Types of Hernias
Occur in the groin, which is the area between you abdomen and thigh. As the most common type of hernia in adults, inguinal hernias are most common in men although they also can occur in women. With an inguinal hernia, the contents of the abdomen, namely the intestine, protrude through a weakness or tear in the abdominal wall muscle creating a visible bulge. Pain from an inguinal hernia can be constant or sporadic. Inguinal hernias can also be bilateral, occurring on both side of the abdomen.
Incisional or Ventral Hernias
Can occur in the abdomen in the area of any prior surgical incision or scar. Hernias of this type are often accompanied by a swelling or bulge near the area of the prior incision, typically along straight incisions or scars running down from the breastbone to the pubic area.
Occur in or around the naval or umbilicus. This type of hernia may be caused by a defect that is present at birth, or may occur over time due to obesity, excessive coughing, or pregnancy. In adults, as with any hernia, an umbilical hernia will not heal and go away but rather grows larger with time. Occasionally an umbilical hernia may become problematic in that incarceration or strangulation can occur. A hernia that becomes tightly trapped, or strangulated, loses blood supply, blocks intestinal flow, and requires emergency surgery.
Frequently Asked Questions
What to know about Hernias
The most typical sign of a hernia is a bulge under your skin in the groin or abdomen. You may also feel pain when you lift, cough or sneeze. Hernias affect men, women and children of all ages. The good news is hernias are highly treatable. Best of all, after successful treatment, you’re able resume your regular activities. We use the newest techniques and materials in treating primary and recurrent hernias. Our center is available to patients for consultation, surgical treatment or just to ask questions.
What is a ventral or abdominal hernia?
An abdominal hernia, or ventral hernia, is a hole in the layers of the abdominal muscle, in particular the fascia, through which the intestines or abdominal contents protrude. On the lateral aspect of our abdomen, there are 3 layers of muscle and in the midline there is a single paired muscle, the rectus abdominis, muscle that meets in the midline. Many hernias occur in the midline where the rectus abdominis muscle has separated, but a hernia may occur anywhere in the abdomen between or through these muscles.
Who gets a ventral or abdominal hernia?
This type of hernia most often occurs after a previous abdominal surgery such as a previous laparotomy or Caesarean section. Not everyone who has had a previous surgery gets a hernia, in fact only about 10% of patients do. A ventral hernia may also occur as a complication or progression of an umbilical hernia. Once the muscles are separated and are no longer together then the abdominal organs are essentially only held back by the skin, which over time can stretch to extreme magnitudes.
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Why do I need to have a ventral or abdominal hernia repaired?
These hernias should be repaired to minimize the risk of intestinal obstruction or intestinal strangulation in which the blood supply is kinked to the intestine and this may lead to needing emergency surgery to prevent rupture and intestinal spillage which if not treated can lead to death. Larger hernias may have less risk of strangulation than smaller hernias, but all have the potential for this feared complication. Not fixing a hernia usually means it will get larger over time and with this change, the muscles of the abdominal wall can get progressively weaker leading to dysfunction in daily activities. The skin of the abdominal wall may stretch and thin, eventually leading to a non-healing skin wound. Larger hernias are generally more difficult to fix and have potentially more complications with their repair, and thus a hernia should be fixed sooner than later to avoid the long term complications of neglecting them.
What are the risk factors for hernia development?
There are many patient related risks that may increase the risk for developing a hernia after surgery. These same risk factors also play a role in a patient redeveloping a hernia after hernia repair. These include but are not limited to diabetes, cigarette smoking, obesity and use of steroids. Cancer patients are at an increased risk for post-operative hernia development because of the inherent immunologic abnormalities seen in some cancers, as well as the possible effects of cancer treatments like chemotherapy or radiation treatment. Other chronic conditions such as asthma, Chronic Obstructive Pulmonary Disease (COPD), and other conditions which may increase intra-abdominal pressure may result in incisional hernia should a patient with one of these conditions require surgery. Certainly patients with any connective tissue disorder or Collagen-Vascular diseases are at an increased risk of hernia development as these conditions all negatively impact wound healing. Opiate pain medications all may slow down GI tract motility and cause constipation and abdominal distension and increased intra-abdominal pressure. Over time this may result in hernia formation. Finally, the patient’s nutritional status can have profound effects on wound healing. Malnourished patients with a depressed serum albumin may heal slowly and poorly. This can have an obvious detrimental impact on the development of abdominal wall hernia after surgery. Many of these factors are beyond patient control, but some such as obesity and tobacco use can be modified prior to surgery to improve outcome.
Surgery related risk factors include such things as the nature of the underlying surgery. Hernia development after elective surgery is far less common than after emergency surgery for conditions such as major trauma, severe infection or massive bleeding. Surgical conditions that involve elements such as these are often associated with massive tissue swelling which may increase tension across a wound, infection which may directly break down a wound or significant anemia from surgical blood loss may decrease oxygen supply to a healing wound. Major abdominal surgery often results in ileus which may exert pressure on the abdominal wall and wound. The metabolic consequences of massive trauma or severe infection may also lead to diminished oxygen supply to a healing wound which later results in a hernia. Certainly all attempts should be made to avoid closing an abdominal wound under tension, but at times this is unavoidable. Hernia development after elective surgery may still occur in spite of all precautions to avoid tension in a wound if any or several of the patient factors mentioned are present.
What symptoms may occur with ventral or abdominal hernias?
These hernias may be associated with pain, intermittent gastrointestinal discomfort or small bowel obstructions, and decrease core muscle strength in the abdomen from pain or malalignment of the musculature. Changes in bowel function such as diarrhea or constipation may also accompany hernias, although there are other reasons for these symptoms that may be unrelated to a hernia.
What are my surgical options for repairing my hernia?
If there were one perfect way of performing a surgical procedure that worked for every patient every time with every surgeon then there would be only one way of doing that procedure. Nothing could be further from the truth when it comes to ventral hernia surgery. There are several options that may be utilized depending on location of the hernia, size of the hernia, size and body type of the patient and of course, surgical expertise. The development of newer mesh materials has also expanded the ability to repair complex hernias even under the most challenging of situations. Surgical repairs may be performed by both open procedures or minimally invasive laparoscopic procedures.
For smaller hernias, or for the repair of first time hernias the procedure is often done by a general surgeon. The hernia can be simply closed with suture, or the hole can be covered by a mesh material or the muscle can be closed and reinforced with a mesh material. These techniques may have hernia recurrence rates as high as 30% and may be even higher in patients with risk factors as discussed above.
Why Christiana Hernia Care?
There are always many options for where and who should be performing your surgery. At Christiana Hernia Center, complex abdominal wall reconstruction first started in the late 1990’s when Dr. Zabel was learning advanced techniques at the University of Pittsburgh. At Christiana, Dr. Zabel paired with Delaware Surgical Group more than 10 years ago to start working on these complicated patients. As time progressed, newer techniques and innovation were implemented to continue to serve as an example of how our patients do. We now have a database of over 800 patients that have undergone abdominal wall reconstruction. Our current technique has been performed in the last 500 or more patients. We are the only hernia center in the country where both the plastic and general surgeon are present and working throughout your entire procedure. In many centers the plastic surgeon enters and leaves the operation at different points of the procedure. We feel that our team approach can minimize your time in the operating room (average OR time is under 3 hours) where many centers report that these procedures take over 5 hours on the average.
Our center now presents our work at national and international hernia and surgical meetings. The results are published in the Hernia Journal. We continue to educate ourselves by attending other surgeons in their operating room and we teach visiting surgeons our procedure to help share ideas and improve outcome.
As our expertise grows, our patient volume also does. We now perform approximately 10 of these procedures a month. All patient outcomes are analyzed and this has lead us to implement several innovations such as epidural anesthesia and perforator sparing incisional approaches.
I have had a hernia repair in the past and now I have a recurrence. What now?
Hernias recur for many reasons (see above patient and surgical factors).
Traditional methods to repair abdominal wall hernias may have recurrence rates of 20 – 40%. This does not mean that your surgeon recommended or performed your procedure incorrectly. It does not mean that you rejected or are allergic to your mesh material. Most likely your repair consisted of an approach to fix your hernia problem with a procedure that was selected to have reasonable success while minimizing your complications. Many of these procedures are often done as an outpatient or a single night or two in the hospital. This is often appropriate because as many as 70% of patients are doing well with this approach and are back to activities. Once you start to have one or more recurrences, the question is, should you have a similar approach or would a larger and more definitive procedure be better for you.
I had a repair before and now have a recurrence, did my mesh fail?
Often times mesh is employed to fix hernias. There are generally two main types of mesh on the market today, synthetic and biologic. With the synthetic mesh, there are at least 100 different types of mesh in a variety of sizes. With biologic mesh, there are over 15 different varieties harvested from human, pig, cow and even sheep, also in a variety of sizes.
The market and scientific study of implantable materials is constantly evolving. Synthetic mesh material has been used in the United States for over 50 years while the biologic meshes have been present for a little over 15 years. Mesh materials may fail for many reasons. Mesh may become infected and need to be removed. Mesh may become walled off or encapsulated and shrink which may make it pull away from where the surgeon originally put it. Mesh may in rare instances tear.
Biologic mesh materials were introduced in order to help eliminate the risk of the material getting infected or encapsulated by providing a framework where the patient’s own body could grow into the mesh material and minimize these complications. Although debate still exists, these biologic materials are expensive and are becoming less used because studies have shown that when using these materials, that hernia recurrence rates are higher than 40%.
Interestingly, around the same time as biologic materials were introduced, synthetic mesh materials evolved to be less dense and more porous so that the body could also grow into the body and avoid the need to be removed with infection and to prevent encapsulation.
You will have to have a detailed discussion with your doctor to try and answer the question about how or if your mesh failed leading to a new hernia. However, it is interesting to note that most mesh materials do not tear or fail down the middle but that a hernia recurrence occurs at the top, bottom or sides of the previously placed mesh. This has lead many hernia experts to the conclusion that mesh seldom fails but mesh is usually not large enough.
My doctor recommended that my hernia be repaired using a technique called abdominal wall reconstruction. What is that?
After initial consultation with your surgeon and evaluating your hernia, its size, your risk factors and overall health and often considering CT scan results, you may be recommended for a ventral hernia repair with abdominal wall reconstruction. The term abdominal wall reconstruction may mean many different things to many different surgeons. As mentioned above, there is no consensus amongst surgeons as to what this procedure may entail.
At the Christiana Hernia Center, for abdominal wall reconstruction we have employed a multi-disciplinary team of general and plastic surgeons that work together through your evaluation process, your entire surgical procedure and your post-operative care. We believe that in order to minimize a recurrence and to maximize patient outcomes, your procedure should be done with set goals for safely reducing your hernia contents back to the abdomen, selecting an incision that will maximize healing, re-approximating your muscles back together and reinforcing this repair with a light weight, low density mesh that acts as an internal corset.
Most hernia repairs use mesh and place the mesh under the muscles and next to the abdominal contents. This may be referred to as an onlay position. The size of the mesh is limited in this position by competing with the abdominal contents. The mesh placement also has potential to have more interactions with abdominal adhesions or erosion in to the intestines. We place our mesh in the space below the muscle but above the outer lining of abdomen called the peritoneum. This space is either the retro-muscle space or the pre-peritoneal space. A very large piece of mesh may be place in these positions and is separated from the abdominal contents minimizing potential complications with the intestines.
The central muscles of the abdomen are typically separated with a hernia, and we feel that in order to improve your overall muscle strength that these muscles should be approximated at the surgery. This is done with a technique called component muscle separation and may separate one of the muscles of the abdomen that will allow the rectus muscles to be moved together back in the midline. Separating a muscle does not lead to a new hernia as the muscle is divided at a specific point where there are still one or two muscles left behind to prevent a new hernia.
This procedure is not meant to be performed for every abdominal wall hernia but is reserved for large hernias, recurrent hernias and/or patients with many risk factors as described above. Patient selection is determined from a team approach with both your general and plastic surgeon.
Is robotic surgery right for me?
Robotic surgery is a newer technique for repairing hernias. Like laparoscopic surgery, robotic surgery uses a laparoscope, and is performed in the same manner (small incisions, a tiny camera, inflation of the abdomen, and projecting the inside of the abdomen onto television screens).
In robotic surgery, however, the surgeon is seated at a console in the operating room, and handles the surgical instruments from the console. While robotic surgery can be used for some smaller hernias, it can also be used to rebuild the abdominal wall.
Just to be clear, Robotic surgery does not mean that a “Robot” is doing your surgery. It is a platform for appropriately trained surgeons to utilize minimally invasive techniques to do your surgery. Similar to the way Laparoscopic surgery had evolved from the early 1990’s. Your surgeon is always present in the room and begins your case by placing the Robotic instruments through 3 or 4 small incisions. He then goes on to sit at a console 10 feet away from the operating room table, using the advanced technology to manipulate the small instruments to do a multitude of different types of surgeries, including hernias.
All of the surgeons of Delaware Surgical Group perform Robotic Surgery on a regular basis for Inguinal, Ventral, Umbilical and Incisional Hernias. This does not mean that everyone’s hernia can be fixed using the Robotic platform. Appropriate patient selection is crucial to matching the correct procedure (Robotic, Laparoscopic, or Open) to a specific patient’s needs, in order to maximize their outcomes and minimize recurrences. As with any new technology, patient selection is key, and this is where “Experience Matters”.