Hernia - Standard Treatment Guidelines

A hernia is an area of weakness or disruption of the fibromuscular tissue of body wall. Often hernia is also defined as an actual anatomical weakness or defect. Strictly it is defined as “an abnormal protrusion of a viscus or a part of viscous through an opening artificial or natural with a sac covering it.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Hernia. Following are the major recommendations :

Incidence :

75% of the abdominal hernias are groin hernia.

15 % males and 5% females will develop groin hernia.

Femoral hernia incidence is 17%.

Incidence of Umbilical hernia is 8.5%.

Others type of hernias are seen in 1.5%.

These figures exclude incisional hernias which can form after any surgery through abdominal wall or lumbar area.

Differential Diagnosis

1. Hydrocele – Infantile, Encysted, Large vaginal and bilocular – absence of cough impulse, getting above the swelling and transillumination. The swelling is not reducible.


2. Undescended testis – the corresponding half of the scrotum is empty and underdeveloped.


3. Femoral Hernia- the sac is below and laterals to the pubic tubercle.


4. Lipoma of cord – the localized swelling moves with pulling of the spermatic cord. Cough impulse is absent and the swelling can not be reduced.


5. Groin abscess- May mimic small strangulated hernia. Signs of acute inflammation are present. Cough impulse is absent and it can not be reduced.

Prevention and Counseling

No specific preventive measures except in incisional hernia where various factor can lead to development of incisional hernia.

All patients having hernia other than direct inguinal hernia or hernia with wide neck are counseled to undergo surgery at the earliest convenience to prevent any chance of complications like obstruction and strangulation etc.

Optimal diagnostic criteria, Investigations, Treatment and referral criteria ( Situation 1 )

Clinical Diagnosis

A swelling in groin or abdominal wall exhibiting cough impulse and showing sign of reducibility is clinically diagnosed as hernia. The clinical spectrum includes :-

• Epigastric hernia exhibiting above features in a swelling in epigastric region.


• Umblical and para-umblical hernia- in umbilical and para-umblical area.


• Incisional hernia or ventral hernia


• Inguinal hernia ( Direct ,Indirect and Congenital hernia ) presenting in groin area.


• Femoral hernia also presenting as a swelling of variable dimension in groin area. In congenital hernia the inguino-scrotal swelling is present since birth or during childhood .

Investigations

In most of the cases practically no investigations are required to confirm the diagnosis of hernia. Clinical diagnosis is enough. Ultrasound of whole abdomen may be done in cases of hernia to rule out other abdominal pathology .

Treatment

In-Patient

Principles of Hernia surgery include reduction of hernia , excision of the sac and repair of wall. Repair may be done by suture or mesh.

• Congenital inguinal hernia is treated by herniotomy alone.


• Direct and indirect inguinal hernia is treated by herniorrhaphy or hernioplasty using a mesh by various techniques.


• Epigastric hernia with small defect may be treated by suture repair using double breasting technique . When the defect is large , hernioplasty using a mesh may be done.


• Umblical and Para-umblical hernia – approach is same as for epigastric hernia.


• Femoral hernia – Same principles of hernia repair are applied by High, Low or inguinal approach depending upon the case and expertise of surgeon.


• Incisional hernia – An anatomical repair or mesh repair may be considered depending upon individual case and expertise of the surgeon.

Out-patient – None

Day care – In appropriate situation and setting viz local anesthesia, small size hernia , patient residing within approachable distance etc . day care practice may be considered.

Referral Criteria

Referral can be considered from situation 1 in hernia only if the patient has associated severe co-morbidities requiring special care.

Optimal diagnostic criteria, Investigations, Treatment and referral criteria (Situation 2)

Clinical Diagnosis

A swelling in groin or abdominal wall exhibiting cough impulse and showing sign of reducibility is clinically diagnosed as hernia. The clinical spectrum includes :-

• Epigastric hernia exhibiting above features in a swelling in epigastric region.


• Umblical and para-umblical hernia- in umbilical and para-umblical area.


• Incisional hernia or ventral hernia


• Inguinal hernia ( Direct ,Indirect and Congenital hernia ) presenting in groin area.


• Femoral hernia also presenting as a swelling of variable dimension in groin area. In congenital hernia the inguino-scrotal swelling is present since birth or during childhood .

Investigations

In most of the cases practically no investigations are required to confirm the diagnosis of hernia. Clinical diagnosis is enough. Ultrasound of whole abdomen may be done in cases of hernia to rule out other abdominal pathology .

Treatment

In-Patient

Principles of Hernia surgery include reduction of hernia , excision of the sac and repair of wall. Repair may be done by suture or mesh.

• Congenital inguinal hernia is treated by herniotomy alone.


• Direct and indirect inguinal hernia is treated by herniorrhaphy or hernioplasty using a mesh by various techniques.


• Epigastric hernia with small defect may be treated by suture repair using double breasting technique . When the defect is large , hernioplasty using a mesh may be done.


• Umblical and Para-umblical hernia – approach is same as for epigastric hernia.


• Femoral hernia – Same principles of hernia repair are applied by High, Low or inguinal approach depending upon the case and expertise of surgeon.


• Incisional hernia – An anatomical repair or mesh repair may be considered depending upon individual case and expertise of the surgeon.


• In addition, patient can be offered laparoscopic repair , particularly in bilateral and recurrent hernia after informed patient consent provided that the infrastructure, equipment and expertise is available.

Out-patient – None

Day-care – In appropriate situation and setting viz local anesthesia, small size hernia , patient residing within approachable distance etc . day care practice may be considered.

Referral Criteria

None

Who does what ? and timelines

Doctor

The job of diagnosis, treatment including surgery, post-operative care and follow up.

Nurse

Pre-operative care, operative assistance, post-operative care, administration of treatment instructed by the doctor and monitoring as instructed.

Technician

Keeps all machines and equipments in order and assist the anesthetist during operation.

Further reading

1. Bailey & Love’s Short Practice of Surgery


2. Schwartz’s Textbook of Surgery


3. Abdominal Operations by Maingot

Resources required for one patient/procedure

Guidelines by The Ministry of Health and Family Welfare :

Dr Ajit Sinha Department of Surgery Safdarjung Hospital New Delhi