ABDOMINAL WALL HERNIAS: Types, Risk Factors, Diagnosis and Treatment
The role of the allied health community is critical in identifying hernias and determining if a patient requires referral for treatment or in some cases even deemed a medical emergency. With hundreds of patients coming through your doors for treatment each week and your teams undertaking hands on assessments, it’s very likely that you will may come across a lump or unusual swelling that may require further assessment. Furthermore, many patients are referred for physiotherapy or exercise physiology for groin pain or discomfort that is thought to have a musculoskeletal basis but may instead be due to hernia. Especially in overweight or obese patients it can be difficult to detect a small hernia. This applies especially to the more dangerous femoral hernias. Hernias may also cause pain or discomfort outside the groin, for example in the anterior thigh or hip region, leading to misdiagnosis and referral to allied health instead of sugery. Therefore it’s important you know what to look out for and the key risk factors.
What is a hernia?
A hernia is described as a protrusion of an organ or tissue from its normal cavity pushing through a weakened section of the abdominal wall.
Protrusions outside the abdominal wall are reviewed here, but there are other hernias (such as hiatus hernia) that protrude between body cavities.
What are the different types of hernias?
There are several different types of hernias, these include;
- Inguinal (direct and indirect)
- Epigastric, and
What are the common risk factors for hernia development?
The risk factors for hernias often depend on the hernia type however come factors include;
- BMI, and
Obesity and smoking are risk factors for hernia recurrence and for wound infection. Therefore, smoking cessation and weight loss are strongly recommended prior to hernia repair.
- Cumulative mechanical load or stress (physically demanding work, lifting weights, repetitive coughing)
- Defects in collagen and elastic fibre function, such as those with Marfan or Ehlers-Danlos syndromes, or polycystic disease
- Connective tissue variants – Some data suggests an aetiological role in the connective tissue many hernia types in patients without a phenotypic abnormality.
- Potential genetic variations including mutations have been identified that may link hernia development, connective tissue alterations and a complex multifactorial inheritance pattern for hernias is seen in some families.
Is it the hernia that is causing the pain?
It is important to clarify is that the hernia is really the cause of pain for the patient. Especially if it is a very small hernia detectable by imaging alone and is found in a young male, as this group has the highest rate of postoperative chronic pain following hernia surgery.
Specialised ultrasound examination, possibly MRI imaging, and referral to a sports physician are valuable in this group of patients, who often have a musculoskeletal cause for their pain. A hernia operation may worsen rather than relieve symptoms in these patients. The most valuable treatment for musculoskeletal groin pain is physiotherapy.
Operative techniques that seem to reduce postoperative pain include laparoscopic approach, possibly use of a larger pore soft mesh, and in my experience use of absorbable tacks and absorbable glue to hold the mesh in place, along with gentle tissue dissection (Figures 1 and 2).
INGUINAL HERNIAS (Groin Hernias)
UMBILICAL AND EPIGASTRIC HERNIAS
This brief review includes the common primary abdominal wall hernias: inguinal and femoral groin hernias, and umbilical and epigastric midline hernias.
It incorporates the guidelines of the British/European/American Hernia Societies and the international HerniaSurge group, with comments from personal experience. Uncommon hernias of the abdominal wall including hernias of the lumbar area in the lower back and the very uncommon hernias of the pelvic floor (obturator, perineal, and sciatic hernias) are not discussed. Secondary hernias including incisional hernias are also not reviewed.