by Thomas H. Lewis, M.D.
Hernias happen. They happen to overweight, out-of-shape smokers, and they happen to highly trained athletes. They happen to persons who strain too much while lifting, and they happen to those who merely sit in a chair. While they are more common in men, they also occur frequently in pregnant women.
A hernia happens when a small portion of tissue from inside pushes through a weak spot in the abdominal wall. In about 75 percent of cases, this occurs in the inguinal canal, the area where the abdomen meets the thigh. Men are 25 times more likely than women to develop an inguinal hernia, and the bulge sometimes protrudes into the scrotum.
Other abdominal hernias likely to affect women as well as men include femoral (also in the groin, nearer the thigh), umbilical (around the naval) and epigastria (above the stomach).
It was once believed that hernias were caused by heavy lifting, straining, coughing or sneezing. Such activities may well bring on a hernia if a weakness already exists in the abdominal tissue, but the current belief is that the weakness is usually caused by impairment in collagen metabolism.
When the predisposition exists, smoking, infection and obesity–as well as straining–can increase the risk. But even fit, muscular individuals develop hernias.
If you have a hernia, you may not know it until a doctor detects it on a routine examination. When you’re asked during a physical to turn your head and cough, the goal is to feel for a hernia.
A hernia can be seen or felt as a tender bulge or round lump that becomes more prominent when you cough, strain or stand up. In the early stages, it’s possible to push the protruding tissue back in place temporarily. In medical terms, a bulge that can be pushed back in place is known as a “reducible” hernia. When the condition worsens, the lump can no longer be pushed back.
The hard part about dealing with a hernia is the uncertainty about what to do. A break in the abdominal wall will not get better on its own and is likely to get worse. Various trusses, belts and other devices to hold the hernia in have had mixed success. And a serious problem could occur if fatty tissue or an organ gets trapped inside the hernia (known as “incarceration”) and deprived of blood flow (“strangulation”). Because of the risk of gangrene and tissue death, strangulation is a life-threatening condition requiring emergency surgery.
Surgery Now or Later?
Sooner or later, most persons with a hernia have it surgically repaired. This involves re-positioning the internal tissue and repairing the defect in the abdominal wall.
About a million procedures are performed each year; it’s one of the most common types of surgery and one of the safest. Complications include pain, discomfort and recurrence of the hernia.
Because of the risk of strangulation, many persons undergo surgery right away, even if the hernia is not causing pain or other symptoms. A study published in the Journal of the American Medical Association [January 18, 2006] found, however, that immediate action may not always be necessary.
More than 700 men with hernias causing only minimal symptoms were recruited over a five-year period at five academic and community hospitals and randomly assigned either to watchful waiting or traditional surgery. Over a two to three year follow-up period, researchers found that the overall rate of pain and other complications was similar in the two groups and concluded that “watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.”
Of the men assigned to watchful waiting, 23 percent crossed over to the surgery group–primarily because their pain had gotten worse and the hernia was protruding more.
Infants and children are more likely than adults to have tissue become trapped (or incarcerated) in a hernia; as a result, they may be advised to have surgery sooner rather than later.
Adults choosing to delay surgery might need to wear a truss, belt or other device in order to handle every day activities without pain or discomfort. It’s important, however, to be instructed in the use of a truss since an improperly worn device could actually increase the risk of incarceration.
While hernia surgery is usually worry-free, recurrence has been a problem. The traditional repair involves suturing together the ends of the defect in the abdominal wall. With the resulting increased tension on the abdominal muscle tissue, another tear is eventually likely to happen.
Newer surgical approaches aim to reduce tension by stitching a mesh patch made of synthetic material into the defect. The recurrence rate has been shown to be dramatically improved over the traditional method of suturing the tissue together. Laparoscopic repair of some hernias is also an option in some patients and should be discussed with your doctor.
As far as the patient is concerned, the best procedure is usually the one with which the surgeon has had the most experience.
If you have a small hernia that doesn’t cause symptoms, there’s no need to let it worry you. When it becomes large enough to cause you pain, the surgeons at Brattleboro General Surgery practice would be glad to consult with you.
Thomas H. Lewis, MD, is a general surgeon on the BMH Medical Staff. He is in the Brattleboro General Surgery practice with Gregory Gadowski, MD, and Joseph Rosen, MD.