About Hernia

15%–20% of individuals in the general population have hernias. There are 1.5 to 2 million inguinal hernias in India, according to statistics. Men are more likely than women to have an inguinal hernia. Men undergo about 90% of inguinal hernia procedures, whereas women undergo 70% of femoral hernia repairs. 

The inguinal hernia has been reported to have a standing risk of 27% in men and 3% in women. Inguinal hernias are five times more frequent than femoral hernias in women, even though femoral hernias are more common in women overall. At the same time, children are most frequently affected by umbilical hernias. 

What is Hernia ?

A hernia occurs when an organ or tissue protrudes through a weak spot in the muscle or connective tissue that normally contains it. Common types include inguinal, femoral, umbilical, hiatal, and incisional hernias. They can result from factors like heavy lifting, chronic coughing, pregnancy, obesity, or previous surgeries. Hernias can cause discomfort, pain, and visible bulging at the site of the protrusion.

What are the Types of Hernia?

Hernia can be of many types. But some of the most common types of hernia are as follows:

Inguinal Hernia

It is the most common type of a hernia. According to western studies, inguinal hernias constitute 75% of all cases of hernia. In this condition, a part of the intestine protrudes through the weakened abdominal wall cavity and appears at the groin or the inguinal region. This type of hernia results from weakened muscles due to ageing, strenuous physical activity and repeated coughing. Abdominal weakness that leads to a hernia could also be a result of an injury or an abdominal surgery This is of 2 types:

• Direct Inguinal Hernia
• Indirect Inguinal Hernia
• Hiatal Hernia

This occurs when the upper part of the stomach slides through an opening in the diaphragm (hiatus) through which the esophagus passes. Increase pressure on the muscles around the stomach leads to pushing of the stomach through the diaphragm.

Umbilical Hernia

Umbilical hernia occurs when a part of the small intestine protrudes through the umbilicus and appears as a bulge at the umbilicus. It is more common in newborns and in women with multiple pregnancies.

Femoral Hernia

These hernias are less common and appear in the upper part of the thigh. A part of the intestine enters into a region called a femoral canal and appears at the upper thigh. It is commonly seen in obese or pregnant women due to a wider pelvic structure.

Obturator Hernia

This is the least common type of hernias of the pelvic floor and usually does not present externally as a bulge. It is seen in women with significant weight loss and multiple pregnancies.

Other Types of Hernia:

• Spigelian Hernia: It occurs when the small intestines protrude through the layers of the abdominal wall. It is also known as a lateral ventral hernia.
• Diastasis Recti: It occurs when the abdominal muscles separate and the internal organs protrude between them.
• Incisional Hernia: It usually occurs as a complication of abdominal surgery and occurs at the site where an incision is done.
• Diaphragmatic Hernia: When a part of the intestine or other organs in the stomach cavity protrude through openings in the diaphragm, then it is called diaphragmatic hernia. These can be congenital or a result of injuries.
• Most hernias develop after birth. These are called acquired hernias. But some hernias are present in newborn babies and are observed at or before birth. These hernias are called congenital hernias.

Depending on the site of origin various types of a hernia have been described.

Hernia Signs & Symptoms

Hernia signs and symptoms include:

• Discomfort or pain upon straining, standing, and lifting 
• Visible bulge or lump upon straining, lifting, and coughing 
• Weakness or pressure in the groin 
• Nausea, vomiting, and constipation are seen in strangulation (cessation of blood supply to the hernia) 
• Swelling under the skin of the groin or abdomen 
• Tenderness (feeling pain upon touch)

Note: The above symptoms are the most common symptoms that are mostly observed in hernia patients. However, there might be some specific uncommon symptoms in hernias, such as hiatal hernias, ventral hernias, diaphragmatic hernias, congenital hernias, etc.

Hernia Causes

The causes of hernia disease are as follows:

• Conditions that increase abdominal pressure, such as strenuous activities, heavy lifting, and jobs with long-lasting hours.
• Excessive straining due to chronic cough and constipation.
• Being overweight.
• Frequent or repeated pregnancies.
• Congenital defects such as hip dysplasia, undescended testicles, reproductive or urinary abnormalities, premature birth, cystic fibrosis, etc.
• Environmental or other factors such as poor nutrition and smoking.
• History of abdominal or groin surgeries.

Hernia Risk factors - Risk Factors

Risk factors for hernia disease are as follows:

• Ageing: An inguinal hernia may occur in persons who are getting older. The lower abdominal wall muscles and connective tissues covering the inguinal canal weaken with age, resulting in the risk of developing a hernia.
• Gender: Men tend to experience inguinal hernias more frequently than women do because men have a wider inguinal canal than women do. 
• Hereditary factors or family history: Inguinal hernias have a genetic component, and the genes connected to inguinal hernia susceptibility have also been linked to connective tissue homeostasis. 
• Obesity: Overweight patients are at higher risk of developing an umbilical hernia, as excess weight increases pressure on the abdominal wall. 
• Chronic constipation: People who strain while constipated may experience increased abdominal pressure and have a greater likelihood of developing hernias. 
• Chronic cough: Prolonged or severe coughing adds pressure on the abdominal wall muscles and can result in a hernia. 
• Pregnancy (frequent or multiple): As the gravid uterus grows larger during pregnancy, there is an increased risk of developing a hernia as a result of the increased intra-abdominal pressure. Pregnant women may also develop hernias due to hormonal changes. 
• Premature birth or premature infants: Inguinal hernias (inguinal scrotal hernia or testicular hernia) occur when the inguinal canal, through which the testicles descend from the belly into the scrotum, fails to close at delivery. This disorder affects 1 to 5% of children and is prevalent in premature newborns. 
• History of abdominal or groin surgeries 
• Long-term peritoneal dialysis: One of the mechanical side effects of peritoneal dialysis is an abdominal hernia. 
• Congenital conditions: Congenital conditions like cystic fibrosis, undescended testicles, reproductive system abnormalities, premature birth, and hip dysplasia can contribute to hernia development..
• Males who have undergone prostatectomy (the surgical removal of the prostate gland) previously: Men who have had robotic-assisted radial prostatectomy, a prostatectomy procedure, increase the risk of developing an inguinal hernia as a consequence of incontinence. 
• Liver cirrhosis with ascites (fluid buildup in the abdomen): Around 20% of patients with liver cirrhosis associated with ascites may be at risk of developing an umbilical hernia because of elevated abdominal fluid accumulation. 
• Chronic abdominal distension: Hernias may form in people with chronic abdominal distension, which usually comes from an intestinal obstruction. 

Hernia complications

If a hernia is left untreated, it may cause complications such as: 

• Strangulation (strangulated hernia): A strangulated hernia no longer receives blood flow. Consequently, the tissue may experience inflammation, infection, and eventually death (tissue necrosis). The medical emergency of strangulation requires rapid medical or surgical care. 
• Incarceration (incarcerated hernia): Occurs when a weak point in the abdominal wall allows the hernia's protrusion (and its contents) to become trapped therein. In addition to intense pain, nausea, vomiting, and the inability to urinate, it might lead to bowel obstruction.   
• Bowel obstruction (obstructed hernia): The blockage may result from the small intestine becoming stuck and squeezed due to a herniation. This medical condition prevents the person from passing gas or stool, which causes intense stomach discomfort, nausea, and vomiting. 
• Pain or pressure due to enlargement of hernia: Hernias can get larger and exert pressure if they are not treated. This disorder causes the scrotum to bulge downward in men, which causes discomfort and oedema.   
• Infections: Inadequate blood supply to the abdominal wall might lead to severe pain and infections. 

Hernia Diagnosis

There are various diagnostic approaches that a gastro surgeon might suggest to the patient to diagnose the hernia. They are as follows:

• Physical examination and thorough history taking (family, medical and medication histories)
• Performing blood tests for infections
• Barium X-ray 
• Endoscopy 
• Ultrasonography (USG)
• Computed tomography (CT scan) 
• Magnetic resonance imaging (MRI scan) and more

Hernia Treatment

There are various treatment approaches for hernia; based on the type or severity of the hernia, the gastro surgeon might suggest any one of the following approaches:

Hernia treatment without surgery

• Non-surgical treatment approaches for hernia include:
• Wait and watch approach
• Lifestyle modifications such as management of weight, diet (hernia diet), and smoking cessation
• Medications 

Hernia surgery or operation

Surgery or operations for hernias are mainly of two types:

Open hernia repair (herniorrhaphy): In open hernia repair, a surgeon makes an incision near the hernia sites and pushes the protruding tissue back into place. The surgeon then reinforces the weakened abdominal wall with stitches and often uses a hernia mesh patch to provide additional support. This procedure is used for both inguinal and incisional hernias; the following procedures are done under open hernia repair.

• Suture repairs, includes Primary suture repair, Mayo technique
• Tissue Repairs
• Prosthetic Repairs
• Mesh repairs, repair can be performed by Open approach, Onlay method, Sublay method

3D Laparoscopic hernia repair (laparoscopic herniorrhaphy): Laparoscopic hernia repair is a minimally invasive procedure in which small incisions are made, and a laparoscope (a thin, flexible tube with the camera) is inserted to guide the surgery. The surgeon uses certain instruments to push the hernia back into place and secure a mesh patch over the weak spot. This technique is commonly used for inguinal and hiatal hernias. Various laparoscopic techniques are as follows:

• Transabdominal preperitoneal approach (TAPP)
• Intraperitoneal Onlay mesh technique (IPOM) 
• Total Extraperitoneal Procedure (TEP) etc.

Note: Based on the type and severity of the hernia, the surgical gastroenterologist might suggest the appropriate procedure that is suitable for the patient.