hernia.london

In lay terms, a hernia is a weakness in the muscles of the tummy, through which some fat or bowel is trying to come out.

Imagine the tummy as a drum, lined by muscle, which is holding all our bowels and belly fat and keeping them from spilling out. If there is a weakness or a tear in the muscles, then things can start to spill out from there. Hernias occur in men and women.

Common spots where weakness may develop are:

1. The belly button, where we had our umbilical vessels going in when we were in the womb. A hernia at the belly button or navel is called an umbilical hernia.
2. Above the groin crease, where – in males – the weakness is caused by the fact that the testicles have come out of the tummy from there and worked their way down to the scrotum (this happens around the time we are born). This is called an inguinal hernia. Although the weakness is often an inherent one, these hernias can show up at any age.
3. Below the groin crease, where the blood vessels to the legs are coming out of the tummy and working their way down to the thigh. There is weak spot at the inner aspect of these blood vessels through which a hernia can pop out. This is called a femoral hernia.
4. Through a previous surgical scar that has divided the muscles and then not healed properly. This is called an incisional hernia. If a hernia develops adjacent to a colostomy or ileostomy (an opening through which bowel has been brought out to the surface), it is a called a parastomal hernia.

There are other rarer types of hernia that one may encounter, that we have not discussed here. There is also hiatus hernia which is an internal matter, with a part of the stomach sliding into the chest through the diaphragm, the sheet of muscle that partitions the chest from the abdomen.

The inner lining of the tummy wall is a thin glistening sheet called the peritoneum. Often a bit of peritoneum protrudes though the hernia like the finger of a glove. This is called the hernia sac. Bowel or fat may slide out and in within the hernia sac.

Sometimes the rectus muscles (what we refer to in lay terms as “six-packs”) pull away towards the sides, causing weakness or a visible bulge in the centre of the abdomen. This is referred to as Divarication or Diastasis of the rectus muscles. This is not dangerous and is not a hernia that necessarily needs to be surgically repaired. If you have this, please discuss the matter with your doctor.

Hernias typically manifest as a lump or a swelling, that is more obvious when you stand, walk, exercise or strain, but disappears when you lie down or can be pushed back into the tummy. As time goes by, the swelling may be always present and not go back in at all. It can sometimes be painful. In some people, pain may be the first symptom and the swelling can be quite subtle and only picked up on physical examination or on a scan.
Very rarely, a lump may pop out suddenly, become very painful, and not go back in. This may be associated with marked pain in the tummy, plus vomiting, constipation and bloating of the tummy. If that is the case, it usually means that the content of the hernia (bowel or fat) is being pinched and its blood supply is getting cut off. This is called strangulation and represents a surgical emergency. If this happens, you should immediately seek medical attention.

Sometimes the diagnosis is quite obvious and no tests or scans are required. Sometimes an ultrasound scan may be required. Alternatively, a CT or MRI scan may also provide the answer.

This is a structural flaw and there is no medicine that will repair a hernia. It requires an operation to fix it.

Hernias that are not causing symptoms can be left alone for the time being, but the small risk of strangulation should be kept in mind. If left alone, a hernia will persist. It may gradually get bigger and begin to cause symptoms.

If an operation is not possible, one can try wearing a belt, a truss or a corset to keep the hernia in place. These can sometimes be more trouble than they are worth.

The anaesthesia required is usually general anaesthesia (i.e. you are rendered unconscious for the duration of the operation). If a general anaesthetic is deemed very risky, or you strongly prefer to avoid a general anaesthetic, in some instances it may be possible to do the operation using local or regional anaesthesia. But this is something you will need to discuss with your surgeon and your anaesthetist.

Think of a hernia as a tear or a hole in a sheet of muscle. Sometimes it may be possible to repair this by excising the hernia sac, and just drawing the edges of the muscle together with stitches. But it is important that this does not place undue tension on the tissues by pulling them too tight. If that happens, they will usually pull apart again and the operation will be a failure. This is why meshes are often used in hernia repair. These are made of a sheet of soft but tough material, that is cut to size and stitched to the edges of the defect as a patch. Meshes are made of inert substances that are well tolerated by the body and very rarely provoke any reaction in the surrounding tissues. Most meshes will remain indefinitely in the body and not get fully absorbed. Many of them are made of woven material that looks a bit like cloth that is used for mosquito nets.

Meshes have led to complications when used as narrow strips or bands in the pelvic floor. But when used to repair hernias on the front of the abdominal wall, they work very well.

You may be able to go to home the same day or within 24 hours, unless there are specific reasons why you need to stay in longer.
You will be sore for the first few days. Exactly how painful it might be and for how long is difficult to predict. Everyone is different in how they respond to or cope with pain. But you should be able to walk around the house in the first few days and then extend that to walking around the neighbourhood and doing stairs. Most people with sedentary jobs are back at work in 2-3 weeks but if you have a very physical job you may need to wait longer. Avoid strenuous exertion or lifting of weights for at least 6 weeks. If something hurts, stop doing it!
You will be given instructions about wound care when you leave the hospital. I usually close my incisions with absorbable stitches under the skin, so there are no stitches to be removed.
You will be given pain killers, please take them as prescribed. There is no virtue in suffering pain. If you develop a cough please get that looked at. If you develop constipation, please take laxatives. Straining or coughing will hurt your scar and may weaken the repair.