Abdominal Hernia – Lloyd M. Krieger, MD. Beverly Hills, Ca.

The Causes and Surgical Treatment of Abdominal Hernia

The National Center for Health Statistics estimates that about 5 million people in the United States have an abdominal hernia. Only a fraction of these people seek treatment. If not treated, a hernia can worsen over time, sometimes to the point that emergency medical treatment is required. If you suspect you have a hernia, it is wise to see your doctor. Repair of a hernia is generally a minor procedure that will end the discomfort associated with a hernia and help ensure that further complications do not arise.

What Is an Abdominal Hernia?

In general, a hernia refers to the protrusion of an organ through a weak area in the muscles or tissue that surround and contain it. Most commonly, the word hernia is used to refer to an abdominal hernia. This type of hernia occurs when an organ or fatty tissue pushes the inner lining of the abdominal wall (the outer layer of muscle, fat and tissue that extends from the bottom of the ribs to the top of the thighs) through a weak area in the abdominal muscles, causing an outpouching of the abdominal wall. This area may have been weak at birth, or it may have been weakened by age, injury or a previous surgical incision. The outpouching, which turns into a noticeable bulge, can contain fat, intestine or other tissue. The bulge can be either reducible, meaning that the fat or tissue can be pushed back into the abdominal cavity and the hernia will flatten and disappear, or nonreducible, which means the fat or tissue cannot be pushed back into the abdomen and the hernia will not flatten. Whether a hernia is reducible depends on how far it protrudes through the abdominal wall and how tightly it is held by the abdominal muscles. If the hernia is nonreducible, it must be repaired surgically, because the outpouching can contain intestine, which can lose its blood supply and die if it becomes tightly trapped (called strangulation). Strangulation of an intestine causes extreme pain, can block digestion and may even cause gangrene in that area of intestine. In this case, emergency surgical repair is required.

Who Is at Risk for an Abdominal Hernia?

A hernia can literally develop in anyone, from a newborn baby to a senior citizen. The following factors can increase an individual’s risk for developing a hernia by straining or increasing pressure on the abdominal wall:

  • A chronic cough, such as smoker’s cough
  • Obesity
  • Straining during bowel movements or while urinating
  • Pregnancy
  • Straining to lift heavy objects
  • Persistent sneezing, such as that caused by allergies

Are all abdominal hernias the same?

The following are different types of abdominal hernia:

Epigastric Hernia
This type of hernia occurs as a result of a weakness in the muscles of the upper-middle abdomen, above the navel. Men are about three times more likely to have an epigastric hernia than women, and the majority occur in people between 20 and 50 years of age.

Umbilical Hernia
Another natural area of weakness in the abdomen is the navel, which, like the internal ring, is made up of tissue that is thinner than that in the rest of the abdomen. These hernias can occur in babies, children and adults.

Femoral Hernia
A femoral hernia occurs in the area between the abdomen and the thigh, and appears as a bulge on the upper thigh. This type of hernia is more common in women than men.

Incisional Hernia
A type of hernia called incisional can occur at the site of an incision from a previous surgery. The fat or tissue pushes through a weakness created by the surgical scar. An incisional hernia can occur months or years after the initial surgery.

What are the Warning Signs?

A hernia usually first becomes noticeable as a bulge somewhere in the abdomen or pelvic area or in the scrotum for men. If the bulge is reducible, it may enlarge when the person is standing and become smaller when he or she lies down. The changes in the hernia’s size are due to the increased pressure on the abdominal wall caused by gravity when we stand. A hernia may cause sharp or dull pain that worsens when having a bowel movement, during urination, or while lifting a heavy object. The pain might worsen as the day progresses, especially with long periods of standing, because of gravitational pressure. Nonprescription drugs such as aspirin and acetaminophen may relieve minor discomfort. In the case of a strangulated hernia that contains intestine, the herniated section of intestine might become blocked. This blockage may cause blood in the stool, constipation, fever, severe pain, vomiting and even shock. If these symptoms are experienced, emergency medical attention is needed. Even with suspected hernias that do not cause these symptoms, it is best to schedule an appointment with a doctor to avoid these complications. The doctor will probably want to perform a physical examination and discuss the patient’s symptoms and medical history to determine if a hernia has developed.

How Are Hernias Treated?

Treatment options for a hernia include the following:

  • Hernia repair surgery
    Hernia repair surgery is an effective treatment for hernias. As with almost any surgery, there are some risks involved with a hernia repair operation. These risks, along with the risks of not having surgery, should be discussed with a doctor before a treatment decision is made. Remember that successful surgery will end discomfort, repair the hernia, and stop the hernia from progressing.
  • Traditional hernia repair surgery
    Traditional hernia repair surgery 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. This type of hernia repair often does not require an overnight hospital stay.
  • Laparoscopy
    Laparoscopy is a surgical procedure for hernia treatment in which a fiber optic viewing tube and special instruments are used to repair the hernia without making a large incision. This procedure requires less recovery time than traditional hernia repair surgery. The possibility and effectiveness of laparoscopic repair should be discussed with a doctor.
  • A supportive truss
    A garment known as a truss may be helpful if the hernia is reducible and causes mild symptoms. A truss is an elastic band or brief that holds the hernia inside of the abdomen and keeps the area flat. Wearing a supportive truss can help stop a hernia from protruding, but cannot cure it.
  • No treatment
    A patient always has the option of not undergoing treatment, but he or she should understand that the hernia may become worse and that there is a risk of intestinal strangulation.

What Can Be Done to Prevent a Hernia From Worsening?

To help make sure that the hernia does not worsen, the risk factors mentioned earlier should be avoided, since it is likely that one or more of them contributed to the hernia. Lifting, pushing, or pulling heavy objects should be avoided. Quitting smoking is highly recommended. Smoker’s cough can contribute to the development or worsening of a hernia. Quitting smoking can also improve blood flow, which speeds the healing process if surgical repair is scheduled. Eating a high-fiber diet, which includes grains, whole-grain bread and cereals, bran, and raw fruits and vegetables, can help relieve constipation, as can drinking at least eight glasses of water per day. If these suggestions do not work, a stool softener or enema can be used as directed by a doctor. If allergies are a problem, a doctor may prescribe medication to treat the sneezing. Deep-breathing techniques can help ease a chronic cough.

What Can Be Expected From Hernia Repair Surgery?

In preparation for the surgery, blood tests, an electrocardiogram (EKG), and/or a chest X-ray might be ordered to evaluate the patient’s health. He or she may be required to stop all medications before surgery, including aspirin, because they can have dangerous interactions with anesthetics or increase the risk of abnormal bleeding.

Hernia repair surgery is often done on an outpatient basis, meaning that it is possible to return home on the same day of the surgery. This depends on the severity of the hernia. If a hospital stay is necessary, it will likely be for one day to three days, depending on how quickly the incision heals. After hernia repair surgery, time should be allowed for rest and recovery at home. Help around the house may be necessary until the patient recovers enough to be able to perform household tasks without assistance.

On the day of the surgery or at a prior visit, an anesthesiologist (a doctor who specializes in administering anesthesia) will explain to the patient the type of anesthetic that will be used. The type of anesthetic used depends on the patient’s health and the severity of the hernia. The options for anesthesia include the following:

  • General anesthesia
    A general anesthetic puts the patient in a deep sleep. It is a safe, common method of ensuring that no pain is felt while the hernia is repaired. There are some risks involved with general anesthesia, especially if the patient has significant medical problems, which can factor into the choice of anesthetic. These risks will be discussed with the patient. If a general anesthetic is chosen, the patient should not eat or drink anything after midnight of the night preceding the surgery.
  • Local anesthesia
    A local anesthetic causes the loss of sensation in only the area to be operated on, and the patient remains awake during the surgery. It is generally considered to carry fewer risks than a general anesthetic. There is no special preparation needed for a local anesthetic.

During the surgery, the surgeon will make an incision at the hernia and either move the contents within the protruding hernia back into the abdominal cavity or remove the contents, especially if the protrusion includes strangulated intestines. Following repair of the hernia, the weakened tissue that contributed to the development of the hernia will be closed and strengthened with stitching or, if the hernia is larger, synthetic mesh.

After the surgery, the patient may receive fluids and pain-relieving medication through an intravenous (IV) tube for a few hours.

Recovery time will depend on the health of the patient and the type of surgical repair that was performed. Once the patient is back at home, he or she should try to slowly ease back into normal activities. Light activities can usually be resumed in a few days. How soon the patient can return to work depends on the type of job that he or she has. A job that is very physically demanding may require more recovery time before returning than a job that does not require putting strain on the body. It is recommended that no strain be put on the body for six to eight weeks after the surgery. Light exercise, such as walking, helps increase blood flow and promotes healing. Appropriate types of exercise should be discussed with a doctor. Lifting should be avoided, but if it is absolutely necessary, only manageable objects should be attempted and lifting should be done with the legs, not the back. Activities such as driving and sex can also strain the incision. The patient should ask when these activities can be resumed. Pain medications may be prescribed for the first few days at home. A patient should never drive while taking pain medications.

The patient will be informed about how much tenderness, swelling and bleeding are to be expected. Before leaving the hospital, a follow-up appointment should be set up so that recovery can be monitored. A doctor should be notified immediately if any of the following symptoms are experienced after the surgery:

  • Fever
  • Difficulty urinating
  • Excessive bleeding
  • Redness in the area of the incision
  • Excessive tenderness or swelling
  • Severe or increasing pain
  • How Can a Hernia Recurrence Be Prevented?

    After a hernia has been treated, there is some risk that it will recur. Most hernias cannot be prevented, but there are certain things that can be done to decrease the risk of recurrence. The following suggestions can help reduce the risk of a hernia recurring:

    • Maintaining a healthy weight
    • Exercising to tone the muscles of the abdomen
    • Receiving medical help for chronic constipation, allergies or a chronic cough
    • Eating high-fiber foods
    • Avoiding the risk factors mentioned earlier
    • For more information about hernia or its treatment, contact Dr. Krieger.

      Content courtesy of the American Medical Association.

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