk that an internal organ will become stuck in the hole and become strangulated, which is the most dangerous risk with hernias. Although not common, if an organ were to become strangulated, then emergency surgery would be necessary. The larger the hernia defect, however, the less likely that strangulation will occur.
Some hernias are present at birth, when normal processes of closure fail to occur. Congenital hernias include belly button hernias (umbilical), groin hernias (inguinal), and other abdominal wall hernias (epigastric). They may present themselves early in life when an infant cries or strains, or they may go unnoticed until the hole becomes large enough that tissue may protrude through it. Commonly, pregnancy will draw attention to a previously undetected umbilical hernia. These hernias may also develop over time from progressive weakening of the abdominal wall muscles with age or excessive strain. Femoral hernias are not as common as inguinal hernias, but they can also occur, and are usually located below the groin crease. And, finally, incisional hernias occur as a result of a previous surgery.
The primary indication for hernia repair is pain. Most people will experience some level of discomfort associated with the hernia, which only increases with time. The pain is generally described as a dull ache with exercise or a heavy feeling in the groin at the end of the day. At some point, the discomfort becomes so unpleasant that patients begin to avoid normal daily activities that they otherwise enjoy. This should not occur. A patient should not have to alter his or her lifestyle because of a hernia. On the other hand, if a patient is otherwise relatively inactive and has a large hernia, which causes no pain, then there is no overwhelming reason to repair the hernia.
An inguinal hernia is typically diagnosed when a patient presents with a lump in the groin or groin pain with activity. Oftentimes, patients may experience groin pain from a muscle strain, and not have an actual hernia. A groin strain presents as pain without a bulge and a hernia defect cannot be identified on examination. Treating a groin strain involves restricting activity for 4-6 weeks, using Motrin or Advil for pain, and applying ice packs the first 24-48 hours after injury, and warm heat thereafter.
Once a patient is diagnosed with a symptomatic inguinal hernia, operative repair is usually recommended. In order to reduce the risk of hernia recurrence, most repairs are performed with mesh. The mesh acts as a patch to cover the hernia defect, much like patching a hole in a tire. Although a variety of mesh repairs are available, the best repair for you is the one with which your surgeon is most experienced. The mesh does not dissolve but, rather, becomes incorporated into the surrounding tissue. In my practice, I use the Prolene Hernia System (PHS) mesh repair. This procedure takes less than an hour and can be done with intravenous sedation and local anesthesia, and I have been very happy with the results and the low rate of recurrence. More information about this approach can be found at www.herniasolutions.com.
An umbilical hernia usually presents as a bulge at the belly button, which may or may not be uncomfortable. Sometimes, patients will have had an “outie”, which is actually an underlying umbilical hernia. Most umbilical hernias are present at birth, but will go unnoticed until the hole becomes large enough that tissue can pass through it. This commonly occurs after pregnancy or significant weight gain. Most umbilical hernias can be repaired without mesh, since the defect is usually quite small. The general rule of thumb is that if the hole is less than a nickel in size, then it can be closed without mesh without a significant risk of recurrence.
An epigastric hernia is also usually present at birth, and may occur simultaneously with an umbilical hernia in up to 20% of patients. Similar to an umbilical hernia, the defect of an epigastric hernia is usually quite small and can be repaired without mesh. An epigastric hernia is usually located in the upper abdomen, in the midline, and at a variable distance from the belly button.
An incisional hernia is a defect in the abdominal wall that occurs in the area of a previous incision from a previous surgery. In most cases, tension on the sutures, which were placed to close the fascia layer (the strength layer of the abdominal wall), may cause the sutures to tear through the fascia leaving a hole. In other cases, the fascia layer may not have been closed completely, leaving a hernia defect. Most incisional hernias require mesh for repair. Depending on the size of the defect, the procedure may be performed under intravenous sedation and local anesthesia as an outpatient for smaller defects, or require general anesthesia and even a short hospital stay for larger defects. Larger hernias may also require placement of a drain to prevent fluid build-up after surgery. The drain will be removed in the office once the fluid drainage slows, which usually takes 1-2 weeks.