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Laparoscopic Hernia

What is a Hernia?


A hernia is a protrusion of an organ or tissue through an abnormal opening in the body. Most hernias occur when a piece of intestine slips through a weakness in the abdominal wall creating a bulge you can see and feel. Hernias can develop around the naval, in the groin, or any place where you may have had a surgical incision. Some hernias are present at birth. Others develop slowly over a period of months or years.


There are many different types of hernias. The most familiar type are those that occur in the abdomen, in which part of the intestines protrude through the abdominal wall. This may occur in different areas and, depending on the location, the hernia is given a different name.


An inguinal hernia appears as a bulge in the groin and may come and go depending on the position of the person or their level of physical activity. It can occur with or without pain . In men, the protrusion may descend into the scrotum. Inguinal hernias account for 80% of all hernias and are more common in men.

Femoral hernias are similar to inguinal hernias but appear as a bulge slightly lower. They are more common in women due to the strain of pregnancy .

A ventral hernia is also called an incisional hernia because it generally occurs as a bulge in the abdomen at the site of an old surgical scar. It is caused by thinning or stretching of the scar tissue, and occurs more frequently in people who are obese or pregnant.


An umbilical hernia appears as a soft bulge at the navel (umbilicus). It is caused by a weakening of the area or an imperfect closure of the area in infants. This type of hernia is more common in women due to pregnancy, and in Chinese and black infants. Some umbilical hernias in infants disappear without treatment within the first year.


A hiatal or diaphragmatic hernia is different from abdominal hernias in that it is not visible on the outside of the body. With a hiatal hernia, the stomach bulges upward through the muscle that separates the chest from the abdomen (the diaphragm). This type of hernia occurs more often in women than in men, and it is treated differently from other types of hernias.


Who gets hernias?


According to the National Center for Health Statistics, approximately five million Americans have hernias. Hernias in the groin area (inguinal hernias) are most common in men, primarily because of the unsupported space left in the groin after the testicles descend into the scrotum. Hernias in the femoral area, at the top of the thigh, occur most often in women. They commonly result from pregnancy and childbirth.


Will the hernia go away?


No. An untreated hernia will not get better or go away on its own.




Once an abdominal hernia occurs it tends to increase in size. Some patients with abdominal hernias wait and watch for a while prior to choosing surgery. In these cases, they must avoid strenuous physical activity such as heavy lifting or straining with constipation. They may also wear a truss, which is a support worn like a belt to keep a small hernia from protruding. People can tell if their hernia is getting worse if they develop severe constant pain, nausea and vomiting , or if the bulge does not return to normal when lying down or when they try to gently push it back in place. In these cases they should consult with their doctor immediately. But, ultimately, surgery is the treatment in almost all cases.

Femoral hernia

Femoral hernia

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There are risks to not repairing a hernia surgically. Left untreated, a hernia may become incarcerated, which means it can no longer be reduced or pushed back into place. With an incarcerated hernia the intestines become trapped outside the abdomen. This could lead to a blockage in the intestine. If it is severe enough it may cut off the blood supply to the intestine and part of the intestine might actually die.


When the blood supply is cut off, the hernia is termed "strangulated." Because of the risk of tissue death (necrosis) and gangrene , and because the hernia can block food from moving through the bowel, a strangulated hernia is a medical emergency requiring immediate surgery. Repairing a hernia before it becomes incarcerated or strangulated is much safer than waiting until complications develop.


Surgical repair of a hernia is called a herniorrhaphy. The surgeon will push the bulging part of the intestine back into place and sew the overlying muscle back together. When the muscle is not strong enough, the surgeon may reinforce it with a synthetic mesh.


Surgery can be done on an outpatient basis. It usually takes 30 minutes in children and 60 minutes in adults. It can be done under either local or general anesthesia and is frequently done with a laparoscope. In this type of surgery, a tube that allows visualization of the abdominal cavity is inserted through a small puncture wound. Several small punctures are made to allow surgical instruments to be inserted. This type of surgery avoids a larger incision.




Abdominal hernias generally do not recur in children but can recur in up to 10% of adult patients. Surgery is considered the only cure, and the prognosis is excellent if the hernia is corrected before it becomes strangulated.


Hiatal hernias are treated successfully with medication and diet modifications 85% of the time. The prognosis remains excellent even if surgery is required in adults who are in otherwise good health.


Inguinal Hernia


An inguinal hernia occurs in the groin. The groin is the area between the abdomen and thigh. It is called "inguinal" because the intestines push through a weak spot in the inguinal canal. The inguinal canal is a triangle-shaped opening between layers of abdominal muscle near the groin. Some of the causes of inguinal hernias are: obesity , pregnancy , heavy lifting, and straining to pass stool can cause the intestine to push against the inguinal canal.


There are two types of inguinal hernias: direct and indirect.

  • A direct inguinal hernia occurs when a weak spot develops in the lower abdominal muscles from the normal stresses of living and aging. Tissues push through this weak spot as pressure within the abdomen increases.
  • An indirect inguinal hernia is the most common type of inguinal hernia. Normally, an opening in the inguinal canal closes shortly before birth. An indirect hernia develops when this opening does not close, causing abdominal tissues to push through the inguinal canal. Symptoms may be present at birth or may develop later in life. In men, the hernia may push into the scrotum . In women, it may push into the large fold of genital skin (labia).

Indirect hernias are more common in men because the testicles (when they descend) and their blood vessels pass through the inguinal canal, making the opening from the abdomen less likely to close completely. Women are more likely to have an indirect inguinal hernia than a direct hernia.


What causes an inguinal hernia?


An indirect inguinal hernia is caused by an opening that does not close as it should before birth. The cause of a direct inguinal hernia often is unknown. It's believed to be caused by the wear and tear of daily life and aging.


However, lifting a heavy object or doing other activities that put pressure on the abdominal muscles, such as frequent coughing or straining when urinating or having a bowel movement, are thought to cause a hernia. Excessive weight gain, pregnancy, and constipation also are possible causes.


Older adults and people who are overweight are at a higher risk for direct inguinal hernias than are other people because of increased stress on the lower abdominal muscles.


What are the symptoms of an inguinal hernia?


The main sign of an inguinal hernia is a tender bulge in the groin or scrotum. The bulge may appear gradually over a period of several weeks, or it may form suddenly after you have been lifting heavy weights or coughing, bending, straining, or laughing.


In some cases, you may feel groin pain or other discomfort, especially when bending or lifting. The discomfort may be felt in the scrotum. Some hernias cause a bulge but no pain.


Other possible symptoms include heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. Sometimes the discomfort is relieved only by lying down.


You may have nausea and vomiting if part of the intestine bulges outside the abdomen and becomes trapped, or incarcerated , in the hernia.


How is an inguinal hernia diagnosed?


The diagnosis of inguinal hernia is usually based on a medical history and a physical examination. A health professional will ask about your symptoms and will examine your groin area for a bulge. You may be examined while standing and coughing or straining (as if trying to have a bowel movement).


Imaging tests such as abdominal ultrasound and computed tomography (CT) scan also may be done; a CT scan can confirm the type of hernia.


How is an inguinal hernia treated?


Surgery is necessary to repair an inguinal hernia. Two surgical approaches are available.

  • Open surgery: The surgeon repairs the hernia through an incision in the groin. A piece of mesh is sewn over the weakened area of the abdominal wall to reduce the risk of the hernia recurring. This is a common method of repairing a hernia. In some cases, the tissue of the abdominal wall can be repaired without using a mesh.
  • Laparoscopic surgery: The surgeon inserts a thin, lighted scope into a small incision in the abdomen; instruments to repair the hernia are inserted into another small incision. Mesh also is used in this surgery to reinforce the abdominal wall. Laparoscopic surgery is relatively new. Studies show that people have less pain after this type of surgery and return to work and other activities more quickly than after open repair; however, this surgery is more expensive than open repair.

The risk of a hernia coming back varies for each surgery. Recurrence rates for open surgery range from 1% to 7% for an indirect hernia and from 4% to 10% for a direct hernia; for laparoscopic surgery, the risk of recurrence is up to 6%.


Femoral Hernia


A femoral hernia is a loop of intestine, or another part of the abdominal contents, that has been forced out of the abdomen through a channel called the "femoral canal" - a tube-shaped passage at the top of the front of the thigh. The loop is usually only the size of a grape.

A femoral hernia can cause serious medical problems if left untreated, even if there are no troublesome symptoms to begin with. Treatment is by an operation to return the herniated intestine to its proper place and close the weakness in the abdominal wall.


Femoral hernia

Femoral hernia

Incisional Hernia


Incisional hernias are caused by thinning or stretching of scar tissue that forms after surgery. This weakened scar tissue then creates a weakness in the abdominal wall. Excessive weight gain, physical activity that places pressure on the abdomen, pregnancy, straining during bowel movements because of constipation, severe vomiting, or chronic and intense coughing causes the scar tissue to thin or stretch. Because the abdominal wall is weak, the hernia occurs during abdominal strain.


What are the symptoms?


An incisional hernia causes a bulge in the abdominal area. This type of hernia is often painless, but may be tender and can cause discomfort during any type of physical strain, such as lifting or coughing. The bulge may disappear when the patient is lying down, and be more visible when standing up. A hernia can often be pushed gently back into place. This is called a reducible hernia. When a hernia cannot be pushed back into place, it means a piece of the organ has become trapped, or incarcerated. Symptoms include pain, nausea, vomiting, inability to have a bowel movement, and a bulge that remains even when lying down. When a portion of an organ is incarcerated, its blood supply can be cut off, which means the organ's tissue will die. This condition is called a strangulated hernia. Incisional hernias can increase in size with time.


How is it diagnosed?


To diagnose an incisional hernia, a doctor must perform a physical examination. Your doctor will look for a bulge in the abdominal area and may ask you to cough as he puts light pressure on the area. Coughing causes the hernia to bulge out further.


What is the treatment?


Patients with incisional hernias can wear a special type of belt, called a truss, to support the hernia and keep it from bulging out. They should also avoid any activities that cause abdominal strain. However, most patients elect surgery to repair incisional hernias and avoid the possibility of a strangulated hernia. The procedure to repair a hernia involves pushing the piece of the organ back into place and repairing the abdominal wall so the organ cannot push through again. Hernia surgery, called herniorrhaphy, used to involve a large incision and a long recovery period. However, many hernia repairs can now be performed through laparoscopic surgery.


The surgeon uses a special viewing instrument called a laparoscope, inserted through a small incision in the abdomen. The laparoscope is like a tiny video camera that gives the surgeon a clear view of the abdominal area. Other small incisions are made to insert the surgical instruments used to push the organ into place and repair the abdominal wall. The surgeon may use a procedure called hernioplasty to reinforce the entire weakened area with synthetic material, like a tire patch. Laparoscopic hernia surgery can be performed on an outpatient basis. Incarcerated and strangulated hernias require emergency surgery and hospitalization. Laparoscopic surgery may not be recommended for very large hernias.


Umbilical Hernia


Umbilical hernias are protrusions of bowel related to the belly button (umbilicus). Congenital umbilical hernias form through the gap where the umbilical cord vessels enter the abdomen during fetal life. They are usually present at birth but may not be noticed until the umbilical cord separates and heals. They rarely cause symptoms and 90 per cent disappear during the first few years of life as umbilical scar tissue contracts and thickens. Repair is not usually attempted until the child is at least two years old.


Acquired umbilical hernias are common in the obese. Those hernias that protrude through umbilical scar tissue are usually caused by conditions that raise pressure inside the abdomen and distend it. This causes the bellybutton to bulge outwards. Treatment is not necessary unless the hernia is large or giving rise to unpleasant or painful symptoms.


Acquired para-umbilical hernias protrude through a gap to one side of the umbilical scar and convert the belly button into a crescent-shaped slit. These do need repair as they cause pain and swelling around the umbilicus and can strangulate.


A hiatal hernia is treated differently. Medical treatment is preferred. Treatments include:


Treatment of hiatus hernias involves losing weight, which often improves symptoms, eating little and often (rather than large meals), avoiding bending or lying down after meals, giving up smoking and raising the head of the bed slightly to prevent reflux during sleep. Some patients find they can only sleep at night if propped fully upright.


There are also several types of medications that help to manage the symptoms of a hiatal hernia. Antacids are used to neutralize gastric acid and decrease heartburn. Drugs that reduce the amount of acid produced in the stomach (H2 blockers) are also used. This class of drugs includes famotidine (sold under the name Pepcid), cimetidine (Tagamet), and ranitidine (Zantac). Omeprazole (Prilosec) is not an H2 blocker, but is another drug that suppresses gastric acid secretion and is used for hiatal hernias. Another option may be metoclopramide (Reglan), a drug that increases the tone of the muscle around the esophagus and causes the stomach to empty more quickly if symptoms are severe; surgery to repair the hiatus hernia is undertaken. This is a major operation in which the protruding stomach is brought back down into the abdomen and tethered into place.


Diagnosis of Hiatus Hernia


Hiatus hernias are investigated by passing a flexible telescope down the throat while the patient is under light sedation. This procedure is called oesophagoscopy or gastroscopy. Occasion-ally, a barium X-ray is also used to see whether there is reflux of stomach contents into the esophagus.


Alternative treatment


There are alternative therapies for hiatal hernia. Visceral manipulation, done by a trained therapist, can help replace the stomach to its proper positioning. Other options in addition to H2 blockers are available to help regulate stomach acid production and balance. One of them, deglycyrrhizinated licorice (DGL), helps balance stomach acid by improving the protective substances that line the stomach and intestines and by improving blood supply to these tissues. DGL does not interrupt the normal function of stomach acid.


As with traditional therapy, dietary modifications are

important. Small, frequent meals will keep pressure down on the esophageal sphincter. Also, raising the head of the bed several inches with blocks or books can help with both the quality and quantity of sleep.



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