Hernias

Key Points

• Hernias are defects in the connective tissue of the abdominal wall which allow tissue within the abdominal cavity to protrude.

• Often hernias do not require treatment. They can be monitored, and the patient can be instructed to report changes in the hernia or the development of symptoms.

• An incarcerated hernia is a hernia for which the protruding tissue gets "stuck" (the tissue cannot be pushed back in). This requires urgent assessment and treatment.

• The definitive treatment for a hernia is surgical correction.

 

What is a hernia? 

A good definition of a hernia is found on the Cleveland Clinic website :

"A hernia occurs when part of your insides bulges through an opening or weakness in the muscle or tissue that contains it. Most hernias involve one of your abdominal organs pushing through one of the walls of your abdominal cavity." 

A hernia usually causes a noticeable lump. Hernias may be uncomfortable, but many people do not have symptoms.

There are other kinds of hernias that occur within the abdominal cavity, but they are different than the hernias being discussed and will not be addressed in this article.

 

Are hernias more common in people with Down syndrome?

Hernias may be more common in people with Down syndrome. This statement is based on our experience, but we have not found research that confirms our clinical experience. We suspect hernias may be more common in people with Down syndrome due to differences in connective tissue (the tissue that “holds us together”).

 

Where do hernias occur?

In people with Down syndrome, the common areas for hernias include: 

• Inguinal (in the groin; seen more commonly in men)

• Umbilical (at the umbilicus or belly button)

• Epigastric or ventral (in the abdominal area above and sometimes below the umbilicus)

• At the site of a previous abdominal surgery

Femoral hernias occur in the lower abdominal area near the thigh. They are less common.

 

Do hernias need to be treated?

Many people have a hernia for years that does not require treatment. In these individuals, the hernias are not causing symptoms (such as pain) and the person “just lives with it.” The person with the hernia can be instructed to report any changes, and the primary health care provider can monitor it regularly. If the hernia is getting larger and especially if it is causing discomfort, it should be reported to the health care provider, and further evaluation is indicated. Femoral hernias are the exception. They have a higher risk of causing complications and surgery should be considered when they are diagnosed.

Some individuals will pursue treatment because the hernia is large, it is bothersome or obtrusive, or it is their personal preference to have it repaired. Sometimes people with Down syndrome and their families choose to have it treated because the person has limited ability to report symptoms of discomfort or communicate if it were to become urgently worse (see incarcerated hernia below).

Pain can be a sign that a hernia is more at risk for tissue protruding through the defect and getting stuck (not being able to push it back in through the hernia). When the tissue is pushed back in, it is called “reducing” the hernia. When the person is having intermittent, recurrent pain, a consultation with a surgeon is indicated to discuss possible surgery.

The urgent situation when the tissues become “stuck” and cannot be pushed back in is called an incarcerated hernia. This is a serious condition that requires urgent assessment and treatment. Sometimes, lying down can reduce the pressure in the abdomen and allow the tissue to go back through the hernia. However, if the tissue is truly “stuck,” the typical symptoms include:

• The protruding tissues cannot be pushed back through the hernia even when the person lies down.

• There is pain at the hernia and the pain tends to increase progressively and rapidly and can become severe.

• The site may change colors (become red, purple, or blue), swollen, and very tender.

If the blood supply to the protruding tissue is compromised because it is "stuck" and swelling has occurred, it can become strangulated (the blood supply to the tissue is reduced or stopped altogether). 

 

How is a hernia diagnosed?

Hernias are typically diagnosed by listening to the patient’s history and doing a physical examination. The health care provider can usually feel a hernia with his/her hands. However, sometimes, an imaging study (usually a CT scan or ultrasound) may be necessary to determine whether a bulge is really a hernia (rather than a mass in the abdominal wall, for example).

 

What is the treatment for a hernia?

For hernias that are not causing symptoms, monitoring, as noted above, may be sufficient. Avoiding heavy lifting may be helpful to prevent the hernia from getting larger and possibly to limit the chance it will become incarcerated. 

Some individuals will use a hernia truss or belt. These devices help reduce tissue protruding through the hernia. They can reduce the size and discomfort. They are mostly used by people for whom their other health problems make surgical treatment too high risk.

When indicated, the definitive treatment of a hernia is surgery. There are a variety of surgical techniques that a surgeon can use. Surgeons select a technique based on the findings of the evaluation, the overall health of the patient, the person’s tolerance of surgery, and the location of the hernia. Some considerations to discuss with the surgeon include:

• Length of stay: same-day surgery (go home the same day) vs. spending one to several days in the hospital

• Laparoscopic surgery (done with a scope) vs. an open procedure

• Use of mesh to prevent the hernia from recurring. During the procedure, a device called mesh may be inserted to strengthen the abdominal wall and reduce the chance of the hernia recurring.

Many of the individuals seen at our Center will go home the same day. In addition, for many, the surgery can be done laparoscopically, which often reduces the time for recovery. We have noted that our patients are more likely to have their hernias repaired with mesh if it is difficult to pull the connective tissue together to close the defect during the surgery and/or the hernia is recurrent.

Unfortunately, after a hernia is repaired, it does sometimes recur. Our clinical experience is that hernias may be more likely to recur in people with Down syndrome after surgical repair, possibly due to connective tissue differences as described above.

If a hernia becomes incarcerated or strangulated, it is considered a surgical emergency and requires immediate assessment and treatment. Often, emergency surgery is recommended.

 

What about after surgery?

After surgery, the person generally needs to limit work and other activities for several days to several weeks. The surgery team will provide appropriate guidance based on the individual needs and condition of the patient.

 

For more information: Mayo Clinic Q and A: Abdominal Hernias Do Not Go Away on Their Own .