A Family Doctor's Tale - HERNIA

DOC I HAVE HERNIA

Hernia especially in the inguinal (groin) area is very frequent in older patients. There is generally a bulge on one side of the groin and even swelling of the testis. 
Most patients will ask whether I can remove it or treat with medication to shrink the bulge. It is easy to detect because when they cough, it becomes more obvious in the upright position but the swelling will subside on lying down. 
Treatment is usually by surgery although there is a truss to prevent the bulge becoming worse in the past.
The truss is seldom used in present times.


Inguinal Hernia is protrusion of the part of the viscera(contents in the abdominal cavity) through the inguinal canal which is the tunnel which leads the spermatic duct from the testis to the urethra or seminal vesicles in the abdomen.

1.Indirect:
The abdominal contents such as small intestine enter the the enlarged internal inguinal ring and protrude into the inguinal canal entering the scrotum.


2:Direct:
There is a weak spot in the abdominal wall and the intestine form a bulge at that spot.



The causes of Inguinal Hernia are mostly due:

A.Congenital :

The inguinal canal follows the same route as the descent of the testes from the abdomen out to the scrotum outside the abdomen during the embryonic stage.
If there is partial closure of the internal inguinal ring, then weakness of the of abdominal wall occurs allowing abdominal content to protrude through the inguinal canal.


B.Increased abdominal pressure occur due to:




1.coughing


2.straining


3.distension


4.obstruction


C.Weakening of the abdominal muscle:
1.Obesity


2.muscle wasting diseases


Hernias are more common in men than in women because the inguinal canal is usually closed in women wheras in men the canal carries the spermatic duct.


Symptoms:

1.Swelling in the groin area which is worse on coughing, straining or standing up


2.swelling of the groin usually disappear on lying down(abdominal contents is returned to the abdominal cavity).


3.Pain or discomfort may be present


Signs:

1.Swelling in the groin can be felt.
If a finger is pressed into the external inguinal ring, coughing can make the swelling feel more palpable


2.There may guggling sounds of intestinal gas movement on auscultation of the swelling with the stethoscope.


3.Local tenderness of swelling


Complications of hernia are:
1.Irreducible hernia may occur when the abdominal contents cannot be returned to the peritoneal cavity due to adhesions of the inguinal canal of the faecal matter stuck in the protruded intestine.
This complication may be serious


2.Strangulated hernia occur when the blood circulation is cut off due to constriction of the neck of the hernial sac resulting in ischemia and gangrene of the gut.
Signs and symptoms of intestinal obstruction then becomes obvious with increased abdominal pain and local tenderness.


This is a medical emergency and should be treated immediately.


3.Peritonitis-burst abdomen as a result of intestinal obstruction


Diagnosis depends on:
1. clinical features of swelling in the inguinal area


2. CT and Ultrasound scan of the inguinal region and scrotum to exclude hydrocoele and tumors


Treatment of hernia depend on the stage :
1. At the early stage of inguinal hernia, a truss which press against the int inguinal ring may help to reduce symptoms and prevent the hernia from bulging out.

They are useful in patients with poor general condition who are unable to tolerate full surgery.

They are seldom used now.


2.All inguinal hernia patients should undergo elective (non-emergency) surgery to repair the hernia before complications such as strangulated hernia sets in.


Such surgery called herniorrhaphy or hernioplasty can be done on a day surgery under local anaethesiaand using laporoscopy.


It usually involved sewing a wire mesh over the inguinal ring to tighten the inguinal ring and prevent the contents of the abdomen from pushing its way out into the inguinal canal.


Patient is usually asked to cough after the surgery to make sure the abdominal wall is tight enough to prevent any intestine to protrude out.


3.Emergency surgery is required if there is any strangulated inguinal hernia or intestinal obstruction.


4.Some congenital hernia may disappear by the end of the first year.


Most cases of inguinal hernia usually will recover with proper surgical treatment.


Very rarely there may be complications such as postoperative infections or recurrence.


Avoid straining at stools, severe coughing.


Avoid carrying heavy weights.


Lose some weight.