Stephen didn’t notice any pain, but he was seriously concerned about the lump in his groin he discovered one day in the shower. It was soft and squishy, and he tried to convince himself it was only misplaced fat. When he lay down, it seemed to disappear.

After a physical examination, Stephen’s doctor gave him news that was mostly good. He was in excellent overall health but had a hernia that could be repaired through surgery.
A hernia is a lump of intestine or organ tissue that bulges through a tear in the wall of the abdomen. Some compare it to an inner tube protruding through a weakness in the sidewall of a bicycle or auto tire. It’s not normal but can be readily fixed.

An estimated five million Americans have hernias, and it’s the most common reason primary care physicians refer a patient for surgery.

A hernia can occur anywhere–around the navel, the upper abdomen or the groin–as a result of weakness in abdominal tissue, often associated with a congenital condition or a previous incision.

In men, the majority are in the groin area (inguinal hernias). Some inguinal hernias occur at the point where the top of the thigh meets the abdomen; others protrude into the scrotum, creating a swollen appearance. The inguinal canal is the passage through which the testes of a male child descend into the scrotum before birth. This is an area where there’s some natural weakness in the abdominal lining, and some men are more vulnerable than others to tears.

Femoral hernias (near the top of the thigh) are three times more common among women than men. Some of this increased risk may be related to weaknesses in the abdominal lining associated with prior pregnancy and childbirth.

Usually a Predisposition
Heavy lifting, straining or coughing can bring on a hernia, but in most cases, there is simply a predisposition for weakness in the abdominal wall. This lining is made of connective tissue, not muscle, and cannot be strengthened–although strengthening the outer layer of abdominal muscle can help reduce stress on it.

A hernia may develop gradually or appear rather suddenly. Symptoms include pain, pressure or a heavy feeling in that area, particularly when lifting, coughing or bending at the waist. Men may have swelling of the scrotum, on one side or both.
In many cases, however, there are no symptoms except for the tell-tale lump. Most hernias are easy to diagnose, but when there’s pain but no visible protrusion, ultrasound or a CT scan may be needed.

Although some protrusions can be pushed back in–temporarily–a hernia will never get smaller or go away on its own. A truss can be used to hold it in place, but it’s only a temporary measure, and some today worry that a truss may actually damage protruding organ tissue. More important, there’s always a risk that a portion of the bowel can become trapped in the opening, shutting off blood supply and creating a medical emergency.
Although some individuals can get along with a hernia for some time, the only real solution is surgery. And 700,000 hernia surgeries are performed every year.

Surgical Options
In traditional hernia surgery, the doctor makes an incision four to six inches long over the site of the hernia. After the tissue is pushed back to its proper place, the weakened abdominal wall is sutured together. Various techniques that have been introduced over the past several decades include a multi-layer closure that has decreased the rate of recurrence.

Open hernia surgery can be done in an outpatient setting using local anesthesia. The patient, however, usually requires some bed rest at home and a week or two away from work, especially if the job involves physical activity, while the incision heals.

Particularly when the incision is large, tension can remain high over the hernia site. To decrease this tension and lower the risk of recurrence, surgeons over the past decade have frequently inserted a patch made of synthetic mesh material behind the sutures. Initially, doctors worried about possible infections arising from the implanted material, but with improved methods and materials, long-term studies have found minimal risk.

Today, the recurrence rate is usually less than three percent when surgery is performed by a skilled, experienced team. Once a repeat hernia repair has been made, however, the risk of subsequent recurrences can be as high as 20 to 30 percent.

A less invasive surgical option introduced over the last decade is laparoscopic hernia repair. Instead of one long incision at the site of the hernia, the surgeon makes three small cuts through which narrow tubes are threaded into the abdomen to view and repair the hernia from the inside. One tube contains a small video camera; the others have small surgical instruments.

Laparoscopic surgery takes about the same amount of time as the traditional procedure, but it usually requires general anesthesia. General anesthesia has risks of its own, and in rare instances the laparoscopy can lead to severe complications such as perforation of the bowel or bladder.

Hernias are frequently bilateral–occurring on both sides of the abdomen. With traditional surgery, bilateral hernias require two incisions, but laparoscopy can be performed with the same three small incisions.

Laparoscopy is also a good choice for the repair of a recurrent hernia that was previously repaired by traditional surgery. Rather than cutting through scar tissue, the surgeon can make the repair from the inside out.

Although laparoscopic surgery is more expensive than open surgery, healing is faster, allowing most patients to return to work within a week. For some individuals, the reduction in lost time may make the laparoscopic approach more cost effective.

Probably as important as the type of surgery chosen is the skill and experience of the surgical team. If you have a troublesome bulge in the abdomen that requires repair, look for a surgeon who has performed numerous hernia surgeries with good results.

REFERENCES:
Tim Bax, Brett C. Sheppard, and Richard A. Crass, “Surgical Options in the Management of Groin Hernias,” American Family Physician, January 1, 1999.
Bill Bush, “New Help for Hernias: The Latest Surgical Techniques Will Help You Conquer the Battle of the Bulge,” Men’s Fitness, September, 1998.
Mark Davenport, “Inguinal Hernia, Hydrocele, and the Undescended Testis,” British Medical Journal, March 2, 1996.
Andrew Kingsnorth, “Experts Versus Evidence in Hernia Surgery,” The Lancet, September 29, 2001.
“Laparoscopic Hernia Repair: A Faster, Easier Way,” Mayo Clinic Health Letter, February, 2001.
David W. Rattner and Gale M. Abass, “Mending Inguinal Hernias,” Harvard Health Letter, April, 1997.
Dan Santow, “Blowout,” Men’s Health, November, 1993.
“Surgery–A Short, Practical Guide to Hernias,” Harvard Health Letter, January, 2002.
“Surgical Options in the Management of Groin Hernias,” American Family Physician, February 15, 1999.