London Hernia Clinic :: Your hernia and how to treat it

What is a hernia?
The abdominal wall is a sheet of muscle, when a weakness occurs the contents bulge through: this is a hernia. The most common symptoms are pain and swelling. If left untreated, hernias can develop into an emergency: a strangulated hernia which cannot be pushed back. For this reason consultant surgeon, Dugal Heath recommends most hernias should be repaired as a matter of routine.

There are a number of different types of hernias, to see where they are roll your mouse over the images below:

Epigastric hernia
These hernias come through a weakness in the join between the right and left rectus abdominis muscles (these muscles are described as the “six pack”). The right and left rectus abdominis muscles fuse together at the linea alba (literally a white line). In epigastric hernias a tiny piece of fat squeezes through a tiny hole in the linea alba. These hernias can be exquisitely tender but the hole is too small for a piece of bowel to come through and therefore they are not dangerous.

Treatment
Since the defects of epigastric hernias cannot be seen from inside the abdominal cavity, they need to be repaired in an open operation (rather than laparoscopically). Surgery involves repair of the area of weakness and return of the abdominal contents back into their normal position. If the hole in the muscle is less than 2cm we can stitch it, otherwise we usually use a mesh to reinforce the area. Since muscle is not cut nor sewn together under tension, this technique is called a tension free repair.

Often small to moderate Epigastric Hernia repair can be performed under local anaesthetic. You will be kept relaxed, comfortable and pain-free during the short procedure and patients with non-complex Epigastric Hernia repairs can be usually be safely discharged on the day of surgery.

Femoral hernia
This hernia occurs more commonly in women than men. On occasions, it can be difficult to tell between an inguinal and femoral hernia. But it is usually smaller than an inguinal hernia appearing just below where you would expect an inguinal hernia to be. It is also unusual for a femoral hernia to come and go in the same way an inguinal hernia does: it is always present.

Because the hole through which the hernia has to pass is so very tight, there is a significant chance that any bowel that passes into it will become incarcerated or strangulated. Therefore, early repair is strongly advised.

Treatment
Like inguinal hernias, Femoral hernias are excellently suited to repair using a tension free technique. A mesh, placed under local anaesthetic, avoids the need for cutting muscle or tendon, and eliminates high-tension stitching. This advanced technique is excellently suited for repair of Femoral Hernias and usually allows for patient discharge on the same day, within hours of surgery.

Incisional hernia
Whenever a cut is made into the abdominal cavity the resulting wound, even when fully healed, may not to be as strong as the original abdominal wall. If the muscle gives way then an incisional hernia develops. These hernias develop in many cases as a result of too much tension placed when closing the abdominal incision.

Incisional hernias can occur any time after surgery, most however become evident within 2 years or less of the initial operation. Incisional hernias gradually increase in size and become progressively more symptomatic. A bulge may not be evident at the hernia site initially and pain may be the only early symptom.

The length of the wound can vary hugely: some are big enough to allow a knuckle of bowel to enter, but tight enough to strangle its blood supply (see strangulated hernia). Immediate medical advice is strongly advised.

Treatment
Incisional hernias vary enormously in size and complication and a preliminary examination is required for evaluation and determination of the correct treatment. Effective repair would usually involve a tension free approach as these hernias develop in many cases as a result of too much tension placed when closing the original abdominal incision. If the wound over the incisional hernia is unsightly and needs to be removed then it is better to offer an open operation. For all other incisional hernias a laparoscopic repair should be considered.

Inguinal hernia
This is the most common type and the one we tend to think of when someone says they have a “rupture” or “hernia”. It occurs predominantly in men and may be confined to one side or be present on both (bilateral). Patients with hernias on both sides may have them appear together or there may be a gap of many years before the second one becomes apparent. Not uncommonly patients develop an inguinal hernia after heavy lifting during which they may experience a sharp pain in the groin and notice the appearance of a swelling.

Treatment
There are a number of possible ways of repairing the weakness although the most effective uses a mesh as it is tension free. The repair of an inguinal hernia can then be divided into open and laparoscopic procedures.

In the open operation a cut approximately 8 cm long is made in the groin.

The repair of an inguinal hernia using a laparoscopic approach is a relatively recent innovation. The operation is performed through three tiny cuts, the largest of which is only 1.5cm in size. The surgery is then performed via a laparoscope, which transmits a picture of the internal organs onto a monitor.

This is a very specialised form of surgery and Dugal Heath, our consultant surgeon at the London Hernia Clinic, is a highly experienced laparoscopic surgeon. Indeed, Dugal Heath trains laparoscopics at the Royal College of Surgeons.

Both open and laparoscopic repairs can normally be performed as outpatient operations (the patient goes home on the day of surgery). The major difference in the two operations is in the amount of postoperative pain.

Patients start walking and return to work far sooner following laparoscopic repair (as much as 6 to 18 days earlier). Wound numbness is also reduced. One study also showed an increased quality of life after laparoscopic hernia repairs.

Paraumbilical and Umbilical hernias
Umbilical hernias are congenital i.e. they are present from the time of birth. Most significant umbilical hernias are repaired in childhood. Whilst it is not uncommon for them to be noticed on abdominal examination, most are small, cause no problems and do not require repair.

Paraumbilical hernias appear above the “belly button” and like epigastric hernias come through the linea alba. They are usually larger than epigastric or umbilical hernias and require repair because of the risk of bowel contained within them becoming strangulated.

Treatment
More traditional techniques attempt to repair these hernias by simply closing the defect with stitches, placing the muscle tissue under significant tension. Umbilical and parumbilical hernias over 2cm in length should be repaired using a tension free technique.

This operation can either be performed as open or laporoscopic surgery. We do not remove or alter the navel and patients are often discharged on the same day as surgery.

Spigelian hernia
This is a rare type of hernia that appears on the edge of one of the rectus abdominis muscles (these muscles are described as the “six pack” which are readily seen in athletic individuals) 4 or 5 cm below the “belly button”.