All You Need to Know About Hernias: Q&A with Mr Paul Flora

Hernias can appear as strange lumps from your body. There are 70,000 hernia repair operations each year in the UK. Hernias are common but the sooner you seek help, the easier they are to repair.

Q: What is a Hernia?

Any hernia is an abnormal protrusion of an organ or tissue through a weak area in the muscle or other tissue that normally holds it in place. The term hernia is most commonly used to describe to the protrusion of the intestine through a weak area in the abdominal wall.

Q: Are there different types of hernias?

Hernias are classified according to their position within the abdomen, as follows:

•  Inguinal hernia. This is the most common form of hernia in men, accounting for around 94% of all cases. When a male’s testicles descend into the scrotum, this causes a naturally weakened area of the abdominal wall, known as the internal ring. There are two kinds of inguinal hernia:

In an ‘indirect inguinal hernia’ a portion of the intestine drops down into the internal ring and may extend down into the scrotum. An indirect inguinal hernia tends to occur as a result of an inherited weakness in the internal ring, or a weakness acquired in later life from, say, a groin injury.

Less common is the ‘direct inguinal hernia,’ which occurs near the internal ring, rather than within it. This usually occurs after the age of 40years, as a result of ageing or injury.

• Epigastic hernia. This type of hernia results from a weakness in the muscles of the upper-middle section of the abdominal wall, above the navel. Men are three times more likely to have epigastric hernia than women.

• Umbilical hernia. The tissue around the navel is thinner than that in the rest of the abdominal wall, making this area prone to the development of a hernia.

• Femoral hernia. The area between the abdomen and upper thigh adjacent to the femoral vein is another site where a hernia may develop. This is the one hernia that is far more common among women.

• Incisional and stoma-related hernias. A surgical incision creates an area of weakness in the abdominal wall, where a hernia may develop. Incisional hernia sometimes occurs after, for instance, removal of the appendix. It is more likely to happen when the operation wound has become infected – a fairly common occurrence, in fact. Similarly, creation of a stoma (an artificial opening for the bowel, often done in treatment of colon cancer or other intestinal diseases) strains the tissue in the surrounding area.

Multiple hernias, occurring at more than one site on the abdominal wall, may sometimes develop.

Q: What causes a Hernia?

A hernia results from the protrusion of a part of the contents of the abdominal cavity (usually the intestines) through a weak point in the abdominal wall. The job of the abdominal wall (a sheet of muscle and tendon stretching from the ribs to the thighs) is to act as a support to the tissue and organs within the abdomen/pelvic cavity.

The abdominal wall has some natural weak spots – in males where the blood vessels serving the scrotum and leg pierce it and also in the umbilicus (navel) region for both men and women. The abdominal wall can also be weakened by surgery, injury or any action that overstretches it or exerts undue pressure, like coughing or sneezing.

Q: What are the main symptoms?

If you have an inguinal hernia, the most common is swelling of the groin. For males, the scrotum may also be enlarged. This lump will often be clearly visible beneath the skin. It may disappear when you lie down (reducible), and appear again if you cough, sneeze or strain on the toilet. Some hernias cause no pain at all, while others cause a dull aching sensation which is more pronounced during physical activity. The pain and discomfort of an abdominal hernia come from the pressure of the abdominal contents upon the weak spot of the wall.

Hernias that cause a constant bulge, whatever your position, are called non-reducible and these are the ones that are most likely to cause the complications of strangulation and obstruction which are medical emergencies.

Whilst a swelling is a very common symptom of hernia, not all hernias swell…and not all groin pain is hernia. To find out with more certainty in cases that are difficult to distinguish, you should be seen by a hernia specialist.

Over time, the abdominal contents will start to protrude, even more, weakening the wall still further. In other words, hernia tends to be a progressive condition that worsens over time. Hernias do not get better on their own.

A strangulated hernia, which is a dangerous complication of the condition, is a medical emergency where the blood supply to the hernia contents (usually intestine) becomes restricted by the hernia defect. It presents with severe abdominal pain and can be lethal.

Q: What’s the risk of developing a Hernia?

Anyone can develop a hernia at any age – from the new-born to the very old. However, the following factors seem to increase the risk of abdominal hernia:

• Being male – 12 times more males than females develop groin hernias!
• Obesity
• Previous abdominal surgery such as an appendicectomy
• A chronic cough, such as a smoker’s cough
• Straining during bowel movements (because of constipation) or while urinating
• Straining to lift heavy objects
• Persistent sneezing, such as that caused by allergies

Q: How can I prevent it?

There is no real way of preventing a hernia from developing, particularly if it results from an inherited weakness in the abdominal wall. However, avoiding certain risk factors may be helpful. For instance, if you have a smoker’s cough, stop smoking; if you are prone to violent sneezing attacks because of hay fever, try to get some effective treatment from your doctor or chemist. Similarly, chronic constipation that causes you to strain on the toilet should be treated with a high-fibre diet or medical intervention.

Q: Should I see a doctor?

If you suspect you have a hernia, you should always seek medical advice. A doctor should be able to tell whether you have a hernia or some other problem by physical examination. Most cases should be treated by surgical repair as soon as possible after diagnosis – this removes the discomfort and pain associated with the condition, which could seriously affect your quality of life and, more importantly, prevents the development of a strangulated hernia, which is potentially life-threatening.

Q: What are the main treatments?

The only way of curing a hernia is by surgical repair. There are no drug treatments for the condition. The prospect of having an operation may seem daunting, especially if you have a reducible hernia which is not really causing much discomfort. However, remember that hernias do tend to get worse over time, and there is always a risk – however small – of developing the serious complication of a strangulated hernia. Hernia surgery is better carried out sooner, rather than later. The type of surgery will depend on the type of hernia you have.

Traditional hernia surgery

The surgeon makes an incision in the abdominal wall around the hernia and first pushes the hernia back into position within the abdominal cavity. The weak portion of the abdominal wall is then repaired by a combination of stitching and a mesh. You may be admitted as a day case, or you may need to stay in the hospital overnight, or even for a few days.

Mesh repair and groin hernias

The principle of treating all groin hernias involves identifying the underlying defect and repairing this with a combination of sutures and ‘mesh,’ which is usually made of plastic. The mesh provides a durable reinforcement of the hernia defect or weakness. The ‘mesh’ repair has led to a drastic reduction in the recurrence rates of groin hernia repairs and is relatively easy to perform.

Most such operations are performed as a day case with the patient arriving and leaving on the same day. The incision is only 5-7cms in length and hence causes minimal cosmetic disruption. The meshes used in the groin have become thinner and more lightweight with improving technology in an effort to reduce the amount of foreign material implanted whilst not compromising on strength.

Approximately 5-10% of men have hernias in both groins either on the first presentation or on subsequent follow up (so-called bilateral hernias). These may be repaired at the same time or on separate occasions, but if done together usually require an overnight stay unless done performing ‘keyhole’ surgery (see below).

In some circumstances, the operation is performed under ‘local’ anaesthetic and sedation. This local anaesthetic technique renders the area numb and avoids the effects of having a general anaesthetic and is particularly useful in the elderly and unfit.

After the operation, the patient is encouraged to walk immediately after the effects of the anaesthetic have worn off and normal exercise is resumed within 2 weeks. The wound is closed with ‘dissolving stitches’ and simply needs to be kept dry for 5 days postoperatively.

Laparoscopic surgery

Sometimes known as keyhole surgery, the laparoscopic technique involves a repair of the hernia from inside the abdomen. Using either general or spinal anaesthesia, the surgeon makes a tiny incision near the hernia. Through this, miniature surgical instruments – including a video camera – are introduced and used to make the repair. The camera projects an image of the operation site onto a screen, which guides the surgeon’s actions.

Because the incision is very small, there is less post-operative pain and faster healing than with the two ‘open’ techniques described above. However, in the hands of an inexperienced operator, laparoscopic techniques can cause damage to surrounding tissue because the surgeon has less control than with ‘open’ surgery. Laparoscopic repair for hernia has only really come into its own in the last few years but recent guidance from NICE (the National Institute for Clinical Excellence) says that it should be considered as an option alongside open surgery, depending on the exact nature of the hernia, the surgeon’s experience in laparosopic surgery and the patient’s ability to take general anaesthetic.

A surgical truss might be suggested if there has to be a wait for surgery or if, for some reason, surgery is not advisable. This is an elasticated belt which supports the abdomen and keeps the hernia from protruding. There is some evidence that wearing a truss weakens the muscles and restricts the circulation. There may have been some justification of their use in the past when hernia repair was not so successful, but these days the patient should ask to know why if his/her doctor recommends wearing one of these appliances.

Q: How can I help myself?

After a hernia has been repaired, there is always a risk that it will recur. You can help prevent recurrence by keeping the abdominal wall strong and healthy. The following tips should help:

• Try to maintain a healthy weight
• Exercise to tone the abdominal muscles
• Get medical help for chronic constipation, allergies, or chronic cough
• Eat high-fibre foods. There is an increased risk of deep-vein thrombosis (DVT) after a hernia operation so ask your surgeon about preventive measures such as wearing compression stockings.

Q: What’s the outlook?

Elective hernia repair has a high success rate, but the hernia may recur in between 1-20% of cases. Recurrence is more likely with traditional surgery but also depends upon the type of hernia and any complicating health factor. Mesh repair of a simple case of abdominal hernia is almost certain to last for life. Once a hernia has recurred it does, however, become progressively harder to repair on subsequent occasions.

Mr Paul Flora is a Consultant General & Vascular Surgeon at Highgate Private Hospital specialising in varicose veins, endovenous surgery (laser and radiofrequency), hernias, haemorrhoids, hyperhidrosis, minor surgery, vascular diseases (peripheral arterial disease, aneurysms, carotid disease, diabetic disease) and vascular tumours.