Introduction and history

A hernia occurs when an internal part of the body pushes through the muscles or wall surrounding it to occupy a space that organ normally would not occupy. The most common examples are groin hernias, hernias occurring through or around the umbilicus, and hernias occurring in previous surgical scars. Hernias are one of oldest surgical afflictions known to humankind, with references dating back to 1500 BCE. Many of the hernias are inguinal (more on that later), and let’s talk about the fascinating history of inguinal hernia surgery a little here. The earliest surgical attempts at definitive treatment began circa 700 CE. Effective surgical treatment of hernias became possible after the invention of anesthesia in 1842-6. The revolution in hernia surgery came with the work of Dr Eduardo Bassini beginning in 1884. When he published his first report of 250 patients in 1889, it took the world of surgery by storm. The second revolution came with the development of tensionless prosthetic repair by Dr Lichtenstein in 1986, a technique and its extensive variants currently known by the umbrella term “Open mesh repair technique”. A third revolution came with the application of laparoscopic surgery to inguinal hernia in the 1990s and 2000s. Together the open mesh repair (and its variants) and laparoscopic repairs represent the current standard of care for the most common hernias.

Types and their natural histories

Hernias are very common around the abdomen due to the nature of the abdomen: the human abdomen has many structures coming in and out via various openings in the musculature of the abdominal wall, and the abdominal wall has practically no bony support!

The most common type of abdominal hernia is the inguinal hernia, a type of hernia occurring in the groin at the top of the thigh. The next most common hernias are hernias occurring around the umbilicus, incisional hernias: that are hernias occurring through scars of previous abdominal surgeries, and hiatus hernia, whose treatment is radically different from that of other types of abdominal hernias. The discussion that will follow will exclude hiatus hernias for all practical purposes.

Other uncommon hernias are:

1. Femoral hernia: that another type of groin hernia occurring at the top of the thigh.\
2. Epigastric hernias.
3. Spigelian hernia.
4. Diaphragmatic hernia.

When to seek medical advice:

When you think you have a hernia, you should consult your doctor who may refer you to a surgical specialist. A doctor is usually able to identify a hernia on examination alone, but occasionally he may ask for an ultrasound. Once the diagnosis is certain, your doctor and you should consider whether surgery is necessary.

The decision for surgery is based on a few considerations: the type of hernia, the contents of the hernia, symptoms and impact on daily life, and whether your general health would permit a safe surgery. Some hernias have a high risk of complications, such as most inguinal and femoral hernias, large hernias: specially those with small necks, and hernias that do not go back inside the abdomen with pressure. Such hernias should be operated at the earliest possible convenience. Some hernias have a very low risk of complications such as small umbilical hernias. In these hernias, the choice of surgery depends on the wish of the patient to get rid of the hernia, because the only treatment that can cure a hernia is surgery. In certain patients, the risk from a major surgery or anesthesia may be so high that it may be safer to not to operate. However, in modern surgical practice with a skilled surgeon and anesthetist, hernia surgery can essentially be offered to all patients with very minimal risk. We will discuss this in greater detail later.

You may need to seek advise on an emergent basis for your hernia if any of these symptoms occur:

1. The hernia becomes tense and painful.
2. It stops going back inside the abdomen.
3. You experience a combination of vomiting (which may be greenish in color), colicky abdominal cramps, inability to pass stools, and your abdomen starts to well up. These symptoms may not occur together, but they may appear sequentially over a few hours, and they may occur in a different order than that is described here. These symptoms imply that the intestines in the hernial contents have become obstructed and an emergency surgery will be required to free them up.

Treatments

This discussion will exclude treatment options for a hiatus hernia and the other rarer forms of hernia such as lumbar hernias and muscle hernias. We will discuss the options available for the commoner types of hernias here: that is inguinal, femoral, umbilical, paraumbilical, epigastric, and incisional hernias. Three treatment options are available for a hernia: a truss/belt, surgery, and watchful waiting.

Watchful waiting: Watchful waiting has been advocated in many quarters in the last 25 years as a method of managing a hernia. This essentially means not extending any treatment to the patient and letting the hernia remain as it is. This may be a good approach for small asymptomatic paraumbilical and midline epigastric hernias in adults, small incisional hernias specially in upper abdominal incisions that are at low risk of getting complicated, and it is the recommended treatment for umbilical hernias in children younger than 2 years. Watchful waiting is controversial at best in other types of hernias. The usual natural history of groin hernias is to grow over time and become increasingly symptomatic. Watchful waiting should never be a method of management for femoral hernias, groin hernias in females, hernias with narrow necks and large sizes, and hernias that cannot be easily pressed back into the abdomen. Surgery is simpler and has much better results when the hernia is smaller, so what watchful waiting essentially does in most people is to postpone surgery until the hernia is larger, which may not be so desirable an objective. Except for umbilical hernias in young children and toddlers, a hernia never goes away; so, the risks and benefits of postponing surgery should be clear in your mind before embarking on a policy of watchful waiting.

Surgery: Modern surgical techniques are very safe and effective, with very short convalescing times, and rare complications. For selected patients, most open mesh repairs can be done under local anesthesia, that essentially converts the procedure into a walk in and walk out surgery. Laparoscopic repairs, and some open mesh repairs will require general anesthesia, and these can be done in hospital stays of about a day. The quickest return to work is generally after laparoscopic repairs. The patient can expect to be working 10-14 days after a hernia surgery, and I have had a patient who voluntarily returned to work on the third day following laparoscopic surgery! Laparoscopic repairs are best for young active patients with groin hernias, specially if these have recurred after a previous open mesh repair or are bilateral, and in patients in whom an open repair is not feasible under general anesthesia. Open repairs are especially suitable for very large groin hernias. For ventral and incision hernias, the choice of technique and access is highly individualized.

In addition to the general complications of surgery and anesthesia, hernia surgery comes with its own set of issues. Modern hernia surgery essentially rests on the principle of reinforcement of structurally deficient tissues with a prosthetic mesh. This has reduced recurrence rates following surgery to less than 0.5% (from an almost 100% recurrence in the pre-Bassini era, and about 5% in the Bassini era). Rarely, however, the mesh may become infected and require removal. Open mesh repair techniques may uncommonly lead to long term pain at the surgical site termed mesh inguinodynia. This is usually mild and can be managed effectively with medications. Laparoscopic techniques require access into the abdomen, and hence can rarely become complicated due to factors associated with access into the abdomen. Overall, major complications of hernia surgery are quite uncommon, and hernia surgery has one of the most favorable risk benefit ratios.

Truss: Specialized trusses, bandages, and plasters were used for a very long time to achieve local control of hernias in the days before effective and safe surgery. Its use should mainly be considered historical as there are very few contraindications to surgery with today’s variety of anesthetic techniques. A truss may be used when surgery is contraindicated; even here, watchful waiting and lifestyle modification to accommodate the hernia are probably better considering the harms that may ensue from a truss. If a truss is to be worn, the hernia must disappear inside the abdomen. A truss must be worn continuously during waking hours, kept clean and in proper repair, and renewed when it shows signs of wear. It must be applied before the patient gets up and while the hernia is reduced. It must never be applied with the hernia protruding outside. A properly fitting truss must control the hernia when the patient stands, with his legs apart, stoops and coughs violently. If it does not control the hernia effectively, it is a menace, for it increases the risk of serious complications. An improperly applied truss can damage the contents of the hernia and obstruct their blood supply, with potentially disastrous consequences. There is no place for trusses in the management of infant hernias.

Abdominal belts and supports may be useful in carefully selected patients with ventral incisional hernias as a short-term measure. The general rules applicable to trusses are applicable here too, and the risk of mechanical injury to hernial contents remains. The hernia must be reducible for a belt to be worn.

Bandages and adhesive plasters as a means of controlling hernias are mentioned only to be condemned. There is no possible benefit from their use, and long-term use of adhesive plasters specially will cause abrasions and eruptions on the skin over which they are chronically applied, causing unnecessary discomfort to the patient.