- Diseases, Disorders & Conditions
Hernia Causes and Treatment
To say that someone has a hernia really means very little, as a hernia is merely the rupture of tissue out of its normal position into a place where it is not normally situated. There are therefore many different types of hernia in the body. Some are quite rare, but amongst the more common types are the hiatus hernia (see separate entry), the umbilical hernia (where fat or gut bursts out through the wall of the abdomen to lie under the skin around the navel), the femoral hernia (which can occur in a woman's groin), and the most common of all, the inguinal hernia in the groin.
Inguinal hernias occur almost invariably in men, and the reason for this goes back to the time when the man was still a fetus in his mother's womb. The testicles develop inside the abdomen, and before birth they migrate down into the scrotum. Behind them as they move down, they leave a tube (called the inguinal canal) that in the adult is 10 to 12 cm long. Through this tube run the arteries, veins and nerves that supply the testicles. The small vas deferens, a duct that carries the sperm from the testicle to the base of the penis, also passes through the tube left by the descending testicle. Shortly before birth, the inguinal canal closes down so that it is almost shut, leaving just enough room for the vital supplies to pass to and from the testes. In some little boys, the tube does not close properly, and this allows a small amount of fat or intestine to move down the tube from the inside of the abdomen, to form a hernia just under the skin beside the penis. It should now be fairly obvious why this type of hernia is rare in women!
In most men, the tube shuts effectively, but it remains a source of weakness in the strong muscle wall of the abdomen. If excess pressure is put on the lower part of the belly by heavy lifting, prolonged coughing or some other form of strain, the closed inguinal canal may tear open again, allowing some of the gut to protrude as a hernia. Men who are overweight and have their muscles weakened by fat deposits are more likely to develop this type of hernia, and the slackening of muscle tone with advancing age can also lead to a rupture. There is also a hereditary tendency, so that if your father had a hernia, your chances of developing one are increased.
Once a hernia is present, it may be only mildly annoying after exercise, or it may become very painful, and occasionally the gut inside the hernia may become strangled in the inguinal canal, causing that section of gut to become gangrenous. This is a surgical emergency.
To prevent this emergency from occurring, and to relieve the discomfort of the hernia, doctors usually recommend that it be surgically repaired. This is a relatively common and simple operation in which the inguinal canal is opened, the protruding gut is replaced in the abdomen, and the tube is sutured closed in several layers to prevent a further rupture. Sometimes material similar to mosquito netting is stitched into the muscle layers to further strengthen the area. There is some postoperative soreness, but most people can return to office work after two or three weeks, and heavy labour after six to eight weeks. Even in the best surgical hands, however, about 10% of inguinal hernias will recur.
In some older men, particularly if the hernia is very large, surgical repair is not practical, and a suitable truss is used to hold the bulging hernia in place. These larger hernias are less likely to strangle.
There is another point of weakness in the groin, just underneath the skin where the femoral artery passes through a small hole as it leaves the abdomen and starts its journey down the front of the thigh. Under pressure from heavy work or childbirth, a small piece of intestine may be forced into this narrow hole and appear as a small lump under the skin of the groin. Because it is often quite small, it is very easy for the trapped intestine to become pinched, twisted, and gangrenous. Femoral hernias are more common in women than men, but may occur in both sexes.
Femoral hernias may either cause no symptoms or be responsible for vague, intermittent abdominal pains. The lump under the skin may not be noticed until the hernia becomes painful, particularly in fat women. Once the intestine becomes trapped, it will become very painful and obvious to the patient.
Whenever discovered, a femoral hernia should be surgically repaired because of the high risk of gangrene. Once pain has developed in the hernia, surgery becomes a. matter of urgency. The recurrence rate after surgery is about 5%.
Umbilical hernias (protrusions of the navel) come in two forms - those that occur in children, and those that develop in elderly adults.
In children, there is a hole between the muscle layers of the abdomen where the arteries and veins that passed down the umbilical cord from the mother entered the baby. This hole normally closes quickly after birth, but in some children the hole is very large, or is slow to close. In these cases, bulging of the intestine into the area just below the skin of the umbilicus can occur. Umbilical hernias are more common in premature babies, as their systems are not as mature, and the processes involved in closing the hole behind the umbilicus are slower.
Umbilical hernias bulge out while the infant is crying or active, but usually disappear when the child is lying quietly. The hernia almost never gives pain or discomfort to the child. It is very rare for the intestine to become trapped and gangrenous.
The vast majority of umbilical hernias in children close spontaneously without any surgical intervention. This usually occurs within twelve months but may take until three years of age. There is no benefit from strapping or taping the hernia, and no matter how much it bulges, the skin covering the hernia never bursts. If the hernia persists beyond three years of age, surgery may be contemplated, but in Africa, where umbilical hernias appear to be more common, spontaneous repair may occur as late as six years of age.
In adults, the hernia is not strictly speaking an umbilical hernia, but a para-umbilical hernia, as the rupture occurs not immediately underneath the umbilicus but in the slightly weakened fibrous tissue just above (more common) or below the navel. This type of hernia is common in women who have had multiple pregnancies, in the very obese and those who have other causes of excess pressure in the abdomen.
In contrast to the situation in children, umbilical hernias in adults do not reduce in size but steadily increase with time, until they can form the major part of the front of the abdomen. These large hernias can contain a significant amount of intestine and may cause significant discomfort and constipation.
Small umbilical hernias are best repaired surgically when discovered, as delay will only lead to a larger hernia and more difficult repair later. In older patients with particularly large hernias, surgical repair may not be practical as a routine procedure, but if pain occurs as a result of strangulation of the intestine and impending gangrene, emergency surgery is essential. The recurrence rate after surgery depends upon the original size of the hernia, but is generally low.
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