What is an inguinal hernia?A hernia is a protrusion of an organ (usually a loop of bowel) through a weak area in the muscles or tissue that surround or contain it. An inguinal hernia occurs in the groin (the area between the abdomen and thigh). It is called "inguinal" because the intestines push through a naturally weak spot in the inguinal canal, which is a triangular-shaped opening between layers of abdominal muscle near the groin.
To compound this, the upright position of the human posture results in greater pressure at the bottom of the abdomen, thereby increasing the stress on these weaker tissues. The combination of these factors, over time, breaks down the support tissues - enlarging any pre-existing hole, or leading to a tear.
This defect causes bulging of the abdominal wall. The bulging is more noticeable when the abdominal wall is tightened, thereby increasing the pressure in the abdomen. This could be explained as follows: imagine a barrel with a hole in its side and a balloon that is blown up inside the barrel. Part of the inflated balloon would bulge through the hole. The balloon protruding through the hole is illustrative of the tissues of the abdomen bulging through the hernia.
Most hernias can be corrected by surgery. The contents of the hernia sac can be squeezed back into the abdominal cavity without difficulty.
What causes a hernia?Poor nutrition, smoking and overexertion can all weaken muscles and make hernias more likely. Any condition that increases intra-abdominal pressure, can induce a hernia, such as:
- Chronic constipation and prolonged straining
- A chronic cough, such as a smoker’s cough
- Persistent sneezing, such as those caused by allergies
- Lifting of heavy objects.
Who gets hernia and who is at risk?Sometimes a hernia is present at birth; more often, it occurs later in life. Inguinal hernia is a common condition in males affecting in the region of 2% of men at some time. There are two types of inguinal hernia, indirect, in which the intestine protrudes into the scrotum, and direct, in which it protrudes into the groin.
Inguinal hernias occur quite commonly in children. These hernias differ from adult hernias in that the peritoneum (the sack that contains the intestines) fails to seal. Therefore communication exists between the abdomen and the scrotum. The intestines may more easily pass through this opening and become strangulated (have the blood supply cut off).
Groin hernias are somewhat more likely to develop on both sides. This is probably because the structural elements develop symmetrically and the stresses that occur over time are similar. When a patient becomes aware of a groin swelling on one side, examination by a doctor will often identify a small hernia on the opposite side.
Symptoms and signs of herniaSome patients with hernias are unaware of their presence until the hernias are pointed out to them. The patient may notice a bulge beneath the skin in the abdomen or the groin (or in the scrotum in men); it may disappear when you lie down and may, or may not, be tender.
Those who have symptoms complain of discomfort in the groin area when lifting a heavy object, coughing, having a bowel movement, or during urination. In some cases, the pain is a dull ache that becomes worse towards the end of the day after standing for long periods of time. The pain is relieved at night when lying down.
What is the course of hernia? It is possible to simply live with a hernia and monitor it. However, complications of incarceration or strangulation of the intestines are a real danger.
A hernia which remains bulging for a long time may be difficult to reduce (be pushed back). This is called an obstructed or incarcerated hernia. The contents of the hernia, most commonly a piece of bowel, will become swollen and may become strangulated. A strangulated intestinal hernia may result in intestinal obstruction, which can lead to infection, gangrene, intestinal perforation, shock or even death.
How is hernia diagnosed? A doctor’s physical examination is often enough to diagnose a hernia. Sometimes hernia swelling is visible when you stand upright; usually, the hernia can be felt if the doctor places his hand directly over it and ask you to bear down or cough. Abdominal X-rays are done to check for intestinal obstruction.
Not all lumps or swellings on the abdominal wall or in the groin are hernias. Other possible causes include growths or enlarged lymph nodes. These problems require entirely different types of evaluation and treatment.
How is hernia treated?In general, hernias that are at risk for complications, cause pain, or limit activity, should be repaired. If they are not repaired, there is a risk that an emergency procedure may be required at a later date. This can be particularly difficult if timing is an issue around personal plans or during foreign travel.
Hernias of the abdominal wall are one of the most common conditions requiring surgery. Hernia surgery is performed under either local or general anaesthesia – and often on an outpatient basis, meaning that it is possible to return home on the same day of surgery.
The surgery (herniorrhaphy) involves making an incision in the abdominal wall around the hernia, moving the hernia back into the abdomen, and then closing and reinforcing the abdominal wall.
Sometimes the weak area is reinforced with steel mesh or wire, preventing the intestine from protruding through the weakened skin. This operation is a hernioplasty and has proven to be a very effective means of repair.
In the case of a strangulated hernia, the oxygen-starved part of the intestine is removed. This surgery is a bowel resection.
Increasingly, inguinal herniarrhaphy is performed using a laporoscope, a thin, telescope-like instrument that requires smaller incisions and involves a shorter recovery period. The possibility and effectiveness of laparoscopic repair should be discussed with the surgeon. Potential disadvantages are: the fact that a general anaesthetic is required, a higher risk of blood vessel damage during surgery, and slightly higher rate of the recurrence of the hernia a few years post-operatively.
Moving and walking is recommended the day after surgery. There are usually no dietary restrictions, and work and regular activity may be resumed in a week. Help around the house may be necessary until you recover enough to be able to perform household tasks without assistance. Expect complete recovery from surgery in about two to four weeks. Avoid heavy lifting for several months after surgery.
Avoid bathing for at least five days after the operation, because soaking will separate the skin tapes and the wound could break open. The wound tapes should be carefully patted dry after showering.
Trusses and surgical belts are helpful in the management of small hernias when surgery is contraindicated. A truss is an elastic band that supports the hernia site and prevents protrusion, although it cannot cure a hernia. The truss must be carefully applied on a daily basis.
Unfortunately, doing exercises to strengthen the abdominal muscles will not help to improve the situation in this case, since it cannot cure the hernia. In fact, exercising is bound to aggravate the situation, as it increases pressure inside the abdomen.
Can hernia be prevented? Hernias often return after surgery, so preventative measures are especially important to avoid a recurrence. To help prevent a hernia:
- Avoid obesity and physical strain
- Avoid constipation by eating foods high in fibre, using stool softeners, or drinking natural bowel stimulants, such as prune juice
- Be careful to always lift objects in the correct manner by bending from the knees, not the waist. If something is too heavy, don’t lift it at all.
- Stop smoking. A smoker’s cough spells no good for a hernia. Stopping smoking can also improve blood flow, which speeds the healing process if surgical repair is planned.
- Have a chronic cough or persistent sneezing seen to.
When to call the doctorCall your doctor if:
- You suspect that you have a hernia. Sometimes hernias require urgent medical care; an accurate diagnosis important.
- You know you have a hernia, and you are nauseated and vomiting or are unable to have a bowel movement or pass gas. You may have a strangulated hernia or an obstruction, which are emergencies. Seek medical care immediately.
Reviewed by Prof Don du Toit (M.B.Ch.B) (D.Phil.) (Ph.D) (FCS) (FRCS).