Indications and Procedures
A hernia is an abnormal protrusion of an organ or organ part from its normal body cavity, most often tissue protruding through the abdominal wall. Abdominal hernias may occur in the groin (inguinal hernia), upper thigh (femoral hernia), navel (umbilical hernia), and diaphragm (hiatal hernia). They may be congenital or acquired in later life. Herniated tissue is most often part of the small or large intestine. It can also be part of the bladder or the stomach in femoral and hiatal hernias, respectively. Most hernias occur as a result of strain to the abdominal wall or its injury. For example, they are often caused by athletic overexertion or hard labor. Consequently, men are more subject to acquired hernias than women.
Congenital inguinal hernias
in male infants can occur when the testicles of a developing fetus work their way down the inguinal canal to the scrotum. If the tissue sac accompanying them does not close off correctly, congenital hernia occurs. In men, acquired inguinal hernias occur when excess abdominal strain ruptures the intestinal wall and releases a loop of intestine. Inguinal hernias are less common in women and are associated with the canal that holds the round ligament of the uterus. Femoral hernias
in both sexes lie on the inner sides of the blood vessels of the thighs and are always acquired, often by overexertion. Umbilical hernias
, which may be congenital or acquired, protrude from the navel.
Incisional hernia is caused by the incomplete healing of surgical wounds of the abdomen. A fifth hernia type is hiatal hernia
, which occurs at the opening where the esophagus passes through the diaphragm (the hiatus). Such hernias, in which part or all of the stomach passes through the diaphragm, may cause no external symptoms and be diagnosed only when chest X rays are taken for other reasons. If symptoms do occur, they usually include heartburn and chest pain.
Hernias are classified according to severity. Reducible hernias are those which can be resolved by pushing herniated tissue back into its proper position. Irreducible hernias are more serious. They cannot be pushed back manually because of their position, or because of the presence of adhesions that bind them in place. Such hernias can only be corrected with surgery. Strangulated hernias are those whose size and location pinch herniated tissue, cutting off blood flow. They require immediate surgical treatment to prevent the development of gangrene or peritonitis
, both of which can be fatal.
Surgical repair is the suggested treatment for most hernias. If the patient is temporarily too ill for surgery, a truss may be used to diminish pain and swelling for inguinal, femoral, umbilical, and incisional hernias. Trusses, however, provide only temporary, symptomatic relief, except perhaps in umbilical hernias of very young children. Extreme caution is necessary: Reducible hernias treated with trusses can become irreducible or strangulated.
Standard hernia surgery can be accomplished in several ways. For the correction of inguinal or umbilical hernias, first the muscle wall is opened. Then, after the herniated loop is moved into an appropriate position, the muscle wall is closed as normally as possible. In more severe types of hernia repair involving visible protrusions, the abdominal wall is opened, adhesions are cut away, and the tissue is returned to a normal position. Then, the muscle wall is closed to restore normal muscle layers. When strangulation occurs, damaged tissue is cut away, normal sections are joined together, and viable tissue is returned to the abdomen, followed by abdominal closure. Incisional hernias are treated similarly, in a fashion dependent on the extent of the external damage and the degree of herniation.
Hiatal hernias are treated medically, whenever possible, because they tend to recur after surgery. Medical treatment includes restriction of activity, weight loss, and diet modification. Surgery is carried out when these efforts fail or if severe adhesions and/or strangulation occurs. The goal of this surgery is to strengthen the closure at the junction between the diaphragm and the esophagus.
Uses and Complications
The surgeries to correct inguinal, femoral, umbilical, and incisional hernias are straightforward. In all cases, but especially in strangulation, patients are checked before release to ensure that normal bowel movement occurs, that incisions have not become infected, and that fever has not developed. At this time, patients are also shown how to protect their incisions before coughing, are advised to maintain a high fluid intake to engender normal bowel function, are warned against overexertion, and are made aware of signs of incision infection. Furthermore, they are advised to resume work or physical activity only after consulting the physician involved.
Patients who have undergone surgery to correct a hiatal hernia are given much the same advice. Their surgery, however, is more extensive and prone to more complications. Therefore, they are provided with recommendations concerning which foods and activities to avoid. Furthermore, they are advised of the extended time period required before they can return to normal function and are told that without careful compliance, the problem will recur.
Perspective and Prospects
Major advances in the treatment of hernias have included better diagnosis of their extent and the necessary means of their correction. computed tomography (CT) scanning and other imaging techniques can make possible very accurate diagnoses. Progress in the surgical techniques used in hernia repair includes laparoscopy, in which a fiber-optic tube is used to visualize the chest cavity and thus to minimize incision size in the correction of hiatal hernias. All these methodologies are expected to improve in the future.
Bibliography
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"Inguinal Hernia Repair." MedlinePlus, January 29, 2013.
McCoy, Krishna. "Hernia Repair." Health Library, October 11, 2012.
Mulholland, Michael W., et al., eds. Greenfield’s Surgery: Scientific Principles and Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
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Zinner, Michael J., et al., eds. Maingot’s Abdominal Operations. 11th ed. New York: McGraw-Hill, 2007.
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