Hernia

Corpus Curare Spiritumque

When an organ or tissue abnormally protrudes out of the body cavity, it's called a hernia. The most common hernias, by far, develop in the adbdomen. In this case a weakeness in the abdonimal wall turns into a centralized hole, through which an organ or tissue will protrude. Hernia's are often times compared to the failure of the tire, where a split in the sidewall allows the inner tube to protrude through to the outside.

In that example the inner tube of the tire is like the organ that breaks outwards through the opening in the sidewall.

It is this pressure outwards, and the limit of restraint inwards that allows the bulge to develop.

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.

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.

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 the above mentioned are not the true causes of hernia, but are instead an (anatomical) symptom of the true (physiological) cause. Based on hundreds of observations during dissection, they have concluded 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 aponurotic arch.

When a hernia is not repaired, it may become incarcerated or strangulated. When strangulation occurs, there is a danger that part of the intestine be caught in the hernia cutting off blood supply to the tissue. Also, when a bowel obstruction occurs, it leads to severe pain, vomiting, nausea and inability to have a bowel movement or pass gas. Men are more prone to suffer inguinal hernias than women, and they risk a damage to their testicles if a hernia becomes strangulated.[8] Also, the pressure caused on the hernia's surrounding tissues may extend into the scrotum causing pain and swelling.

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:

1.) 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.

2.) 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

3.) Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littre (1658–1726).

4.) 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 (1674–1750).
- Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).

5.) 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.

6.) Obturator hernia: hernia through obturator canal

7.) Pantaloon hernia/ Saddle Bag hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels

8.) Paraesophageal hernia
9.) Paraumbilical hernia: a type of umbilical hernia occurring in adults

10.) 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.

11.) 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.
  
12.) 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 (1742–1812).
  
13.) 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.

14.) 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 of sciatic neuralgia.
 
15.) Spigelian hernia, also known as spontaneous lateral ventral hernia
  
16.) Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal.
 
17.) Velpeau hernia: a hernia in the groin in front of the femoral blood vessels
  
18.) Amyand's Hernia: containing the appendix vermiformis within the hernia sac
  
19.) Busse's Hernia: a testicle within the hernia sac


Hernias 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

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

a.) 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.
  
b.) complete or incomplete: for example, the stomach may partially or completely herniate into the chest.
  
c.) internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
  
d.) 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.
 
e.) bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
  
f.) 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):
a.) 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 later necrosis and gangrene, which may become fatal.
b.) 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.
c.) 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 causing sciatic nerve pain, etc.).

It is generally advisable to repair hernias quickly in order to prevent complications such as organ dysfunction, gangrene and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired, and recovery rarely requires long-term changes in lifestyle. 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.

Modern muscle reinforcement techniques involve synthetic materials (a mesh prosthesis) that avoid over-stretching of already weakened tissue (as in older, but still useful methods). The mesh is placed either over the defect (anterior repair) or more preferably 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 older traditional methods, muscle is not pulled together under tension.

Evidence-based testing initially suggested that these Tension Free methods have the lowest percentage of recurrences and the fastest recovery period compared to older suture repair methods. However, prosthetic mesh usage seems to have a high incidence of infection with mesh usage becoming a study topic for the National Institutes of Health.

One study attempted to identify the factors related to mesh infections and found that compromised immune systems (such as diabetes) was a factor. Mesh has also become the subject of recalls and class action lawsuits.

Increasingly, some repairs are performed through laparoscopes.

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. Surgical complications have been estimated to be up to 10 percent, but most of them can be easily addressed. They include surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence.

Generally, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.), is not advised. Exceptions are uncomplicated incisional hernias that arise shortly after the operation (should only be operated after a few months), or inoperable patients.

It is essential that the hernia not be further irritated by carrying out strenuous labour

Complications 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.

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, at least not without very much external effort. In intestinal hernias, this also substantially increases the risk of bowel obstruction and strangulation.

 

Although hernia's are often as a result of a hereditary trait there is several different things that you can do to prevent them from occuring. It's actually extremely easy to prevent hernia's and the two most common area's where people lose are in: Maintaining a healthy weight, and regularly excercising. Both of these things help to ensure that the body is not dealing with any extra strain that it cannot handle, and will help you in all area's to have a healthier and fuller life.