Hernia

When the inguinal canal gives in

What is a hernia?

The inguinal canal runs obliquely through the layers of the anterior abdominal wall. Located in this canal are major nerves, blood, and lymph vessels. In men, it also encloses the spermatic cord, in women in women the ligament around the uterus.

The groin region is a natural weakness of the human body. Especially the inguinal canal area is often subjected to very high loads, mostly by increasing the pressure in the abdomen. A surrounding system of strong muscles, ligaments, and fascia (inelastic connective tissue to muscles and muscle groups) protects the sensitive structures in the inguinal canal largely from injuries such as bruises or sprains.

Nevertheless, the connective tissue of the abdominal wall in this area is very vulnerable. When the inguinal canal is ruptured (hernia), a gap(s) forms in that area. Through pressure in the abdomen, a hernia sac with parts of the intestines, bulges (herniates) out through this fascia gap of the posterior wall into the inguinal canal.

Operations in which an abdominal incision is made and the presence of connective tissue, additionally increase the risk of a hernia.

Usually a direct hernia arises in connection with an increase in pressure in the abdomen from coughing, vomiting, the heavy lifting, constipation, or pregnancy. Obesity also favors the disease.

Because in rare cases, tumors in the rectum can cause hernias, rectal examination are highly recommended for adults over 35. 

How can I tell I have a hernia? Where does it occur?

The main symptom of an inguinal hernia is a hernia tumor in the groin region. It is easily visible and palpable.  Pain when lifting or straining (e.g. during defecation) are common. In addition, there is usually only a slight, drawing pain in the groin area of the affected side, the increased pressure on the back can sometimes radiate into the scrotum or labia. Other physical activities are in many cases hardly restricted

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A herniation of the wedged in (incarceration) intestines is accompanied by severe pain, and often combined with nausea and vomiting. This is an absolute emergency requiring immediate action, e.g. medical treatment since otherwise there might be serious complications!

What do I do if I discover I have a hernia?

You should immediately seek medical attention to determine whether there is a need for treatment. It is very important to find out whether there is a direct or indirect inguinal hernia since this is especially important for surgical planning. Equally important is the description of the situation as a fracture reducible, irreducible, or incarcerated. Responsible fractures-i.e. fractures, which can be manually pushed back into the abdominal cavity - are most common and offer the least discomfort. Irreducible hernias, i.e. those in which the hernia contents cannot be pushed back, are, however, usually associated with adhesions and the risk of herniation (incarceration) is much greater. If such an entrapment occurs, it is an indication for immediate surgery.

Is the tendency for a hernia also genetic?

Connective tissues that are genetically weak, favor the formation of fractures.

Can fitness training cause a hernia?

Wrongly performed exercises can lead to a strong increase in pressure in the abdomen (lifting weights, etc.), and especially if the connective tissue is poor, it may come to a hernia. As a rule, an examination should be performed prior to serious bodybuilding exercises and the instructions and advice of the coach should be followed to avoid damaging pressure on the inguinal canal.

Does a hernia have something to do with obesity?

The excessive storage of fat from the connective tissue and the biasing of the tissue by the body weight can promote a hernia.

When will a hernia dangerous?

The most important and most dangerous complication of a hernia is strangulated hernia, called incarceration. If intestines or other abdominal organs e.g. pinched in the sac by sneezing or in the fracture gap, due to stasis of blood supply, swelling of the intestinal wall, and loss of blood, it can within a short time come to an intestinal obstruction, achalasia, or the dying of intestinal tissue (necrosis), to intestinal perforation, and eventually to an inflammatory irritation of the peritoneum (peritonitis).

One other problem is a possible fecal impaction fracture in the area in which, by the displacement of the transporting intestine loop an intestinal obstruction may be threatening. A  bowel obstruction (ileus) is the disruption of the intestinal tract, it can in addition to the incidents mentioned,  also be responsible for an inflammatory stimuli in the abdomen, other bowel obstructions in the area may be caused through various metabolic diseases, or surgery.

It must be differentiated between the bowel obstruction and an incarceration of the intestinal wall where although, the  passage is preserved, an inflammation is present. This condition is often caused by irritation of permanent fraction content, and feels like a hernia.

When is surgery necessary?

With intestinal obstruction or strangulation immediately. Remember, a fraction is almost exclusively eliminated by surgery. In rare cases, inguinal hernias suffered during childhood may heal spontaneously.

A strangulated hernia must be removed as soon as possible. If the incarceration is not removed within 4-6 hours after the onset, serious complications can be expected. It should first be attempted to reduce the bulging manually.  Here the physician will carefully push the underlying intestines (sac contents) into the abdominal cavity. If this fails, the fracture needs to be treated immediately by way of surgery.

What are the surgical procedures - hernia operation -  like today?

In most cases, an open surgical procedure is preferential, but in principle, almost all fractions can be operated with minimally invasive techniques. An open surgical procedure means a 7-10 cm long incision in contrast to three small incisions of about 1 cm in the minimally invasive technique. These incisions are the working channels for optics and instruments.

All hernia operations follow the same principles:

• exposure of the rupture (breaking gap)   and the hernia sac

• removal or retraction of breaking content

• removal of the hernia sac

• closure of the fracture gap and wound closure

To ensure that the breaking gap is closed and to prevent a recurrence of the hernia, different techniques have been developed. Among the most common is the stabilization of the abdominal wall Shouldice, the displacement of the spermatic cord in the male into the subcutaneous tissue according to Kirschner, or closure of the break by means of Cooper's Ligament according to the McVay method.

The starting method is the modified method of Bassini, usually combined with the fascia doubling described above. Here, the inguinal canal is reconstructed by reinforcing the posterior wall, doubled the muscle fascia of the innermost abdominal muscle and cross stitched the tendon plate of the inner oblique muscle to the inguinal ligament. A more recent method is the introduction of a plastic net on the closed hernia opening. This plastic mesh would scar with the surrounding tissue, thus improving the durability of the seams.

Common to all methods is the reinforcement of the posterior wall of the inguinal canal as a weak point in the abdominal wall. In particular, it distinguishes between the following methods:

• open suture method: inguinal canal incision and reinforcement of the posterior wall of the inguinal canal by suturing of muscle and tendon sheets, such as procedures of "Shouldice"

• open techniques with plastic mesh: inguinal canal incision and reinforcement of the posterior wall of the inguinal canal through a plastic net, such as in the method of "Lichtenstein"

• laparoscopic procedures with plastic mesh: Access to inguinal canal from the inside via a laparoscopy (keyhole surgery) and also reinforcing the posterior wall of the inguinal canal through a plastic net, such as so-called TAPP (transabdominal pre-peritoneal)

Is a hernia operation a routine?

Yes, however, inexperienced surgeons often can cause injury to vessels and nerves.

Why are there so many failures related to the surgical procedures reported?

The most feared complications of surgery are cutting through one of the two spermatic cords, damages of testicular vessels, the constriction of the great saphenous vein with the possible consequence of a blood clot (thrombosis), and a carryover of such a clot (embolism), violation of bowel or bladder, wound infections, or chronic pain due to knotted or pinched nerves.

The most important complication of a mesh insert is a foreign body reaction, which requires the removal of the mash and the adhesion of the spermatic cord because of the associated tissue irritation.

In general, however, surgery and subsequent healing takes place without complications. A recurrence of the hernia in the same place is relatively common with 5-10% of the cases. In constitutional, e.g.  congenital connective tissue, a hernia often occurs on the opposite side. To prevent recurrence, the patient should check for soft stool consistence for at least 3 months and avoid heavy lifting for at least 3-6 months.

How long is the hospital stay after surgery?

Outpatient or inpatient care for up to three days.

When can I lift something again?

Light loads after 4-6 weeks, after 3 months you can lift heavy loads again.

Can I prevent a hernia with abdominal training?

Preventive measures are very limited. It is advisable to avoid or reduce obesity, specific training of the abdominal muscles and the absence of the heavy lifting. To avoid strong pressing, it is important to pay attention to a soft consistency of bowel movements.

Through these sensible measures, the risk of a hernia can be reduced but especially people with congenital connective tissue are always at risk, even with good prophylaxis.