What Is an Abdominal Wall Hernia? Symptoms, Causes, and Surgery of Inguinal Hernia

An abdominal wall hernia occurs when abdominal tissue protrudes through a weak spot in the muscles. Inguinal hernia is the most common type, presenting with swelling and discomfort in the groin area. Without treatment, hernias may enlarge or lead to severe complications such as strangulation.

Typical symptoms of an abdominal wall hernia include a visible bulge, pain that worsens with activity, and pressure in the affected region. Some patients experience only mild discomfort, while others develop acute pain, nausea, or vomiting, especially in complicated hernia cases.

The main causes of abdominal wall hernia are congenital weakness, increased intra-abdominal pressure, and trauma. Risk factors include obesity, chronic coughing, constipation, pregnancy, and heavy lifting. Preventive strategies focus on lifestyle changes and reducing abdominal strain.

Surgical repair is the only definitive treatment for hernias. Both open and laparoscopic approaches are used, often with mesh reinforcement to prevent recurrence. Surgery not only relieves symptoms but also eliminates the risk of incarceration and strangulation, ensuring long-term health benefits.

What Are Abdominal Wall Hernias?

An abdominal wall hernia is the outward protrusion of an organ or tissue through a weakness or opening in the muscles or connective tissue that form the abdominal wall. When a gap or area of decreased strength develops in this otherwise solid muscle layer, it allows the underlying structures to bulge outward. Often this bulge involves the peritoneum – the membrane lining the abdominal cavity – which forms a sac-like structure known as the hernia sac. Segments of intestine, fatty tissue, or even part of the stomach can then enter this sac.

Abdominal wall hernias develop for a variety of reasons. Some people are born with weaknesses in their abdominal muscles (congenital). In others, these weaknesses arise over time due to natural wear and tear associated with aging. Injuries or surgical procedures can also disrupt the integrity of the abdominal wall, creating opportunities for hernias. Activities that raise intra-abdominal pressure, such as heavy lifting or strenuous effort, typically make an existing hernia more noticeable even though they are seldom the primary cause of the initial weakness. These hernias can appear in different places on the abdomen – in the groin, along the midline, or at the site of a previous surgical incision. This report focuses on hernias that originate in the abdominal wall itself; other types, such as internal hernias within the abdominal cavity and diaphragmatic hernias involving the diaphragm, are not the primary focus here.

Involvement of the peritoneum is a key aspect of how an abdominal wall hernia develops. When a weakness exists in the muscular layer, pressure inside the abdomen can force the peritoneum outward through this weak spot, creating a small pouch or sac. Other intra-abdominal contents can then be pushed into this pouch, producing the characteristic visible bulge of a hernia. A notable feature is that some hernias appear and disappear with changes in activity. When intra-abdominal pressure rises – as when a person stands, coughs, or strains – the abdominal contents are more likely to push through the weakness. When pressure falls – as when lying down – the contents may slip back into their normal positions. This dynamic behavior depends largely on the size of the defect and the specific contents of the hernia. While activities such as lifting heavy objects or straining seldom cause the original defect, they can significantly worsen an existing hernia by forcing more tissue through the weak spot or by enlarging a previously small hernia.

What Are the Different Types of Abdominal Wall Hernias?

The main types include inguinal, umbilical, incisional, epigastric, Spigelian, and femoral hernias. These categories are based on their anatomical location and reflect potential weak areas in the abdominal wall.

• Inguinal Hernias: The most common type, occurring in the groin, usually along the inguinal canal above the inguinal ligament. Far more frequent in men. Classified as direct or indirect based on their exact position within the canal. Seen in about 25 % of men and 2 % of women.
• Umbilical Hernias: Develop at or near the navel where the umbilical cord once attached. Very common in infants and often close spontaneously within the first few years. They can also occur in adults, especially in women. Account for 10–15 % of adult abdominal wall hernias.
• Incisional Hernias: Arise at the site of a previous abdominal surgery where the wall is weakened. May appear soon after surgery or develop gradually over months or years. Make up about 10–15 % of abdominal wall hernias and occur in up to 15 % of abdominal operations.
• Epigastric Hernias: Found in the upper abdomen between the breastbone and navel along the linea alba. Usually small and often contain only fatty tissue. Less common than other types.
• Spigelian Hernias: Rare – occur through the Spigelian fascia on the side of the rectus sheath, usually below the navel. May lack a visible bulge and carry a higher risk of strangulation because of their deep location.
• Femoral Hernias: Occur in the femoral canal, just below the inguinal ligament in the upper thigh. More common in women and prone to incarceration. Generally less common overall.

While the term “hiatal hernia” is sometimes mentioned, it actually refers to a diaphragmatic hernia where part of the stomach bulges into the chest and is not strictly an abdominal wall hernia. Likewise, a “sports hernia” is not a true hernia but rather tears in muscles, tendons, or ligaments in the lower abdomen or groin. Other rare abdominal hernias include perineal, lumbar, obturator, and sciatic hernias. “Ventral hernia” is a broader term covering any defect in the anterior abdominal wall that is not inguinal or hiatal and includes incisional, umbilical, and epigastric hernias. Interparietal hernias, which occur between layers of the abdominal wall, are extremely uncommon.

Classifying abdominal wall hernias by anatomical location underscores the importance of recognizing potential weak spots in the abdominal wall. These areas are not equally strong everywhere, and hernias develop at these points of weakness. Prevalence and risk factors also differ: inguinal hernias are most common in men due to canal anatomy; umbilical hernias in infants relate to the umbilical opening; incisional hernias are linked to surgical history.

What Are the Causes and Risk Factors for Abdominal Wall Hernias?

Abdominal wall hernias result from a combination of congenital weaknesses present at birth, increased intra-abdominal pressure, weakening of tissues after surgery, and certain underlying medical conditions.

Some individuals are born with weak spots in their abdominal muscles, making them more prone to hernias. A common example is an umbilical hernia in infants when the umbilical opening fails to close completely. In newborns and young children, inguinal hernias often arise from a congenital weakness in the abdominal wall.

Conditions and activities that raise intra-abdominal pressure also contribute to the formation or worsening of hernias:

• Obesity: Exerts constant pressure on the abdominal wall.
• Pregnancy: Especially multiple pregnancies, stretches abdominal muscles.
• Chronic cough: From smoking or COPD, repeatedly stresses the wall.
• Chronic constipation: Straining increases pressure.
• Heavy lifting or strenuous activity: Applies significant force to the wall.
• Ascites: Fluid in the abdomen raises pressure.
• Tumors or abdominal fluid collections.
• Long-term peritoneal dialysis.
• Frequent vomiting.
• Benign prostatic hyperplasia (BPH) in men leading to chronic straining.

Previous abdominal surgery is a major risk factor for incisional hernias. Surgical incisions weaken the wall, and infection at the incision can further compromise strength. A midline laparotomy carries a particularly high risk.

Other factors that can increase hernia risk include advancing age, sex differences (inguinal hernias in men; femoral and umbilical hernias in women), family history, smoking, certain ethnicities, prematurity and low birth weight, prior hernia, malnutrition, chronic steroid use, chronic diseases such as kidney or liver failure, diabetes, connective tissue disorders, and multiple pregnancies.

What Are the Symptoms of Abdominal Wall Hernias?

The most common sign is a noticeable bulge in the abdomen accompanied by pain or discomfort, especially during activities that increase intra-abdominal pressure.

A visible lump near the abdomen, groin, or navel often serves as the first clue. The bulge becomes more prominent when standing, coughing, or straining and may diminish or disappear when lying down. Some hernias, such as Spigelian hernias, may not produce an obvious bulge because they occur within muscle layers.

Pain and discomfort vary widely. Pain can range from a mild, dull ache or feeling of pressure to a sharp, intense pain during lifting, bending, or coughing. Some hernias cause no pain (e.g., umbilical hernias in children). Additional sensations can include burning or stinging, pressure or fullness, or a pulling feeling. Some people feel heaviness or general discomfort in the area.

Certain symptoms indicate complications and require immediate medical attention:

• Severe, sudden, or rapidly worsening pain at the hernia site
• Inability to gently push the bulge back (incarceration)
• Nausea and vomiting
• Constipation or inability to pass gas
• Redness, tenderness, swelling, or discoloration over the hernia
• Fever
• Blood in stool
• Pain and swelling around the testicles in inguinal hernias

How Are Abdominal Wall Hernias Diagnosed?

Diagnosis usually begins with a physical examination. The healthcare provider looks for a bulge and may ask the patient to stand, cough, or strain to make the hernia more prominent. The provider will also try to gently push the hernia back into the abdomen (reduction). Common areas examined include the navel, groin, upper thigh, and previous incision sites.

While physical examination is often sufficient, imaging tests confirm uncertain cases, assess complications, or help in obese patients. Ultrasound is a noninvasive option when exam findings are inconclusive. CT scans are considered the most accurate for identifying hernias and their contents, especially in complex cases or when incarceration or strangulation is suspected. CT also distinguishes hernias from other masses. MRI can help in selected situations. Conventional X-rays or barium studies were used historically, but CT is now preferred.

What Are the Treatment Options for Abdominal Wall Hernias?

Surgical repair is the primary treatment for most abdominal wall hernias. Surgery is typically recommended for painful, enlarging, or complication-prone hernias. Inguinal hernias are usually repaired because of the potential for strangulation.

• Open Surgery: A single larger incision over the hernia allows direct visualization and repair. The defect is closed with sutures, and a mesh is often added for support. Preferred for larger or more complex hernias. The Shouldice repair is a notable non-mesh open technique.
• Laparoscopic Surgery: A minimally invasive “keyhole” approach using several small incisions, a camera, and specialized instruments. The surgeon repairs the hernia from inside the abdomen, usually with mesh reinforcement. Advantages include less postoperative pain, smaller scars, faster recovery, and fewer wound complications, though success depends on surgical expertise.
• Robotic Surgery: Another minimally invasive option offering enhanced vision and precision. The surgeon controls robotic arms from a console, potentially improving mesh placement and reducing discomfort.

For extremely large or complex hernias, abdominal wall reconstruction may be necessary, involving extensive repair with mesh and techniques such as component separation.

Mesh reinforcement strengthens the wall and lowers recurrence rates. Mesh types include permanent synthetic mesh (most durable), biological mesh (derived from human or animal tissue, useful when infection risk is high), and bio-absorbable synthetic mesh (provides temporary support and is absorbed). While mesh greatly improves outcomes, it can cause complications such as chronic pain in some individuals. The choice of mesh and technique should be discussed with a surgeon based on the patient’s circumstances and the nature of the hernia.

Frequently Asked Questions

What are the most common causes of abdominal wall hernias?

Abdominal wall hernias are usually caused by heavy lifting, chronic coughing, constipation, excess weight, or weakened areas that develop after previous surgeries. These factors increase intra-abdominal pressure and lead to hernia formation.

What complications can occur if abdominal wall hernias are left untreated?

Untreated hernias may enlarge and cause serious problems such as pain, limited mobility, and bowel obstruction. The most dangerous complication is a strangulated hernia, where the intestine becomes trapped and blood circulation is impaired.

How are abdominal wall hernias related to obesity?

Obesity increases intra-abdominal pressure, raising the risk of hernia formation. Excess fat tissue can also make surgical treatment more difficult and prolong recovery. Therefore, weight control before hernia repair is important.

How do abdominal wall hernias progress during pregnancy?

Due to increased intra-abdominal pressure during pregnancy, existing hernias may enlarge or new ones may develop. In most cases, surgery is planned after delivery, but in cases of strangulated hernia, urgent intervention is required.

What are the advantages of laparoscopic surgery for abdominal wall hernias?

The laparoscopic approach uses smaller incisions, resulting in less pain, faster recovery, and shorter hospital stays. It also provides better cosmetic results compared to open surgery.

What factors influence the risk of recurrence after abdominal wall hernia surgery?

The risk of recurrence depends on the size of the hernia, the surgical method used, the patient’s lifestyle, and compliance with postoperative recommendations. Heavy lifting and obesity particularly increase the chance of recurrence.

What is the recovery process after abdominal wall hernia surgery?

Recovery usually takes 4–6 weeks after open surgery, while laparoscopic procedures may allow a shorter recovery time. Patients should avoid heavy activities and attend regular follow-up appointments.

Why is mesh used in the treatment of abdominal wall hernias?

A mesh strengthens the weakened area of the abdominal wall and reduces the risk of recurrence. In modern surgery, synthetic or biological meshes are commonly used to provide durable repair.

Is exercise safe after abdominal wall hernia surgery?

Once healing is complete, light exercise is recommended. However, heavy lifting and activities that strain the abdominal muscles should be avoided. Exercise should only be resumed with a doctor’s approval.

Can abdominal wall hernias occur in children?

Yes, hernias are common in children, especially in the umbilical and inguinal regions. Many resolve on their own, but in some cases surgical repair may be required. Early diagnosis and follow-up are important.

Dr. Ahmet Bekin

Op. Dr. Ahmet Bekin was born in Istanbul in 1983. He graduated from the Faculty of Medicine at Kocaeli University in 2006 and completed his specialty training in the Department of General Surgery at Istanbul University Çapa Faculty of Medicine in 2011. After his specialization, he worked in the fields of hernia surgery, reflux surgery, obesity surgery, advanced laparoscopic surgery, and robotic surgery. In addition, he received training in endocrine surgery, oncological surgery, and minimally invasive surgery. He is currently accepting patients from Turkey as well as from countries such as Germany and France at his private clinic located in Istanbul.