Abdominal wall hernia

What is an abdominal wall hernia?

An abdominal wall hernia is a pathological condition in which internal organs (most often intestine or adipose tissue) protrude through an abdominal wall defect (Figure 1). This bulge may be visible or palpable as a subcutaneous mass. The most common hernias are inguinal, umbilical, epigastric and incisional. Other, less common locations also occur, but all are essentially abdominal wall defects.

Why does a hernia develop?

Hernia development is promoted by a combination of two factors:

• abdominal wall weakness – congenital connective tissue weakness, age-related changes, postoperative scars, trauma;
• increased pressure in the abdominal cavity – lifting heavy objects, chronic cough, constipation (straining), obesity, pregnancy.

How is a hernia diagnosed?

Diagnosis can often be made during physical examination: abdominal wall defects can be palpated in different positions (lying and standing) and during provocation tests (e.g., coughing). To clarify hernia contents and size, ultrasonography (US) is performed. In complex cases (incisional hernia or a small hernia not detected on examination), computed tomography (CT) or magnetic resonance imaging (MRI) is used.

What are the symptoms of a hernia?

Hernia symptoms vary; most often they include a visible or palpable bulge of the anterior abdominal wall, discomfort or pain (especially during exertion), and abdominal heaviness. They worsen when standing, straining or coughing. A small hernia may initially be asymptomatic.

What complications are associated with a hernia?

The main possible complication is incarceration (entrapment): structures in the hernia sac (bowel loops, adipose tissue) are compressed, blood supply is impaired and tissue necrosis develops (Figure 2). Hernia incarceration is an emergency requiring urgent medical care.

What is the treatment for a hernia?

The only treatment is surgical. The operation is performed minimally invasively (laparoscopically or endoscopically) or traditionally (open surgery). A synthetic mesh is often used to close the defect and reinforce the abdominal wall (Figure 3).

The surgical approach and need for mesh depend on the hernia location and abdominal wall defect size:

• small primary hernias (e.g., a first-time umbilical hernia) are treated with open surgery – the incision is small and the abdominal wall defect is closed with sutures (Figure 4);
• larger defects, inguinal hernias and incisional hernias are treated by closing the abdominal wall defect with synthetic mesh. Surgery is performed either minimally invasively or conventionally (Figure 5).

Conservative treatment (for example, use of an abdominal support belt) can temporarily reduce symptoms but does not cure the hernia.

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