PARAUMBILICAL HERNIA

PARAUMBILICAL HERNIA

AETIOPATHOGENESIS

AYURVEDIC PERSPECTIVE

• Paraumbilical hernia can be correlated with Antravriddhi or Chhiddra Antra Vriddhi, under the broad category of Viddha Guda or Udara Roga.

• It is primarily caused due to weakness in abdominal wall, especially around the navel (nabhi).

• Involvement of Vata Dosha due to its Chalana Guna leads to displacement of intestines.

• Other doshas, especially Kapha and Meda, contribute to Mamsa Daurbalya (muscle weakness).

SANSKRIT REFERENCE:
"नाभ्याः पार्श्वयोर्वा वातेन बाध्यमानः श्लथोदरः स्यात्।"
– Sushruta Samhita, Nidana Sthana, Udara Nidana

• Vata accumulating in the abdominal region leads to weakness and bulging around umbilicus.

MODERN PERSPECTIVE

• Paraumbilical hernia is a protrusion of intra-abdominal contents through a defect adjacent to the umbilicus, typically above it.

• Common in middle-aged females, especially multiparous women due to increased intra-abdominal pressure and weak linea alba.

• Risk factors:

  • Obesity

  • Pregnancy

  • Ascites

  • Chronic cough or constipation

  • Heavy weight lifting

  • Congenital fascial weakness

CLASSIFICATION

MODERN CLASSIFICATION

• Reducible Hernia – contents return to abdominal cavity.

• Irreducible Hernia – contents cannot be returned.

• Obstructed Hernia – intestinal obstruction without vascular compromise.

• Strangulated Hernia – vascular supply is compromised, leading to ischemia.

AYURVEDIC PARALLEL

• Types of Antravriddhi can be considered based on symptoms like Shoola (pain), Udarashoola, Adhmana (distension), etc.

CLINICAL FEATURES

MODERN SIGNS AND SYMPTOMS

• Bulge or swelling just above the umbilicus

• Increases in size during coughing or straining

• May reduce spontaneously in lying position

• Pain or discomfort at the site

• In cases of obstruction or strangulation:

  • Severe pain

  • Vomiting

  • Constipation

  • Tender irreducible mass

  • Signs of peritonitis if perforation occurs

AYURVEDIC CLINICAL CORRELATION

• Shoola (Pain)

• Sotha (Swelling)

• Udarashoola (Abdominal discomfort)

• Atopa (Gurgling)

• Trishna, Chhardi, Malavibandha in advanced cases (related to strangulation).

SANSKRIT REFERENCE:
"वातादुद्धृतमन्त्रं तु नाभ्यां चोत्थितमं हन्याद्।
गुल्मोऽन्त्रग्रहणिः शूलं वातश्चात्र प्रवर्तते॥"
– Charaka Samhita, Chikitsa Sthana

EXAMINATIONS

INSPECTION

• Swelling above umbilicus

• Enlarges on coughing, straining

• Visible peristalsis in thin patients

PALPATION

• Soft or firm swelling

• Expansile cough impulse

• Reducible or irreducible mass

PERCUSSION

• Resonant if containing bowel

• Dull if omentum or fluid present

AUSCULTATION

• Bowel sounds may be heard if intestines are present

AYURVEDIC EXAMINATION

• Darshana (Inspection) – swelling in nabhi region

• Sparshana (Palpation) – tenderness, temperature

• Prashna (History) – pain, strain, aggravating factors

INVESTIGATIONS & DIAGNOSIS

MODERN INVESTIGATIONS

• Ultrasonography (USG) – to detect size, content, and complications

• CT scan – detailed anatomical defect, especially in complicated hernia

• X-ray Abdomen (erect) – in cases of obstruction or strangulation

• Routine blood tests – CBC, renal profile for preoperative evaluation

DIAGNOSIS

• Clinical diagnosis based on physical exam

• Imaging to confirm and plan surgery

COMPLICATIONS

• Irreducibility

• Obstruction

• Strangulation

• Perforation of bowel

• Sepsis and peritonitis

• Recurrence after surgery

• Skin ulceration over hernia sac

AYURVEDIC PERSPECTIVE

• Progression to Adhmana, Shoola, Agnimandya, and Maranam in untreated cases is explained under Antravriddhi and Udara Roga.

SANSKRIT REFERENCE:
"नाभ्यामुत्थाय सशूलं वातः कुर्वेन्मरणाय तम्।"
– Sushruta Samhita, Chikitsa Sthana

MANAGEMENT

AYURVEDIC MANAGEMENT

• Initial approach:

  • Vatahara Chikitsa

  • Deepana-Pachana for Ama and Mandagni

  • Mridu Virechana to relieve pressure

  • Abhyanga with Bala Taila, Nabhi Bandhana (hernia truss)

  • Basti Karma for Vata Shamana

• Surgical Management in Ayurveda (Shastra Karma)

  • Principles of Vrana Chikitsa, Chhedana Karma applicable

  • Use of Kshara Sutra or Agnikarma not typically used for paraumbilical hernia but for anorectal conditions

MODERN MANAGEMENT

• Definitive treatment is surgical

  • Herniorrhaphy – suturing of defect without mesh (small hernia)

  • Hernioplasty – reinforcement with mesh (preferred for large hernia)

    • Open mesh repair

    • Laparoscopic mesh repair

• Pre-operative management:

  • Control of comorbidities (DM, HTN)

  • Reduction of ascites if present

  • Weight reduction

• Post-operative care:

  • Wound care

  • Avoid lifting heavy weights

  • Hernia belt (in selected cases)

PROGNOSIS

• Good with early intervention

• Recurrence risk present with poor surgical technique or in high-risk patients (obese, smokers)

• Delay in surgery leads to life-threatening complications such as strangulation