One of the oldest known diseases to mankind, hernias have been treated in different ancient cultures, from applying external heat on the affected area to inserting gold, silver and other metals there to treat and prevent a recurrence. This commonly encountered surgical problem is still surrounded by many myths and that is why the Abdominal Wall Reconstruction Surgeons Community (AWRSC) of India pledges to educate every health enthusiast about hernias!

What is a hernia?

 A hernia is a gap in the muscles/fascia of the abdominal wall, through which the internal organs, like the small and/or large intestine, omentum, etc. come out beneath the skin.

The abdominal wall provides strength and functional integrity to the torso and also protects the internal organs. Any breach in this dynamic system not only leads to functional loss and aesthetic deformity but may also jeopardize the health of the internal organs. For example, the lung capacities may be drastically diminished in large hernias.

 Hernias can be classified into two broad categories: internal and external. Internal hernias occur inside the abdomen and are not apparent on the outside. External hernias are the ones you most commonly see and hear about. 

 Now that you have understood what exactly a hernia is, let us shift the focus to the reasons why it may occur. Some hernias are congenital (present since birth), while others develop due to stress and strain of ageing, obesity, and pregnancy. Tissue weakness leads to hernia formation due to some collagen disorders.

Severe trauma may result in a muscle getting completely detached from its bony attachment. As a result, the intra-abdominal contents may herniate acutely through the gap. Incomplete/improper healing post open/laparoscopic surgeries may result in large hernias. Irrespective of the cause the treatment remains surgical. There is no way a medicine or injection can cure a hernia. Hernias can be of different types and like every patient is different from one another, so are their hernias.

Secondary hernia or more commonly known as Incisional hernia. According to EHS (European Hernia Society), an incisional hernia is a hernia that develops after surgical trauma to the abdominal wall, including recurrences after surgery for primary ventral hernia. The occurrence following an open abdominal surgery can vary from 2-20%.

 Patients with a higher risk of developing incisional hernias include:

1. Old age
2. Diabetes Mellitus: Poor sugar control leads to poor healing and mesh integration.
3. Obesity
4. Smoking
5. Use of steroid medications for various medical conditions including post-organ transplant recipient.
6. Infection during previous surgery
7. Poor build of the patient
8. Previous failed hernia repair

 These are some common reasons apart from the technical failures of surgery (specifically the healing of the cut on the muscle wall of the belly) that may lead to incisional hernia formation.

Symptoms:

 From being completely asymptomatic to having severe abdominal pain, discomfort, nausea, vomiting and distension along with functional loss of torso and aesthetic disfigurement, the symptoms can vary from patient to patient. There is no one symptom that classically and categorically represents hernia in general and that is why a professional opinion by a hernia expert/surgeon is a must and not a substitute to your google search!

Hernias are notorious in getting complicated unexpectedly without giving any warning signs. The protruded intestines can get obstructed, and the consequences can be disastrous. You know what a tight rubber band can do to your fingers if wrapped around it. A similar phenomenon can occur with any organ stuck within the hernia, leading to intestinal gangrene and uncontrollable infection leading to mortality; therefore, early detection and prevention are important!

 Evaluation:

 Here is what to expect when you meet your hernia surgeon for an examination:

1. A proper history documentation
2. Physical examination for confirmation of hernia/hernias.
3. Nutritional assessment
4. General fitness assessment
5. Your surgeon may ask you to undergo imaging via ultrasound and, in many cases, CT scan to understand the hernia characteristics better. Remember to ask for a CD or, even better, the image files on a pen drive, from the radiology technician (as your hernia surgeon may ask for it).

Pre-surgery preparation:

Your surgeon may form a multi-specialty team to address any physical or psychological concerns. A nutritionist’s help may also be needed to either enhance nutrition or work on excess body weight. All of this is to optimize your health before surgery to obtain the best possible outcome. However, this may not be required in simpler cases of hernia, especially if the patient is young and fit.

Treatment options:

 Surgery is the only recourse for your hernia. Your surgeon, after having discussed with you all the possible options, decides on the surgical option that is likely to be optimal for you. Depending upon the patient’s hernia characteristics, fitness level, logistics and skills available, the surgeon makes a plan for management. This is typically a perfect combination of right surgery and the right mesh. 

 The available access currently is via open, laparoscopic, hybrid, and robotic approaches at the best centers. With advancing skills laparoscopic and robotic approaches are proving to be more patiently friendly in terms of early recovery, minimal pain, and low risk of infection.