Hernia: Wikis

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  • "The Flying Parson" Gil Dodds, record holder in the mile run in the 1940s, suffered a hernia in high school and ran with a truss to protect himself?

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Hernia
Classification and external resources

Frontal chest X-ray showing a hernia of Morgagni
ICD-10 K40-K46
ICD-9 550-553
MedlinePlus 000960
eMedicine emerg/251 ped/2559
MeSH D006547

A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards into the mediastinum through the esophageal opening in the diaphragm.

By far the most common herniae develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica.

Herniae may or may not present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed by or accompanied by an organ.

Most of the time, herniae develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened.

  • Weakening of containing membranes or muscles is usually congenital (which explains part of the tendency of herniae to run in families), and increases with age (for example, degeneration of the annulus fibrosus of the intervertebral disc), but it may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during pregnancy, losing weight in obese people, etc., or because of scars from previous surgery.
  • Many conditions chronically increase intra-abdominal pressure, (pregnancy, ascites, COPD, dyschezia, benign prostatic hypertrophy) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation.

Contents

Characteristics

Hernias can be classified according to their anatomical location:

Examples include:

  • abdominal hernias,
  • diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach)
  • pelvic hernias, for example, obturator hernia
  • anal hernias
  • hernias of the nucleus pulposus of the intervertebral discs
  • intracranial hernias
  • Spigelian hernia [1]

Each of the above hernias may be characterized by several aspects:

  • congenital or acquired: congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistentiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in COPD) provoke the hernia.
  • complete or incomplete: for example, the stomach may partially or completely herniate into the chest.
  • internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
  • intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produce less obvious bulging, and may be less easily detected on clinical examination.
  • bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
  • irreducible (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.

If irreducible, hernias can develop several complications (hence, they can be complicated or uncomplicated):

  • strangulation: pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and later necrosis and gangrene, which may become fatal.
  • obstruction: for example, when a part of the bowel herniates, bowel contents can no longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation.
  • dysfunction: another complication arises when the herniated organ itself, or surrounding organs, start to malfunction(for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing sciatic nerve pain, etc.).

Treatment

It is generally advisable to repair hernias quickly in order to prevent complications such as organ dysfunction, gangrene, multiple organ dysfunction syndrome, and death. Most abdominal hernias can be surgically repaired, and recovery rarely requires long-term changes in lifestyle. Uncomplicated hernias are principally repaired by pushing back, or "reducing", the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy). If complications have occurred, the surgeon will check the viability of the herniated organ, and resect it if necessary.

Modern muscle reinforcement techniques involve synthetic materials (a mesh prosthesis) that avoid over-stretching of already weakened tissue (as in older, but still useful methods). The mesh is either placed over the defect (anterior repair) or more preferably under the defect (posterior repair). At times staples are used to keep the mesh in place. These mesh repair methods are often called "Tension Free" repairs because, unlike older traditional methods, muscle is not pulled together under tension.

Evidence based testing initially suggested that these Tension Free methods have the lowest percentage of recurrences and the fastest recovery period compared to older suture repair methods. However, prosthetic mesh usage seems to have a high incidence of infection with mesh usage becoming a study topic for the National Institutes of Health.[2]

One study attempted to identify the factors related to mesh infections and found that compromised immune systems (such as diabetes) was a factor.[3] Mesh has also become the subject of recalls and class action lawsuits.[4]

Increasingly, some repairs are performed through laparoscopes.

Laparoscopic surgery is also referred to as "minimally invasive" surgery, which requires one or more small incisions for the camera and instruments to be inserted, as opposed to traditional "open" or "microscopic" surgery, which requires an incision large enough for the surgeon's hands to be inserted into the patient. The defensive and misleading term microscopic surgery refers to the magnifying devices used during open surgery.

US Navy surgeon performs a hernia repair surgery while at sea

Many patients are managed through day surgery centers, and are able to return to work within a week or two, while intensive activities are prohibited for a longer period. Patients who have their hernias repaired with mesh often recover in a number of days. Surgical complications have been estimated to be up to 10%, but most of them can be easily addressed. They include surgical site infections, nerve and blood vessel injuries, injury to nearby organs, and hernia recurrence.

Generally, the use of external devices to maintain reduction of the hernia without repairing the underlying defect (such as hernia trusses, trunks, belts, etc.), is not advised. Exceptions are uncomplicated incisional hernias that arise shortly after the operation (should only be operated after a few months), or inoperable patients.

It is essential that the hernia not be further irritated by carrying out strenuous labour.

Individual hernias

A sportman's hernia is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal, although a true hernia is not present.

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Inguinal hernia

Diagram of an indirect, scrotal inguinal hernia (median view from the left).

By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Much insight is needed in the anatomy of the inguinal canal. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. Femoral hernias occur more often in women than men, but women still get more inguinal hernias than femoral hernias.

Femoral hernia

Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.

Umbilical hernia

Umbilical hernias are especially common in infants of African descent, and occur more in boys. They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute.

Incisional hernia

An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.

Diaphragmatic hernia

Diagram of a hiatus hernia (coronal section, viewed from the front).

Higher in the abdomen, an (internal) "diaphragmatic hernia" results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.

A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional "defect", allowing part of the stomach to (periodically) "herniate" into the chest. Hiatus hernias may be either "sliding," in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding (also known as para-esophageal), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.

A congenital diaphragmatic hernia is a distinct problem, occurring in up to 1 in 2000 births, and requiring pediatric surgery. Intestinal organs may herniate through several parts of the diaphragm, posterolateral (in Bochdalek's triangle, resulting in Bochdalek's hernia), or anteromedial-retrosternal (in the cleft of Larrey/Morgagni's foramen, resulting in Morgagni-Larrey hernia, or Morgagni's hernia).

Other abdominal/inguinal hernias

Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with "visceral hernias", where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:

  • Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing almost immediately beneath the skin.
  • Epigastric hernia: a hernia through the linea alba above the umbilicus.
  • Hiatal hernia: a hernia due to "short oesophagus" - insufficient elongation - stomach is displaced into the thorax
  • Littre's hernia: a hernia involving a Meckel's diverticulum. It is named after the French anatomist Alexis Littre (1658-1726).
  • Lumbar hernia (Bleichner's Hernia): a hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains the following entities:
    • Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674-1750).
    • Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840-1913).
  • Obturator hernia: hernia through obturator canal
  • Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels
  • Paraesophageal hernia
  • Paraumbilical hernia: a type of umbilical hernia occurring in adults
  • Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually, is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.
  • Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.
  • Richter's hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (1742-1812).
  • Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.
  • Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of sciatic neuralgia.
  • Spigelian hernia, also known as spontaneous lateral ventral hernia
  • Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal.
  • Velpeau hernia: a hernia in the groin in front of the femoral blood vessels
  • Amyand's Hernia: containing the appendix vermiformis within the hernia sac

Complications

Complications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area. Continuous discharge from the scar is likely for a while after the mesh has been removed.

An untreated hernia may complicate by:

Massage

Massage is locally contraindicated for unreduced hernias, and systemically contraindicated for unreduced hernias that show signs of infection. For recent surgeries, postoperative protocols should be observed. For old hernia surgeries, massage is indicated.

References

  • Surgical recall, 2nd edition, by Lorne. H. Blackbourne, published by Lippincott Williams & Wilkins
  • Sabiston textbook of surgery, 17th edition, Townsend et al.(e.d.), Elsevier-Saunders
  1. ^ 9. Bittner JG, Edwards MA, Shah MB, MacFadyen BV, Mellinger JD. Mesh-free laparoscopic Spigelian hernia repair. Am Surg 2008; 74(8):713-720.
  2. ^ http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=427896
  3. ^ http://www.uptodate.com/patients/content/topic.do?topicKey=~AewAWy90g.DiQX
  4. ^ http://www.usdrugrecall.com/category/kugel-hernia-patch-recall

External links

Pictures


1911 encyclopedia

Up to date as of January 14, 2010

From LoveToKnow 1911

Medical warning!
This article is from the 1911 Encyclopaedia Britannica. Medical science has made many leaps forward since it has been written. This is not a site for medical advice, when you need information on a medical condition, consult a professional instead.

HERNIA (Lat. hernia, perhaps from Gr. g pvos, a sprout), in surgery, the protrusion of a viscus, or part of a viscus, from its normal cavity; thus, hernia cerebri is a protrusion of brainsubstance, hernia pulmonum, a protrusion of a portion of lung, and hernia iridis, a protrusion of some of the iris through an aperture in the cornea. But, used by itself, hernia implies a protrusion from the abdominal cavity, or, in common language, a "rupture." A rupture may occur at any weak point in the abdominal wall. The common situations are the groin (inguinal hernia), the upper part of the thigh (femoral hernia), and the navel (umbilical hernia). The more movable the viscus the greater the liability to protrusion, and therefore one commonly finds some of the small intestine, or of the fatty apron (omentum) in the hernia. The tumour may contain intestine alone (enterocele), omentum alone (epiplocele), or both intestine and omentum (entero-epiplocele). The predisposing cause of rupture is abnormal length of the suspensory membrane of the bowel (the mesentery), or of the omentum, in conjunction with some weak spot in the abdominal wall, as in an inguinal hernia, which descends along the canal in which the spermatic cord lies in the male and the round ligament of the womb in the female. A femoral hernia comes through a weak spot in the abdomen to the inner side of the great femoral vessels; a ventral hernia takes place by the yielding of the scar tissue left after an operation for appendicitis or ovarian disease. The exciting cause of hernia is generally some over-exertion, as in lifting a heavy weight, jumping off a high wall, straining (as in difficult micturition), constipation or excessive coughing. The pressure of the diaphragm above and the abdominal wall in front acting on the abdominal viscera causes a protrusion at the weakest point.

Rupture is either congenital or acquired. A child may be born with a hernia in the inguinal or umbilical region, the result of an arrest of development in these parts; or the rupture may be acquired, first appearing, perhaps, in adult life as the result of a strain or hurt. Men suffer more frequently than women, because of their physical labours, because they are more liable to accidents, and because of the passage for the spermatic cord out of the abdomen being more spacious than that for the round ligament of the womb.

At first the rupture is small, and it gradually increases in bulk. It varies from the size of a marble to a child's head. The swelling consists of three parts - the coverings, sac and contents. The "coverings" are the structures which form the abdominal wall at the part where the rupture occurs. In femoral hernia the coverings are the structures at the upper part of the thigh which are stretched, thinned and matted tog-ether as the result of pressure; in other cases there is an increase in their thickness, the result of repeated attacks of inflammation. The "sac" is composed of the peritoneum or membrane lining the abdominal cavity; in some rare cases the sac is wanting. The neck of the sac is the narrowed portion where the peritoneum forming the sac becomes continuous with the general peritoneal cavity. The neck of the sac is often thickened, indurated and adherent to surrounding parts, the result of chronic inflammation. The "contents" are bowel, omental fat, or, in children, an ovary.

The hernia may be reducible, irreducible or strangulated. A "reducible" hernia is one in which the contents can be pushed back into the abdomen. In some cases this reduction is effected with ease, in others it is a matter of great difficulty. At any moment a reducible hernia may become "irreducible," that is to say, it cannot be pushed back into the abdominal cavity, perhaps because of inflammatory adhesions in and around the fatty contents, or because of extra fullness of the bowel in the sac. A "strangulated" hernia is one in which the circulation of the blood through the hernial contents is interfered with, by the pinching at the narrowest part of the passage. The interference is at first slight, but it quickly becomes more pronounced; the pinched bowel in the hernial sac swells as a finger does when a string is tightly wound round its base. At first there is congestion, and this may go on to inflammation, to infection by micro-organisms and to mortification. The rapidity with which the change from simple congestion to mortification takes place depends on the tightness of the constriction, and on the virulence of the bacterial infection fiom the bowel. As a rule, the more rapidly a hernia forms the greater the rapidity of serious change in the conditions of the bowel or omentum, and the more urgent are the symptoms. The constricting band may be one of the structures which form the boundaries of the openings through which the hernia has travelled, or it may be the neck of the sac, which has become thickened in consequence of inflammation - especially is this the case in an inguinal hernia.

Reducible Hernia

With a reducible hernia there is a soft compressible tumour (elastic when it contains intestine, doughy when it contains omentum), its size increasing in the erect, and diminishing in the horizontal posture. As a rule, it causes no trouble during the night. It gives an impulse on coughing, and when the intestinal contents are pushed back into the abdomen a gurgling sensation is perceptible by the fingers. Such a tumour may be met with in any part of the abdominal wall, but the chief situations are as follows. The inguinal region, in which the neck of the tumour lies immediately above Poupart's ligament (a cord-like ligamentous structure which can be felt stretching from the front of the hip-bone to a ridge of bone immediately above the genital organs); the femoral region, in the upper part of the thigh, in which the neck of the sac lies immediately below the inner end of Poupart's ligament; the umbilical region, in which the tumour appears at or near the navel. As the inguinal hernia increases in size it passes into the scrotum in the male, into the labium in the female; while the femoral hernia gradually pushes upwards to the abdomen.

The palliative treatment of a reducible hernia consists in pushing back the contents of the tumour into the abdomen and applying a truss or elastic bandage to prevent their again escaping. The younger the patient the more chance there is of the truss acting as a curative agent. The truss may generally be left off at night, but it should be put on in the morning before the patient leaves his bed. If, after the hernia has been once returned, it is not allowed again to come down, there is a probability of an actual cure taking place; but if it is allowed to come down occasionally, as it may do, even during the night, in consequence of a cough, or from the patient turning suddenly in bed, the weak spot is again opened out, and the improvement which might have been going on for weeks is undone. It is sometimes found impossible to keep up a hernia by means of a truss, and an operation becomes necessary. The operation is spoken of as "the radical treatment of hernia," in contradistinction to the so-called "palliative treatment" by means of a truss. It should not be spoken of as the radical cure, for skilfully as the operation may have been performed it is not always a cure. The principles involved in the operation are the emptying of the sac and its entire removal, and the closure of the opening into the abdomen by strong sutures; and, in this way, great advance has been made by modern surgery. Without tiresome delay, and the tedious and sometimes disappointing application of trusses, the weak spot in the abdominal wall is exposed, the sac of the hernia is tied and removed, and the canal by which the rupture descended is blockaded by buried sutures, and with no material risk to life. Thus the patient's worries become a thing of the past, and he is rendered a fit and normal member of society. Experience has shown that very few ruptures are unsuited for successful treatment by operation. No boy should now be sent to school compelled to wear a truss, and so hindered in his games and rendered an object of remark.

Irreducible Hernia

The main symptom is a tumour in one of the situations already referred to, of long standing and perhaps of large size, in which the contents of the tumour, in whole or in part, cannot be pushed back into the abdomen. The irreducibility is due either to its large size or to changes which have taken place by indurations or adhesions. Such a tumour is a constant source of danger: its contents are liable, from their exposed situation, to injury from external violence; it has a constant risk of increase; it may at any time become strangulated, or the contents may inflame, and strangulation may occur secondarily to the inflammation. It gives rise to dragging sensations (referred to the abdomen), colic, dyspepsia and constipation, which may lead to obstruction, that is to say, a stoppage may occur of the passage of the contents of that portion of the intestinal canal which lies in the hernia. When an irreducible hernia becomes painful and tender, a local peritonitis has occurred, which resembles in many of its symptoms a case of strangulation, and must be regarded with suspicion and anxiety. Indeed, the only safe treatment is by operation.

The treatment of irreducible hernia may be palliative; a "bag truss" may be worn in the hope of preventing the hernia getting larger; the bowels must be kept open, and all irregularities of diet avoided. A person with such a hernia is in constant danger, and if his general condition does not contra-indicate it he should be submitted to operative treatment. That is to say, the surgeon should cut down on the hernia, open the sac, divide any omental adhesions, tie and cut away indurated omentum, return the bowel, and complete the radical operation by closing the aperture by strong sutures.

In Strangulated Hernia the bowel or omentum is being nipped at the neck of the sac, and the flow of blood into and from the delicate tissues is stopped. The ` symptoms are - nausea, vomiting of bilious matter, and after a time of faecal-smelling matter; a twisting, burning pain generally referred to the region of the navel, intestinal obstruction; a quick, wiry pulse and pain on pressure over the tumour; the expression grows anxious, the abdomen becomes tense and drum-like, and there is no impulse in the tumour on coughing, because its contents are practically pinched off from the general abdominal cavity. Sometimes there is complete absence of pain and tenderness in the hernia itself, and in an aged person all the symptoms may be very slight. Sooner or later, from eight hours to eight days, if the strangulation is unrelieved, the tumour becomes livid, crackling with gas, mortification of the bowel at the neck of the sac takes place, followed by extravasation of the intestinal contents into the abdominal cavity; the patient has hiccough; he becomes collapsed; and dies comatose from blood-poisoning.

The treatment of a strangulated hernia admits of no delay; if the hernia does not "go back" on the surgeon trying to reduce it, it must be operated on at once, the constriction being relieved, the bowel returned and the opening closed. There should be no treatment by hot-bath or ice-bag: operation is urgently needed. An anaesthetic should be administered, and perhaps one gentle attempt to return the contents by pressure (termed "taxis") may be made, but no prolonged attempts are justi fiable, because the condition of the hernial contents may be such that they cannot bear the pressure of the fingers. "Think well of the hernia," says the aphorism, "which has been little handled." The taxis to be successful should be made in a direction opposite to the one in which the hernia has come down. The inguinal hernia should be pressed upwards, outwards and backwards, the femoral hernia downwards, backwards and upwards. The larger the hernia the greater is the chance of success by taxis, and the smaller the hernia the greater the risk of its being injured by manipulation and delay. In every case the handling must be absolutely gentle. If taxis does not succeed the surgeon must at once cut down on the tumour, carefully dividing the different coverings until he reaches the sac. The sac is then opened, the constriction divided, care being taken not to injure the bowel. The bowel must be examined before it is returned into the abdomen, and if its lustreless appearance, its dusky colour, or its smell, suggests that it is mortified, or is on the point of mortifying, it must not be put back or perforation would give rise to septic peritonitis which would probably have a fatal ending. In such a case the damaged piece of bowel must be resected and the healthy ends of the bowel joined together by fine suturing. Matted or diseased omentum must be tied off and removed. Should peritonitis supervene after the operation on account of bacillary infection, the bowels should be quickly made to act by repeated doses of Epsom salts in hot water.

A person who is the subject of a reducible hernia should take great care to obtain an accurately fitting truss, and should remember that whenever symptoms resembling in any degree those of strangulation occur, delay in treatment may prove fatal. A surgeon should at once be communicated with, and he should come prepared to operate. (E. O.*)


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Simple English

A hernia is a condition where an organ or tissue goes into places in the human body that it is not normally in. Most hernias happen in the abdomen. Hernias sometimes give pain and a lump that can be felt. The cause can be hereditary or it can be from lifting objects in a wrong way. There are other things that can give hernias as well.


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