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HERNIAS (GROIN, UMBILICAL, INCISIONAL)
By: RODNEY G. COURSON M.D. F.A.C.S., LAPAROSCOPIC AND GENERAL SURGERY

Hernia disease affects a large segment of the population, and has no regard for age, race, or gender. People of all ages, working in a variety of occupations will develop one or more hernias in their lifetime. Hernias typically fall into categories (congenital and acquired). Congenital hernias arise from anatomic defects present at birth often associated with failure of closure of the processes vaginalis or laxity of the internal ring. Acquired hernias result from an accumulation of events, which cause stretching of and weakening of the structures supporting the abdominal wall. Heavy lifting, pregnancy, tobacco use, obesity, constipation, chronic cough, enlarged prostate and previous surgery have been linked to the formation of hernias.

Anatomy
The umbilical hernia occurs at the umbilicus and may cause people to notice a lump, which may or may not be tender. These hernias tend to look slightly bluish as they enlarge. Inguinal (groin) hernias are found along the line between the pubic bone and the hipbone. The inguinal canal contains the spermatic cord and vessels in men and the round ligament in women. Incisional hernias can occur anyplace that there is an incision, such as with an abdominal exploration, previous hernia repair, or a cholecystectomy scar.

Natural History
A hernia, regardless of its type, is nothing more than a hole in the abdominal wall. When tissue on the inside protrudes through the hole, then a lump forms and allows for the diagnosis of the hernia. If the hernia is not repaired then the tendency is for the hernia to enlarge, which increases the chance that bowel will become trapped inside the hernia. This could lead to significant bowel injury, requiring resection of the damaged bowel.

Symptoms
Patients may often experience local tenderness in the region of the hernia. You may recognize an unusual swelling or mass, which you can sometimes reduce. Groin hernias sometimes produce pain, which extends onto the inner thigh or scrotum. Incarcerated hernias may cause nausea, vomiting, redness, abdominal pain, bloating, fever. If you develop these symptoms then you should seek medical help immediately.

Clinical Findings
Classic findings on examination include a soft tissue mass, which may or may not be tender. Sometimes the area may appear red. Most hernias are reducible by the physician and can be repaired electively.

Treatment
Surgical repair is usually required since these defects do not heal and close spontaneously. Non-surgical therapies like the hernia belt (trusses) are not very effective and should only be used short term or with people who are unable to tolerate surgery. You should be evaluated by a physician when a suspected mass is found since this may represent pathology other than a hernia i.e.: lipomas, neoplasm, adenopathy. If a hernia is indeed present then the type of repair will depend on the hernia. Generally the minimally invasive laparoscopic procedure can be used for all types of hernias including recurrent ones.

Hernia repairs
Multiple open procedures are described and performed by most surgeons, however the laparoscopic repair, for which I specialize, is also available to hernia patients. Practicing laparoscopic surgery for many years has given me an extensive expertise at performing this type of hernia repair and of the advantages it offers. Several advantages are enjoyed by using the laparoscopic procedure especially that of decreased pain. The laparoscope is placed through an incision that is less than 1 inch in length and utilizes natural tissue planes to access the hernia defect in the inguinal region. A prosthetic mesh is then placed inside the abdominal wall and solidly re-enforces the defective tissue in that area. Laparoscopy allows minimal disruption of muscle and fascia and causes only minor discomfort after surgery. Because of the decreased disruption of tissues, patients are able to return to activity sooner and with fewer restrictions. Cosmetically the results are superior since the incisions are small. Most hernia surgeries are performed on an outpatient basis with the patient returning to normal ambulation and self care as early as the night of surgery. A large percentage of patients return to work within a few days, depending on vocational requirements.

RODNEY G. COURSON M.D. F.A.C.S., LAPAROSCOPIC AND GENERAL SURGERY