Run-down on groin hernias
A hernia, often wrongly called a “rupture,” is a bulge of tissue that occurs when a soft part of the body herniates or bulges through a weak spot in the retaining layer of muscle or lining tissue (fascia), penetrating nearby compartments. Hernias most often occur in the abdominal area (from chest to the groin). There are various types of hernia including umbilical hernias, a protruding navel (bellybutton), especially common in malnourished or premature babies; incisional hernias, at the scar-line of a previous operation; paraesophageal hernias – where part of the stomach slips into the chest cavity and may threaten life (fortunately rare); inguinal (upper groin) hernias – mostly in men, usually requiring surgical repair; and hiatus hernia more frequent in women, where part of the stomach protrudes into the chest through the diaphragm in the area where the esophagus (food tube) passes through, causing heartburn. Hiatus and groin (inguinal) hernias are the two most common types. Since Health News discussed hiatus hernia and heartburn in the February 1988 issue, we will concentrate on groin hernias here.
Understanding groin hernias
Inguinal or upper groin hernias are very common, affecting three to eight per cent of the population, about 10 times more men than women. Groin hernias occur when some abdominal contents, usually some fat or part of the intestine (a piece of bowel), protrude into the groin area through a tear or weakness in the abdominal wall, producing a groin bulge. Groin hernias include direct and indirect forms – according to the weakened area of the abdominal wall through which the bulge occurs – and the uncommon but risky femoral hernias, in the lower groin. Femoral hernias are a possibly life-threatening condition in which the blood supply to the bowel is cut off, requiring immediate medical care.
Groin hernias can occur at all ages, often after age 50, on one side of the groin or both. They are also frequent in infancy as a result of a congenital fascial weakness in the abdominal wall that arises during embryonic development. Groin hernias occur in three to five per cent of full-term infants and up to 30 per cent of premature babies. However, the flaw may not show up until later in childhood or during adulthood. Very often an incipient groin hernia does not reveal itself until, with aging and years of strain, the abdominal wall becomes weaker. Groin hernias can arise from chronic straining at the bowels (during defecation), from straining at urination or prostate troubles, or from constant coughing or heavy lifting. Although not a cause in itself, physical exertion such as lifting, can bring it on by suddenly causing the weakened abdominal lining to give way. Smokers with a chronic cough often get groin hernias.
While not generally life-threatening, groin hernias can be dangerous because of “incarceration” or “strangulation,” if a piece of protruding intestine (or bowel) is caught and “strangled,” cutting off the blood supply. The result can be putrefaction in the “dead” piece of bowel, leading to infection, inflammation, and life-threatening peritonitis (widespread abdominal infection).
Symptoms of groin hernias
Groin hernias can produce a swelling or small, egg-like lump that often does not hurt at first, tends to vanish on lying down but becomes prominent with certain activities such as coughing. Children with inguinal hernias may have fever and vomiting. Adults with the condition may experience constant or intermittent groin pain on exertion, or no symptoms at all. Wearing a truss for an inguinal hernia rarely improves symptoms.
While not usually a danger, if the hernia or protruding bulge in the groin is strangulated – squeezed at the neck with the blood circulation cut off – infection may set in. If the incarcerated (squeezed) organ is a piece of bowel, it will die and can perforate, leading to life-threatening infection. The symptoms of a strangulated hernia can include pain, swelling, discoloured, bluish or red skin, vomiting and an inability to urinate – often requiring emergency surgical measures.
Treatment of groin hernias
The usual treatment for groin hernias is surgical repair, or hernioplasty, to bundle the protruding mass back where it belongs and reinforce the weakened area. Groin hernia repair surgery is almost as common as gallbladder surgery and in Ontario alone, there are about 18,000 groin hernia repair operations each year.
Groin hernia repairs are often simple operations, sometimes done under local anaesthetic, most being variations of a technique developed by Dr. Bassini in the 1880s to tighten the weak tissues and close the defect through which the abdominal contents protrude. However, opinions differ as to the best way to tackle hernia repairs and the optimal post-surgical recovery period, owing to the technical difficulty of the procedure, short- and long-term complications, duration of postoperative disability and high recurrence rates. Unfortunately, about 10 percent of those who have had a hernia repair require another at some later date.
Some surgeons favour a swift return to activity; others restrict heavy exercise for many weeks after the operation. There can be considerable post-operative discomfort. Complications can occur immediately after surgery or up to a few months later, including neuralgia and urinary problems (particularly in older men), so regular medical follow-up is recommended.
Toronto’s Shouldice Hospital, a pioneer in repair surgery for groin hernias, attracts over 7,000 patients a year from all over the world. Their technique, which involves overlapping and suturing with stainless steel wires, was developed in the 1950s using local (rather than general) anaesthesia and a speedy return to activity. This method of hernia repair has a low incidence of complications, earning the clinic its reputation. Hospital stays average at most two to three days, and activity is resumed soon, if not immediately, after surgery, with special exercise programs to speed up recovery. (Some patients are even asked to walk from the operating room back to their beds!) However, some surgeons disagree with the Shouldice method, favouring a slower return to activity.
New laparoscopic hernia repairs
Recently, laparoscopic surgery (done through tiny incisions, with the help of fibreoptic viewing instruments) has been developed, avoiding the need for open surgery, and hastening post-operative healing. the surgeon goes in through the navel, also making two other small incisions, and conducts the operation by watching what is happening inside the patient on a TV screen, moving the instruments accordingly – much like doing the now commonplace laparoscopic gallbladder removals. The University of Toronto has played a leading, role in developing this technique.
The laparoscopic method, done under general anaesthetic, causes less disturbance to the muscle layers than traditional hernia repair and uses a polypropylene (Prolene) mesh to close the hole and hold the abdominal contents. The advantages are less post-operative pain and disability than with open surgery, often permitting a return to work within a few days. Studies also suggest reduced recurrence after laparoscopic surgery. The disadvantages of the laparoscopic method for groin hernias are the need for a general rather than local anaesthetic, the possibility of nerve entrapment and the greater cost of thee procedure. But although off to a slow start, this method is likely to gain popularity as surgeons become familiar with the new technique.
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