The Painful Truth About Hernias

The simplest way to think of a hernia is as a hole. There are several layers to the abdominal wall.  Basically you have skin, fatty tissue, and then fascia. This is comparable to a wall in you house, you have paint, dry wall then the framing. The strength to this wall would be the framing. The strength layer of the abdominal wall is the fascia. This is what holds us together.  A hernia is a hole in the fascia.

The hernia tends to develop in a weak are of the fascia. We have three naturally weak areas in the fascia, so hernias tend to develop primarily in these areas. This includes the umbilical area “belly button”, and inguinal region.  This can be on the right or left side, both low on the abdominal wall.

After major surgery of the abdomen, the fascia never heals as strong as it was before surgery.  Therefore, another common place to have a hernia is through a previous incision. There are a few other less common areas that a hernia could develop.

So if a hernia is basically a “hole”, why are hernias generally found as bulging?  When the hernia is bulging, this is because intra-peritoneal “stuff” is coming out through the hole. This can be fatty tissue, intestines, or occasionally other organs.  As long as the bulge goes away with gentle pressure or by lying down, there is no urgency to the repair.  However, if the bulging will not go away or is tender to pressure, then the situation is more urgent.

Generally speaking, all hernias should be repaired. It will not heal itself, or get better. There are three basic reasons. The first is that it tends to be uncomfortable. This can be a mild aching pain, towards the end of a hard day of work, or occasional burning shooting pain. A bit more unusual would be very severe intractable pain. Often, initially there may be very little or no pain. Over time the pain does not tend to improve. In fact, the tendency is for the pain to worsen over time.

The second reason it is recommended to repair the hernia is that over time, the “hole” or defect in the fascia tends to enlarge or stretch. Also the tissue around the hernia tends to weaken and become more attenuated.  The larger the hole and the weaker the surrounding tissue the more difficult the hernia is to repair.  Even when using mesh to close the hole, it has to be attached to the surrounding tissue, therefore the repair will only be as strong as the surrounding tissue. For this reason, with the larger hernia the chances of recurrence may be higher.

The most important reason, however, to repair the hernia in a timely fashion, is due to the risk of incarceration. This is when the bulge or knot is not able to be pushed back into the abdominal cavity. This becomes a more urgent situation.  If a loop of intestine prolapsing through the hernia, then timely surgical intervention is required.  If this is ignored, the tissue will start swelling with associated increased tenderness.  As this progresses, it will start to block the blood flow to the tissue.  The medical term for this is strangulation. This would be a true surgical emergency.  If left unattended, the gangrene would be the end results.  This would require life saving surgery, sometime even removing a portion of the intestines.  Obviously, a much more involved surgical procedure, with associated higher risk and prolonged recovery.

Unless there is extenuating circumstances, it should be repaired in a timely fashion. The complexity of the operation depends on the type, size, and location of the hernia.

by Jeff Ryan, MD, FACS of NW Alabama Surgical Center