Monday, November 27, 2006

Types of Hernias

INCISIONAL or Ventral Hernias may occur in the area of any prior surgical incision, and can vary in size from very small, to very large and complex. They develop as the result of disruption along or adjacent to the area of abdominal wall suturing, often subsequent TENSION placed on the tissue or other inhibition to adequate healing (infection, poor nutrition, obesity, or metabolic diseases). These hernias present as a bulge or protrusion at or near the area of the prior incision scar. Virtually any prior abdominal operation can subsequently develop an Incisional Hernia at the scar area, including those from large abdominal procedures (intestinal surgery, vascular surgery), to small incisions (Appendectomy, or Laparoscopy). These hernias can occur at any incision, but tend to occur more commonly along a straight line from the breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence if repaired via a simple suture technique under tension and it is especially advised that these be repaired via a TENSION FREE repair method using mesh These hernias may develop soon after the original surgery, or at any time thereafter. Incisional Hernias gradually increase in sizeonce they develop and become progressively symptomatic. A bulge may not be evident at the hernia site initially, and pain may be the only early hernia symptom. These hernias develop in many cases as a result of too much tension placed when closing the abdominal incision, as stated above. Tension creates poor healing, swelling, wound separation and eventual Incisional Hernia formation.

INGUINAL or 'groin' hernias are by far the most common site for hernias to develop in adults, and are second only to Umbilical Hernias in infants and children. While a bit more common in men, they do occur in women as well. These hernias will develop as the result of a weakness, tear, gap or opening in the muscle wall of the lower abdomen or groin, in a region called the Myopectineal Orifice. As a result, the contents of the abdomen, such as intestine, may protrude through the opening creating a pain and a bulge. The pain and bulge may be constant, or intermittent in duration. Inguinal Hernias are located in the lower abdomen (right side, left side or both), just above the leg crease, near or adjacent to the pubic area. Inguinal Hernias can occur on both sides ('Bilateral') in about 8-10% of patients. INGUINAL HERNIAS may be CONGENITAL (present since birth) yet may become evident with pain or as a bulge at any time during life. They can also be ACQUIRED, the result of repetitive pressure, strain or injury to the muscles of the abdominal wall. This can be acute and occur abruptly, or develop over a long period of time. Congenital Hernias are usually called"INDIRECT" hernias, whereas Acquired hernias are referred to as "DIRECT" hernias, and are so called because of their anatomic direction of travel into the area known as the Inguinal Canal. These hernias frequently show up as a lump, swelling or "bulge" which gradually increases in size and become progressively more uncomfortable. Sometimes only a mild pain, ache or burning in the groin area may occur prior to the development of an obvious bulge. This pain, again often described as an ache or burning sensation, may not only be present in the inguinal area, but may also radiate into the hip region, back, leg or even down towards the genitalia region. Called "REFERRED PAIN", this discomfort can be quite bothersome and at times severe. In addition, in the absence of a bulge, the diagnosis of the cause of this pain may be delayed or mistakenly and incorrectly ascribed to other causes such as muscular groin strains, epididymitis, prostatitis or orchitis etc. These diagnoses may be maintained erroneously until the bulge develops, thereby heralding the real cause of the pain...a hernia. The discomfort with hernias usually is initiated by or increases in severity with activity, then becomes relieved, although not always completely, with rest.

UMBILICAL Hernias, and nearby hernias called "Paraumbilical Hernias" develop in and around the area of the umbilicus (belly button or navel). A Congenital (present since birth) weakness in the naval area exists. This was the area at which the vessels of the fetal and infant umbilical cord exited through the muscle of the abdominal wall. After birth, although the umbilical cord disappears (leaving just the dimpled belly-button scar), the weakness underneath may persist. Hernias can occur in this area of weakness at any time from birth through late adulthood. The signs and symptoms include pain at or near the navel area as well as the development of an associated bulge or navel deformity. This bulge pushes out upon the skin beneath or around the navel, distorting the normal contour and architecture in or around the navel (creating an 'OUTIE' instead of a normal 'INNIE').Although often appearing at or just after birth, these hernias can also occur at any time during later life. In INFANTS, these hernias may gradually close by age 3 or 4 and surgery can often be delayed until then, unless the hernias are causing problems or enlarging. This decision should be made after examination by a Pediatrician or skilled Surgeon. In ADULTS however, umbilical hernias cannot "heal", and do gradually increase in size and often become problematic. Incarceration or Strangulation may occur.

FEMORAL hernias, like Inguinal Hernias develop in the groin area, but occur about 5 times more commonly in females than they do in males. These hernias develop at or very near the leg crease itself, but in an area somewhat lower than the more common Inguinal Hernia. In fact, it is often difficult to differentiate clinically between these and Inguinal Hernias on examination by those not experienced in hernia evaluation. The defect itself occurs in an anatomic triangular-shaped "gap", located between the following 3 structures:
1. the inguinal ligament (a tendinous cord that creates the leg crease),
2. the lower side of the pubic bone, and
3. The femoral vein (the major vein of the leg).This gap is somewhat larger in famles due to the shape and angle of the pelvis, therefore making femoral hernias more common in females. NOTE: the congenital gaps and weak areas of the inguinal canal are somewhat larger in males, making Inguinal Hernias more common in men. The findings of an acutely painful lump or bulge on the leg crease, adjacent to the pubic region (especially in females) suggests a diagnosis of a Femoral Hernia. The femoral hernia defect is very close anatomically to that found in Inguinal Hernias. Examination by a Hernia Specialist is often needed to confirm this particular diagnosis. Often, a Femoral Hernia can occur simultaneously with an Inguinal Hernia, and be overlooked at surgery using 'conventional' repair techniques. FEMORAL hernias are much more common in females, but can occur in males as well. These hernias are more prone to develop INCARCERATION and/or STRANGULATION as an early complication than are Inguinal Hernias. Therefore, early repair once these hernias are diagnosed is very strongly advised before such complications occur.

SPIGELIAN hernias are ventral hernias occurring through the spigelian fascia along the Spieghel’s semilunar line and lie under the external oblique aponeurosis just outside the outer border of the Rectus or "six-pack" muscles. They commonly occur at a level referred as ‘spigelian hernia belt’ which is a transverse band between the level of umbilicus (navel) and the line joining both anterior superior iliac spines (Photo). Rarely they can occur above or below this level. Spigelian hernias are more common in women and have a peak occurrence around 50 years of age. The symptoms may vary from well-localised constant abdominal pain with or without palpable lump to vague inconstant ache. Clinically it is difficult to feel a definite bulge or a hernial defect as they are typically submuscular. Therefore, imaging studies are frequently necessary to make or confirm the diagnosis. They often develop complications like incarceration due to delay in diagnosis. Ultrasound or CT Scan are the goldstandard investigational imaging studies used for the diagnosis of Spigelian hernia in patients suspected of having these often occult hernias. Once diagnosed, surgical repair using an "open" Tension-Free technique, similar to that used for ventral/insisional hernias is extremely effective, well tolerated and is therefore highly recommended to prevent complications.

. DIASTSIS RECTI is not a hernia. Although often confused and at times mis-diagnosed as an epigastric hernia, which it is not, these abdominal wall protrusions occur due to a widened band of non-contractile fascia or tendon normally present between the rectus musles. There is no defect or true hernia present in a normal Diastaasis Recti. Since this fascia does not contract as does normal adjacent muscle, when individuals with DR strain (e.g., do a sit-up), an elongated bulge in the upper abdomen, tappered at each end will appear. This non-tender bulge extends from just below the breast bone, down to the navel. Unlike Epigastric Hernias, a Diastasis Recti is not localized along the linea alba line, but involves the entire space between the breast bone and the navel. They are likened to a narrow foorball in shape. There is no pain associated with this bulge and it is not apparent when standing or walking, but is evident only when straining (sit ups). This is a variant of normal anatomy and Diastasis Recti is not a hernia. Surgery is not indicated for this condition and we disuade ill-advised attempts at surgical correction.

EPIGASTRIC hernias develop in the mid upper abdomen, anywhere along a line drawn from the lower point of the breastbone straight down to the Umbilicus. They rarely deviate to any extent away from this straight-lined area, but can occur at any point along it. These not-too-uncommon hernias arise in a defect of the mid-line fascia or tendon that is present between the two rectus or six-pack muscles (called the linea alba). These hernias are generally small in size and localized, rarely larger thatn the size of a golf-ball. Because of the small defect, the contents are easily pinched and these hernias therefore can cause a great deal of pain. Epigastric Hernias are extremely well suited for repair using a Tension Free method. Epigastric Hernias should not be confused with a condition called DIASTASIS RECTI (DR)

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