What Is a Hernia?
A hernia occurs when the contents of a body cavity bulge out of the area where they are normally contained These contents, usually portions of intestine or abdominal fatty tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity


Hernia Causes
Although abdominal hernias can be present at birth, others develop later in life. Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia. Examples include obesity, heavy lifting, chronic cough ,straining during a bowel movement or urination, chronic lung disease, and fluid in the abdominal cavity. A family history of hernias can make you more likely to develop a hernia

Hernias by themselves may be asymptomatic, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency as the tissue needs oxygen which is transported by the blood supply.
 

Types of abdominal-wall hernias include the following:

Inguinal (groin) hernia: Making up 75% of all abdominal-wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into two different types, direct and indirect

Femoral hernia: The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) to protrude into the canal

Umbilical hernia: These common hernias occur in the naturally weakened area of the navel, where the umbilical cord was attached, and can affect both women and men as well children.

Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall. This flaw can create an area of weakness in which a hernia may develop. This occurs after 2%-10% of all abdominal surgeries, although some people are more at risk. Even after surgical repair, incisional hernias may return.

A hiatal hernia happens when the upper stomach squeezes through the hiatus, an opening in the diaphragm through which the esophagus passes

Other hernias; Spigelian hernia,Obturator hernia Epigastric hernia:
 

Symptoms and Signs
The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen (an incarcerated strangulated hernia).Irreducible hernia is painful enlargement of a previously reducible hernia that cannot be returned into the abdominal cavity on its own or when you push it. Signs and symptoms of bowel obstruction may occur, such as nausea and vomiting.Strangulated hernia is an irreducible hernia in which the entrapped intestine has its blood supply cut off. Pain is always present, followed quickly by tenderness and sometimes symptoms of bowel obstruction (nausea and vomiting).The affected person may appear ill with or without fever. This condition is a surgical emergency.


Management of hernia
In general, all hernias should be repaired unless severe preexisting medical conditions make surgery unsafe. to avoid the possibility of future intestinal strangulation.Treatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.

1. primary tissue repair
Primary tissue repair with out mesh have been the mainstay of hernia surgery for decades. Disadvantages include higher recurrence rates due to tension on repair and slower return to unrestricted physical activity.

2. tension free mesh repair ; hernia is repair with mesh, with out tension over fascia .this repair avoid the approximation of attenuated tissue under tension .and recurrence rates is less.

3. Laparoscopic repair ; Laparoscopic hernia repair also called as posterior hernia repair the advantage of posterior repair is that pressure from with in abdominal cavity actually help to hold the mesh in place.


It appears that the laparoscopic approach has several advantages:
- Tension free repair that reinforces the entire myo-pectoneal orifice.
- Less tissue dissection and disruption of tissue planes
- Three ports are adequate for all type of hernias
- Less pain postoperatively.
- Low intra-operative and postoperative complications.
- Early return to work.


Laparoscopic Ventral Hernia Repair

Incisional, Ventral, Epigastric, or Umbilical hernias are defects of the anterior abdominal wall. They may be congenital (umbilical hernia) or acquired (Incisional). These hernias present much the same way inguinal hernias do. That is, they present with a bulge near or at a previous incision. Some patients may experience discomfort, abdominal cramping or complete intestinal obstruction, or incarceration as a result of these hernias.

The principles governing a laparoscopic ventral hernia repair are based on those of open Stoppa ventral hernia repair. A large piece of prosthetic mesh is placed under the hernia defect with a wide margin of mesh outside the defect The mesh is anchored in to place with eight full thickness sutures and secured to the anterior abdominal wall with a varying number of tacs, placed laparoscopically.
A patient is a candidate for laparoscopic Incisional hernia repair if they are medically able to undergo general anesthesia.

 
Inguinal Hernia

What Is It?
When part of an organ protrudes through an abnormal opening or in an abnormal way, this is called a hernia. A groin (inguinal) hernia occurs when part of the intestine bulges through a weak spot in the abdominal wall at the inguinal canal. The inguinal canal is a passageway through the abdominal wall near the groin. Inguinal hernias are up to 10 times more common in men than in women. About one in four men develop a hernia at some point in life.

There are two types of inguinal hernias:
Indirect inguinal hernia — This occurs when the internal opening of the inguinal canal, which usually closes around the time of birth, remains open. This allows a portion of the intestine to slip through the inguinal canal. These hernias often are diagnosed within the first year of life, but may not show up until adulthood. This condition affects between 1% and 5% of normal newborns and up to 10% of premature infants.

Direct inguinal hernia — This occurs when a portion of the intestine protrudes through a weakness in the abdominal muscles along the wall of the inguinal canal. These are common in adults, but rarely occur in children.

In adults, direct and indirect inguinal hernias look and feel about the same. They can occur on one or both sides of the groin. Your doctor may not know which type of hernia you have until surgery is performed. However, both types of hernias are treated in a similar manner.

A type of hernia called a femoral hernia can appear similar to an inguinal hernia. Femoral hernias are much more common in women than in men. They may cause a lump that appears just below the groin and extends into the upper portion of the thigh. In a femoral hernia, a portion of the intestine protrudes through the passage that is normally used by large blood vessels (the femoral artery and vein) when they pass between the abdomen and the leg. Femoral hernias are most common in older, overweight women.


Symptoms
At first, an inguinal hernia either may not cause any symptoms or may cause only a feeling of heaviness or pressure in the groin. Symptoms are most likely to appear after standing for long periods, or when you engage in activities that increase pressure inside the abdomen, such as heavy lifting, persistent coughing or straining while urinating or moving the bowels.

As the hernia grows, it eventually causes an abnormal bulge under the skin near the groin. This bulge may become increasingly more uncomfortable or tender to the touch. As the hernia increases in size, a portion of herniated intestine may become trapped and unable to slide back into the abdomen. If this happens, there is a danger that the trapped intestine may twist and die because its blood supply is cut off. This causes severe pain and requires immediate treatment.


Diagnosis
Your doctor will review your symptoms and medical history. He or she will ask you when you first noticed the lump in your groin, whether it has become larger, and whether it hurts.
Doctors can diagnose most inguinal hernias by examining the area. Your doctor will look for an abnormal protrusion near your groin and will feel the area to check for a mass. Often, the protruding hernia can be pushed back temporarily into the abdomen with careful pressure. Your doctor may ask you to cough or strain, which may make the hernia easier to feel or see.
In some cases, your doctor may need to confirm the diagnosis with an ultrasound or computed tomography (CT) scan. In these procedures, painless sound waves or X-rays can distinguish a hernia from other causes of a mass in the groin area, such as an enlarged lymph node (swollen gland).


Expected Duration
An inguinal hernia will not heal on its own. It is likely to become larger and cause increased discomfort until it is repaired. Hernias that are not repaired can cause bowel obstruction or strangulation, which is when part of the intestine dies because its blood supply is cut off.


Prevention
Indirect hernias in children cannot be prevented. To reduce the risk of inguinal hernia as an adult, you can:
- Maintain a normal body weight.
- Exercise regularly to strengthen abdominal muscles.
- Avoid straining while defecating or urinating.
- Avoid lifting heavy objects.


Treatment
most hernias that cause symptoms or that become even a little larger should be repaired by a surgeon. While awaiting surgery, some people wear a device called a truss, which puts pressure on the hernia and may help relieve discomfort temporarily. Except in very rare cases, the truss should not be considered a long term solution. There are two basic types of hernia repair: open surgery or laparoscopic surgery. Both usually are done on an outpatient basis and take about one hour to complete.

Open surgery — Most inguinal hernias are repaired by open surgery with the patient under general or local anesthesia. After the surgeon makes an incision in the groin, he or she pushes the herniated tissue back into place and repairs the hernia opening with stitches. In many cases, a small piece of synthetic mesh material is used to reinforce the area to prevent another hernia.

Laparoscopic surgery — In laparoscopic hernia repair, a surgeon makes three small incisions in the abdominal wall and then inflates the abdomen with a harmless gas. The surgeon then inserts a laparoscope through the incisions. A laparoscope is a tube-like instrument with a small video camera and surgical instruments. While viewing the internal scene on a monitor, the surgeon pushes the herniated intestine back into place and repairs the hernia opening with surgical staples. Although this surgery seems attractive to many people, the long-term success rate is lower compared to open surgery. Laparoscopic surgery often causes less discomfort, and lets the person return to activities more quickly.

 
Laparoscopic inguinal hernia repair: there are two type of Laparoscopic repair in inguinal hernia

TAPP (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized.

TEP (Totally Extra Peritoneal) repair. The mesh is again placed in the pre-peritoneal space, but in this case, the space is accessed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. This is the procedure of choice for bilateral inguinal hernia repair.

In totally extra peritoneal repair of hernia main concern is to make an extra peritoneal space. The extra peritoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissection.

An Incision is made at the level of umbilicus and the anterior rectus sheath on the side of the hernia. A balloon dissector should be introduced with telescope and balloon is inflated for further dissection of the pre-peritoneal space. Two additional working ports of each 5mm are placed between umbilicus and pubic bone. Mesh in appropriate size usually 15X15 Cm is used.. Mesh should be fixed by stapler.

Advantage of Laparoscopic inguinal hernia repair over open hernia repair is that, early hernia on opposite side can be managed and both sides can be operated with only 3 ports. It appears that the laparoscopic approach has several advantages:

• Tension free repair that reinforces the entire myo-pectoneal orifice.

• Less tissue dissection and disruption of tissue planes

• Three ports are adequate for all type of hernias

• Less pain postoperatively.

• Low intra-operative and postoperative complications.

• Early return to work.

Incisional Hernia

What is an incisional hernia?
An incisional hernia result from a hole or defect in the layers of abdominal wall at the site of a previous surgical incision. The incidence of incisional hernia is less common after laparoscopic. surgery but it is a fairly common complication after laparotomy

Why and how incisional hernias develop?
During conventional open surgery an opening is made in abdominal layers which are closed by stitches. With time scar tissue forms creating a bond between the two sides of the previous incision. It is never as strong as normal tissue and can tear and. When the scar tissue gives way an incisional hernia, peritoneum protrudes, forming the sac. The content of intestine can pulled inside the sac. Wound infection after surgery is a common cause of incisional hernia because infection interferes with the normal healing process, result is a weaker scar. Obesity, Smoking, malnutrition, deficiency of vitamins chronic cough after operation, weight lifting after operation also contribute to hernias because they also interfere in normal tissue healing.

What are the methods of hernia repair?
The hernia can be repaired by either conventional or laparoscopic methods. Incisional Herniorrhaphy is a common operation that general surgeons perform. Laparoscopic Herniorrhaphy is being done at a time when Laparoscopic Cholecystectomy has shown definite benefits over the open technique.

What is the principle of laparoscopic repair of hernia?
We can imagine a bathtub. When we put the rubber stopper at the outlet and fill it with water, the water pressure pushes the stopper in place and keeps it fixed there. The more the water, the firmer is the stopper. Now, if we were to put the stopper from the outside. Then the water pressure in the tub is going to push the stopper out as the pressure increases. This is Pascal's law.

The same scenario can be imagined with placing a mesh on the hole where the hernia is. Is it going to be better fixed from outside or inside? Open surgery places it from outside and laparoscopic surgery places it from inside.

Is it more risky for patients with other medical problems?
The general anaesthesia and the pneumoperitoneum required as part of the laparoscopic procedure do increase the risk in certain groups of patients. Most surgeons would not recommend laparoscopic hernia repair in those with pre-existing disease conditions. Patients with Cardiac diseases and COPD should not be considered a good candidate for laparoscopy. The laparoscopic hernia repair may also be more difficult in patients who have had previous lower abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum.

What is the mesh made of?
There are several types of mesh used in hernia. Each of these materials is made of special kind of plastics that are compatible with living tissue. Surgeon will select the mesh that is best for the site and size of the incisional hernia.

How long does it take to do a laparoscopic hernia repair?
The laparoscopic herniorrhaphy generally takes an hour or two to perform, and most patient are able to return home within 48 hours of the surgery.

How safe is it to leave a mesh inside the body?
The mesh used is the same as the one used for open operations over last 30 years. Its safety and efficacy is beyond doubt as proved by the numerous trials all over the world.

Is this all very expensive? How can one justify the cost of the equipment and surgery?
The cost of laparoscopic equipment and instrument that is used to fix the mesh inside increases the cost of surgery. Unfortunately these are still imported and will remain expensive till they are locally produced. However, the increased cost should be compared with the gain associated by a quicker and more productive return to work by the majority of the patients. The hidden lowering of cost is due to less leave, early return to normal activity and work, and also from the greatly reduced disruption of the family routine.

What are the advantages of laparoscopic hernia repair?
Laparoscopic approach has several advantages:
1. Tension free repair.
2. Less tissue dissection and disruption of tissue planes
3. Less pain postoperatively.
4. Low intra-operative and postoperative complications.
5. Early return to work.

Appendicitis is swelling (inflammation) of the appendix. The appendix is a small pouch attached to the large intestine.

Signs and symptoms of appendicitis may include:

• Aching pain that begins around your navel and often shifts to your lower right abdomen

• Pain that becomes sharper over several hours

• Tenderness that occurs when you apply pressure to your lower right abdomen

• Sharp pain in your lower right abdomen that occurs when the area is pressed on and then the pressure is quickly released (rebound tenderness)

• Pain that worsens if you cough, walk or make other jarring movements

• Nausea

• Vomiting

• Loss of appetite

• Low-grade fever

• Constipation

• Inability to pass gas

• Diarrhea

• Abdominal swelling

The location of your pain may vary, depending on your age and the position of your appendix. Young children or pregnant women, especially, may have appendicitis pain in different places.

Appendicitis can cause serious complications, such as:

• A ruptured appendix. If your appendix ruptures, the contents of your intestines and infectious organisms can leak into your abdominal cavity. This can cause an infection of your abdominal cavity (peritonitis).

• A pocket of pus that forms in the abdomen. If your appendix has burst, infection and the seepage of intestinal contents may form an abscess — a pocket of infection (appendiceal abscess) around the appendix. Appendiceal abscess requires treatment before the abscess tears, causing a more widespread infection of the abdominal cavity.

The pain from appendicitis may change over time, so establishing a diagnosis can sometimes be difficult. In addition, abdominal pain can arise from a number of health problems other than appendicitis. To help diagnose appendicitis, your doctor will likely take a history of your signs and symptoms and perform a thorough physical examination of your abdomen.


Tests and procedures used to diagnose appendicitis include:

• Physical exam to assess your pain. Your doctor may apply gentle pressure on the painful area. When the pressure is suddenly released, appendicitis pain will often feel worse, signaling that the adjacent peritoneum is inflamed. Other signs your doctor may watch for include abdominal rigidity and a tendency to stiffen your abdominal muscles in response to pressure over the inflamed appendix (guarding).

• Blood test. This allows your doctor to check for a high white blood cell count, which may indicate an infection.

• Urine test. Your doctor may want you to have a urinalysis to make sure that a urinary tract infection or a kidney stone isn't causing your pain. If it is a kidney stone, red blood cells are usually seen during microscopic examination of the urine.

• Imaging tests. Your doctor may also recommend an abdominal X-ray, an ultrasound scan or a computerized tomography (CT) scan to help confirm appendicitis or find other causes for your pain.

Appendicitis treatment usually involves surgery to remove the inflamed appendix.


Surgery to remove the appendix (appendectomy)

Appendectomy can be performed as open surgery using one abdominal incision that's about 2 to 4 inches (5 to 10 centimeters) long. Or appendicitis surgery can be done as a laparoscopic operation, which involves a few small abdominal incisions. During a laparoscopic appendectomy, the surgeon inserts special surgical tools and a video camera into your abdomen to remove your appendix.

In general, laparoscopic surgery allows you to recover faster and heal with less scarring.

laparoscopic surgery mayn't appropriate for everyone.