What are hernias?

Hernia is a term that describes a situation in which an internal organ or tissue presses against and protrudes through an opening or weakness in the muscle tissue supporting it, creating a bulge usually felt in the muscle wall.

Hernias can be associated with organs throughout the body, whether an inguinal hernia in the groin area, a hiatal hernia where the stomach meets the esophagus, or even a hernia of the iris in the eye. Inguinal hernias are by far the most common type. However, this information deals with inguinal hernias and other hernias of the abdominal area.

These include:

  • Femoral hernias
  • Umbilical hernias
  • Ventral hernias

In some cases hernias cause pain and discomfort. Others may show no symptoms at all. Often, in the case of an inguinal hernia, the protruding tissue or organ — usually fatty tissue or a loop of intestine protruding through a weakness in the abdominal wall — can be physically pushed back into place. However, an inguinal hernia can carry with it the risk of a section of intestine becoming trapped (or "incarcerated") in place in the opening.

While incarceration is not necessarily an emergency, it is a situation that needs to be dealt with in a timely manner. More importantly, it carries with it the prospect of strangulation — the cutting off the of blood supply to the trapped tissue. This is a serious emergency that needs to be dealt with immediately, as it can lead to severe pain, gangrene, and, conceivably, death.

There is no medical or rehabilitative cure for a hernia. The only treatment — and a highly effective one — is surgical repair of the defective muscle.

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How common are hernias?

With more than 500,000 procedures done in the United States each year, hernia repair is one of the most frequently performed operations in our society. Hernias can affect anyone of any age.

Although inguinal hernias occur in both men and women, they are found far more frequently in men. And, they are found in approximately two percent of all newborn babies.

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What causes hernias?

Hernias occur because of weakness in the supporting tissue against which an organ or other tissue exerts pressure. The cause of the weakness may be congenital, it may be developmental or it may simply be a matter of the activities of life that wear on our muscle tissue as we get older.

Your risk of experiencing an inguinal hernia is increased if you have a family history of them. As a fetus develops before birth, failure of the inguinal canal to close properly enhances the possibility of a hernia occurring. Being born prematurely or having a disease that causes build-up of fluid in the abdomen can be risk factors.

Stress on the abdominal wall or pressure within the abdomen contribute to the development of hernias. Being overweight, straining to urinate or have a bowel movement and coughing chronically (such as smoker's cough) can be factors. Ironically, going on a crash diet that results in poor nutrition can contribute to the occurrence of a hernia. And being out of shape — that is, having weak abdominal muscles — doesn't help.

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What are the characteristics of hernias?

A hernia can develop gradually, over a period of weeks or months, or it can come on suddenly, when you strain to lift something heavy. Some hernias will exhibit clear symptoms, such as pain, discomfort and a bulge in the abdomen. Some hernias will be discovered only during a routine physical examination by a doctor.

A protrusion that lessens in extent upon lying down or that can be physically pushed back into place is called a reducible hernia. While this can be tolerated for a period of time and doesn't represent a medical emergency, it should be discussed with a doctor and very likely dealt with surgically.

Tissue or organs that become incarcerated — or trapped while protruding through an area of weakness — place the patient at risk for strangulation, or the loss of blood supply and death of the tissue. If the trapped organ is a loop of intestine, the result can be bowel obstruction, with cramping, abdominal pain and nausea and vomiting. Tissue death can lead to gangrene and a life-threatening situation.

Hernia repair is essential, since even a small hernia will not cure itself and will grow larger and possibly more serious over time.

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What are inguinal hernias?

Inguinal hernia is a term that applies to hernias in the groin — the area of the juncture of the abdomen and the thighs. Inguinal hernias account for about 80 percent of all hernias, and because of the way that male anatomy develops are much more common in men than women. However, women can also experience them.

Inguinal hernias can occur on one or both sides of the groin. They can contain a loop of intestine, fluid or fatty tissue from inside the abdomen or the peritoneal tissue that lines the inside of the abdomen.

Inguinal hernias are characterized into two types — direct and indirect.

  • A direct inguinal hernia is a bulge or protrusion in the lower abdominal wall as a weak spot develops in muscles there and pressure is exerted from within the abdomen. The weakness is likely to reflect the normal wear and tear our bodies experience as we age.
  • An indirect inguinal hernia results from weakness in the tissue associated with the inguinal canal — a channel leading from the abdomen to the groin. In men, the testicles descend through the canal to the scrotum during fetal development. In addition, the spermatic cords and blood vessels pass through it. In women, it's the channel for ligaments that keep the uterus in place. Before birth, the canal usually closes up, but a defect in the closure represents a weakness that can develop into a hernia. This can happen at any stage of life, with the likelihood increasing as one ages and tissues become weaker.

In men, indirect inguinal hernias usually are expressed as bulging toward the scrotum, and the scrotum may become swollen. In women, they appear as a bulge toward or in the pubic area.

Indirect inguinal hernias are much more common than direct inguinal hernias, and are more prevalent in men than in women.

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What are femoral hernias?

The femoral canals are channels through which blood vessels and nerves pass between the abdomen and the thighs. Any bulge is usually located in the upper part of the affected thigh just below the groin, and is subject to the same symptoms and risks of incarceration and strangulation as other hernias.

Femoral hernias account for about four percent of groin-area hernias, but are much more common in women than in men.

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What is an incisional hernia?

This is a hernia that occurs at the location of an incision for a previous surgical procedure, caused by pressure on the reunited tissues. This is less likely to occur in a case of mesh-augmented repair than with a direct resewing of tissue.

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What are umbilical hernias?

Umbilical hernias are hernias associated with a weakness located at the umbilicus — the naval. In the womb, it is normal for some of the fetus' intestines to be located in a sac within the umbilical cord outside the abdomen — the abdominal cavity doesn't develop at the same rate as the intestines. By birth, the intestines normally have returned to the abdomen and the opening is closed up. If the closure is defective, an umbilical hernia can result, either at birth or as a result of weakening later in life.

Umbilical hernias are subject to the same symptoms and risks of incarceration and strangulation as other hernias. However, in infants an umbilical hernia is likely to present itself as a soft swelling that protrudes with crying or other straining. Umbilical hernias present at birth are a case in which the hernia is likely to cure itself. Most usually close up without treatment by the age of two. If they don't surgery is usually indicated.

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What are ventral hernias?

Ventral is a term that refers to the belly, and a ventral hernia is a protrusion through a weakness in the muscles that form the abdominal wall. Ventral hernias represent the same symptoms and risks of incarceration and strangulation as other hernias.

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How are hernias diagnosed?

If you have a bulge in your side — even one that does not cause pain or discomfort or that seems to go away when you lie down — you should consult a physician. This is especially true if you cannot push it back into place.

A hernia that is incarcerated may not be a medical emergency, but it represents a potential of becoming one and needs to be dealt with in a timely manner. A hernia that is strangulated — and with symptoms of severe pain, cramps and nausea — is an urgent, life-threatening emergency and needs to be dealt with immediately.

Usually your doctor can diagnose your hernia from your medical history and a physical examination. Ultrasound and computerized tomographic scanning may be used to aid in the diagnosis. A herniogram, an x-ray examination involving injection of a contrast medium to obtain an image of the hernia, may be ordered. Tests such as urinalysis may be done to rule out problems such as a urinary tract infection.

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How is surgery for hernias done?

Surgical repair is the only effective treatment for hernias — but it is highly effective, with hernias recurring in less than 10 percent of patients. Surgical techniques available range from traditional conventional approaches to laparoscopic procedures using flexible fiber-optic instruments and minimal incisions.

  • For many years, hernia repair has been done with excellent outcomes using herniorrhaphy, a conventional open-incision technique in which the surgeon made a long incision, restored the internal organs or tissue to their proper location and repaired the weakness in the abdominal wall by sewing surrounding muscle tissue together to create a strong repair. Often performed as outpatient or day-surgery, this technique is frequently done under local anesthetic.
  • In the late 1980s, hernioplasty, the surgical use of synthetic mesh materials such as GORE-TEX was extended to hernia repair, covering and reinforcing the area of weakness with a mesh patch rather than simply sewing surrounding muscles back together. Strong, soft and pliable, the mesh is easily accepted by the body. Its use as a patch places less tension on the surrounding tissues than is the case with direct rejoining. Also often done on an outpatient basis, the mesh technique also may well be done under local anesthetic.
  • Laparoscopic surgery is the use of flexible fiber-optic instruments to allow surgery to be performed on internal organs without large, conventional incisions. Operating these thin instruments through several tiny incisions, an experienced surgeon can accomplish the repair with equally excellent outcomes, whether rejoining surrounding tissue or placing a mesh patch.

Since the technique involves the surgeon's inflating the abdomen with carbon dioxide (a measure that can be uncomfortable for the patient) laparoscopic hernia repair is performed with a general anesthetic. Even so, the procedure is often done on an out-patient basis and recovery time and risk of complications are greatly reduced compared to open-incision surgery.

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How can I prevent hernias from occurring?

In the sense that hernias are the result of an existing weakness in muscle tissue, it is difficult to do anything to prevent them. You can minimize your risk of their occurring by trying not to place too much pressure or stress on your abdominal muscles.

Use good body mechanics to reduce stress from heavy lifting. Avoid straining to urinate or have a bowel movement. Avoid coughing chronically, even if it means stopping smoking. Lose excess weight.

Exercise such as walking, running and swimming can improve your overall physical condition. Seek to gradually strengthen your abdominal muscles. Walking (or running) and swimming are excellent exercises.

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Is hernia repair covered by insurance?

Hernia repair is sometimes described as elective surgery, but a serious hernia, even one that does not currently cause pain, has the potential for becoming a serious emergency. With the exception of many umbilical hernias in infants, hernias do not cure themselves and they usually get worse. Most health insurance plans cover hernia repair even when it is an "elective" procedure.

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What about "trusses"?

I used to see advertisements for trusses to hold in hernias. Can't I just wear one of those?

A truss is not a reliable permanent solution for a hernia, and may cause problems if an unrepaired hernia becomes strangulated.

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What complications can result from hernia repair surgery?

Overall, complications from hernia repair are rare. Any surgery carries with it very small-but-possible risks of complications such as allergic reaction to anesthesia, bleeding and infection.

Surgery in the lower abdomen carries a slight chance of injury to an intestine, bladder or testicle.

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For Additional Information

You can find additional information about hernia repair at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.

Sources include:

Hartford Hospital's Health Library:

The National Digestive Diseases Information Clearinghouse (www.niddk.nih.gov)

The American College of Surgeons (www.facs.org)

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