The young man was about 30 years old and had been a wrestler in college.  He was very strong.  He had a weight lifting program in which he would do “squats”.  This is an exercise where he would put the barbell on his shoulder and then do knee bends.  He was aware that there was a slight protrusion of flesh around his belly button and this seemed to become more prominent when he had been lifting heavily.  He had been told that he had an “umbilical hernia” and that he should get this fixed “some day”.

     A hernia can be thought of as a hole.  It is a hole through which the contents of one part of the body are pushed into another place where they don’t belong.  An example would be an umbilical hernia in which there is a defect in the abdominal wall and intestines can be forced out to a position under the skin.  When a person with a hernia strains they can push the intestines out through that hole in the abdominal wall.  Most of the time when the person relaxes, the intestine will go back inside the abdomen and nothing bad happens.  The bigger the hole in the abdominal wall, the more likely it is that the intestines will slip back into the abdominal cavity easily and nothing bad happens.

     But if the hole in the abdominal wall is still small and the pressure pushing intestines out is big enough, the intestine can get pushed out through the hernia and wedge outside the abdominal cavity.  When this happens, that part of the intestine, which is pushed out of the abdominal cavity, doesn’t get enough blood and it begins to die which is very painful.

     To continue the story above, the young man was doing his squat lifts and had part of his intestine pushed out through the umbilical hernia that he had.  He was lifting very heavily and part of the intestine got wedged outside the abdominal cavity.  It wasn’t getting enough blood and began to hurt so he came to the emergency room.  In the emergency room, the diagnosis of a strangulated hernia was easy to make.  The question was how to help alleviate his pain.  Sometimes the herniated intestine can be gently massaged back into the abdominal cavity and this was attempted but was unsuccessful.  In x-ray, a CAT scan of the abdomen was done and demonstrated that the hernia cross section was only about 1 inch but the abdominal cavity material pushed out through the hole in the abdominal wall was almost 3 inches in diameter.

Now this became an emergency surgery situation.  He was taken to the operating room and the hernia was repaired.  There were no complications and he went home the next day.

     The above story illustrates a definite time when the hernia should be fixed.  Rule #1:  Fix it when it still small and in danger of causing a strangulation.  If a person has a strangulated hernia but makes the mistake of thinking that they just have a little indigestion, the herniated intestine can die and recovery from the needed surgery takes much longer.  Occasionally, we run into somebody who waits way too long and the herniated intestine dies, becomes infected and causes blood poisoning, which can be fatal.

When is the right time to fix a hernia?  Usually hernias start small and slowly increase in size.  As a hernia increases in size there is a slight tearing along the edges of the developing hole.  This is slightly painful but is often not bothersome enough for the person to seek medical attention.  Finally, one day the hole gets big enough so intestinal contents can get pushed through the hole.  This is the most dangerous time in the course of a hernia.  This is the time when the intestinal contents can get wedged into small hole and get strangulated.  This is also the easiest time to fix the hernia.  In answer to the above question, a hernia should be fixed as it is developing and causing painful symptoms.  Don’t wait until it strangulates and emergency surgery is required.

     Other common places where hernias may occur are in the groin area where the pressure on the abdominal wall is the greatest and there is a natural small hole in the abdominal wall where the testicles descend into the scrotal sac.  Hernias in this area are perhaps the most common type.  The rules for fixing them are the same as above.  The other type of abdominal wall hernia is that which occurs after a surgical procedure and the incision breaks down postoperatively.

     Sometimes, people let hernias go until they are very large.  As a general rule, the larger the hernia, the less likely it is that the intestinal contents going through the hernia will strangulate.  Intestinal contents can go back and forth through a large hole much easier than they can through a little one.  Thus, the reason to fix the large hernia is “cosmetic” or if the hernia provides an inconvenience or discomfort.  Fixing very large hernias is a trickier business and requires the use of a patch material sown over the hole.  The problem is that the area to which the patch is sewn is often weak with a breakdown of the area that patch is sown onto the abdominal wall.  Recurrence of the hernia is relatively frequent.  Thus the rule sited above is reinforced here.  Hernias should be fixed early if possible.

     The last type of hernia to talk about is called a “hiatal hernia”. The diaphragm forms the top of the abdominal wall.  The swallowing pipe (esophagus) goes through a hole that is naturally present in the diaphragm.  As a person grows older, this hole naturally tends to get a little larger and by the time people are 50 years old there is a 40% incidence of a hernia in the diaphragm big enough to let the stomach come out of the abdominal cavity and end up partially up in the chest.  Thus a person winds up with an “hour glass” stomach, which can lead to a great deal of indigestion, excessive burping, and even vomiting.  Symptomatic hiatal hernias are best dealt with through small feedings, weight loss, and remaining in an upright position after eating.  When these measures are not effective in alleviating the person’s symptoms, there are surgical procedures to close the hole in the diaphragm to prevent the stomach from herniating up into the chest.  This is a very involved surgery, not always a success.  It is reserved for individuals who have uncontrollable symptoms or bleeding from the stomach being caught above the diaphragm.

     The young man described above was told that he now had a Dacron mesh applied over the hole in his abdominal wall.  It would grow into place over the course of several weeks and then be stronger than the rest of his abdominal wall.  He wanted to know if he could go on exercising as he had.  He was told that after 2 weeks, his activity limitations would be his own.

     In summary, hernias should be fixed early when they are developing and symptomatic.  This is the time when they are the most dangerous to strangulate and require emergency surgery.  Once a hernia becomes very large, repairing it is much more difficult but at that point, generally the hernia’s risk of strangulation is much less and not as dangerous.