Abdominal Wall Hernias

Hernia

A hernia diagnosis can be scary and stressful. You may have questions and anxiety. Our goal is to arm you with information, provide you with the best patient experience possible, and deliver optimal outcomes.

Until your first appointment, the information below is designed to help you understand a bit more about hernias, their related surgeries, and expectations around treatment. To learn more or to schedule an appointment, call an Epic Care Surgeon today.


About Hernias

A hernia occurs when the inside layers of the abdominal wall have weakened, resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon-like sac.

The weakness may be present at birth, can be caused by wear and tear of daily living, or it may occur as a result of abdominal surgery.

A hernia does not get better over time, nor will it go away by itself.

The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these areas.
Anyone can develop a hernia at any age.
Surgeries that require cutting through the abdominal wall can also create weaknesses and hernias.
The common areas where hernias occur are in the groin (inguinal), belly button (umbilical), and the site of a previous operation (incisional).
You may notice a bulge under the skin.
You may feel pain when you cough, lift heavy objects, strain during bowel movements or urination, or during prolonged standing or sitting.
Some hernias do not cause pain or a bulge, and may be discovered during CT or MRI, or during routine physical exam.
You should always have a hernia evaluated by a doctor. The doctor will help you determine if surgery is necessary and if surgery is safe in your situation.
If your hernia is enlarging rapidly, causing pain or intestinal blockage, or limiting normal activities, surgery is the likely option.
Hernias that aren’t causing pain, intestinal blockage and aren’t enlarging may be observed only. Consult your doctor.

A hernia repair usually involves 2 steps:

1. Closing the hole or weakened area, and
2. Applying mesh to reinforce the repair

Repairs can be accomplished with open, laparoscopic, robotic or a combination of techniques. Each technique has pros and cons. Usually, repairs using small incisions, such as laparoscopic or robotic, lead to faster recovery and fewer complications. Larger or recurrent hernias can be very complex and require a hernia specialist to obtain the best results. The hernia specialist will have more knowledge, tools, techniques, and skills to tailor the best operation to your situation.


Hernia Types

This is another name for groin hernias. It’s the second most common type of hernia, and ten times more common in men. These hernias can be divided into direct or indirect.

This is the most common type of hernias. Everyone has a small opening in the belly button left by the umbilical cord. This opening can enlarge, resulting in a hernia. The hernia needs to be repaired when it is enlarging or causing symptoms like pain or intestinal blockage.

This type of hernia develops where a surgeon has previously cut through the abdominal wall. These hernias come in all sizes and complexity. Many can be difficult to repair, and require a robotic hernia specialist to achieve a durable repair.

This type of hernia occurs when the stomach slips through the diaphragm hiatus into the chest. Frequently patients have heartburn, chest pain or trouble swallowing. There are four types of hiatal hernias. Repairs are usually done through the abdomen and involve pulling the stomach into the abdomen, tightening the diaphragm hiatus and performing an fundoplication (wrap).

Paraesophageal
This is a type of hiatal hernia, but it is frequently is used by surgeons to refer to very large hiatal hernia where more than one-third of the stomach is in the chest.

Epigastric
This is a hernia that occurs in the linea alba in the upper midline of the abdomen. These usually are small and feel like small lumps under the skin.

Diaphragmatic
The diaphragm is a muscle and can develop hernias. Hiatal & paraesophageal hernias are among the most common. Less common types include Morgagni or Bochdalek.

Spigelian
These occur in either lower quadrant of the abdomen, above the groin, where the posterior connective tissue layer thins.

Parastomal
A hernia that forms around a stoma (colostomy, ileostomy or urostomy) is known as a parastomal hernia. More than 50% of patients with stomas will eventually develop a parastomal hernia. These should be fixed when the hernia affects the function of the stoma, or causes pain or blockage.

Ventral
This is a term that applies to all hernias in the front of the abdomen. Usually they refer to larger umbilical hernias.


Surgery Options

This is the traditional approach with a larger incision at the hernia bulge. This type of surgery is still preferred when the hernia is either very small or very complex. For example, many inguinal and umbilical hernias are many times best performed open. Open surgery is sometimes better in complex hernia repairs when there is mesh to be removed, when intestine needs to be resected or when there is a lot of skin/fat that needs to be removed.

A form of minimally invasive surgery introduced in the 1980’s, Laparoscopic surgery uses small incisions away from the hernia bulge. It frequently leads to less complications than open surgery. Today, it is used for hernia repairs that don’t require advanced robotic surgical systems. It has several limitations: the surgeon uses straight instruments that may limit the precision of surgery, it is difficult to place mesh outside the abdominal cavity, there’s a chance of more surgeon fatigue due to poor ergonomics, and it may require painful fixation tacks and sutures.

A form of minimally invasive surgery through small incisions, robotic-assisted surgery uses surgical systems such as the daVinci robot. The robot is not autonomous. It is simply a more advanced surgical tool and is FULLY controlled by the surgeon. The robotic platform offers the surgeon fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot does not tire and the surgeon sits during surgery, so there is reduced surgeon fatigue. Also, the surgeon is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.For the patient, this translates into quicker recovery, less pain and less complications.

This is the preferred approach for medium to large hernias and many inguinal hernias as it combines the best of open and laparoscopic surgeries.

Sometimes the best option is to combine multiple techniques. We call this a hybrid technique because we may perform part of the operation robotically and another part open. Hybrid surgery is frequently performed for complex or unusual hernias, and ones that require skin or soft tissue removal.


Mesh FAQs

Mesh is a sheet of material designed to reinforce a hernia repair. It can also be called a “screen” or “patch.”

Mesh can be divided into synthetic or biologic, and permanent or absorbable. Biologic mesh can be made from human, pig, sheep or cow tissue. The newest meshes are made with a combination of synthetic and biologic material.There are many factors that determine which mesh your surgeon will use. Most hernia repairs use permanent synthetic meshes that are made with either polyester or polypropylene.

Mesh is safe when implanted properly. Hernias develop from weakened tissue. To prevent a future hernia, mesh is needed to reinforce the repair.

The best available evidence shows that using mesh for hernia repairs does not lead to increased chronic pain. However, using mesh decreases recurrences significantly compared to not using mesh. Below are two good quality studies in the surgical literature:van Veen RN, Wijsmuller AR, et al. Randomized clinical trial of mesh versus non-mesh primary inguinal hernia repair: Long-term chronic pain at 10 years. Surgery, Volume 142, Issue 5, 695 – 698.
In this study 300 patients were randomized to open repair with mesh and open repair without mesh. This is the gold standard method of performing a comparison study in surgery. After the surgery, the patients were followed for a median of over 10 years. The patients whose repair did not utilize mesh had a 17% recurrence rate (i.e. 17% failed over 10 years). Patients whose repair utilized mesh had a 1% recurrence rate. The authors also found “that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity.” In other words, patients who had mesh did not have more pain or discomfort than patients who didn’t have mesh repair.

Scott N, Go PM, et al. Open Mesh versus non-Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3.

This study is from Cochrane. It is a non-profit, non-government organization formed to organize medical research findings to facilitate evidence-based choices about health interventions faced by health professionals, patients, and policy makers. Cochrane includes 53 review groups that are based at research institutions worldwide.

This review by Cochrane examines the evidence from studies comparing different types of open surgery for people with groin hernia. They included only randomized studies comparing methods using synthetic mesh versus methods without mesh. There were 20 studies comparing mesh with non-mesh repair analyzed in this study.

Based on their analysis, there was strong evidence that fewer hernias recur after mesh repair than following non-mesh repair. There was a suggestion that people had less persisting pain after mesh repair, but results were only available for nine out of 20 trials. Open mesh methods were shorter to perform than Shouldice procedures (an open non-mesh repair) but took longer than other types of non-mesh repair. They found no clear differences between mesh and non-mesh methods for operative complications and persisting numbness. Overall, people spent less time in hospital and returned to their usual activities quicker after mesh repair.


Pre and Post Surgery Preparation

Getting ready for surgery
The success of surgery is frequently determined by how you prepare for surgery and what condition your body is in before surgery. Many complications after surgery can be prevented by modifying risks factors before surgery.

Rehabilitation before surgery
The medical term “prehabilitation” comes from combining “pre” and “rehabilitation.” “Rehabilitation” is what we do after surgery to speed up recovery. “Prehabilitation” is what we do before surgery to speed up recovery.

Great news: Our Commitment!
Like giving an important presentation or running a race, preparation before surgery can ensure success. Many complications after surgery can be prevented by you. Taking an active role in your own care is very important for a fast and smooth recovery. We are serious about prehabilitation. We will work closely with your family doctor and the preop anesthesia clinic to improve your medical condition and overall health before surgery.

Smoking
Cigarette smoking and nicotine use in any form will reduce your ability to heal, and increases your risk of complications such as infections, wound separation, heart attacks, pneumonia and stroke. Stop smoking at least four weeks before surgery.

Weight
Obesity increases complications. We measure obesity by the BMI (body mass index). A BMI of 30kg/m2 or less is ideal for hernia surgery. A BMI over 35kg/m2 is associated with more complications. If obesity makes surgery too risky to proceed, we will ask you to work with your medical doctor or dietitian to lose weight first. In some circumstances, we can offer weight loss surgery before hernia surgery.

Diabetes
Poorly controlled diabetes is a major reason patients have complications with surgery. If your HgA1C is above 7.5%, surgery should be postponed.

Nutrition
Eating a healthy balanced diet is good for your overall health, but it also helps your body heal faster after surgery. Increase fresh fruits and vegetables, and reduce processed foods and sugary drinks.

Overall health
Major hernia repair surgery is like running a marathon. The success of surgery frequently depends on your physical and mental condition going into surgery. Regular exercise and learning stress-reduction techniques before surgery will reduce your risks of complications.

A form of minimally invasive surgery through small incisions, robotic-assisted surgery uses surgical systems such as the daVinci robot. The robot is not autonomous. It is simply a more advanced surgical tool and is FULLY controlled by the surgeon. The robotic platform offers the surgeon fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot does not tire and the surgeon sits during surgery, so there is reduced surgeon fatigue. Also, the surgeon is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.For the patient, this translates into quicker recovery, less pain and less complications.

This is the preferred approach for medium to large hernias and many inguinal hernias as it combines the best of open and laparoscopic surgeries.

Most patients undergoing hernia surgery for the first time will safely and comfortably go home the same day. Patients who need an abdominal wall reconstruction for large hernias or have advanced medical conditions will remain in the hospital.

Many factor inform the rate of recovery, such as the type of surgery, pre-existing pain, cultural expectations, personal pain threshold, and the complexity of surgery. We focus on these factors as it applies to you, and develop a multi-pronged Enhanced Recovery and Comfort (ERC) Program to help you recover as quickly and comfortably as possible. Our ERC Program focuses on the three stages of surgery: pre-operative, operative and post-operative.

Pre-Operative Pain Management
Studies have shown that medications and nerve/field blocks can blunt the pain signals transmitted to the brain. This is called pre-emptive analgesia. By blunting the pain signal transmission, patients usually experience less pain during and after surgery. With our ERC Program, we can use several medications including (oral or IV) acetaminophen, Cox-2 inhibitors (e.g. Celebrex), gabapentinoid (e.g. Lyrica) and/or opioid-receptor agonists (e.g. Tramadol).

Operative Pain Management
One of the best ways to improve the speed of recovery is to perform surgery through small incisions using laparoscopy or advanced robotic surgical systems. As part of our ERC Program, we usually perform nerve or field blocks prior to incision or early in the surgery to blunt the pain signals. Our anesthesiologists are trained in performing advanced nerve and field blocks such as TAP (transversus abdominis plane), Quadratus Lumborum, or Rectus Sheath blocks.

Post-Operative Pain Management
Most patients are concerned about pain after surgery. We will ensure that you are comfortable after surgery, but it is important to remember that pain is a way for the body to guide you. Pain is one way of telling you to take it easy, especially if you’ve overexerted yourself after surgery, and pain will tell you when you are potentially harming the repair. We do not want to completely eliminate pain. Also, to completely eliminate pain after surgery would require narcotics that can lead to severe constipation, dizziness and nausea. Constipation after hernia surgery is usually worse than the incisional pain itself.

The most important thing to do after surgery is to rest. After most hernia surgeries you will need 2-3 full days of rest. When you get home after surgery, plan to sleep a lot or rest on the couch. You will be able to walk around the house or in the yard, but mostly, focus on relaxing and resting. Many patients find herbal teas to be very soothing and relaxing. Icing the incisions during the first 2 days is also recommended.

For the first 2 days following surgery, we recommend alternating Ibuprofen and Tylenol. When you get home, start by taking Ibuprofen. Three hours later, take Tylenol. Continue alternating each medication every six hours. This way every three hours you’re are taking a pain reliever. With this regimen, narcotic pain pills are not necessary.