Abdominal Hernias

Hernias are abnormal protrusion of organs from the wall which contains it. Abdominal hernias are usually inguinal hernias, femoral hernias, paraumbilical hernias or incisional hernias.
Inguinal & femoral hernias occur in the inguinal (groin) region and may occur on one side (unilateral) or both sides (bilateral).

A huge Right sided indirect inguinal hernia which has entered the scrotum

Inguinal hernias are the commonest type of abdominal hernias. The main causes are: chronic cough, straining due to constipation or urine obstruction, weakness of the abdominal muscles or congenital defects (patent processus vaginalis). Inguinal hernias can be further divided into direct or indirect inguinal hernias but the management for both is the same. Direct inguinal hernia occurs thru the weakness in the transversalis muscle of the abdominal wall while indirect inguinal hernia occurs thru a defect in the deep inguinal ring. 
Both present with a swelling in the groin which expands on standing or upon straining. Most of the time the swelling is reducible. Sometimes the hernia may be stuck (incarcerated) or obstructed or strangulated (blood supply compromised). The swelling in an indirect inguinal hernia may enter into the scrotum in men. 
The management for inguinal hernia include treatment of the causes of the hernia and the mainstay of treatment is surgery.
Surgery can be either open surgery or laparoscopic surgery. Open surgery is a simple procedure which can be done under local anaesthesia as a day case in uncomplicated hernias. The hernia is reduced, the hernial sac excised and a polypropylene mesh inserted above the muscles to strenghten it. This is known as the Lichtenstein repair. Complicated cases (incarcerated or obstructed or strangulated) would need general anaesthesia and hospital stay. At the moment laparoscopic is indicated for recurrent hernias or bilateral inguinal hernias. The scars are smaller, it is less painful and patients are discharged earlier. 

Femoral hernias occur thru the femoral canal in the groin. The presentation is the same as inguinal hernias with a groin swelling. However, it has a much higher risk of strangulation due to the narrow opening of the femoral canal. Femoral hernias are more common in women. Treatment is with surgical repair which can be done under local anaesthesia for uncomplicated cases. Some surgeons approximate the femoral canal with sutures and reinforce with a pectineal fascia flap while some use a polypropylene mesh plug repair. Laparoscpoic repair can also be done. 

Paraumbilical hernias occur commonly is people with ascites (excess fluid collection in the abdominal cavity), those who are obese and those who have abdominal wall weakness. The swelling is usually noted just around the umbilicus. This should not be confused with umbilical hernias which occur in babies due to congenital defects. Paraumbilical hernias are repaired surgically. The surgery entails reduction of the hernial contents, excision of the hernia sac and application of a big piece of polypropylene mesh to cover the defect. 

Incisiona hernias occur as a late complication of abdominal surgery. A history of infection of the abdominal wound, malnutrition, complicated bowel surgery and obesity are predisposing causes. The swelling occur just under the incision scar of the abdominal wound. Surgery includes revision of the previous scar, reduction of the hernial contents and excision of the hernial sac. A big polypropylene mesh is used to cover the defect. Laparoscopic repair is also feasible for both paraumbilical and incisional hernias.

The complications of hernial repair are: bruising, bleeding, infection of the wound, infection of the mesh, seroma collection and recurrence. 
Complications specific to inguinal hernia repair include: ischeamic orchitis, testicular atrophy, scrotal oedema, hydrocoele, chronic pain due to neuroma or osteitis and numbness around the groin area.