Herniae, or ruptures, of the abdominal wall are of several types.
Inguinal hernia is the type that occurs in the groin when there are normal openings through the muscle layers for the spermatic cord in the male and a supporting ligament of the womb in the female. When there is a weakening of the muscle layers in the region between the internal and external inguinal rings which presents a bulging out in this area, the hernia is said to be direct. When the muscle layer’s openings are larger than need be, or when the tract in the canal through which the testes passed in their descent from the abdomen to the scrotum has not sealed itself off, and there is a sac bulging down through the canal adjacent to the cord, the hernia is known as indirect. Either may reach tremendous proportions, to stretch the scrotum to a very large size in the male or present a similar large mass in the female. Surgical repair of the inguinal hernia of either type entails opening into the region, closing the sac at its base and removing it, and reconstructing the muscle layers. Several different methods of repairing the region are employed, which reinforce the entire area yet leave a pathway for the cord. Most reconstruction procedures are designed for the placement of the cord openings at different regions with no overlap onto each other, so that the end result is again quite similar to the normal anatomy. The smallest possible openings are left about the cord, but care is taken not to constrict it.
Femoral hernia is the type which occurs in the region below the inguinal ligament. Under the outer section of the ligament the space is taken up by muscles which attach between the pelvis and the thigh. Inside this there are a large nerve, an artery, and a vein. It is just inside this that a hernia may develop, to be known as the femoral type. This variety of hernia is more common in females and may develop very large sacs and bulges. Surgical repair entails the closure of the sac at its base and its removal; and reinforcing the area by uniting the ligament to the fascia of the thigh or by covering the opening with fascia from the abdomen, or both.
Ventral hernia is that type which occurs over the surface of the abdomen away from normal openings. Ventral herniae may be either of the types. There may be actual openings in the layers, or just thinning and weakening of the layers over the herniated site, or a combination of both. Untreated, this type of hernia progresses in size to reach disabling proportions. The repair rests with opening into the region and reinforcing the defective area by reconstruction of the perforated or weakened layers. If a layer has an actual opening, it must be closed. Figure shows one method of repair of hernia with stretched and thinned layers; the tissues are doubled onto themselves, or imbricated, by overlapping one half over the other—the so-called “apron” type of repair. The type of repair rests with the quality of the tissues in the area. Frequently fascial grafts from other areas of the abdomen or from the thigh are used to reinforce the region. Occasionally metal screens or gauzes are placed in the hernial site to assure adequate abdominal wall strength. Large ventral herniae often entail formidable procedures. Occasionally a two-stage operation is required.
Incisional hernia is a type of ventral hernia which results at the site of a previous abdominal incision. The same principles of treatment given for ventral herniae apply to incisional herniae.
That type of hernia which occurs at the site of the umbilicus or navel is umbilical hernia. In the unborn child there is an opening at this site where the umbilical cord attaches and through which pass the vessels for the fetus to receive fresh blood from and discharge old back to the mother’s circulation. After birth, the area normally obliterates and closes, as the infant puts his own respiratory system in action for the oxygenation of blood. Occasionally, however, the area does not properly seal itself off completely, and a weakness at this part of the abdominal wall permits the development of a hernia. If noted early in life and properly held reduced for a long enough period of time, the umbilical hernia may seal itself off by normal growth processes so that surgical correction will not be necessary. But, after the first few months of life, even this type of hernia cannot be expected to be cured short of operative repair. The operation for small umbilical hernia usually involves the closure of the sac at its base and re-uniting the edges of the defective layers. Frequently the apron type of operation by overlapping the weakened layers onto themselves, is employed. For very large umbilical herniae, the same methods used for large ventral herniae are used. Untreated umbilical hernia may acquire very large dimensions and become quite disabling. Like all herniae, the earlier treatment is instigated, the better.
Recurrence of Herniae
Recurrence of herniae does occur, but is becoming less and less frequent with the newer improved surgical methods and equipment. No doubt no matter how far the surgical profession advances, there will be operational failures. And since the abdominal wall is normally subjected to strain of many various types, such as coughing, sneezing, lifting, twisting, etc., the abdominal wall hernia will probably necessitate a repeated repair in an occasional case. The recurrence of a hernia after a surgical repair, as already mentioned, is quite rare. But should it occur, the repeat of an operation is best accomplished early.