29th October 2000
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A painful sac

Ask a question from Dr. Maiya Gunasekera, MBBS Hon (Cey), MS, FRCS (Eng), FRCS (Ed), FICS Fellow Sri Lanka, Consultant Surgeon/Gastro Enterologist at the Nawaloka Hospital. If you wish to consult him on your personal health through this page, do write in, c/o The Sunday Times, P O Box 1136, Colombo
By Chris Fernando
Q: I am a 50-year-old male who was diagnosed with inguinal hernia and was advised to undergo surgery. One of my friends underwent surgery for the same problem but the hernia came back after some time. Some of my friends advised me to wear a hernia belt. Please enlighten me on the subject. What do you recommend?

Dr. Maiya says: 

A hernia is an abnormal protrusion of abdominal contents, which could consist of intestines or omentum (a fatty apron inside the abdomen), through an orifice (opening) in the abdominal wall.

The orifice can either be artificially created by a laparotomy scar which has not healed properly or it can be a naturally occurring opening in the abdominal wall such as an opening in the umbilical region which could give rise to an umbilical hernia. It could also arise from the inguinal orifice as in your case.

An umbilical hernia, which occurs in the umbilicus is common in females, especially in those who've had repeated pregnancies.

Hernia occurs in the inguinal (groin) region in both males and females due to a weakness of the muscles, and is usually associated with old age. This is known as the direct inguinal hernia. This type of hernia can also occur in people who are in the habit of lifting heavy weights.

Another type of hernia is the indirect inguinal hernia, which is due to a natural opening, which does not close up. Here, the abdominal contents (intestines and fatty tissue) go down to the scrotum along the inguinal canal. This type of hernia is common at any age, but more common in younger people.

Indirect hernia, which is very common in younger males, is due to the persistence of the inguinal sac, which comes along with the testes. To give you a clearer picture, the birthplace of the testicles is the abdominal cavity. As the male foetus grows inside the womb, the testicles travel down towards the scrotum to assume its proper position in the scrotum at the time of birth.

Along the track of the testicles, together with the testes, a small peritoneal sac is brought along with it, which in most cases gets completely obliterated. But if this sac persists, the abdominal contents such as the bowels and omentum can get inside this sac and produce the indirect inguinal hernia, which will travel through the canal and go into the scrotum.

A patient suffering from hernia will always feel a lump coming out from the area where the defect is, such as the umbilical or the inguinal region or from the site of previous surgery.

The patient will also initially notice that the lump disappears on lying down and becomes prominent on standing up. There can also be pain associated with the presence of the lump because the hernia brings with it, a sac of peritoneum, which is the inner lining of the abdominal cavity, and which is very sensitive.

If this condition is neglected, the patient will then notice that the lump, which appeared and disappeared at one stage, is now permanent and could be felt even when lying down. It would be firm to the touch and will not move or reduce when pressed down with the finger. The pain at this point would also increase. A doctor would now be dealing with an irreducible hernia, which will have to be urgently attended to, surgically.

Signs and symptoms of the pain would vary with the contents inside the hernial sac. For e.g. if only the omentum (fatty tissue) is trapped inside the hernial sac, a patient might feel a little pain and discomfort without encountering major problems.

However, if the bowels, both large and small, are trapped inside the hernial sac, then a patient will be induced to vomit due to intestinal obstruction. This could be classified as a surgical emergency.

All types of hernia can be repaired very easily without the danger of it coming back. The procedure involves the hernial opening being covered by a synthetic mesh, either prolein or Maalox, which is stitched in place. When a prolein mesh is stitched, no muscle is stitched together under tension and therefore, healing takes place without a problem and there will be no recurrence whatsoever.

I think in your friend's case, the repair would have been done with the use of nylon, which was the practice prior to the usage of prolein. These hernias recurred because tissue (muscle) was stitched together under some tension and this would allow for the nylon to break through. The usage of the prolein mesh has completely stopped the recurrence of hernia.

Synthetic prolein or Maalox meshes are used for the repairing of other hernias such as large abdominal ventral hernia with complete success and no recurrence.

My advice to you is to undergo surgery. I'm sure the surgeon will use a prolein mesh and therefore you need not fear a recurrence.

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