What does hernia mean?

Herni oluşumu görseli

What does hernia mean?

A hernia is the displacement of any organ or tissue part into a potential cavity, forming a sac around it. Hernias occur as a result of a tear or loosening in the natural supporting tissue between the muscle and fat layers in the abdominal wall (Figure 1). Most hernias are located in the anterior abdominal wall, particularly in the groin area. Discomfort, pain, or swelling may occur in the hernia area after coughing, strenuous exercise, or straining. While they are often not life-threatening at the time of their initial formation, they require surgical treatment to prevent potential life-threatening complications, as they do not heal spontaneously.

Smoking, chronic obstructive pulmonary disease (COPD), pregnancy, various soft tissue disorders, previous surgeries, peritoneal dialysis, and pregnancy all increase the risk of developing a hernia. Studies have shown that it has a partially familial (genetic) component. Therefore, patients with a family history of hernias in first-degree relatives are considered to be at risk. Although it can occur in both sexes, hernias are more common in men. On average, one in five men worldwide may have a hernia. Childhood hernias are mostly present at birth and their frequency decreases with age.

The most important complaint in patients is swelling in the area of the hernia, especially after prolonged standing or physical activity. Pain or discomfort is also common. In advanced cases, impaired blood supply or obstruction to the organs within the hernia sac (especially the intestines) can lead to nausea, vomiting, inability to pass gas and stool, and significant abdominal swelling. These advanced cases can be life-threatening and require emergency surgery. Therefore, early diagnosis and treatment of hernias are crucial. Diagnosis can largely be made through physical examination, and can be supported by ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI). Radiological imaging methods provide an almost 100% accurate diagnosis.

Adult hernias do not resolve spontaneously. Surgical closure of the tissue opening, including the hernia sac, is necessary. The opening in the hernia area needs to be closed and supported with a mesh to prevent recurrence (Figure 2). Open or closed (laparoscopic) surgical methods are preferred depending on the location of the hernia. The surgery is performed under general or partial (spinal) anesthesia. Postoperative complications may include infection in the wound area, bodily reactions to the mesh, bleeding, and most importantly, recurrence of the hernia. With appropriate and effective surgical treatment, the recurrence of hernias is minimized today. Factors contributing to recurrence include patient-related factors such as continued physical activity, smoking, structural defects in wound healing, and hernias that have undergone surgery for a second or third recurrence. Factors related to surgical technique include inappropriate surgical methods, insufficient mesh or surgical materials, or errors in surgical technique.

Hernias are named according to their location. Hernias that occur in potentially weak areas of the anterior abdominal wall are called "abdominal wall hernias," those originating from the navel are called "umbilical hernias," those occurring at the site of previous abdominal surgery are called "incisional hernias," and those occurring in the groin area are called "inguinal hernias." Postoperative recovery varies depending on the cause, size, and location of the hernia. Patients with simple hernias may be discharged the day after surgery, while in more advanced cases, this period can extend to 3 or 4 days. The important factor here is that the hernia is not advanced and is treated early. Patients can return to their normal lives within the first week after discharge. It is recommended to avoid strenuous physical activity for one month following the first week's follow-up; otherwise, there are no restrictions on normal daily life. Patients typically reach their normal level of physical activity within the first 3 months.

GROIN HERNIAS:

There are two openings in the groin area, one on the right and one on the left, present from birth. In males, the blood vessels of the testicles and the sperm duct pass through these openings, while in females, the suspensory ligaments that hold the uterus in place pass through them; this is called the "inguinal canal." In healthy individuals, this canal is supported by surrounding muscle and fat tissue. Inguinal hernias occur when this canal ruptures due to strenuous physical activity, chronic cough, prolonged constipation, or congenital connective tissue disorders, causing organs from the abdominal cavity to shift into the inguinal canal. Right-sided inguinal hernias are more common than left-sided, and the presence of a unilateral inguinal hernia increases the risk of developing a hernia on the opposite side. The inguinal hernia sac may contain intra-abdominal fat tissue (omentum), abdominal wall fat tissue (preperitoneal fat), small intestine, or large intestine (Figure 3).

As with other types of hernias, the primary symptom is swelling, which becomes more pronounced when standing. Pain, a feeling of fullness, and numbness may also occur in the affected area. Initially, the swelling is noticeable when standing, but in later stages, it becomes visible even when lying down. This is because the organ or tissue that initially enters the hernia sac while standing tends to return to the abdominal cavity when lying down. Over time, the organ or tissue that enters the hernia sac extending into the inguinal canal remains permanently within the sac, regardless of position, and swelling and pain become more pronounced. At this stage, patients often report that they can manually reduce the swelling. Symptoms vary depending on the organ or tissue located within the hernia sac. Prolonged retention of the intestines within the hernia sac can result in constipation and intermittent groin and abdominal pain. Impaired blood supply to the organ or tissue within the sac can cause severe pain, general abdominal swelling, inability to pass gas or stool, nausea, and vomiting. Hernias in this condition are called strangulated (incised) hernias and require emergency surgery.

Inguinal hernias that extend into the inguinal canal are called "indirect" hernias, while those resulting from weakness in the supporting muscles of the inguinal floor are called "direct" hernias. Both types of inguinal hernias can occur at any stage of life and do not alter the treatment option. Diagnosis of inguinal hernias can be made through the patient's history and a detailed physical examination. The diagnosis is almost certain, especially when supported by ultrasonography. Additionally, computed tomography (CT) and magnetic resonance imaging (MRI) can support the diagnosis.

Following diagnosis, elective surgery is recommended for patients. This is because there is no drug treatment available. Due to the life-threatening risks in advanced disease, surgery is the most appropriate approach for the patient's health after diagnosis. In inguinal hernias, mesh repair is currently the globally accepted and most effective method with the lowest risk of recurrence. The hernia sac is removed, the enlarged opening in the groin area is anatomically closed, and then a mesh is applied to the closed area to prevent recurrence. The mesh is applied to the subcutaneous tissue over the muscle layers and is not visible from the outside. For this purpose, open or closed (laparoscopic) surgical methods are preferred in suitable patients. Studies have found no significant difference between open and closed surgical options in terms of disease recurrence. The closed (laparoscopic) method is a superior option due to less postoperative pain.

The average hospital stay after surgery is around 1-2 days. Patients can return to their daily lives after discharge. A follow-up appointment at the end of the first week will provide necessary advice. There are no restrictions other than avoiding strenuous physical activity for the first month. Depending on the mesh used, intermittent numbness and tingling sensations are expected during the first month. Although rare, permanent sensory loss, chronic pain, and tension in the surgical area may occur after surgery. In such cases, additional imaging techniques are used, and appropriate treatment methods are applied if necessary.

UMBILICAL HERNIAS:

The navel is a structure through which blood vessels pass between the mother and fetus during pregnancy, and it closes spontaneously after birth. In healthy individuals, it closes spontaneously within the first two years after birth due to the fusion of the abdominal wall muscles, remaining only as a depression throughout life. In cases where this opening does not close spontaneously, especially in childhood, umbilical hernias occur as a result of the small intestine, intra-abdominal fat tissue, or fat tissue from the anterior abdominal wall displacing under the skin through the navel (Figure 4). Although mostly seen in childhood, it can also occur in adulthood. In adulthood, umbilical hernias can develop in cases of increased intra-abdominal pressure (chronic cough, chronic constipation, intra-abdominal ascites), strenuous physical activity, and connective tissue diseases. Smoking and obesity are considered risk factors for the development of umbilical hernias.

Patients present with a visible swelling around the navel at the time of admission. Initially, it may be quite small and undetectable during a physical examination; at this stage, only fatty tissue from the anterior abdominal wall is herniating into the sac. Patients may experience significant pain upon palpation. In cases of chronic cough, constipation, or intra-abdominal ascites, the hernia sac continues to grow, and segments of intestine begin to enter it. At this stage, the patient notices the hernia sac externally, and the intestinal segments that have spontaneously entered the abdominal cavity can be felt during a physical examination. In advanced cases, the intestinal segments that have entered the hernia sac may not retract, and patients experience sudden onset of severe pain, nausea, vomiting, and inability to pass gas or stool. These patients require emergency surgery due to strangulated (incarcerated) hernias, which can be life-threatening. This condition is less common than inguinal hernias. Diagnosis can be made through physical examination and ultrasonography.

Treatment for umbilical hernias, as with inguinal hernias, is surgical intervention following diagnosis. For hernias smaller than 2 cm, removal of the hernia sac and closure of the abdominal wall using a simple method is usually sufficient. For hernias larger than 2 cm, a mesh patch is necessary to minimize the risk of recurrence. Simple umbilical hernias are operated on under partial (spinal) anesthesia, while advanced, large umbilical hernias are operated on under general anesthesia. Depending on the size of the hernia, open or closed (laparoscopic) surgical options may be chosen. The average hospital stay after surgery is one or two days, depending on the size of the hernia and the patient's general condition.

As with inguinal hernias, apart from avoiding excessive physical activity for the first month, no additional restrictions are applied, and patients can return to their daily lives within the first week. In advanced umbilical hernias, abdominal corsets may be recommended for the first three months after surgery to prevent recurrence and provide support to the anterior abdominal wall. The most significant risk after surgery for umbilical hernias is recurrence. In experienced centers, the likelihood of recurrence after surgery is quite low.

INCISION HERNIAS:

Incisional hernias are hernias that occur when abdominal muscles cut during abdominal surgery do not heal completely (Figure 5). They develop due to incomplete fusion of abdominal muscles as a result of blood accumulation (hematoma), infection, or fluid accumulation (seroma) at the wound site after intra-abdominal surgery. The presence of a disease that delays wound healing or having undergone emergency abdominal surgery are risk factors. The main symptom is swelling and herniation at the incision site after surgery. Incisional hernias can occur in 12-15% of patients who have undergone intra-abdominal surgery for any reason. Surgical treatment is recommended after diagnosis.

The traditional treatment method involves open surgery to free the hernia sac, close the abdominal muscles again, and support it with a mesh. In suitable patients, this procedure can also be successfully performed laparoscopically, again with a mesh. The fundamental principle in repairing incisional hernias is to choose a tension-free approach that is appropriate to the patient's anatomical structure. The risk of recurrence after hernia repair is higher in these patients compared to other types of hernias. Nevertheless, in experienced centers, the probability of recurrence is quite low.

CONCLUSION:

Hernias are common in the general population. Risk factors include male gender, family history, smoking, obesity, chronic diseases that increase intra-abdominal pressure, and a history of previous surgery. Initial symptoms may include swelling, discomfort, and pain in the hernia area. In advanced disease, impaired blood supply to the organ or tissue within the hernia sac can become life-threatening. This risk is higher in inguinal hernias and lower in umbilical hernias.

Regardless of the type of hernia, surgery is the only treatment option after diagnosis. The basic principle of surgical treatment is the complete removal of the hernia sac and the repair of the resulting opening in the tissue in a tension-free manner that is appropriate to the patient's anatomical structure. There is no significant difference in the risk of recurrence between open surgery and closed (laparoscopic) surgery. In closed (laparoscopic) surgery, patients experience less pain and a faster return to daily physical activity. Worldwide, closed surgery is currently preferred, as it is in our hospital, due to the less postoperative pain and the earlier return to daily life.

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