Herniation

In the simplest sense, a hernia is when something goes where it shouldn’t. This requires a breakdown of the usual barriers in the body. Sometimes these barriers are simple, and sometimes they are quite elaborate. The consequences of a hernia, as you therefore might imagine, range from mildly irritating to rapidly fatal. As general surgeons we deal a lot with inguinal hernias, or hernias that arise in the groin area. This a place of natural weakness in the body – especially in males – and therefore has a predilection for herniation to occur. The bowel pushes through the floor in this region and can cause pain, or even a true obstruction of the gut. If there is enough pressure on the bowel it can become ischemic and die – off hand, I can think of one person who died under these circumstances. As trauma surgeons, we deal a lot with traumatically injured brains. When the brain is injured – from assault, or a car accident – blood forms inside the skull. When the condition worsens, there is too much pressure that then expels the brain downward through the base of the skull – the foramen magnum – on its way to the spinal column in a vain attempt to relieve the pressure. This kind of herniation is rapidly fatal. The other day I saw a hernia unlike any I have ever seen. This woman had her uterus removed several years ago. The remaining cuff – that is, the portion where the uterus opens into the back of the vagina – is either sutured or stapled. This particular woman had recently undergone chemotherapy, and as a result that cuff opened. As luck would have it, her intestines worked there way through that opening – she eviscerated her intestines through her vagina. By the time we got her to the operating room, that portion of her small bowel was dead and needed to be removed. It’s a miracle she didn’t die. It’s safe to say that none of us – neither me, nor the colo-rectal surgeon on call – had ever seen anything like this before. But we were all in agreement: nothing we had ever seen just looked so wrong and obviously in need of repair. The body has countless built-in defensive barriers, and when they fail the consequences are too-often catastrophic. Something things are just supposed to stay put. As we look towards the new year, let us assure the barriers in our own lives are solid, and that we don’t herniate where we’re not supposed to. Let us stay where we belong, wherever that is.