In Latin the word Hernia means "a rupture". When tissue protrudes through a structure, or a part of an organ through the muscle tissue or the membrane, that is a hernia. There are three parts to a hernia - the orifice, the hernia sac, and the hernia's contents. The most common place for hernias to occur in humans is the abdomen. A part of the abdominal wall is weak and allows a localized hole to develop - this hole is also known as a defect. Tissue, or abdominal organs may stick out through this hole. A hernia that involves the spinal discs commonly causes sciatica (pain in the lower back, the pain can radiate down one or both legs). Not all hernias are painful. It is possible for somebody to have a hernia and feel nothing. In general, a patient with a hernia will feel pain, and often feel a lump in the affected area. Fatty tissue will usually jut through first, then an organ may protrude later. In most cases a hernia will occur when the compartment which envelopes an organ receives increased pressure, this weakens the boundary. This may happen for several reasons, including:

Genetic propensity - if either or both of your parents had a hernia you are more likely to develop one.

Age - the older you are the higher is your risk of developing a hernia.

Ehlers-Danlos syndrome - a group of uncommon genetic disorders that affect humans and domestic animals caused by a defect in collagen synthesis.

Marfan syndrome - a is genetic disorder of the connective tissue.

Pregnancy - the muscles of the mother stretch, making it easier for tissue to poke through.

Drastic weight loss - when obese people lose weight they may be more prone to developing hernias.

COPD, Whooping cough - the patient may cough a lot. Coughing raises pressure in the abdomen. Any illness that includes severe coughing can cause hernias to occur. A severe bout of flu may sometimes cause a hernia to develop.

Ascites - the buildup of extra fluid in the abdomen (peritoneal cavity).

Benign prostatic hypertrophy - the prostate gland enlarges, increasing pressure around it.

Intracranial pressure - if intracranial pressure rises parts of the brain may develop hernias which protrude through the cranial cavity.

Excessive lifting - raises pressure on the abdomen and others parts of the body.

Prior surgery - some surgeries may result in the weakening of membranes.

Obesity - if a person is obese his chances of developing a hernia are significantly higher, compared to people who are not obese.

What types of hernias are there?There are many types of hernias. Below is a list of some of the most common hernias:

Abdominal Hernia - an abdominal organ or fatty tissue juts through a weakened area of the abdominal wall, resulting in a protrusion

Anal Hernia - tissue protrudes through the membrane around the anal region.

Diaphragmatic Hernia - hernia resulting from the protrusion of part of the stomach through the diaphragm - a hole in the diaphragm which the bowel can pass through, also known as congenital diaphragmatic hernia.

Hiatal Hernia - forms at the opening in the diaphragm where the esophagus (food pipe) joins the stomach. A part of the stomach pushes through this opening.

Herniatied Disc - the cushion that lies between the spinal vertebra is squeezed outside its normal position. As the spinal disc loses its elasticity, it may rupture - rupturing may cause a portion of the spinal disc to push outside its normal boundary - resulting in aherniated disc

Intracranial Hernia (in the brain) - caused by extreme intracranial pressure. This is a protrusion of brain from the cranial vault through the foramina (tentorial notch or foramen magnum) or ventral dural septae. The patient may need immediate medical attention as intracranial hernias might be life-threatening, especially if the hernia takes place in the brain stem region. Usually caused by brain edema or hemorrhage which results in increased intracranial pressure.

Pelvic Hernia, Inguinal Hernia - an interstitial hernia (happens in the small opening between tissues or parts of an organ) projecting into the pelvis from the internal inguinal ring. The inguinal ring is at the entrance to the inguinal canal. The inguinal canal is an oblique canal through the lower abdominal wall; in males it is the passage through which the testicles move down into the scrotum, it contains the spermatic cord; in females it transmits around the ligament of the uterus.

Femoral Hernias - more common among females. Occurs when part of the intestine protrudes through the femoral canal, it juts through at the top of the thigh. Blood vessels that supply the legs with blood go through the femoral canal.

Umbilical Hernia - more common among children. The abdominal wall is weakened where the umbilical cord enters/leaves the body (the belly button, the naval). Umbilical herniascan also be found in puppies.

Epigastric Hernia - occurs between the naval and the breastbone. Fat protrudes through the abdominal wall.

Ventral Hernia - most commonly after a surgical operation or trauma (e.g. car accident or bad fall). When tissue is scarred it weakens the abdominal wall, leading to hernia.

Obtuator Hernia - bits of intestine penetrates through the space between bones in the front part of the pelvis.

Treatment for hernia

Your GP may initially try to push the hernia back, if he/she thinks it is possible. In many cases surgery is required to repair a hernia. During the operation the surgeon will put the protrusion back. If the protrusion is through the abdominal wall, for example, a synthetic mesh may be fixed to the muscles to strengthen the area. Surgery can be either open surgery, where a large incision is made, or keyhole (laparoscopic) surgery, where only a tiny incision is made, using a specially designed camera and instruments to carry out the operation. Advantages and disadvantages of open surgery and laparoscopic surgery Both open surgery and keyhole surgeries have their own advantages and disadvantages. Although open surgery involves a longer recovery time and more post-operative pain, it can be done with a local anesthetic. A patient who undergoes keyhole surgery will recover faster and experience less pain. However, keyhole surgery requires a general anesthetic. Elderly patients, or those with bad health may be too weak to undergo a general anesthetic. Gastrointestinal experts say that despite faster recovery time and less pain after the operation, laparoscopic surgery carries a higher risk of damage to the bowel. A European study found that laparoscopic hernia surgery has a 5 in 1000 risk of serious complications, compared to 1 in 1000 with open hernia surgery (NHS Choices, UK) . In the UK approximately 2% of hernia surgery patients will require further surgery later on. The 2% risk is the same for both types of surgery (NHS Choices, UK) . If you have to wait a long time for your surgery your doctor may recommend you wear a truss till the day of your operation. Trusses keep many hernias in place.

Prevention of hernias

In many cases, hernias are due to age and your genetic propensity. There is not much you can do about that. However, there are some factors which can raise your risks of developing a hernia. Heavy lifting - heavy lifting is known to cause hernias. Try to avoid heavy lifting. If you can't, learn how to position yourself for lifting. According to www.bodybuilding.com, if you are weight training you should use an appropriate amount of weight relative to your strength. You should make sure you are warmed up before lifting any weights. Make sure you bend at the knees when lifting a weight - do not bend at the waist as this will cause excessive pressure. If you are lifting a heavy object in the gym (or anywhere) take a squatting position, keep your back straight and as vertical as you can. Make sure your bodyweight is centered over your feet when you start your lift. Frequent abdominal training will strengthen those areas most susceptible to hernias. Smoking and coughing - coughing, especially persistent coughing can cause a hernia to develop. Anything you can do to reduce or eliminate your cough will help enormously. If you smoke, try to give up, or at least cut down. Quitting smoking will prevent several other serious diseases. Studies indicate that your chances of succeeding in giving up smoking are significantly greater if you seek help from your GP (primary care physician) and join a support group. Nutrition - a diet that is high in fiber will help your bowel movements. Constipation, especially if the person is often constipated, greatly increases hernia risk. Eat plenty of fruits, vegetables and wholegrains. Make sure you drink plenty of fluids. Obesity - being overweight can increase your risk of developing a hernia considerably. The more overweight you are, the higher your risk. Try to lose weight. Make sure, if you are obese, that you lose weight gradually. It is always advisable to seek professional help before you embark on any exercise program. Ask your doctor for advice on diet and exercise.

How common are hernias?England According to the National Health Service, approximately 70,000 people undergo a surgical operation for inguinal hernias each year - 98% of these patients are men. 16 out of every 100,000 people develop femoral hernias. Incisional hernias, which develop as a complication of abdominal surgery, occur in 0.5% to 10% of patients, depending on the type of surgery involved. Children of blackAfrican descent are ten times more likely to have an umbilical hernia compared to white children (in most cases umbilical hernias do not need treatment and get better as the child becomes older). USA Approximately 5 million Americans have a hernia (National Center for Health Statistics, USA). However, only about 750,000 of them seek treatment each year. Most common male and female hernias Inguinal hernias (hernias in the groin area) are most common among men - mainly because there is unsupported space in the groin area after the testes descend in the scrotum. Femoral hernia is most common among women.

Written by Christian Nordqvist Copyright: Medical News Today Hernia InformationA hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained. These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity. Hernias by themselves may be asymptomatic (produce no symptoms) or cause slight to severe pain. Nearly all have a potential risk of having their blood supply cut off (becoming strangulated). When the content of the hernia bulges out, the opening it bulges out through can apply enough pressure that blood vessels in the hernia are constricted and therefore the blood supply is cut off. If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply. Different types of abdominal-wall hernias include the following: Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect. Both occur in the groin area where the skin of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal area. Distinguishing between the direct and indirect hernia, however, is important as a clinical diagnosis.

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Indirect inguinal hernia: An indirect hernia follows the pathway that the testicles made during fetal development, descending from the abdomen into the scrotum. This pathway normally closes before birth but may remain a possible site for a hernia in later life. Sometimes the hernia sac may protrude into the scrotum. An indirect inguinal hernia may occur at any age.

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Direct inguinal hernia: The direct inguinal hernia occurs slightly to the inside of the site of the indirect hernia, in an area where the abdominal wall is naturally slightly thinner. It rarely will protrude into the scrotum. Unlike the indirect hernia, which can occur at any age, the direct hernia tends to occur in the middle-aged and elderly because their abdominal walls weaken as they age.

Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal. A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area. Usually occurring in women, femoral hernias are particularly at risk of becoming irreducible (not able to be pushed back into place) and strangulated. Not all hernias that are irreducible are strangulated (have their blood supply cut off ), but all hernias that are irreducible need to be evaluated by a health-care provider.

Umbilical hernia: These common hernias (10%-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than half an inch), this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot may remain a weaker place in the abdominal wall. Umbilical hernias can appear later in life or in women who are pregnant or who have given birth (due to the added stress on the area).

Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.

Spigelian hernia: This rare hernia occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which is several inches to the side of the middle of the abdomen.

Obturator hernia: This extremely rare abdominal hernia develops mostly in women. This hernia protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen). This will not show any bulge but can act like a bowel obstruction and cause nausea and vomiting. Because of the lack of visible bulging, this hernia is very difficult to diagnose.

Epigastric hernia: Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, epigastric hernias are composed usually of fatty tissue and rarely contain intestine. Formed in an area of relative weakness of the abdominal wall, these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

Hernia Symptoms and SignsThe signs and symptoms of a hernia can range from noticing a painless lump to the severely painful, tender, swollen protrusion of tissue that you are unable to push back into theabdomen (an incarcerated strangulated hernia). Reducible hernia

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It may appear as a new lump in the groin or other abdominal area.

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It may ache but is not tender when touched.

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Sometimes pain precedes the discovery of the lump.

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The lump increases in size when standing or when abdominal pressure is increased (such as coughing).

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It may be reduced (pushed back into the abdomen) unless very large.

Irreducible hernia

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It may be an occasionally painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it.

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Some may be chronic (occur over a long term) without pain.

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An irreducible hernia is also known as an incarcerated hernia.

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It can lead to strangulation (blood supply being cut off to tissue in the hernia).

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Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.

Strangulated hernia

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This is an irreducible hernia in which the entrapped intestine has its blood supply cut off.

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Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).

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The affected person may appear ill with or without fever.

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This condition is a surgical emergency.

Hernia DiagnosisIf you have an obvious hernia, the doctor may not require any other tests (if you are healthy otherwise). If you have symptoms of a hernia (dull ache in groin or other body area with lifting or straining but without an obvious lump), the doctor may feel the area while increasing abdominal pressure (having you stand or cough). This action may make the hernia able to be felt. If you have an inguinal hernia, the doctor will feel for the potential pathway and look for a hernia by inverting the skin of the scrotum with his or her finger.

Hernia Treatment Self-Care at HomeIn general, all hernias should be repaired unless severe preexisting medical conditions make surgery unsafe. The possible exception to this is a hernia with a large opening. Trusses and surgical belts or bindings may be helpful in holding back the protrusion of selected hernias when surgery is not possible or must be delayed. However, they should never be used in the case of femoral hernias. Avoid activities that increase intra-abdominal pressure (lifting, coughing, or straining) that may cause the hernia to increase in size.

Medical TreatmentTreatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated. Reducible hernia

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In general, all hernias should be repaired to avoid the possibility of future intestinal strangulation.

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If you have preexisting medical conditions that would make surgery unsafe, your doctor may not repair your hernia but will watch it closely.

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Rarely, your doctor may advise against surgery because of the special condition of your hernia.

Some hernias have or develop very large openings in the abdominal wall, and closing the opening is complicated because of their large size.

These kinds of hernias may be treated without surgery, perhaps using abdominal binders.

Some doctors feel that the hernias with large openings have a very low risk of strangulation.

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The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus nonsurgical management needs to take place between the doctor and patient.

Irreducible hernia

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All acutely irreducible hernias need emergency treatment because of the risk of strangulation.

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An attempt to reduce (push back) the hernia will generally be made, often after giving medicine for pain and muscle relaxation.

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If unsuccessful, emergency surgery is needed.

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If successful, however, treatment depends on the length of the time that the hernia was irreducible.

If the intestinal contents of the hernia had the blood supply cut off, the development of dead (gangrenous) bowel is possible in as little as six hours.

In cases in which the hernia has been strangulated for an extended time, surgery is performed to check whether the intestinal tissue has died and to repair the hernia.

In cases in which the length of time that the hernia was irreducible was short and gangrenous bowel is not suspected, you may be discharged from the hospital.

o Because a hernia that was irreducible and is reduced has a dramatically increased risk of doing so again, you should therefore have surgical correction sooner rather than later. o Occasionally, the long-term irreducible hernia is not a surgical emergency. These hernias, having passed the test of time without signs of strangulation, may be repaired electively. Nursing management of hernia include: Patient History, an infant or a child may be relatively free from symptom until she or he cries, coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal area. Physical Examination, If the patient has a large hernia, inspection may reveal an obvious swelling in the inguinal area. If he has a small hernia, the affected area may simply appear full. Auscultation should reveal bowel sounds. Diagnostic tests, made on the basis of a physical examination. Although assessment findings are the cornerstone of diagnosis, suspected bowel obstruction requires X-rays and a white blood cell count, which may be elevated. Treatment.

Nursing Care Plan For Inguinal HerniaDo you want to share? Do you like this story?Nursing Care Plan for Inguinal Hernia. Hernia is a protrusion or projection of an organ or organ part through an abnormal opening in the containing wall of its cavity, a hernia results. An inguinal hernia occurs when the omentum, the large or small intestine, or the bladder protrudes into the inguinal canal. In an indirect inguinal hernia, the sac protrudes through the internal inguinal ring into the inguinal canal and, in males, may descend into the scrotum. In a direct inguinal hernia, the hernial sac projects through a weakness in the abdominal wall in the area of the rectus abdominal muscle and inguinal ligament.

Hernia is classified into three types:

Reducible, Hernias can be reducible if the hernia can be easily manipulated back into place Irreducible or incarcerated, this cannot usually be reduced manually because adhesions form in the hernia sac. Strangulated, if part of the herniated intestine becomes twisted or edematous and causing serious complications, possibly resulting in intestinal obstruction and necrosis.

Inguinal hernias can be direct which is herniation through an area of muscle weakness, in the inguinal canal, and inguinal hernias indirect herniation through the inguinal ring. Indirect hernias, the more common form, can develop at any age but are especially prevalent in infants younger than age 1. This form is three times more common in males.

Causes for Inguinal Hernia An inguinal hernia is the result of either a congenital weakening of the abdominal wall, traumatic injury, aging, weakened abdominal muscles because of pregnancy, or from increased intra-abdominal pressure (due to heavy lifting, exertion, obesity, excessive coughing, or straining with defecation).

Inguinal hernia is a common congenital malformation that may occur in males during the seventh month of gestation. Normally, at this time, the testicle descends into the scrotum, preceded by the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine can slip, causing a hernia.

Complications for Inguinal Hernia Inguinal hernia may lead to incarceration or strangulation. That can interfere with normal blood flow and peristalsis, and leading to intestinal obstruction and necrosis.

Nursing Assessment Nursing care plan for Inguinal Hernia Patient History, an infant or a child may be relatively free from symptom until she or he cries, coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal area. On adult patient may occurs of pain or note bruising in the area after a period of exercise. More commonly, the patient complains of a slight bulge along the inguinal area, which is especially apparent when the patient coughs or strains. The swelling may subside on its own when the patient assumes a recumbent position or if slight manual pressure is applied externally to the area. Some patients describe a steady, aching pain, which worsens with tension and improves with hernia reduction Physical Examination, If the patient has a large hernia, inspection may reveal an obvious swelling in the inguinal area. If he has a small hernia, the affected area may simply appear full. As part of your inspection, have the patient lie down. If the hernia disappears, it's reducible. Also ask him to perform Valsalva's maneuver; while he does so, inspect the inguinal area for characteristic bulging. Auscultation should reveal bowel sounds. The absence of bowel sounds may indicate incarceration or strangulation. Palpation helps to determine the size of an obvious hernia. It also can disclose the presence of a hernia in a male patient.

Diagnostic tests

Commonly No specific laboratory tests are useful for the diagnosis of an inguinal hernia. Diagnosis is made on the basis of a physical examination. Although assessment findings are the cornerstone of diagnosis, suspected bowel obstruction requires X-rays and a white blood cell count, which may be elevated.

Treatment for Inguinal Hernia The choice of therapy depends on the type of hernia. For a reducible hernia, temporary relief may result from moving the protruding organ back into place. Afterward, a truss may be applied to keep the abdominal contents from protruding through the hernial sac. Although a truss doesn't cure a hernia, the device is especially helpful for an elderly or a debilitated patient, for whom any surgery is potentially hazardous. Herniorrhaphy is the preferred surgical treatment for infants, adults, and otherwise-healthy elderly patients. This procedure replaces hernial sac contents into the abdominal cavity and seals the opening. Another effective procedure is hernioplasty, which involves reinforcing the weakened area with steel mesh, fascia, or wire. Strangulated or necrotic hernia requires bowel resection. Rarely, an extensive resection may require a temporary colostomy

Primary Nursing Diagnosis: Pain related to swelling and pressure Primary nursing Outcomes: Pain, disruptive effects; pain level Primary nursing Interventions: Analgesic administration; pain management

Nursing Outcome, Nursing Interventions, and Patient Teaching For Inguinal Hernia Common Nursing diagnoses found on Nursing care plan for Inguinal Hernia

Activity intolerance Acute pain Ineffective tissue perfusion: Gastro Intestinal Risk for infection Risk for injury

Nursing outcomes nursing care plans for Inguinal Hernia

The patient will perform activities of daily living within the confines of the disease process. The patient will express feelings of comfort. The patient's bowel function will return to normal. The patient will remain free from signs or symptoms of infection. The patient will avoid complications.

Nursing interventions Nursing Care Plan For Inguinal Hernia

Apply a truss only after a hernia has been reduced. For best results, apply it in the morning before the patient gets out of bed.

Assess the skin daily and apply powder for protection because the truss may be irritating.

Watch for and immediately report signs of incarceration and strangulation. Closely monitor vital signs and provide routine preoperative preparation. If necessary, When surgery is scheduled

Administer I.V. fluids and analgesics for pain as ordered. Control fever with acetaminophen or tepid sponge baths as ordered. Place the patient in Trendelenburg's position to reduce pressure on the hernia site.

After surgery,

Provide routine postoperative care. Don't allow the patient to cough, but do encourage deep breathing and frequent turning. Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on rolled towels also reduces swelling.

Administer analgesics as necessary. In males, a jock strap or suspensory bandage may be used to provide support.

Patient teaching home health guide Nursing Care Plan For Inguinal Hernia

Explain what an inguinal hernia is and how it's usually treated. Explain that elective surgery is the treatment of choice and is safer than waiting until hernia complications develop, necessitating emergency surgery.

Warn the patient that a strangulated hernia can require extensive bowel resection, involving a protracted hospital stay and, possibly, a colostomy.

Tell the patient that immediate surgery is needed if complications occur. If the patient uses a truss, instruct him to bathe daily and apply liberal amounts of cornstarch or baby powder to prevent skin irritation.

Warn against applying the truss over clothing, which reduces its effectiveness and may cause slippage. Point out that wearing a truss doesn't cure a hernia and may be uncomfortable.

Tell the postoperative patient that he'll probably be able to return to work or school and resume all normal activities within 2 to 4 weeks.

Explain that he or she can resume normal activities 2 to 4 weeks after surgery. Remind him to obtain his physician's permission before returning to work or completely resuming his normal activities.

Before discharge, Instruct him to watch for signs of infection (oozing, tenderness, warmth, redness) at the incision site. Tell him to keep the incision clean and covered until the sutures are removed.

Inform the postoperative patient that the risk of recurrence depends on the success of the surgery, his general health, and his lifestyle.

Teach the patient signs and symptoms of infection: poor wound healing, wound drainage, continued incision pain, incision swelling and redness, cough, fever, and mucus production.

Explain the importance of completion of all antibiotics. Explain the mechanism of action, side effects, and dosage recommendations of all analgesics.

Caution the patient against lifting and straining.

HerniaFrom Wikipedia, the free encyclopedia

Hernia

Classification and external resources

Frontal chest X-ray showing a hernia of Morgagni

ICD-10

K40-K46

ICD-9

550-553

MedlinePlus

000960

eMedicine

emerg/251 ped/2559

MeSH

D006547

Colonic herniation.

A hernia is the protrusion[1] of an organ or the fascia of an organ through the wall of the cavity that normally contains it. There are different kinds of hernia, each requiring a specific management or treatment.Contents[hide]

1 Signs and symptoms

2 Causes 3 Diagnosis

o o o o o o o

3.1 Inguinal 3.2 Femoral 3.3 Umbilical 3.4 Incisional 3.5 Diaphragmatic 3.6 Other hernias 3.7 Characteristics

4 Treatment 5 Complications 6 References 7 External links

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7.1 Pictures

[edit]Signs

and symptoms

By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm. Hernias may or may not present either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ. Symptoms may not be present in some inguinal hernias while in some other hernias, including inguinal, they are. Symptoms and signs vary depending on the type of hernia. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.[2] Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.

Strangulated hernias are always painful and pain is followed by tenderness. Nausea and vomiting also may occur as well due to bowel obstruction. The patient may also experience fever.[3] In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.[4]

[edit]CausesMost of the time, hernias develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened.

Weakening of containing membranes or muscles is usually congenital (which explains part of the tendency of hernias to run in families), and increases with age (for example, degeneration of the annulus fibrosusof the intervertebral disc), but it may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during pregnancy, losing weight in obese people, etc., or because of scars from previous surgery.

Many conditions chronically increase intra-abdominal pressure, (pregnancy, ascites, COPD, dyschezia, benign prostatic hypertrophy) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation.

Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, tight clothing and incorrect posture.[5] Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination, chronic lung disease, and also, fluid in the abdominal cavity.[6] Also, if muscles are weakened due to poor nutrition, smoking, and overexertion, hernias are more likely to occur. The physiological school of thought contends that in the case of inguinal hernia, the above mentioned are only an anatomical symptom of the underlying physiological cause. They contend that the risk of hernia is due to a physiological difference between patients who suffer hernia and those who do not, namely the presence of aponeurotic extensions from the transversus abdominis aponeurotic arch. [7]

[edit]Diagnosis

An incarcerated inguinal hernia as seen on CT

[edit]InguinalMain article: inguinal hernia

Diagram of an indirect, scrotal inguinal hernia (median view from the left).

By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. In some selected cases, they may require surgery.

[edit]FemoralMain article: femoral hernia

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.

[edit]UmbilicalMain article: umbilical hernia They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute.

[edit]IncisionalMain article: incisional hernia An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.

[edit]DiaphragmaticMain article: diaphragmatic hernia

Diagram of a hiatus hernia (coronal section, viewed from the front).

Higher in the abdomen, an (internal) "diaphragmatic hernia" results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.

A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional "defect", allowing part of the stomach to (periodically) "herniate" into the chest. Hiatus hernias may be either "sliding", in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding (also known as paraesophageal), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised. A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral (in Bochdalek's triangle, resulting in Bochdalek's hernia), or anteromedial-retrosternal (in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia, or Morgagni's hernia).

[edit]Other

hernias

Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with "visceral hernias", where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:

Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing almost immediately beneath the skin.

Epigastric hernia: a hernia through the linea alba above the umbilicus. Hiatal hernia: a hernia due to "short oesophagus" insufficient elongation stomach is displaced into the thorax

Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littr (16581726).

Lumbar hernia (Bleichner's Hernia): a hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains the following entities:

Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (16741750).

Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (18401913).

Maydl's hernia: two adjacent loops of small intestine are within a hernial sac with a tight neck. The intervening portion of bowel within the abdomen is deprived of its blood supply and eventually becomes necrotic.

Morgagni hernia: a type of hernia where abdominal contents pass into the thorax through a weakness in the diaphragm

Obturator hernia: hernia through obturator canal Pantaloon hernia/ Saddle Bag hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels

Paraesophageal hernia Paraumbilical hernia: a type of umbilical hernia occurring in adults Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.

Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.

Richter's hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (17421812).

Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.

Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause ofsciatic neuralgia.

Spigelian hernia, also known as spontaneous lateral ventral hernia Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial inguinal ring.

Velpeau hernia: a hernia in the groin in front of the femoral blood vessels Amyand's hernia: containing the appendix vermiformis within the hernia sac Busse's Hernia: a testicle within the hernia sac

[edit]CharacteristicsHernias can be classified according to their anatomical location: Examples include:

abdominal hernias diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach) pelvic hernias, for example, obturator hernia

anal hernias hernias of the nucleus pulposus of the intervertebral discs intracranial hernias Spigelian hernia [8]

Each of the above hernias may be characterized by several aspects:

congenital or acquired: congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistantiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in COPD) provoke the hernia.

complete or incomplete: for example, the stomach may partially or completely herniate into the chest. internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).

intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produce less obvious bulging, and may be less easily detected on clinical examination.

bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.

irreducible (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.

If irreducible, hernias can develop several complications (hence, they can be complicated or uncomplicated):

strangulation: pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and laternecrosis and gangrene, which may become fatal.

obstruction: for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation.

dysfunction: another complication arises when the herniated organ itself, or surrounding organs, start to malfunction (for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causingsciatic nerve pain, etc.).

[edit]TreatmentMain articles: Hernia repair and Inguinal hernia surgery

Hernia repair being performed aboard the amphibious assault ship USS Bataan

For a hernia like inguinal hernia, surgery is no longer recommended in most cases. However, it is in few cases advisable to repair some other kinds of hernias, in order to prevent complications such as organ dysfunction, gangrene and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired, but surgery often has complications, such as chronic groin pain. Time needed for recovery after treatment is greatly reduced if hernias are operated on laparoscopically, the minimally invasive operation most commonly used today.[9] Uncomplicated hernias are principally repaired by pushing back, or "reducing", the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy). If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary. Muscle reinforcement techniques often involve synthetic materials (a mesh prosthesis). The mesh is placed either over the defect (anterior repair) or under the defect (posterior repair). At times staples are used to keep the mesh in place. These mesh repair methods are often called "tension free" repairs because, unlike some suture methods (e.g. Shouldice), muscle is not pulled together under tension. However, this widely used terminology is misleading, as there also exists many tension-free suture methods that do not use mesh (e.g. Desarda, Guarnieri, Lipton-Estrin...). Evidence suggests that tension-free methods (with or without mesh) often have lower percentage of recurrences and the fastest recovery period compared to tension suture methods. However, among other possible complications, prosthetic mesh usage seems to have a higher incidence of chronic pain and, sometimes, infection.[10] One study attempted to identify the factors related to mesh infections and found that compromised immune systems (such as diabetes) was a factor.[11] Mesh has also become the subject of recalls and class action lawsuits.[12] Laparoscopic surgery is also referred to as "minimally invasive" surgery, which requires one or more small incisions for the camera and instruments to be inserted, as opposed to traditional "open" or "microscopic" surgery, which requires an incision large enough for the surgeon's hands to be inserted into the patient. The term microscopic surgery refers to the magnifying devices used during open surgery. Many patients are managed through day surgery centers, and are able to return to work within a week or two, while intensive activities are prohibited for a longer period. Patients who have their hernias repaired with mesh often recover in a number of days, though pain can last longer, and often forever. Surgical complications have been estimated to be more than 20 percent. They include chronical pain, surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence.

Due to surgical risks, mainly chronic pain risk, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.) are often used. In particular, we can mention uncomplicated incisional hernias that arise shortly after the operation (should only be operated after a few months), or inoperable patients. There have been known cases where hiatal and esophageal hernias have shown signs of improvements after the patient stopped producing stress on the affected area by fasting or parenteral nutrition. It is essential that the hernia not be further irritated by carrying out strenuous labour.

[edit]ComplicationsComplications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed. A surgically treated hernia can lead to complications, while an untreated hernia may be complicated by:

Inflammation Irreducibility Obstruction of any lumen, such as bowel obstruction in intestinal hernias Strangulation Hydrocele of the hernial sac Haemorrhage Autoimmune problems Incarceration, which is where it cannot be reduced, or pushed back into place,[13] at least not without very much external effort.[14] In intestinal hernias, this also substantially increases the risk of bowel obstruction and strangulation.

HerniaHernia - inguinal; Inguinal hernia; Direct and indirect hernia; Rupture; Strangulation; IncarcerationLast reviewed: November 21, 2011.

A hernia is a sac formed by the lining of the abdominal cavity (peritoneum). The sac comes through a hole or weak area in the fascia, the strong layer of the abdominal wall that surrounds the muscle. The types of hernias are based on where they occur: Femoral hernia appears as a bulge in the upper thigh, just below the groin. This type is more common in women than men.

Hiatal hernia occurs in the upper part of the stomach. In this hernia, part of the upper stomach pushes into the chest. Incisional hernia can occur through a scar if you have had abdominal surgery in the past. Inguinal hernia appears as a bulge in the groin. This type is more common in men than women. The bulge may go all the way down into the scrotum. Umbilical hernia appears as a bulge around the belly button. It occurs when the muscle around the navel doesn't close completely.

Causes, incidence, and risk factorsUsually, there is no obvious cause of a hernia. Sometimes hernias occur with heavy lifting, straining while using the toilet, or any activity that raises the pressure inside the abdomen. Hernias may be present at birth, but the bulge may not be noticeable until later in life. Some patients may have a family history of hernias. Hernias can be seen in infants and children. This can happen when there is weakness in the abdominal wall. About 5 out of 100 children have inguinal hernias (more boys than girls). Some children may not have symptoms until they are adults. Any activity or medical problem that increases pressure on the abdominal wall tissue and muscles may lead to a hernia, including: Chronic constipation, straining to have bowel movements Chronic cough Cystic fibrosis Enlarged prostate, straining to urinate Extra weight Fluid in the abdomen (ascites) Heavy lifting Peritoneal dialysis Poor nutrition Smoking Overexertion Undescended testicles

SymptomsMost often there are no symptoms. However, sometimes there may be discomfort or pain. The discomfort may be worse when you stand, strain, or lift heavy objects. In time, most people will complain about a growth that feels tender and is growing. Although a hernia may only cause mild discomfort, it may get bigger and strangulate. This means that the tissue is stuck inside the hole and its blood supply has been cut off. If this occurs, you will need urgent surgery.

Signs and testsA health care provider can confirm that you have a hernia during a physical exam. The growth may increase in size when you cough, bend, lift, or strain.

The hernia (bulge) may not be obvious in infants and children, except when the child is crying or coughing. In some cases, anultrasound may be needed to look for a hernia. If you may have a blockage in your bowel, you will need an x-ray of the abdomen. CT scans are also very useful for finding some hernias.

TreatmentSurgery is the only treatment that can permanently fix a hernia. Surgery may be more risky for patients with serious medical problems. If the hernia is small and not causing symptoms, your surgeon may just need to watch it to make sure it is not growing or causing problems. Surgery will usually be used for hernias that: Are getting larger Are painful Cannot be reduced without surgery May involve a trapped piece of bowel

Surgery secures the weakened abdominal wall tissue (fascia) and closes any holes. Today, most hernias are closed with cloth patches to plug up the holes. An umbilical hernia that does not heal on its own by the time your child is 5 years old may be repaired. Emergency surgery is sometimes needed. The sac containing the intestine or other tissue may become stuck in the hole in the abdominal wall. If it cannot be pushed back through, this can lead to a strangulated loop of intestine. If left untreated, this portion of the intestine dies because it loses its blood supply. Today, hernias can be fixed by open surgery or with the use of a laparoscope (camera). The advantages of using a camera include smaller surgical cuts, faster recovery, and less pain after the procedure. For information on hernia surgery, see also: Femoral hernia repair Inguinal hernia repair Umbilical hernia repair

Expectations (prognosis)The outcome for most hernias is usually good with treatment. It is rare for a hernia to come back (1 - 3%). Incisional hernias are more likely to return.

ComplicationsIn rare cases, inguinal hernia repair can damage structures involved in the function of a man's testicles. Another risk of hernia surgery is nerve damage, which can lead to numbness in the groin area. If a part of your ball was trapped or strangulated before surgery, it may lead to a bowel perforation or dead bowel.

Calling your health care providerCall your doctor right away if: You have a painful hernia and the contents cannot be pushed back into the abdomen using gentle pressure You develop nausea, vomiting, or a fever along with a painful hernia You have a hernia that becomes red, purple, dark, or discolored

Call your doctor if:

You have groin pain, swelling, or a bulge You have a bulge or swelling in the groin or belly button, or that is associated with a previous surgical cut.

Prevention Use proper lifting techniques. Lose weight if you are overweight. Relieve or avoid constipation by eating plenty of fiber, drinking lots of fluid, going to the bathroom as soon as you have the urge, and exercising regularly. Men should see their health care provider if they strain with urination. This may be a symptom of an enlarged prostate. Turnage RH, Richardson KA, Li BD, McDonald JC. Abdominal wall, umbilicus, peritoneum, mesenteries, omentum, and retroperitoneum. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier;2008:chap 43.Review Date: 11/21/2011. Reviewed by: Shabir Bhimji MD, PhD, Specializing in General Surgery, Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

References1.

A.D.A.M., Disclaimer Copyright 2012, A.D.A.M., Inc.

What works?Open surgery using mesh for groin hernia repairOpen surgery using mesh for groin hernia repair

This review examines the evidence from studies comparing different types of open surgery for people with groin hernia. We included only randomised studies comparing either 1) methods using synthetic mesh versus methods without mesh or 2) flat mesh methods versus plug and mesh methods. We divided mesh methods into flat mesh, plug and mesh or preperitoneal mesh and nonmesh methods into Shouldice or other nonmesh repair. See all (20)...

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Presentation Inguinal hernia repair - series

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