Close to two million hernia repairs are done in the US every year…in fact, it’s among the most common surgeries around the world. A hernia can appear in various places in the body causing pain and/or deformity. Bottom Line Personal asked Andrew Luhrs, MD, of the Comprehensive Hernia Center at Brown University, to explain this common disorder.
What Is a Hernia?
A hernia appears when tissue or an organ protrudes through a hole in the abdominal wall or surrounding structures. What we often think of as a “hernia” can be an inguinal hernia, which occurs in the groin area and is fairly common in men—but there are other types named for their location.
Ventral hernia develops anywhere on the abdominal wall…one subtype is an incisional hernia, because it happens at the site of an incision from a past surgery.
Diaphragmatic hernia is when tissue pushes through the diaphragm…one subtype is a hiatal hernia, occurring at the hiatus, a small opening in the diaphragm. In this situation, it’s possible for the stomach to push up through the hiatus and into the chest. A hiatal hernia can happen to anyone but is more common among women over 60. You may never know you have one unless your health-care team discovers it when checking for another condition, although in some cases it causes difficulty swallowing, severe acid reflux and pain.
Internal hernia involves a loop of intestine bulging through a space in the adjoining tissues. Technically any organ within the abdomen can herniate—colon, bladder, even an ovary.
Femoral hernia occurs when fatty tissue or part of the bowel pushes through into the groin at the top of the inner thigh around the femoral vessels that travel into the leg. It is rare in women and even more rare in men.
What Does a Hernia Feel Like?
If you have a hernia, you’re likely to notice an abnormal bulge somewhere on your abdomen or groin. It often looks like a golf ball sitting under your skin. You may or may not have pain when you touch the bulge. While the bulge might seem big, the hernia itself—the hole—can be quite small.
Not everyone experiences pain from a hernia, but if you do, it can feel sharp or like a pinching or pulling sensation. The pain can become quite severe if an organ or a piece of fat is poking through and blood flow is compromised or even cut off, a condition called strangulation—this is not only very painful but also an emergency situation.
Hiatal hernia symptoms are different. If it’s small, you may not even be aware you have it—some are discovered only when you have an imaging test for something else. But a large hiatal hernia can allow food and acid to back up into your esophagus, potentially causing heartburn, acid reflux and difficulty swallowing along with chest or abdominal pain.
What Causes a Hernia?
A surgical incision that didn’t heal properly is the cause of an incisional hernia. All other types of hernia stem from congenital weak points on the abdominal wall that get stretched out as you live your life doing routine things such as being pregnant and strenuous weightlifting.
People who have connective tissue disorders such as Ehlers-Danlos syndrome are more prone to developing hernias than the general population, but anyone who has had one hernia is at an increased risk for more.
Hernia Treatment
If you have a hernia bulge, particularly in the groin, and you don’t have any hernia symptoms, your doctor might just keep an eye on it over time. But strenuous activity that engages your core muscles, from sit-ups to golfing, is going to put more pressure on that hernia and likely will cause it to get bigger over time.
Surgery is advised if you’re having pain, even if the hernia is relatively small, particularly with ventral hernias because they can get large quickly. Pain is a strong predictor of a hernia developing into an emergency scenario.
With incisional hernias, the entire incision may be compromised so a repair is needed. A very large hiatal hernia might need surgery though smaller ones may not.
Advances in both open and minimally invasive techniques have made hernia surgery extremely effective and safe. Most hernia repairs incorporate mesh. In the past, mesh has had problems…it could erode or get infected and need to be removed. But with modern meshes, there is a very low risk of those adverse events. Mesh significantly reduces the recurrence rate. Example: Without mesh, in the groin, there is a one-in-five chance of the hernia returning within two years. With mesh, it drops to less than one in 100. Modern hernia surgeons rarely perform hernia repair without mesh because the outcomes are so poor.
There are two main categories of mesh—permanent and absorbable. Absorbable mesh is linked to a higher recurrence rate and more complications such as fluid collection around the mesh or infection. That is why absorbable mesh is used only in certain emergency settings.
Of the hundreds of meshes to choose from, lighter-weight macroporous meshes—thinner material with larger holes—generally are best. This type of mesh encourages the body to grow scar tissue between the weaving, increasing its strength, while at the same time allowing blood to get to the area and clear any bacteria.
In terms of the surgery itself, the addition of robotics has been a game-changer. Surgeons can operate faster with better visualization and more precise movements in the abdominal wall space. What used to be an open surgery with a five-to-seven-day hospital stay, an epidural for pain control and a tough recovery is now a minimally invasive outpatient procedure with minimal pain and an easier recovery—60% of my patients don’t need narcotics after abdominal wall surgery, even with very big hernias. Important: Depending on the hernia size and other factors, traditional open surgery may be needed.
Often, people can resume doing light everyday activities within a few days of the procedure, but you still need to avoid any strenuous activity and lifting anything heavier than 10 pounds for six weeks. There’s a very important reason for this: Until the mesh is established, heavy exertion can cause it to shift and the hernia can reopen. It’s extremely challenging to have to go back into that space a second time to correct this.
There really are no nonsurgical options to treat hernias. You can try to avoid activities that cause symptoms, but that’s certainly not an option for someone whose work or favorite activities involve heavy lifting or pulling on their core muscles. There are supportive devices called hernia bolsters or binders, but these are more of a bandage for people who aren’t candidates for surgery because of serious health conditions such as late-stage heart disease and metastatic cancer.
Finding the Right Hernia Surgeon
General surgeons are trained to do hernia repairs, but there’s a growing movement within the field of general surgery to identify specialists in hernia surgery. Not all hernias are created equal, and if yours is complex, you want a surgeon who devotes a significant proportion of his/her practice to treating and managing hernias. The Abdominal Core Health Quality Collaborative (achqc.org/patients) is a resource for finding a hernia center near you. You can also use the surgeon locator at the American Hernia Society (AmericanHerniaSociety.org/patients).
