A CONCISE PICTURE OF HERNIA

A hernia is a disease wherein organs or tissues, like the bowel, bulge through the abdominal wall. The etiological, as well as precipitating factors for hernia include abdominal pressure, pre-existing weakness of abdominal muscles, gender, obesity, age, diet, lack of regular exercise, and smoking. Swelling, stiffness, and discomfort seem to be the most prevalent hernia symptoms, particularly while straining, moving, or bending down. Open and laparoscopic techniques are mainly used for hernia repair, both use mesh to counterbalance the abdominal wall flaws and provide a tension-free restoration.


INCIDENCE OF HERNIA
As per the report of The National Institute of Health the surgical description of hernias and treatment dates back to ancient Egypt. Although there was written proof of patients suffering from inguinal hernia as early as 1500 B.C., the hernia was likely a surgical disease long before that. Due to a lack of data from poor nations, the frequency and prevalence of certain diseases is unknown. Hernias are thought to be distributed similarly by gender and anatomical location in developed countries. In adults, the majority of hernias occur in the groin. Indirect inguinal hernias are the most prevalent hernias in both men and women, according to the Asia Pacific Hernia Society (Aphernia) 2020 figures; there is a right-sided predominance. Inguinal hernia accounts for about 75% of all hernias. Incisional and epigastric hernia describes for about 10% of all hernias. 5-7% umbilical, femoral hernias account for only 3% of all hernias and its incidence is 4 times higher in females than males [9]. Abdominal wall hernias affect between 10% and 30% of children; the majority of these hernias resolve spontaneously by the age of 1 year [4].

AGE AND SEX
Indirect hernias usually emerge within the 1 st year of life; however, they may not appear until the middle or later years. Because the musculature of the abdominal wall relaxes and the fascia thins in older people, direct hernias develop more in older people. It rarely occurs in young adults [19]. Umbilical hernias are most common in infants, and they normally grow to their full size within the 1 st month. The majority of these hernias resolve spontaneously by the 1 st year of life, with just a 2-10% occurrence in children older than 1 year [20]. Males account for approximately 90% of all inguinal hernias. Femoral hernias (rare) are more common in women because of the variances in the pelvic anatomy between men and women. Obturator hernias have a 6:1 female-to-male ratio. This is linked to a gender-specific greater canal diameter; elderly people are much more likely to develop this hernia.

TYPES OF HERNIA
The abdominal wall is made up of layers rather than a single muscle sheet. When the abdominal muscle weakens, a portion of the intestine bulges through and appears as a lump under the skin. Figure 1 represent different types of hernia based on their location. Inguinal hernias are the most prevalent type of hernia and it occurs in the groin [21,22].

Inguinal hernia
It is the most common form of hernia. Most commonly occurs in the groin, attributing about more than nine out of ten hernias. The inguinal ring of muscle in the groin is pushed against by a loop of the intestine, which eventually splits the muscle fibers apart. Inguinal hernias affect more men than women and are particularly common in middle age and old age [23]. It can account for about 75% of all hernias; two-third of these hernias is indirect and onethird direct [24].
It is an indirect inguinal hernia that travels through the inguinal canal from the abdomen to the scrotum [25].
The direct inguinal hernia arises where the abdominal wall is thinner on the interior of the indirect hernia. It will only rarely descend to the scrotum. Inguinal hernias can occur at any stage of life but it happen more often in babies who born early (Indirect Inguinal hernia). They are more common on the right side [26,27].

Femoral hernia
A femoral hernia occurs in the femoral canal [28]. Femoral hernias are less frequent than inguinal hernias [29]. This hernia generates a protrusion on the inside side of the thigh, below the inguinal canal. Intestines force through the weak muscle ring at the femoral canal until they protrude. Due to differences in pelvic anatomy, femoral hernias are more common in women.

Umbilical hernia
A part of the gut propels through a muscular weakness near the navel, or belly button. Newborns are the most common victims of this type of hernia. Although umbilical hernia repair is often considered a simple operation, recurrence rate is considered to be higher than the others. Mayo clinic report suggest that recurrence rate of umbilical is up to 50% [30,31].

Hiatal (hiatus) hernia
Through an incision in the diaphragm, a piece of the stomach climbs up into the chest cavity [32].
Hernias can also be divided into the following categories:

Incisional hernia
Tissue pushes its way through the scar from an abdominal or pelvic procedure. Incisional hernias are a common complication of laparotomy incisions [33].

Epigastric hernia
Between the navel and the lower section of the sternum, fatty tissue pushes through the abdominal area. Epigastric hernia is a hernia in the midline of the anterior abdominal wall between the umbilicus and the xiphisternum and through a defect in the linea alba [34].

Spigelian hernia
The intestine protrudes below the navel on the side of the abdominal muscle. A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line [35]. Symptoms vary from insidious to localized pain, an intermittent mass, and/or a bowel obstruction [36].

Diaphragmatic hernia
Birth defect in which there will a hole in the abdomen. Through the opening in the belly, organs in the abdomen can travel upward into the chest [37].

CAUSES OF HERNIA
A combination of muscular weakness and strain causes hernias [38]. Some common causes are: • Congenital • Aging • Damage from an injury or surgery • COPD • Arduous exercise or lifting heavyweights • Pregnancy, mainly possess multiple pregnancies • Constipation • Being overweight or obese • Fluid in the abdomen, or ascites [39]. Figure 2 diagrammatically represent risk factors for hernia.

Symptoms of hernia
The prevalent symptom is a visible bump or protrusion [42]. Other common symptoms of hernias include: • A dragging sensation or heaviness • Pain -intermittent or continuous • Occasional digestive upsets • Hernia can be called reducible if the lump pushes back into the abdomen. If the lump persists, it is an irreducible hernia [43].
The signs and symptoms of a reducible hernia may include: • A perceivable lump or an enlarged area • A massive unbearable perception in the gut • Pain or ache while lifting or carrying heavy objects [44] • Digestive upsets, such as constipation • The mass dissipates when the person is lying down [44].
Symptoms of irreducible hernia may include: • Painful growth • The growth that cannot be replaced [45] • The pain could be more serious if the blood supply is break off • Nausea and vomiting could be presenting symptoms if the bowel is obstructed or blocked [46].

HERNIA DIAGNOSIS
The primary diagnosis includes a detailed physical examination. During this examination, the physician may look for a swell in the abdominal or groin area [47,48]. Doctors will take a medical history. There will be a variety of questions, including things like: • When did you first notice the bulge?
• Have you experienced any other symptoms?
• According to you what could be the cause for this?
• Describe lifestyle. Does your occupation involve heavy lifting? Do you exercise vigorously? Do you have a history of smoking? • Does any among your family members diagnosed with hernias?
• Do you ever have surgeries done in the area of your abdomen or groin?
Imaging tests used for diagnosis include: • Abdominal ultrasound. The clinical application of ultrasound had shown great promise. Ultrasound has a sensitivity of better than 90% for detecting groin hernias and the specificity of 82-86% [49][50][51][52]. • CT scan and MRI scan, physician consider MRI and CT scan in the workup of patients with activity-related groin pain [53,54]. • Barium X-ray, a sequence of X-ray images of the digestive tract using barium. After finishing a liquid containing liquid barium solution, the photographs are taken. Both are visible on X-ray scans [55]. • Endoscopy is a procedure in which a small camera linked to a tube is threaded down your throat, up to your esophagus, and into your stomach [46].

PATHOPHYSIOLOGY Common
A weakening or deficiency in the abdominal wall can be congenital, acquired, or caused by trauma Intra-abdominal pressure rises as a result of risk factors Herniation can occur when the abdominal contents protrude When the contents of the hernia sac are manipulated into the abdominal Cavity, hernia is reducible The term "irreducible and imprisoned hernia" refers to hernias that are not reducible It gets strangulated when the pressure from the hernia ring cuts off the blood flow to the herniated portion of the colon

Inguinal hernia
The internal ring musculature's primary function is to keep the intestine from protruding during abdominal muscular straining. This process might be hampered by muscle paralysis or injury [56]. Repetitive stress is also a factor in hernia development. Increased intra-abdominal pressure is linked to the development of hernias in a range of diseases. Increased intra-abdominal pressures are related to the chronic cough, ascites, and increased peritoneal fluid from biliary atresia, peritoneal dialysis, or ventriculoperitoneal shunts, and intraperitoneal masses [16]. In 1981, Cannon and Read found that the increased serum elastase and decreased alpha 1 -antitrypsin levels associated with smoking contribute to an increased rate of hernia in heavy smokers. The role of biochemical or metabolic variables in the development of inguinal hernias is still a subject of debate [57].

Femoral hernia
A femoral hernia occurs in the femoral canal. The canal lies medial to the femoral vein and ligament. Femoral hernias usually become imprisoned because they extend through a specified area [58]. Malformed perihernial fasciae or muscles are possible [59].

Umbilical hernia
An umbilical hernia is caused by a congenital defect in the umbilical fibromuscular ring. If they last in children aged 2-4 years, they are restored [60,61]. Although the failure of the umbilical ring to close causes umbilical hernias in children, only one in ten adults with umbilical hernias had this problem as a child. Multiparty and increased abdominal pressure is also associated with umbilical hernias. Congenital hypothyroidism, fetal hydantoin syndrome, and disorders of collagen are the other factors.

Richter hernia
A Richter hernia occurs when the anti-mesenteric border of the bowel herniates. This hernia mainly occurs in the bowel. Richter hernias are more deadly than ordinary abdominal hernias because a piece of the bowel is strangulated, resulting in perforation and peritonitis [62].

Incisional hernia
An incisional hernia is a type of hernia that occurs when a hole is made in the skin. It is a secondary condition that occurs in 2-10% of all abdominal operations. Even after repair, the chance of recurrence is higher [8].

Obturator hernia
It is more prevalent in the elderly and in the female gender (because of a larger canal diameter). It occurs in the obturator canal. A bowel blockage rather than a protrusion of bowel contents is the most prevalent symptom of an obturator hernia [63,64].

Other hernias
Other main causes of hernias include multiparity and age-related pelvic floor laxity [65]. Spigelian hernia formed due to a defect in the spigelian fascia. Obesity, increased intra-abdominal pressure, aging, and rapid weight loss are the main causes of this hernia [66].
Defective closure of the developing anterior wall at the umbilical stalk is the underlying embryogenic factor in omphalocele and gastroschisis [67].

TREATMENT STRATEGY FOR HERNIA
• Indications for surgery and urgency of treatment • Organizing surgical care • Techniques of hernia repair • Local anesthesia • Aftercare complications and outcome • Information for patients.

SURGERY FOR HERNIA
• To avoid complications such as irreducibility and strangulation, all hernias are routinely treated surgically [68] • Every hernia is treated differently depending on the patient's condition [69,70].

Reducible hernias
• To avoid the risk of strangulation in the future, all reducible hernias should be surgically corrected [71][72][73] • If pre-existing medical issues make surgery risky, the doctor may elect to not treat the hernia but instead offer a temporary support belt. The patient will be monitored regularly to check whether the underlying condition subsides or not [74].

Irreducible hernias
• Because of the heightened risk of strangulation, all irreducible hernias require emergency surgery [75,76] • If the bowel becomes gangrenous due to a lack of blood supply during surgery, that portion of the intestine is resected [77].

Strangulated hernias
• All strangulated hernias need emergency surgery • A necrotic hernia or strangulation needs bowel resection.

Types of surgical procedures
• Abdominal open repair surgery: Done by creating small incisions over the herniated area [77] • Laparoscopic surgery: is done through a keyhole puncture. It is a minimally invasive procedure. The surgery can be done in the outpatient setting, and could only take around an hour. The method of repair will depend on the individual's situation [77] • Different techniques employed for hernia repair are: • Herniotomy is the preferred treatment for Small Reducible Hernia.
Here the contents of the hernial sac will be returned to the abdomen and close the opening. This procedure is commonly performed laparoscopically [76] • Another surgical procedure is herniorrhaphy or hernioplasty, where weakened areas are reinforced with sutures, or a mesh wire (sheet made of synthetic material usually called Prolene mesh). This is mainly used for large irreducible hernias [76].

Abdominal open repair surgery
• This is the surgery of choice for all irreducible or strangulated hernias [78].

Laparoscopic surgery
This procedure is performed under general anesthesia. To observe the interior structures, the abdomen is inflated with a safe gas (such as carbon dioxide). The procedure begins with several small abdominal incisions, in which the laparoscope and other surgical tools were inserted. A laparoscope is a thin, telescope-like instrument. A camera, which is attached to the laparoscope, captures, and produces continuous images. Using laparoscopic surgical equipment, the hernial sac is cut and tied. In this posture, the intestines inside the hernia sac is forced back into the muscular wall. To complete the repair the muscle wall is reinforced with stitches or synthetic mesh. Small abdominal incisions heal quickly, and the incision is barely noticeable after a few months [79].
Laparoscopic hernia surgery has the following advantages: • Three tiny scars are made for laparoscopic repair instead of a single larger incision made for abdominal repair • Reduced post-operative pain • Faster return to work • It has a shorter recovery time compared to abdominal open repair surgery and the patient can early get back into their daily activities.

HERNIA MEDICATIONS Antibiotics
• Ampicillin 1.5 g is used along with gentamicin (240 mg diluted in 10 ml saline) given intravenously for prophylaxis to prevent infection • Multiple regimens of cefoxin 1-2 g can be used for bowel perforation and ischemic bowel.

Antianxiety agents
• Lorazepam and midazolam can be used for patients who experience significant anxiety before surgery [83,84].

Non-steroidal anti-inflammatory drugs (NSAIDS)
• Ibuprofen is the treatment of choice for patients with mild to moderate pain • Others include diclofenac, sulindac, naproxen, meloxicam, and ketoprofen.

Analgesics
• Acetaminophen is the preferred pain reliever in patients who are hypersensitive to NSAIDs or who have an upper gastrointestinal illness • Others include hydrocodone and tramadol • For hiatal hernia, over-the-counter and prescription medications that reduce stomach acid can relieve discomfort and improve symptoms. These include proton pump inhibitors, H-2 receptor blockers, and antacids.

POST-SURGICAL PATIENT CARE
The current standard of care after hernia repair is general wound care [85,86]. Who have had a simple hernia repair may be able to go home within a few hours or the next day. However, in more complicated circumstances, the patient may need to stay in the hospital for a few days longer. Patients usually feel good within a few days of surgery and can resume normal eating habits and activities. Exercises are advised after hernia repair as it works to strengthen muscles around the hernia and promote weight loss, helping reduce some symptoms. Heavy exercises and activities that strain the abdomen, such as weight lifting, are prohibited for 4-6 weeks after surgery because they may increase pressure in the hernia area [87]. Table 1 represent Do's and Don'ts after hernia Surgery.

Home remedies
Home remedies will not cure hernia, but some things can do to help with symptoms. Constipation, which can cause straining during bowel motions, may be relieved by increasing fiber intake. Symptoms of a hernia can be controlled with dietary changes and by avoiding large or heavy meals. Others include not lying down or bending over after a meal, maintaining healthy body weight, and quitting smoking [21]. To  Roy et al.
prevent acid reflux, avoid foods that could make you sick, such as spicy and tomato-based foods.

WHAT ARE HERNIA COMPLICATIONS?
Incarceration is the major complication of a hernia, where a piece of bowel or fat gets stuck in the hernial sac which cannot be reduced. Swelling and pain can occur to the point where the tissue's blood supply is cut off, and it dies. This is referred to as a strangulated hernia. It can obstruct the bowel and can cause severe pain, nausea, or constipation [88]. Others include a bulge that turns color to red or purple, fever, bleeding, infection, urinary retention, bladder injury, scrotal edema, and anesthetic complications like a post-spinal headache. In rare case, intra-abdominal tumors may herniate through weak portions of the abdominal wall [89]. Late complication includes recurrence, neuropraxia, hydrocele, and even death [90].

PROGNOSIS OF HERNIA REPAIR
The prognosis depends on the size and type of hernia as well as on the ability to reduce risk factors associated with it. Complications such as strangulation and intestinal blockage are more likely as people get older, their hernias last longer, and their irreducibility lasts longer. Abdominal hernias usually do not recur in children. They do reappear, however, in about 10 percent of adults [68]. The complications associated with inguinal hernias occur rarely in those children who were diagnosed later in childhood or whose hernias were strangulated [67].

HERNIA IN BABIES
The National Centre for Biotechnology Information 2019 Observer reports that between 10 and 30% of babies are born with an umbilical hernia. Umbilical hernias are common in babies who are born prematurely or born with low birth weight. Umbilical hernias are a type of hernia that develops near the belly button. They arise when the muscles that surround the umbilical cords hole do not shut properly.
A part of the intestine may also protrude as a result of this. Umbilical hernia can be noticed more when crying or coughing [79]. Umbilical hernias in children are usually painless. However, when symptoms such as pain, vomiting or swelling at the hernia site occur, the baby should seek emergency medical attention. Umbilical hernias normally go away by the time a child is 1 or 2 years old. If it does not go away by the age of five, surgery can be done to fix it [91]. If minor hernias exist before or during pregnancy and begin to grow or cause discomfort, surgery may be recommended to treat them. The second trimester is the best time to do this [92]. Hernias can also occur following a cesarean delivery. During a cesarean delivery, an incision is made into the abdomen and uterus. An incisional hernia can sometimes occur at the location of cesarean delivery.

CASE REPORTS
A rare case of enormous growth in the right scrotum was reported in a 2-month old infant. On physical examination, the mass was found to be 10 cm in diameter and had episodes of vomiting with green fluid. During laparotomy investigation, an inguinal sac with intestine and appendix contents was discovered. During histopathology examination, the morphological feature shows an appearance of the mesenteric chylous cyst. An unusual case report of Type II Amyand's hernia with an enlarged mesenteric chylous cyst [93].
A 72-year-old male presented with complaints of swelling on both sides of the groin for the past 40 years. The patient had undergone bilateral inguinal hernia suture repair 50 years ago. On physical examination, the left groin had swelling of 10 cm in diameter, while the right groin had swelling of 3 cm in diameter. CT showed herniation in the left groin. The patient was diagnosed with persistent mullerian duct syndrome caused by a unique case of bilateral recurrent inguinal hernia, which was treated with transabdominal preperitoneal repair [94].

CONCLUSION
Early detection and treatment are essential to decrease the morbidity and mortality associated with hernia. This review is intended to provide an overview of hernia and its current treatment method. The present study will provide technical mastery in confirmatory to the existing guidelines, for both medical practitioners and patients dealing with this disease. Thereby give patients with best possible treatment in light of the existing scientific knowledge.