Hernias happen. They happen to overweight, out-of-shape smokers, and they happen to highly trained athletes. They happen to persons who strain too much while lifting, and they happen to those who merely sit in a chair. While they are more common in men, they also occur frequently in pregnant women.

A hernia happens when a small portion of tissue from inside the abdomen pushes through a weak spot in the abdominal wall. In about 75 percent of cases, this occurs in the inguinal canal, the area where the abdomen meets the thigh. Men are 25 times more likely than women to develop an inguinal hernia, and the bulge sometimes protrudes into the scrotum.

Other abdominal hernias likely to affect women as well as men include femoral (also in the groin, nearer the thigh), umbilical (around the naval) and epigastric (above the stomach). It was once believed that hernias were caused by heavy lifting, straining, coughing or sneezing. Such activities may well bring on a hernia if a weakness already exists in the abdominal tissue, but the current belief is that the weakness is usually caused by a pre-existing impairment in collagen metabolism.

When the predisposition exists, smoking, infection and obesity–as well as straining–can increase the risk. But even fit, muscular individuals develop hernias. If you have a hernia, you may not know it until a doctor detects it on a routine examination. When you’re asked during a physical to turn your head and cough, the goal is to feel for a hernia. A hernia can be seen or felt as a tender bulge or round lump that becomes more prominent when you cough, strain or stand up. In the early stages, it’s possible to push the protruding tissue back in place temporarily. In medical terms, a bulge that can be pushed back in place is known as a “reducible” hernia. When the condition worsens, the lump can no longer be pushed back.

The hard part about dealing with a hernia is the uncertainty about what to do. A break in the abdominal wall will not get better on its own and is likely to get worse. Various trusses, belts and other devices to hold the hernia in have had mixed success. And a serious problem could occur if fatty tissue or an organ gets trapped inside the hernia (known as “incarceration”) and deprived of blood flow (“strangulation”). Because of the risk of gangrene and tissue death, strangulation is a life-threatening condition requiring emergency surgery.

Surgery Now or Later?

Sooner or later, most persons with a hernia have it surgically repaired. This involves re-positioning the internal tissue and repairing the defect in the abdominal wall. About a million procedures are performed each year; it’s one of the most common types of surgery and one of the safest. Complications include pain, discomfort and recurrence of the hernia.

Because of the risk of strangulation, many persons undergo surgery right away, even if the hernia is not causing pain or other symptoms. Some studies suggest, however, that immediate action may not always be necessary.

Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.

Infants and children are more likely than adults to have tissue become trapped (or incarcerated) in a hernia; as a result, they may be advised to have surgery sooner rather than later. Adults choosing to delay surgery might need to wear a truss, belt or other device in order to handle every day activities without pain or discomfort. It’s important, however, to be instructed in the use of a truss since an improperly worn device could actually increase the risk of incarceration.

Surgery Options

While hernia surgery is usually worry free, recurrence has been a problem. The traditional repair involved suturing together the ends of the defect in the abdominal wall. With the resulting increased tension on the abdominal muscle tissue, another tear is eventually likely to happen.

New surgical approaches aim to reduce tension by stitching a mesh patch made of synthetic material into the defect.

Recurrence rates over a 10-year period are around 30 percent for patches compared to about 60 percent for traditional suture repairs.

To enhance the strength of the repair, many doctors today place the patch under the abdominal muscle as deeply as possible. With this approach, pressure from inside the abdomen may even strengthen the repair by pressing it firmly against the abdominal muscles. Some studies have shown recurrence rates of less than five percent for this method.

Another new approach is laparoscopic surgery–using three smaller incisions rather than one large one and a thin scope to view and repair the hernia. The major advantage with this procedure is a quicker recovery and return to work. Operative time and costs are higher with laparoscopic procedures and complications–although rare–are more likely to be serious. As far as the patient is concerned, the best procedure is usually the one with which the surgeon has had the most experience.

If you have a small hernia that doesn’t cause symptoms, there’s no need to let it worry you. When it becomes large enough to cause you pain, you should have no trouble finding an experienced surgical team.

Michelle Herbert Thomas, PharmD, CDE

Clinical Director

Richmond Apothecaries