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Hernia

When an organ abnormally protrudes or squeezes through a weakness in the wall of the cavity in which it resides, is a condition termed as a hernia. Hernias mostly involve the abdomen and the groin. They can be lethal when incarcerated or strangulated.

Causes

The most common cause of a hernia is an increase in intra-abdominal pressure.

Etiologies are commonly associated with:

  • Obesity

  • Coughing

  • Lifting of heavy weights

  • Straining during defecation or urination

  • Peritoneal dialysis

  • Ascites

  • Genetics or family history of a hernia

  • COPD or chronic obstructive pulmonary disorder

  • Ventriculoperitoneal shunt

  • Congenital manifestations

Types of Hernias

There are several types of Hernias:

  • Inguinal hernia – the inguinal floor is reinforced with the flattening of the transversus abdominis aponeurosis leading to the buttressing effect. Repetitive stress, elevated intra-abdominal pressure, neonatal intraventricular hemorrhage, undescended testes, etc. are some of the causes of an inguinal hernia.

  • Incisional hernia – the fascial closure of a surgical intervention is compromised leading to the iatrogenic condition.

  • Umbilical hernia – congenital in origin and occurring through the umbilical fibromuscular ring, the condition obliterates by 2 yrs.

  • Richter hernia – herniation of the anti-mesenteric border (a circumferential portion) of the bowel through the fascial defect causes Richter hernia.

  • Spigelian hernia – occurs when there is a defect in the Spigelian fascia (interstitial and subcutaneous).

  • Obturator hernia – passing through the obturator foramen along the obturator nerves and muscles, it mostly occurs in females and the elderly due to the enlarged diameter of the canal.

  • Epigastric hernia – developing in the epigastrium, they trap tissues and fat in the hernial cavity.

  • Internal supravesical hernia – a rare occurrence of intestinal obstruction, they are of two types internal and external.

  • Congenital abdominal wall defects develop due to non-closure of the anterior wall of the umbilical cord.

Diagnosis

  • The physical examination requires patient to be in standing and in a supine position with or in the absence of a Valsalva maneuver. Attempts are made to identify the fascial defect and the hernial sac. Strangulated hernias are recognized with fever, toxic appearance, and excruciating pain in the area.

  • Urinalysis – detects genitourinary causes of pain in the groin

  • CBC – for leukocytosis

  • Culture of nodal tissue – for atypical tuberculosis

  • BUN, creatinine and electrolyte levels to assess hydration in the patient

  • Lactate levels – elevated due to hypoperfusion

  • Tangential plain radiographs show air in the intestine

  • CT scan of the pelvis and abdomen with IV contrast for hernias that are difficult to locate

  • Ultrasound for scrotal and lower inguinal masses

Treatment and medication

A strangulated hernia requires broad-spectrum antibiotics such as Cefoxitin and Ampicillin to address ischemic bowel. NSAIDs like Advil or Ibuprofen decrease pain and prostaglandin synthesis.

Strangulated and incarcerated hernias cannot be ignored and require emergency surgical intervention. Dr. Deepak offers both laparoscopic and open surgeries for all these hernias.

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