Summary of Hernia
The word hernia means “a rupture or protrusion of an organ or part through the wall of the cavity that normally contains it.” The term is often reserved for situations in which organs break through anatomic boundaries, which can occur spontaneously (e.g., umbilical and crural hernias) or secondary to increased intra-abdominal pressure (e.g., Hiatal hernias).
Most patients with abdominal pain are referred to colorectal surgeons because of concerns over appendicitis risk; only 10% will have appendicitis. When there is no clear explanation for the cause, doctors advise that they suspect that the patient may be suffering from an inguinal hernia.
1) Description of the problem:
A hernia is caused when an area in the body that holds fat, tissue, or organ is weak and causes a hole through which it protrudes out into the surrounding area. In males, this lump may be felt in front of the scrotum along one side of the midline or inside their scrotum at the junction between where it attaches to the lower abdomen.
Males who have this lump are typically aware if they have a hernia in their scrotal sac region because they will experience pain in addition to seeing swelling there. A doctor can diagnose inguinal hernias by examining them with ultrasound imaging or other technology such as MRI scans during office visits.
Women typically don’t feel pain in addition to seeing swelling because these hernias generally are smaller than the ones seen in males. Therefore, they may not seek medical attention unless they experience it during pregnancy when an inguinal hernia can lead to complications such as severe pain, inflammation of tissues surrounding the area, or bleeding.
2) Symptoms:
Generally, the symptoms that men with this condition feel include:
-The bulge itself, which is usually small and soft, inconsistency
-may be slightly tender at times but usually is not painful
-can become more evident when coughing heavily or engaging during physical activity
-it may disappear on its own or become less apparent spontaneously but will often recur again
Females may experience the following symptoms:
-a small, soft lump or swelling at the site of the hernia
-feeling as if there’s a ball in the groin area
-the bulge can be present during all stages of life and increases with pregnancy due to pressure from the growing fetus
3) Diagnosis:
-In addition to a physical exam, another option that can be used to determine if the hernia is indeed a groin hernia involves ultrasound imaging. A doctor will use transducers or other devices on the scrotal sac region and may also inject a special dye to get a better sense of what’s going on inside.
-A doctor may also palpate (touch) for this lump with their fingers by doing so in the inguinal canal area where it is located. This lump can frequently become more noticeable during coughing or when experiencing pressure in the abdomen, which occurs when one bears down while having bowel movements.
-X-rays are performed using radioactivity with this disorder because it can ensure no associated condition such as a tumor. In addition, it can also allow doctors to see if the hernia has become strangulated or even pinpoint it more accurately within the body.
4)Treatment for inguinal hernia:
In most cases, surgery is performed on those with an inguinal hernia when they do not respond well to non-surgical treatment. There are many procedures that a surgeon may consider, but the most common ones include:
-open repair of groin hernias which entails an incision being made just above or in front of the lump and all of its contents, including protruding fat and tissue being pushed back inside
-laparoscopic repair uses 3 to 4 small incisions made in the abdomen to insert the necessary instruments.
Causes of hernia:
There are four leading causes of hernia formation: increased intra-abdominal pressure, weakened muscles in the abdominal wall from age or genetic factors, failure of embryonic fusion processes, and trauma.
Increased intra-abdominal pressure can result from a chronic cough due to asthma, bronchiectasis, or cystic fibrosis. This high pressure results in a bulge at the site where the most muscular fibers of the abdominal wall have been torn during difficult coughing.
It may also be seen in athletes who participate in sports such as weightlifting that involve intense straining (“effort” hernia), and it is frequently seen with any disease process resulting in significant abdominal distention (e.g., ascites).
Withdrawal of support can result in herniation of abdominal structures through the defect, as seen with incarcerated hernias. Hernias may also occur after surgical procedures that reduce the pressure within the abdomen, such as laparoscopic adjustable gastric banding or Roux-en-Y gastric bypass surgery (see postoperative hernia).
Weakness in the abdominal wall can result from aging, leading to increased risk for all types of hernia, decreased physical activity, and chronic illness. Congenital disorders with associated weakness or redundancy of abdominal musculature include Marfan syndrome and Ehlers-Danlos syndrome.
A general lack of compliance (a key feature of Marfan syndrome) causes most joints to have an increased incidence of subluxation and dislocation, which predisposes to hernia formation.
Hernias can also be acquired, usually during abdominal procedures. For example, following the insertion of a central venous catheter through the internal jugular vein, small gaps may form at the suture line where lymphatic fluid drains from the highest point in the superior mediastinum.
Typically, these are asymptomatic unless they enlarge to create a true hernia. Some types of bariatric surgery have been associated with specific herniation sites after gastroplasty involving adjustable gastric banding or Roux-en-Y gastric bypass surgery.
Laparoscopic adjustable gastric banding has been shown to cause intramural herniation at the site of staple-line disruption posteriorly through the band and at the gastroesophageal junction anteriorly.
Roux-en-Y gastric bypass surgery has been shown to result in herniation of posterior omentum into a para esophageal right upper quadrant hernia, as well as more common incisional and ventral hernias.
Trauma is a classic cause of inguinal and femoral hernias, but any event that results in increased intra-abdominal pressure can contribute to their formation. This includes falls or motor vehicle accidents, which may damage the abdominal wall directly at the impact site or more remotely by increasing intrauterine pressure by compressing the pregnant uterus against the spine.
Types of hernia:
The most common types of hernia occurring in males are the following (among others).
Inguinal hernias:
These are the most common type of groin hernia, comprising approximately 50% of all cases. The inguinal canal is located at the medial side of the pubic tubercle. It contains the spermatic cord and vessels that travel from the deep inguinal ring to exit through this canal into the scrotum.
In an indirect inguinal hernia, a portion of the bowel passes superior to the inferior epigastric vessels as they converge with blood vessels traveling within or immediately adjacent to Cooper’s ligament before entering or exiting through the internal inguinal ring.
In a direct inguinal hernia, a portion of the bowel passes inferior to the inferior epigastric vessels immediately before entering or exiting through the internal inguinal ring.
Femoral hernias:
Femoral hernias are more common than direct inguinal hernias and account for approximately 10% of all groin hernias. Femoral hernias usually occur medial to the femoral vein or artery, depending upon whether they are direct or indirect type.
Fallen (strangulated) ovary:
A strangulated ovary has become incarcerated within the broad ligament of the uterus, causing it to twist and cut off its blood supply. The disorder can be associated with torsion of the ovary or with a defect allowing the ovary to herniate through the inguinal ring.
Umbilical and epigastric hernias:
Umbilical hernias are the most common type of abdominal wall hernia in children, occurring in up to 11% of births. They result from incomplete closure of the internal umbilical ring during embryonic development.
Males are affected more frequently than females because their umbilical openings lie within a vertical line that extends further into the groin than in women (because their embryonic cloacal membranes remain open longer).
Epigastric hernias occur less frequently, projecting out of a horizontal line between anterior superior iliac spine points and extending into the umbilicus. These hernias are most common in obese women who have had multiple pregnancies and usually contain omentum, bowel, or both.
Intra-abdominal fat protrudes through the diastasis rectus (separation of the two muscle layers of the rectus abdominis), which forms during pregnancy because of pressure on the muscles by growing the uterus.
strangulated hernia:
a strangulated hernia is a severe complication of an inguinal or femoral hernia, typically resulting from incarceration and inadequate blood supply. Strangulation occurs when abdominal contents put pressure on the inferior epigastric vessels and occlude their blood flow.
As a result, ischemia (decreased arterial blood flow) and venous congestion (increased return of venous blood to the heart) occurs in the bowel, which becomes increasingly distended as fluid accumulates in the bowel wall.
The strangulated loop undergoes necrosis (tissue death), leading to perforation with bacterial contamination and abscess formation (acute enterovesical fistula).
The most common site for incarcerated groin hernias is at the femoral ring, secondary to incomplete closure of the embryonic cloacal membrane. A direct hernia follows the pathway of embryonic testicular descent into the scrotum. In contrast, an indirect inguinal hernia shares this pathway but passes superior to the inferior epigastric vessels before entering or exiting through the internal inguinal ring.
A femoral hernia occurs almost exclusively between 9 and 12 o’clock, immediately medial to the femoral vein or artery. The type depends upon whether it is an indirect or direct femoral hernia. Women’s femoral hernias are rare because their embryonic pelvic lymphatics drain into the abdominal cavity rather than into a retroperitoneal space as they do in men.