Understanding hernias...

HAVE you ever felt swelling and pain in your groin area, only for it to subside when you lie down? Have you felt a swelling in your groin, which gets worse when you cough or when you do some heavy lifting?

If you have experienced these symptoms, chances are, you may have a groin hernia, medically known as an inguinal hernia. Locally, people refer to it as angin pasang,uluran or burut. 

A hernia can either cause mild discomfort or debilitating pain to the patient. Most people assume that hernias are a male-only medical condition. It is true that some types of hernia are more common in males than females. But females are also susceptible to hernias.

While more common in men, they also occur in women, with a ratio of about 10 to one. An inguinal hernia develops as a result of a weakness or opening in the abdominal wall of the lower abdomen at the inguinal canal.

Small inguinal hernia on the both sides

Hernias can occur  almost anyone, and does not discriminate according to gender or age group. It can happen to both sexes; infant or elderly; healthy or unhealthy. Yes, even infants may not be spared from developing an hernia.

Statistically, it is estimated that one in 500 have some form of hernia. This is an alarmingly high figure. While a hernia does not result in fatality, timely diagnosis and treatment can prevent much pain and a reduced quality of life.

Understanding hernias

What is an inguinal hernia? Can such hernias be cured? What can be done to prevent them?

Put simply, an inguinal hernia is a gap, hole or defect in the abdominal wall. The gap can be caused by damage to the abdominal walls or a muscle tissue tear. When this occurs, the contents of the abdominal cavity, such as intestine, fat and tissues, can sometimes be pushed through this gap.

Anatomy of Inguinal Hernia

Physical exercise also tends to aggravate the hernia. Demanding physical activities – such as exercise, coughing, games and jogging – increase the pressure within the abdominal wall. Consequently, more abdominal contents tend to protrude through the gap. This results in enlargement of the size of the hole, which can cause great pain to the patient.

As the internal body parts protrude through the gap, a bulge or localised area of swelling will become evident beneath the skin of the abdominal wall. This causes much pain and discomfort. The pain usually worsens when one is lifting heavy objects, standing or undergoing stress.

At later stages, the hernia can lead to excruciating pain. In most patients, the hernia starts off as a small bump, which subsequently grows. The area will start to hurt and severe nausea may occur.

Huge bilateral inguinal hernia

If left untreated, hernias can lead to a major medical emergency. Almost all hernia patients risk having the blood supply of the trapped organ being cut off, due to “strangulation”. This happens during a hernia bulge in which the blood vessels are constricted due to pressure. This causes the blood supply to be cut off. When this occurs, an emergency surgery may be required as it is a life-threatening condition.

Death bowel due to the strangulated inguinal hernia which is a life-threatening condition

The good news is that inguinal hernias are treatable. The only treatment for an inguinal hernia is surgery. The aims of surgery are to close the abdominal wall defect, alleviate the symptom of pain/discomfort, prevent serious complication and reduce the risk of recurrence.

Locally, many patients seek massages as a form of treatment for hernias. Going for a massage will only help push the contents that protrude back into position. However, massages will not be able to provide a lasting solution as the gap is not closed.

In 1989, Dr Irving Lichtenstein put forth a bold new way to treat hernias – an open operation by using a polypropylene mesh. His idea was to place the mesh to cover the hernia gap. According to Dr Lichtenstein, patients who were treated using the polypropylene mesh experienced minimal complications after a follow-up period of between one and five years. This was remarkable, indeed.

Open inguinal hernia repair

The other alternative is laparoscopy surgery. It is a minimally invasive surgical procedure; some patients can usually go home a few hours after surgery. However, laparoscopic surgery can only be performed by trained and experienced surgeons.

Both the laparoscopic and Lichtenstein methods have their advantages and disadvantages. The laparoscopic method provides for a smaller incision compared to the Lichtenstein method. Laparoscopic method is a minimally invasive surgery with smaller skin incisions and allows us to repair the hernia defect from the inside of the abdomen cavity using a piece of mesh (10cm x 15cm). The abdominal pressure will hold the mesh in position, thus reducing the risk of recurrence.

Keyhole inguinal hernia repair

However, the laparoscopic procedure is not suitable for everyone, for instance, patients who cannot undergo general anaesthesia and those who have had previous abdominal surgery with bad adhesions.

Camera view of the keyhole inguinal hernia repair

In contrast, the Lichtenstein method can be performed without the use of general anaesthesia, thereby avoiding general anaesthesia-related complications. The Lichtenstein method can be performed under regional or even local anaesthesia (in suitable patients), which may save procedural costs.

Comparison of wound after open inguinal hernia repair and keyhole inguinal hernia repair

The pros and cons of both procedures should be discussed with the patients when deciding on the best approach. The individual skills of the surgeon and institutional facilities should also be taken into consideration.