Hernias: An Overview of Types, Symptoms, and Treatment

If the hernia is visible from the outside, or if the bulge caused by the hernia extends from inside the body toward the skin, it is called an external hernia. If the hernia is located inside the body (e.g., between the chest and abdominal cavities), it is called an internal hernia. The most common external hernias are inguinal, umbilical, incisional, abdominal wall, and femoral hernias, and the most common internal hernia is a diaphragmatic hernia. Since soft-tissue hernias do not resolve on their own but grow larger over time, hernias should be treated with hernia surgery, provided the patient’s overall condition allows for surgery.

The most common types of hernias and their surgical procedures are:

• inguinal hernia and inguinal hernia surgery,
• femoral hernia and femoral hernia surgery,
• umbilical hernia and umbilical hernia surgery,
• incisional hernia and incisional hernia surgery,
• diaphragmatic hernia and diaphragmatic hernia surgery.

These are described below.

Inguinal hernias are the most common type of hernia, accounting for 80 percent of cases. Men are nine times more likely to be affected than women. In 10 percent of cases, the inguinal hernia occurs on both sides. The hernia is located above the inguinal ligament. In most cases, it initially presents as a painless bulge in the groin. Pain often does not occur until during physical exertion or after prolonged sitting. When lying down, the bulge usually disappears again. Since, depending on the size of the hernia, the intestine can become trapped—possibly leading to the death of sections of the intestine—hernia surgery is essential.

Femoral hernias occur predominantly in older women. In this case, the hernia develops below the inguinal ligament, so that the bulge is usually visible on the inner side of the thigh. Unlike inguinal hernias, femoral hernias are usually painful from the outset. And because intestinal segments can also become strangulated in this case, a femoral hernia is likewise treated with hernia surgery.

Umbilical hernia

For most people affected, an umbilical hernia causes no symptoms. However, this type of hernia results in a more or less noticeable bulge in the area of the navel. Since portions of the intestine can also become strangulated in an umbilical hernia, it should likewise be treated with hernia surgery. Hernia surgery is performed even for small umbilical hernias because strangulation can occur in these cases as well. Umbilical hernias that occur immediately after birth, on the other hand, usually resolve spontaneously. If necessary, they are treated with a support bandage, but are generally not treated with hernia surgery.

Incision hernia (scar hernia, abdominal wall hernia)

An incisional hernia is a rupture of the abdominal wall that occurs in the area of a surgical scar. Wound infections, impaired wound healing, or multiple surgeries can increase the risk of developing an incisional hernia. Weaknesses in the connective tissue or obesity can also contribute to incisional hernias. This results in the protrusion of abdominal organs through the surgical scar, which often causes a pulling pain in the area of the scar. And because incisional hernias also grow larger over time and carry the risk of intestinal obstruction, hernia surgery should be performed.

Diaphragmatic hernia

If a diaphragmatic hernia is present, organs from the abdominal cavity can slip through the opening in the diaphragm into the chest cavity and become trapped. Strictly speaking, a diaphragmatic hernia is not a hernia but rather an enlargement of the opening through which the esophagus passes through the diaphragm into the stomach. This enlargement of the normal opening can result from weakened connective tissue or prolonged increased pressure in the abdominal cavity (e.g., pregnancy, obesity). This can lead to pain, especially after eating or when lying down, because gastric juice then flows back into the esophagus. This type of hernia also requires hernia surgery.

Hernias are usually treated surgically, unless there are compelling reasons against surgery (e.g., poor physical condition). In the case of an incarcerated hernia, emergency surgery may even be necessary. Hernia surgery can be performed under local or general anesthesia. In the case of a strangulated hernia, general anesthesia is usually preferred because it allows the surgical incision to be expanded more easily if necessary.

In principle, there are different methods of hernia surgery. First, a decision must be made as to whether the hernia will be treated using open hernia surgery or closed hernia surgery. Laparoscopic hernia surgery is also known as keyhole surgery. Some surgeons refer to this type of hernia surgery as minimally invasive hernia surgery.

In addition to this fundamental choice between open and laparoscopic hernia surgery, a decision is usually made as to whether the procedure will involve the insertion of a synthetic mesh or whether this can be omitted. In hernia surgery, the synthetic mesh serves to reinforce the closed hernia and generally leads to fewer recurrences (the hernia reappearing in the same location). For very small hernias that are closed with a direct suture during hernia surgery, or in children and adolescents, the use of a synthetic mesh can usually be avoided.

Even in cases of large abdominal wall hernias—where the rectus abdominis muscles have shifted laterally—mesh-free procedures are usually used because large hernias are difficult to cover with a mesh. The specific procedure used depends on the type and size of the hernia, as well as the patient’s age and overall health. Determining the most appropriate procedure for each individual patient is the primary focus of diagnosis and treatment planning in hernia surgery.

Hernia Surgery: Preoperative Examinations

Depending on where the hernia is located and how large it is, it may be asymptomatic or progress to a life-threatening infection. Therefore, the first step is to determine exactly what type of hernia is present and how extensive it is. To this end, a thorough physical examination is conducted prior to any potential hernia surgery. Other methods for accurately diagnosing the condition include ultrasound and, if necessary, a CT scan. Sometimes X-rays are also taken, either with or without contrast dye, such as the examination known as a barium swallow for a diaphragmatic hernia.

In addition, a consultation with the operating surgeon takes place before hernia surgery, during which the patient is informed about the planned procedure and the most common complications of the surgery and the postoperative course are explained. Likewise, prior to hernia surgery, an informational consultation with the anesthesiologist should be held to discuss the type of anesthesia to be used (general or local anesthesia).

Hernia Surgery for Inguinal Hernias

Since an inguinal hernia does not resolve on its own, it should be treated surgically. This is especially important because—as with all hernias—there is a risk that parts of the intestines could become trapped and die. The choice of surgical method depends on the patient’s age and the location and size of the hernia. In general, there are three different methods of hernia surgery for an inguinal hernia: the Shouldice procedure, the Lichtenstein procedure, and minimally invasive laparoscopic procedures.

Shouldice Inguinal Hernia Repair

In the Shouldice procedure, the surgeon makes an incision in the groin area and exposes the hernia. He opens the hernial sac, pushes the hernial contents back into the abdominal cavity, and sutures the opening closed using adjacent connective tissue. The Lichtenstein procedure follows the same basic principle, except that the hernia is stabilized with a synthetic mesh that is sutured into place during closure. In the minimally invasive procedure, an endoscope (a tube with a miniature camera) and the necessary instruments are inserted through small abdominal incisions and advanced to the site of the hernia. Here, too, the internal organs are returned to their proper position, and the hernia is stabilized using a synthetic mesh.

Femoral Hernia Surgery

For femoral hernias, there are also two basic methods of hernia surgery: the open and the laparoscopic methods. In open femoral hernia surgery, after the hernial sac has been repositioned or removed, the hernial defect is closed with sutures. However, this often results in tension that can cause pain and lead to a recurrence. Laparoscopic inguinal hernia surgery (minimally invasive) is performed through small incisions. Surgical instruments and a video camera are inserted into the abdominal cavity through these small incisions, and the hernia is exposed at its origin.

Inguinal Hernia Surgery with Synthetic Mesh

A non-absorbable (non-self-dissolving) polypropylene mesh is stretched across the hernial orifice and secured to the abdominal wall from the inside. The peritoneum is then closed over the mesh. The scar tissue grows into the mesh structure, forming a new layer that is usually less tense than if the skin had been sutured directly. For all inguinal hernia surgical procedures that involve the placement of a mesh, it is important to ensure that the size of the synthetic mesh is selected so that it overlaps the healthy and stable tissue significantly and can heal properly. In an emergency situation involving acute incarceration, open inguinal hernia surgery with an inguinal incision is always performed.

Umbilical Hernia Surgery

Depending on the size of the hernia and the patient’s age, an umbilical hernia is also treated using either open hernia surgery or laparoscopic hernia surgery. In open umbilical hernia surgery, the abdominal wall is opened and the hernial sac is exposed through an incision. The contents of the hernial sac are then returned to the abdominal cavity. Closure is typically achieved by directly suturing the abdominal wall fascia (layer of connective tissue). Sometimes this fascia is sutured twice to make it more stable. For larger umbilical hernias, the closure may also be performed using a synthetic mesh.

In closed hernia surgery for an umbilical hernia, access is gained through the abdominal wall via laparoscopy. Using special instruments, the hernial orifice is closed directly. Here, too, a synthetic mesh can be inserted to provide additional stability. Laparoscopic hernia surgery for umbilical hernias is a minimally invasive surgical procedure that reduces post-operative pain and lowers the rate of wound infections. In addition, patients who undergo hernia surgery via endoscopy are generally able to resume physical activity more quickly.

Hernia Surgery for Incisional Hernias

In the case of a large incisional hernia, a pneumoperitoneum is often created prior to hernia surgery. This means that the abdominal cavity is pre-stretched over a period of several weeks by filling it with air every 2–3 days. This makes it easier to return the contents of the hernial sac (e.g., the intestine) to their original position and reduces the pressure exerted by the abdominal contents on the abdominal wall after hernia surgery.

During incisional hernia surgery, the separated muscle layers are sutured back together. In hernia repair by direct suture, small incisional hernias up to about two centimeters in diameter in patients without risk factors for recurrence (repeat hernia) are treated by directly suturing them with non-absorbable sutures. In cases of large defects, existing risk factors for recurrence, or repeated hernia surgery, a synthetic mesh or a spherical patch is placed over, within, or beneath the defect and secured to a muscle layer. Depending on the layer of the abdominal wall into which the mesh is inserted, different methods of hernia surgery are distinguished (sublay, inlay, and onlay methods).

There are several surgical methods for diaphragmatic hernias, with the so-called fundoplication being the most common. In this procedure, a cuff is formed from portions of the stomach and placed around the lower part of the esophagus. This reduces the backflow of acidic stomach contents into the esophagus (reflux). Food, on the other hand, can continue to pass from the esophagus into the stomach. This surgery is usually performed laparoscopically. In over 90 percent of patients, fundoplication leads to a permanent cure. This spares young people with reflux disease, in particular, from having to take medication for many years.

Another method of hernia surgery for diaphragmatic hernias is gastropexy, also known as fundopexy. In this procedure, the stomach is repositioned to its normal location during hernia surgery and sutured to the anterior abdominal wall so that it can no longer shift. In the third method of hernia surgery for diaphragmatic hernias—hiatoplasty (also known as hiatal narrowing)—the hiatal opening is simply sutured closed. The edges of the hiatal opening are then reattached using special sutures. If necessary, a synthetic mesh is sutured over these stitches to reduce the risk of a recurrence.

After hernia surgery, patients can get out of bed immediately or after a sufficient rest period, depending on the type of anesthesia and surgical procedure. Prolonged bed rest is unnecessary after hernia surgery and should be avoided due to the risk of thrombosis followed by embolism. Patients should not experience any pain in the first few hours after hernia surgery, as the surgical site is routinely numbed with local anesthesia, whether the procedure is performed under general or local anesthesia. Mild pain relievers can be used for pain that develops later after hernia surgery.

The first dressing change takes place on the second or third day after hernia surgery. Depending on the physical demands of your job, you should be able to return to work two to three weeks after hernia surgery. You should wait three to four weeks after hernia surgery before resuming athletic activities. Lifting heavy objects weighing more than ten kilograms should be avoided for about two to six months after hernia surgery. Occasionally, the success of the surgery is verified through a follow-up examination, such as a repeat X-ray with contrast dye in the case of a diaphragmatic hernia.

In addition to the general complications common to all surgeries—such as bleeding, infections, thrombosis, and the risk of embolism—swelling in the surgical area—caused by bruising or fluid accumulation in the tissues—is relatively common following hernia surgery. However, these usually subside shortly after hernia surgery. Mild pain in the surgical area or sensory disturbances may also occur after hernia surgery, but these typically resolve on their own as well.

Surgery in close proximity to the intestines, bladder, blood vessels, and nerves always carries a potential risk to these structures. However, injury to major blood vessels during hernia surgery is extremely rare. Recurrence of the hernia at the same site can occur with any hernia surgery procedure, but is less common when synthetic mesh is used. Hardening and shrinkage in the area of the implanted synthetic meshes are extremely rare in hernia surgery; allergies or rejection of the synthetic meshes are virtually nonexistent.

Hernias are common conditions caused by a weakness in the abdominal wall and can take various forms. There are different types of hernias, including external and internal hernias, which differ depending on their location.

Inguinal hernias are the most common type of hernia and mostly affect men, although women can also be affected. The development of hernias is often associated with a congenital or acquired weakness of the abdominal wall. Typical symptoms include pain at the site of the hernia and a visible bulge. In severe cases, an incarcerated hernia may develop, in which parts of the intestine are affected and nausea and vomiting occur. Diagnosis and treatment depend on the type of hernia. Depending on the type of procedure, treatment is surgical, often involving an incision in the area of the hernia.

Not every hernia poses an immediate risk; however, a hernia can cause problems if left untreated. A hernia can worsen, particularly during physical exertion. Various risk factors contribute to the development of a hernia, including obesity or weak abdominal muscles. The structure of the abdominal wall also plays an important role. Overall, it is clear that a hernia should be taken seriously, as complications are possible. Early treatment can help prevent long-term problems.

What is a hernia?

A hernia is a rupture in which tissue or internal organs protrude through a gap in the abdominal wall. This gap is called the hernial orifice.

What types of hernias are there?

There are various types of hernias, including inguinal hernias, umbilical hernias, incisional hernias, and femoral hernias. Diaphragmatic hernias are also included.

What are the symptoms of hernias?

Typical symptoms include a visible bulge, pain, or a feeling of pressure. In the case of a strangulated hernia, nausea and vomiting may also occur.

When is surgery necessary for a hernia?

Surgery is necessary if symptoms occur or if there is a risk that internal organs could become trapped.

What happens during hernia surgery?

During the surgery, the herniated contents are reduced, and the abdominal wall is reinforced, often with a synthetic mesh.