Hernia is a condition where an organ or a part of an organ protrudes through a normal or abnormal opening, causing pain and other serious problems.
Common example is a swelling at the Umbilicus (neural), which is nothing but fat or intestines bulging out of a hole at the neural. This can cause a swelling pain or even a life threatening condition.
If the intestine gets stuck inside, and its blood supply gets hamperedor obstructed .
There are more than fifty different kinds of hernias described, but let us look at the common hernias and a few rarely occurring hernias.
Common hernias :
- Inguinal Hernia
- Umbilical Hernia
- Incisional Hernia
- Hiatus Hernia
Few rarely occurring hernias:
- Epigastric Hernia
- Lumber Hernia
- Femoral Hernia
- Paraoesophageal Hernia
- Diaphragmatic Hernia
- Spigelian Hernia
Relevant Anatomy :
Inguinal canal is situated in the lower abdomen on both sides, it begins at the internal ring and ends at external ring close to midline above serotum. This canal transmits blood vessels and Vas deferens going to tests.
In women, it transmits the round ligament of uterus.
Understanding Genesis of Inguinal Hernia:
- The tests of male persons is inside the abdomen before birth and it travels down from inside the abdomen to outside and into the serotum through inguinal canal. The sac which carries it down, gets closed at birth.
- If this sac remains open completely or even partially, it serves as an open conduit, for intestines or abdominal fat to protrude and travel down, right up till the serotum. Thus an indirect Inguinal Hernia forms.
- In the elderly , the muscles covering the inguinal canal can get break, and intestine can start protruding out the canal area, causing a Direct Inguinal Hernia.
Clinical features of Inguinal Hernia:
- It can occur at any age. At birth or infants it is called congenital hernia, or hydrocele, since it may contain only third.
- Swelling in inguinal region, sometimes even up to serotum.
- Swelling appears in standing position or on coughing and disappearson lying down.
- Pain in Inguinal region on coughing standing working or strenuous activation.
- Sudden pain in abdomen, persisted vomiting painful swelling at inguinal region, which does not reduce, on lying down or manipulating, is suggestive of obstructed Hernia, Which needs emergency surgery.
Although small direct Hernias and a small percentage of asymptomatic Hernias can be observed or, majority of Hernias need to undergo surgery.
Surgery for Inguinal Hernia
Surgical repair of Inguinal hernia can be done by open surgery or Laparoscopically, which is a form of Telescopic surgery.
Although many different types of surgeries are done for Inguinal Hernia, the commonly done types are
- Liechtenstein Repair which is the gold standard now.
- Shouldice Repair
- This surgery can be done under local or spinal anaesthesia.
- An incision is taken over inguinal repair and inguinal canal is opened.
- Hernial sac is dissected all around, separated from chord structures and opened.
- Hernial CO stents like intestinal or fat is put back into the abdomen.
- Hernial sac is excised partially or completely.
- Sac opening is closed at its needs so that nothing comes out of abdomen.
- 15 X 8 cms of prolene mesh is taken and one end is cut to form two fails, to accommodate
- chord structures. This mesh is then fixed or the posterior wall of Inguinal canal from midline to lateral abdomen so that it forms a barrier against further recurrence of hernia.
- Inguinal canal is then closed.
- Skin incision is closed with stapler or sutures.
- This surgery also can be done under local or spinal anaesthesia .
- Similar incision is taken on inguinal Region and inguinal canal is opened. Hernial sac is dissected, emptied and excised and closed.
- Repair is done by creating flaps of tissues of posterior wall and suturing them on one on top of the other in double-breasting fashion.
- Outer layers are also suture done on top of the other in double-breasting fashion. This creates a strong wall, acting as barrier to prevent recreature of Hernia. No artificial mesh is used.
- Patient can go home on the same day.
First Laparoscopic Repair in the world was done by surgery Arregui in 1991, and Laparoscopic repair of Inguinal Hernia started in India by 1995.
Laparoscopic repair of Inguinal Hernia an be done in two days
- We can go to the area through the umbilicus, by entering the abdomen, and entire repair is done from inside the abdoen this is called Transabdominal Preperitonial Repair or TAPP. Our centre specialises in TAPP.
- The other way is Togo to Inguinal area through extra peritoneal space, without entering abdominal cavity. This is called as Trans Extra peritoneal Repair or TEP.
Advantages of Laparoscopic Repair:
- Surgery is done through three small punctures near umbilicus – so only three stitches.
- No big incision on inguinal region.
- Patient goes home on same day or neat day in 24 hours.
- Early return to all physical activity including exercise.
- Very minimal pain.
- Larger mesh can be placed, and size of mesh can be increased to cover larger hernias.
- Both sides can be repair simultaneously.
Disadvantage of Laparoscopic Repair:
- Surgery has to be done under General Anaesthesia.
- Costs are more due to use of specialised Equipments, and fixation devices to fix the mesh.
- Postoperatively, fluid collection can occur at inguinal region causing a bulge, a site. This is called Sarema.
Although most seromas disappear with passing time, few may need aspiration with syringe.
- Anaesthesia general.
- Position : sleep head low.
- A 10mm incision is taken near umbilicus and Telescope is inserted into abdomen.
- Inguinal Region of both sides is inspected for presence, type and size of Hernia.
- Hernial contents are pulled back into abdomen to empty the sac.
- In incision is taken 5cms above the hernia opening on peritoneum, the innermost layer and peritoneum along with Hernial sac is peeled away and dissected away from abdominal wall. The hernia sac is dissected away from chord structures, the Vas deference and vessels.
- Dissection is done from lateral edge to midline and even beyond midline.
- Urinary bladder is dissected away from abdominal wall and space created for placement of mesh. This space is very large as compared to space created in open surgery.
- The Hernial opening as well as all the openings around this which could cause hernia in future care laid bare.
- Type of mesh to be used is choose, and it is cut to desired size. Minimum size used is 12cms X 15cms.
- Mesh is rolled into a tight roll and put inside the abdomen through the camera port.
- Mesh is unrolled and spread and placed on the Inguinal region covering the Hernial opening and all other openings where a future Hernia could occur.
- Mesh is fixed to abdominal wall using sutures, special, screws, or glue.
- Peritoneal flap is sutured to abdominal wall to cover entire mesh.
- Camera and instruments are taken out and the three openings are closed.
Types of Mesh Used:
- Polyprolene heavy weight / normal weight
- Polypolene light weight
- Polyester meshes?
- Large pore mesh
- Composite, partially absorbable meshes.
- 3-D meshes which fit the shape of inguinal region.
- Self fixing meshes , which do not need any fixing sutures or screws.
Types of fixation devices:
- Metal Tackers
- Absorbable tackers
- Seroma-swelling at inguinal region due to accumulation of fluid.
This disappears on its own.
- Pain at the site. Ninety percent of pain disappears within one to three months pain persisting after three months is called as “chronic groin pain” or Inguinodynix.
The causes can be many
Management is complex and multifactorial.
- - Nerve injury
- - Meshalgia
- - Testicular pain
- - Pain due to tackers
- - Ostestis pubis
- Mesh infection:
- - This can manifact is pain, swelling and fever.
- - Sometimes discharging sinuses
- - This is rare but dreaded complication
- - Removal of mesh is necessary in almost all patients.
- Anaesthesia : General
- Position : Headlow
- Procedure : incision is taken on one side of umbilical.
- -Rectus sheath is opened.
- -Rectus muscle is retracted and extra peritoneal space is entered.
- - Extra peritoneal space is enlarged by using various methods like
- a. Using a ballon – commercial or simle ballon made of gloves
- b. Using CO2 gas
- c. Using telescope to dissect the space
- - Telescope is inserted and Two more instruments are inserted under
- - Extra peritoneal space is enlarged by dissecting in midline as well as
- - Hernial sac is dissected off chord structures and abdominal wall.
- - In indirect hernia, sac has to be cut and ligated leaving part of sac in
- - Mesh is selected, cut to desired size minimum being 12 X 15cm.
- - Mesh is rolled and inserted through camera port.
- - Mesh is spread in the space, against abdominal wall to cover all
- - Mesh is fixed at two or three places.
- - Some surgeons do not fix the mesh- It stays in place since it is
sandwitched between two layers.
- - CO2 gas is removed and the port openings are closed.
The umbilicus is the place in the abdomen, and hence Hernias can develop. Especially pregnancy and obesity can stretch the abdominal wall and cause a defect at umbilicus, since it is not covered by any muscles.
It is through this defect that omentum (abdominal fat) or intestines can protrude and later on get stuck inside the hernia.
This hernia also goes on progressively enlarging. TN some cases the skin can be stretched , it can become dangerously thin and can break down, causing a wound (ulcer) on the hernia.
Umbilical Hernias can also poccur is patients having fluid (Ascitis) in abdomen.
Hernias can develop near or next to umbilicus when they are called as paraumbilical Hernia. The treatment is similar to umbilical hernia.
Umbilicus is the weakest part of abdominal wall. This small area is not covered by any muscles. A small hole (defect) can develop at umbilicus, either as a result of congenital ( birth defect) cause or it may occur due to stretching as happens in pregnancy or fluid accumulation due to disease process.
Fat (omentum) or intestine state protruding out through this defect.
Slowly the defect enlarges and the fat or intestine gets stuck inside the cavity.
Occasionally it cause an emergency if the part of intestine stuck inside gets obstructed and its blood supply gets hampered. This will need emergency surgery.
Causes of Umbilical Hernia
- Congenital defect
- Conditions raising intra-abdominal pressure like Ascites, tumour, constipation, chronic,cough
- Swelling at umbilicus which appears in standing or coughing and disappears on lying down.
- Pain at umbilicus
- Swelling at umbilicus of duration with progressive enlargement.
- Sudden pain, redness, vomiting-all suggestive of obstruction.
Surgery for Umbilical Hernia:
- This can be done by the traditional open technique, or through Laparoscopic approach.
- In open surgery a long incision is taken, Hernial sac is opened and excised-contents are put back in abdomen.
- The defect (hole) is closed and a polyprolene / synthetic mesh is placed between 2 layers of abdominal wall and fixed with sutures. Then the incision is closed.
- After giving general anaesthesia, the abdomen is inflamed by putting CO2 gas inside.
- A telescope is inserted inside through 1cm opening. Two more punctures are made awy from Hernia and 2 instruments are put inside.
- The fat or intestines stuck in the Hernia sac are released and pulled back inside the abdomen.
- The opening of defects closed with long stitch.
- A special Dual mesh is put inside the abdomen through the opening for camera, and spread. This mesh is then fixed on the abdominal wall from inside by stitches and a special screws called tacks.
- Since this mesh is placed from inside it has a special layer to present intestines from sticking to the mesh.
- Hence this mesh is very costly, so is the gun carrying the screws. Hence Laparoscopic repair is costly. however, the patient will be able to go home ion next day, and join work in a weeks time.
- After surgery fluid can accumulates in the hernia sac, since it is now empty. This is called Saroma, and will go away slowly.
- Pain can occur to carrying degree and may take longer time to go away.
- If the mesh gets infected then if will have to be removed.
This Hernia occurs through a single or multiple gaps in the scar of previous surgery. This happens due to one or multiple factors. Lack of adequate healing, increased pressure on wound in early days, infection of stitches, or rarely improper technique of closure can result in incisional Hernia.
The fat (omentum) or intestines starts from protruding out of these defects and slowly enlarges in size. Overtime it gets stuck inside the sac.
Like umbilical Hernia, this also can get obstructed or if blood supply in hampered the part of intestine can die and present as Gangrene.
Surgery can be done by open or Laparoscopic technique, very similar to umbilical Hernia.
However,Incisional Hernias are more difficult to tackle since
- There can be multiple defects
- The Hernia tends to be larger
- The intestines are badly stuck
- The mesh needs to be much larger than defect to present recurrence
- Recurrence rate is higher than other hernias.
- The abdomen is inflated by CO2 gas. The adhesions to previous scar are released.
- The omentum, intestines stuck inside the Hernia are released and put back in abdomen. The defect or defects are closed with suture. If the defect is too large,it may not be possible to close it.
- A large dual mesh is put inside and spread across the hernia site to cover it from all sides. It should be at least 5cms larger than defect from all sides. The mesh is fixed with sutures going through abdominal wall and special screws called tacks. These screws can be absorbable.
- complications are similar to Umbilical Hernia.
The valve between the food pipe and stomach prevents acid and food into reregargitating upwards into food pipe. This valve is situated just below the diaphragmatic opening inside the abdomen.
If this valve migrates upwards into the chest, carrying a small part of stomach, it looses its ability to remain closed, and thus remains open. This condition is called Hiatus hernia of Sliding type. This will cause acid and food to regurgitate into food pipe, especially on lying down or at night.
Symptoms are :
- Heart burn off & on
- Chest pain white swallowing
- Bouts of cough & heartburn at night, causing the person to get up.
- Sore throat, asthma, cough due to acid coming up to throat
- Blood vomiting due to ulcers in esophagus.
The other type of Hiatus Hernia is when the valve remains in the abdomen, but a part of stomach migrates up into the chest. This is called Paraoesophageal Hernia. This can cause chest pain after eating occasionally a large part of stomach can migrate into chest. This can suddenly undergo a twist ( volvulus) and cause severe pain and requires emergency surgery.
Diagnosis is done by
- Barium swallow
- 24 hour Ph
Treatment consists of
- Medical management by antacids,PPI drugs and sleeping with head up.
- Surgery is done for failure of medical treatment or complications.
Surgery- Nissen’s Fundoplication
Surgery is done Laparoscopically
- After insufflating the abdomen camera port and 3 smaller ports for instruments are put inside through small punctures
- The stomach and the esophagogastric
- Valve are pulled back into abdomen.
- The lower part of esophagus is dissected free of all attachments and a loop is passed around it to lift it up.
- The diaphragmatic opening has to be narrowed by suturs so that stomach will not migrate up again.
- The upper part of stomach is freed from its blood vessels and wrapped all around the lower esophagus to form a new valve- It is sutured to esophagus .
- This is called Nissen’s Fundoplication.
- Patient is put on liquid diet for one week and then slowly on Regular diet.
- Most patients will have dramatic relief from heartburn and other symptoms.
- Difficulty in swallowing
- Recurrence due to slippage of new valve into chest.
- This can be from birth, or acquired later in life.
- A large part of stomach migrates into chest,and causes pain and difficulty in swallowing after, during eating.
- If it gets twisted, it will swell rapidly inside the chest, causing severe pain. This needs emergency surgery.
- After all laparoscopy instruments are put inside the abdomen, the migrated stomach is pulled back into abdomen.
- The sac in which this stomach has been residing in excised.
- The large opening in diaphragm is narrowed by sutures to prevent migrates of stomach again. This may need help of a synthetic or biologic mesh, to close the large the large opening.
- Stomach is wrapped around lower esophagus to form a new valve.
- Stomach is also fixed to abdominal want to prevent recurrence.