Hernia Repairs

Our surgeons are experts in procedures to correct hernia in adults and children. They can perform open surgical, laparoscopic, or robotic techniques to correct the defects.

 

What is a hernia?  What causes a hernia?

A hernia is a hole ,weakness or tear in the abdominal wall. There is a defect in the normal muscle or support tissues that allows protrusion of tissues or intestines normally contained inside the abdomen with straining, coughing, sneezing or lifting through the weakened area. This protrusion results in a noticeable bulge under the skin and /or discomfort, deformity or intestinal concerns particularly with exertion or standing. These defects may be congenital weaknesses or acquired due to injury, previous surgery, and the effect of aging on our tissue strength. The defects tend to increase in size  and symptom severity over time. The weakness may be aggravated by pregnancy, weight gain and obesity, chronic coughing, repetitive straining with lifting or to urinate or have a bowel movement. Other risk factors include premature birth, male gender, family history, steroid use, chronic cough and smoking.

Watchful waiting…Our doctors may recommend watchful waiting for small hernias that don’t cause symptoms, or for people who have serious heart conditions, or in patients where elective general anesthesia is contraindicated.

 

How is a Hernia diagnosed?

Patients will frequently report a bulge in the groin area, at the belly button or in an area of a previous surgical incision. These bulges generally are more apparent when standing or straining. Any effort or activity that increases intra-abdominal or core pressure may make the bulge protrude more or increase local discomfort, aching or burning sensations. If the intestine protrudes through the defect patients may feel or hear a localized gurgling sensation as well. Rarely the bowel may become entrapped in the hernia leading to significant local pain and/ or symptoms of intestinal obstruction or blockage such as abdominal distention, bloating and eventually nausea, vomiting and inability to pass gas or stool. This is referred to as incarceration and is considered a surgical emergency requiring immediate evaluation by a doctor.
Hernias are usually readily diagnosed by a skilled physical exam. If you think you have a hernia , careful physical examination by a knowledgeable surgeon is the best and least expensive  diagnostic test. Just make an appointment!
On occasion the use of an ultrasound, available in our office, may be a helpful adjunct to physical exam. Ultrasound is a dynamic real time painless imaging tool that can be done while relaxed and straining to detect movement and protrusion in symptomatic areas. Rarely other imaging modalities such as CT scanning or MRI may be useful in diagnosis and surgical planning.

MRI Scans

Occasionally we may recommend an MRI scan.  People who actively participate in sports may have a hernia that has no visible bulge, but causes pain when you exercise.  An MRI is used to detect a tear in the abdominal muscles.

How many types of hernias are there?

There are many types of hernias. The surgeons at Premiere Surgical Specialists are expert at their diagnosis and well versed in their management. We are very interested in routine and complex surgical repairs and abdominal wall reconstructions. We have devoted much study and training on optimizing outcomes for patients with complex hernias, infectious complications from previous hernia repairs and chronic pain resulting from previous hernia repair.
Examples of different types of hernias include:

Inguinal (Groin) Hernias

These are the most common type of hernia. Most occur more frequently in men than in women. The inguinal/ groin area is inherently weakly covered by the supporting muscular- fascial structure due to the exit of blood vessels and nerves originating inside the abdomen and pelvis supplying circulation and innervation to the legs. Where these blood vessels and nerves transgress the groin there are thin or at best weak supporting coverings. In addition, the spermatic cord in males exits in the inguinal area and is the conduit for the testicle. This includes the blood vessels and the vas deferens which is the channel for the sperm produced in the testicle. Hernias in this area are rare in animals walking on four legs, quadrupeds, but much more common in bipeds or upright humans.  In women a supporting ligament (round ligament) to the uterus transgresses the groin instead of the spermatic cord.
There are multiple types of groin hernias including direct (directly through the floor of the inguinal canal), indirect (along the route of the spermatic cord or in women the round ligament) and femoral ( along the blood vessels and nerves exiting under the inguinal ligament). Some large hernias include defects in multiple adjacent areas. All of these hernias are approached comprehensively when repaired surgically.
Generally most groin hernias are repaired electively. The surgery for repair is medically necessary and insurance authorization is readily obtained. Small and asymptomatic hernias may be observed but most patients will eventually experience enlargement of their hernias and increasing symptoms and will come to surgical repair. Inguinal hernia repair is routinely outpatient and recovery is generally swift and uncomplicated. There are options in surgical repair which include open and minimally invasive/ laparoscopic repairs. Each patient requires an individualized approach in terms of timing and technique to optimize outcome.
Most repair options include implantation of a mesh prosthesis to provide a skeleton for effective and strong scar formation. There are a number of procedures performed for effective hernia repair that do not involve mesh placement, but statistically  these repairs are associated with higher failure/ recurrence rates than for those repairs including mesh placement. We currently favor placement of light weight mesh prostheses which have proven to be of adequate strength and have been associated with lower risk of mesh related complications. We are interested in using absorbable mesh prosthetics but are waiting for the results of prospective clinical trials before recommending implantation in our patients. Early reports do look promising. Hernia recurrence or failure of repair without mesh implantation approaches 20%. Mesh repair recurrences have been reliably below 1 % in our experience. Similar results reported without permanent mesh by some institutions have not been reproducible by other experts in hernia repair.
For first time unilateral hernias, open repair is a viable option. This involves an open incision in the groin over the hernia and implantation of a mesh prosthesis to cover the hernia.   This can be performed under sedation and local anesthesia in an outpatient setting. Open repair may also be a favored approach for repair of recurrent hernias which were initially repaired laparoscopically. We generally utilize the Ultra Pro Hernia System prosthesis. Infection and recurrence are both rare complications. Patients generally return to full activity as soon as tolerable. Activity restriction mainly revolves around wound closure technique and may restrict swimming or bathing.  Inguinal hernia repair must stand up to coughing and sneezing which have been proven to put the most strain on the abdominal wall. Therefore lifting and other exercise activities are generally not restricted. Most patients take pain pills for a few days but are capable of activities of daily living. Our goal is have patients ready to return to work at 2 weeks though some return earlier. Complete healing takes up to a year. Patients are generally 80% recovered at two weeks and 90%+ at 6 weeks. Of course all patients recover at their own rate and post-operative care is always individualized.

Femoral hernia

A femoral hernia is a unique type of hernia occurring in the groin or inguinal area. Femoral hernias are more common in women than in men. This hernia occurs inside the space underneath the inguinal ligament transited by the blood vessels  and nerves originating inside the pelvis supplying circulation and innervation to the leg. In women, the pelvis and the pelvic outlet is broader to accommodate childbirth. The area underneath the inguinal ligament, the tether connecting the muscles to the pelvis, is larger. This is an area of weakness inherently and this allows hernias to develop alongside the blood vessels. Femoral hernias are a subtype of inguinal hernias. Femoral hernias, due to their deep and unusual location can be missed in exploration and repair of an inguinal hernia. Attention to detail is thus very important in repair of inguinal hernias particularly in women. The most common failure or recurrence of inguinal hernia in women is a femoral hernia for this reason. Even though femoral hernias are more common in women, other more conventional types of inguinal hernias still are the most prevalent in the female patient. It is important that the entire pelvic hernia outlet be covered with prosthetic mesh to optimize outcome from hernia repair surgery particularly in women. Laparoscopic minimally invasive surgery is favored in women with this type of hernia.

Umbilical Hernias

These are hernias occurring around the belly button (also known as the umbilicus). The potential for this common hernia stems from the inherent opening in the abdominal wall allowing for the passage of blood vessels and urinary structures of the umbilical cord. Usually this opening closes after the cord is ligated at birth, however, this opening can persist and result in an umbilical hernia. These hernias are common in children but usually close by age 5. If they persist, surgery to close the defect may be required. In adults these hernias do not close by themselves and surgical repair will be necessary. Umbilical hernias are prone to incarceration and strangulation.

Surgical options include laparoscopic and open repairs.

Open operations involve making an incision over the hernia the reducing the hernia sac and repairing the defect. Small hernia defects may be sutured directly. Suturing a soft woven piece of surgical mesh to the surrounding muscle tissues may close larger defects. Meshes are implanted to prevent undue tension on the repair. Excessive tension on the closure of the defect increases the odds of recurrence of hernias. Umbilical hernia repairs have a high recurrence risk that is largely mitigated by mesh implantation. These meshes become incorporated by tissue ingrowth during the healing process. Usually if the defect is larger than a dime, recurrence risk will make mesh closure a better option. Potential complications of repair are mainly hernia recurrence but also include infection, poor wound healing and rarely problems related to the mesh itself.

Laparoscopic repairs involve making small incisions (usually 3 in number) at a distance from the hernia through which instruments and a video camera may be introduced to affect the repair. The abdomen is inflated with a nonflammable gas, usually carbon dioxide since it is nonflammable and is rapidly absorbed by living tissues, in order to create a work space for the surgery, In the course of repair, the hernia contents are pulled back into the abdomen, the defect is then sutured closed if possible. Then a mesh prosthesis is sutured or tacked to the surrounding supporting tissues covering the defect.  Special tissue glues have also been used to attach the mesh.  Laparoscopic repairs allow for more precise mesh placement under direct visualization, wider coverage of the defect and perhaps a quicker less painful recovery for the patient.  Since the incisions are remote from the hernia, there is a lower risk for infection.

Your surgeons at Premiere Surgical Specialists have been performing umbilical hernia repair with increasing frequency using robotic assisted laparoscopy with the Davinci system. We are using a self-adhering mesh in select cases, which does not require suturing, or tacking to the abdominal wall. We are finding that this results in less post operative pain for the patient. When suturing is required, the robotic instrumentation and enhanced “3-D” imaging offers delicate precision to the surgical repair.  As our experience expands with this tool so has our exuberance!

Epigastric Hernia

These hernias occur in the midline above the belly button in the tendon connecting the six-pack muscles (rectus abdominus) known as the linea Alba or white line. These hernias are usually small and can be closed through a small incision with sutures alone.  They have a congenital origin but may become more apparent over time. These hernias may also be acquired as aging and weight gain may lead to thinning of the linea Alba by stretching between the rectus muscles. True defects may occur through this thin support structure and the defects may become quite large. Larger defects will require open, laparoscopic or increasingly robot assisted repairs. Because of the weakened thin support tissues, mesh placement is generally required to decrease the risk of recurrence.  The thinning here is referred to as a diastasis of the rectus muscles.

Diastasis Recti

Diastasis of the rectus muscles in the upper abdomen is usually not a true hernia defect and does not have the associated risks of incarceration or strangulation. As people age they experience spreading of the upper abdomen and rib cage due to increased lung capacity and weight gain. This results in spreading and thinning of the connecting midline tissues between the rectus (“six pack”) muscles. A linear concave bulging of the upper abdominal midline seen most easily when initiating a sit up or crunch exercise manifests this deformity.  Usually this thinning is more of a cosmetic deformity than anything else. However this diastasis may be symptomatic in some patients leading them to seek repair. As mentioned above in the  epigastric hernia discussion true hernias may develop in the diastasis necessitating repair. Open, laparoscopic or robot assisted laparoscopic repairs may be options for diastases. Careful preoperative evaluation by hernia surgery specialists is highly recommended, as repair of this condition could be technical and challenging.  Experience with this particular condition will improve the quality of the surgical outcome.

Spighelian and Lumbar Hernias

These hernias are uncommon and may be difficult to diagnose.

Spighelian hernias occur at the lateral border of the rectus muscle (“six pack”) usually  about a third the distance between the umbilicus and the pubic bone. They usually have the symptoms of a hernia but may not always have a readily apparent bulge as the hernia may only be between the layers of the muscle and not all the way through the abdominal wall.  They are usually suspected because of the anatomic location of symptoms. Although they may be diagnosed by careful physical examination, radiologic imaging such as ultrasound, CT scanning or MRI may be diagnostic. Ultrasound is available and utilized by the surgeons of Premiere Surgical Specialists in our office for hernia diagnosis.

Lumbar hernias are also rare and usually result from trauma to the lateral abdominal wall and pelvis such as in seatbelt related injury. They may be missed injuries initially. The trauma surgeons at Premiere have experience with the diagnosis and repair of these hernias.

Spighelian and lumbar hernias may be repaired with open, laparoscopic or robotic assisted laparoscopic surgical approaches. Robot assisted laparoscopic repair again offers enhanced precision and imaging for these unusual hernia repairs.

Ventral and Incisional Hernias

Ventral Hernias can occur spontaneously in the anterior abdominal wall. More commonly they occur in areas of previous surgical wounds and are referred to as incisional hernias. Incisional hernias may develop in up to 20% of surgical closures.  Ventral hernias are then very common with over 300,000 repairs being done annually in the United States and similar numbers in Europe. They may be primary (initial) or recurrent . Having a recurrent hernia is the biggest risk for future recurrence following repair. Surgery for repair of ventral hernias has been vexing for surgeons due to high risks for failure or recurrence. The surgeons at Premiere Surgical Specialists have devoted themselves to improving surgical outcomes through extensive study, interest, experience and dedication. We have sought out the latest technologies to improve our results. This has recently included training and increasingly extensive experience with robot assisted laparoscopic surgery.  Complex abdominal wall reconstruction has become an area of interest and expertise for our group.

Where as suturing alone may close small hernias, larger hernias will usually require mesh implantation as a bridge between muscle tissues or more ideally as reinforcement for the supporting tissue structure.  Being able to close large defects particularly for recurrent hernias requires careful planning and extensive experience to optimize outcomes. The options include open as well as laparoscopic and now robotic assisted laparoscopic techniques. Each hernia patient is evaluated individually and an optimal approach is chosen through collaboration of the surgeons at Premiere.

Since there may be extensive scar tissue and intestinal adhesions associated with incisional hernias, the risks of surgery for repair are increased. The chief risk is hernia recurrence occurring up to 50% or more of the time in some reported series.  Other risks include but are not limited to wound complications, fluid accumulation around the repair (seroma), intestinal or organ injury, adhesion formation, bleeding, infection, respiratory complications, blood clots, chronic pain and even death. The risk factors for hernia recurrence are the same as for primary hernias. Risk factor reduction is mandatory to optimize outcome of ventral hernia repair.  Everything we do is aimed at controlling risk for our patients.

The risks of not having proper surgical repair usually out weigh the risks of repair. Ventral hernias have the risk of incarceration and strangulation of intra-abdominal organs. Ventral hernias weaken the abdominal wall, compromise breathing and the ability of the patient to exercise, work or function.  Ventral hernias can be very symptomatic and often cause a significant cosmetic deformity for patients as well.  Elective medically necessary repair of ventral hernias is certainly safer than operating on hernias presenting as a surgical emergency.

Hiatal and Diaphragmatic Hernias

The diaphragm is a respiratory muscle dividing the chest cavity from the abdominal cavity. Hernias may occur in the diaphragm as a result of errors in development (congenital), may be acquired or result from injury. They may present due to symptoms related to organ incarceration or be diagnosed coincidentally on radiologic imaging. They may present as life-threatening emergencies particularly at birth for congenital defects due to associated poor lung development or when there is a strangulated incarceration.

The most common diaphragmatic hernia is a hiatal hernia. These occur where the esophagus or swallowing tube passes through the diaphragm and into the stomach. Hiatal Hernias may be associated with acid reflux conditions and this is the most frequent indication for repair.

Diaphragmatic hernias resulting from compressive trauma to the abdomen are most frequently repaired by an open incision in the abdomen. There are usually other associated injuries requiring repair.  Elective repair of these hernias is better suited to laparoscopic repair particularly with the Davinci robotic platform due to the better optical video system and more precise instruments.

Anterior Abdominal Wall Hernias

There are multiple types of hernias of the anterior abdominal wall musculature. Again, these are defects in the supporting structure that allow protrusion of internal organs and tissues from inside out. These hernias are generally covered by a peritoneal lining extension or sac. Hernias of the abdominal wall usually cause symptoms of localized pressure and discomfort particularly with effort or straining. These hernias generally become larger and more symptomatic over time.

Usually abdominal wall hernias will slide easily in and out of the defect.  Generally they will disappear with recumbentcy or may gently be manipulated or pushed back inside. A hernia of this type is referred to as reducible. Occasionally the bowel or other tissue may become entrapped in the hernia defect and sac. These hernias may be non-reducible. This may lead to bowel obstruction. Such patients may experience increasingly severe localized pain and tenderness, abdominal distension, and nausea progressing to vomiting. Entrapped organs or tissues is referred to as incarceration of the hernia. If the bowel or tissues entrapped loose their blood supply due to a choking off effect of the incarceration it is referred to as a strangulated hernia. A surgeon or another knowledgeable physician should evaluate incarcerated hernias urgently. Strangulated hernias are a true surgical emergency and time will be of the essence to more favorable outcomes. Incarcerated hernias are the second most common cause of bowel obstruction in developed countries (second only to adhesions from previous surgery) and the most common cause in underdeveloped countries.

Incarcerated and Strangulated Hernias.

If a hernia is reducible, the abdominal contents can be returned to their original compartment. Reduction allows symptomatic relief for patients and reduces the risk of future incarceration. Although reduction helps alleviate patient’s symptoms, elective surgical repair is warranted.

If a hernia is not reducible a rare but serious condition, it is called a strangulated hernia.  It is generally sudden and the patient will have severe abdominal pain.  There will be a swollen, hard and tender bulge in the abdomen or groin.  This is a surgical emergency.

How is a Hernia Repaired?

Open Procedure

For first time unilateral hernias, open repair is a viable option. This involves an open incision in the groin over the hernia and implantation of a mesh prosthesis to cover the hernia defect in many patients.   This can be performed under sedation and local anesthesia in an outpatient setting. Open repair may also be a favored approach for repair of recurrent hernias which were initially repaired laparoscopically. We generally will utilize the Ultra Pro Hernia System prosthesis. Infection and recurrence are both rare complications. Patients generally return to full activity as soon as tolerable. Activity restriction mainly revolves around wound closure technique and may restrict swimming or bathing.

Minimally invasive repairs

Minimally invasive hernia repairs are an alternative approach to open hernia repair. These repairs are performed through small incisions under a general anesthetic using traditional laparoscopic hand held instruments or more recently using the da Vinci robotic assisted instrumentation.  These repairs offer the potential advantage of less postoperative pain, a quicker recovery and return to full activity, less risk of infection and less risk of chronic post hernia repair pain. These repairs are preferred for bilateral hernias; recurrent hernias previously repaired by open incision and for females due to the increased incidence of femoral type inguinal hernias in women. Minimally invasive repairs are still done on an ambulatory basis as outpatient surgeries. The surgeons at Premiere have been involved in pioneering these repairs since inception of these surgical techniques in the early 1990’s. These repairs involve insertion of ports through small incisions in the abdominal wall, usually three in number, accessing either the pre peritoneal space or the true abdominal cavity itself. The peritoneum is the innermost lining of the abdominal cavity and the hernia sac is the peritoneal lining protruding through the hernia defect in the abdominal wall. Surgical repair using these techniques involves reducing the hernia or pulling the sac back into the abdomen then repairing the defect with implanted mesh prosthesis to cover the hole. The mesh serves as a skeleton for eventual incorporation in the abdominal wall by tissue ingrowth and scar formation adding necessary strength to the repair. The mesh is implanted and covered by the peritoneum at the end of the procedure to prevent the mesh from interfacing or coming into direct contact with the intestines. Such contact could result in eventual incorporation of the prosthetic into the intestine which could result in late infection. Think of a horseshoe nailed to a tree. Eventually the living tissue of the tree will grow around the horseshoe and incorporate the shoe internally. The surgical field or space is held open during the procedure by insufflation of carbon dioxide gas under low pressure. Carbon dioxide is utilized and is quickly and readily reabsorbed by all tissue surfaces when the procedure is concluded.
Minimally invasive repairs using traditional laparoscopic hand held instruments have been very successful. Most published surgical series have documented a higher failure rate or hernia recurrence rate compared to traditional open repair with mesh. Still these repairs have been highly successful with recurrences on the order of 1-2% compared to open repair of less than 1%. The advantages of less pain and quicker recovery have still led patients to choose this option. Failure of repair usually is primary or apparent in the first 8 months. Re-operation has been necessary for these patients. We believe that recurrences occur due to the rolling up of the mesh prosthesis like a window shade when the pressure in the operating space is removed at the end of the procedure. Due to the exit of blood vessels and nerves from the pelvis to the leg in the groin, fixation of the mesh to these structures has not been possible with traditional sutures or tacks. This lack of fixation has allowed the mesh to roll up undetected by the surgeon as the space is collapsed.
Since 2015 the surgeons at Premiere have been trained, certified and credentialed in using the daVinci robotic assisted laparoscopic platform. We have gained considerable experience and expertise utilizing this highly precise instrumentation performing complex surgical procedures. This platform has been very well suited to performing surgical procedures in confined surgical fields such as inguinal hernia repair. Although the robot facilitates the movement of the surgical instruments, the surgeon operates the controls. The binocular video camera offers 3D imaging with unsurpassed clarity and detail. Hernia repair using this platform allows the surgeon to place the mesh prosthesis, cover it with the peritoneal lining and visualize exactly where the mesh will be positioned at the end of the procedure.  We have recently been implanting Progrip mesh which is self-adhering and requires no suture fixation by a Velcro like design. We believe that this will reduce the risk of nerve entrapment and the incidence of chronic post hernia repair pain.
We are committed to continuously refine and adopt technology and treatments to optimize the outcomes for our patients.

Mesh

No discussion about hernias is complete without a discourse on mesh.  Ads on television and the Internet by attorneys looking for patients harmed by mesh implants make mesh seem like a 4 letter word. Mesh has been used in hernia repair since the 1950”s.  Implantation of mesh prostheses has greatly reduced recurrences of hernias following surgical repair and has benefitted thousands if not millions of patients. Mesh implantation does have inherent though rare risks, particularly late infection. Infection occurring in a mesh-repaired hernia may be a difficult problem to solve and is a very costly complication.

There are many different types of mesh used in hernia repair.  Most are made of synthetic plastic materials woven into different configurations tailored to their application. They serve as a skeleton or base matrix and the body incorporates them into the structure by tissue ingrowth over time. Some are coated with materials designed to prevent the bowel from becoming adherent to them in the course of healing. Just as a horseshoe nailed to tree will eventually become incorporated into the trunk as the tree grows, a mesh adhered to the living bowel may eventually be incorporated into lumen or channel of the intestine leading to late infection.  In general every effort is made to reduce this unlikely complication. Whenever possible the mesh is implanted so that intestinal contact may be avoided. The surgeons at Premiere generally favor meshes made of lighter weight materials with bigger spaces in the weave. These materials tend to have less shrinkage or contraction during the healing process.  In normal wound healing collagen the structural protein is laid down by healing cells in rows. Later cells come in and cross-link the collagen enzymatically to strengthen the matrix. Generally during this phase the matrix contracts or tightens then later relaxes. Mesh is flexible but not elastic. When the wound contracts implanted mesh may ball up and form an uncomfortable scar or lose its configuration. Larger spaces in the weave allow for some contraction without undesired deformation. As long as the mesh retains the necessary strength to affect the hernia repair the lighter the material the better.

There are biologic meshes made of treated animal or human tissues, which may be implanted in situations where infection is likely or already established.  These biologic meshes are more resistant to infection. They are eventually replaced by tissue ingrowth and the foreign collagen protein is replaced by the patient’s own collagen. These biologic meshes are very expensive and tend to weaken and allow bulging to occur. The patient may feel that the hernia has recurred even when technically it has not due this bulging phenomenon.  Meshless hernia repairs can be successful in specific circumstances, but in general hernia recurrence rates are considerably higher.

Chronic Pain after Hernia Repair

Chronic pain after hernia repair is the most frequent long-term complication of hernia repair. It has been reported to be as high as 30% in some surgical series. There are prediction models, which have been validated to help define the risk of chronic pain for the individual patient facing hernia repair. Most patients at elevated risk for postoperative chronic pain have elevated preoperative pain levels. This has led hernia experts to conclude that nerve damage may have already occurred in these patients. Over 50% of patients presenting with chronic post operative pain syndromes have a recurrence of their hernia as a cause. Chronic postoperative pain may be addressed through reoperation, medical pain management, nerve blocks or a combination of these approaches. Most patients experience complete cure or have significant improvement through these therapies. The surgeons at Premiere are constantly studying this clinical problem and in turn are very knowledgeable on this subject.  We apply what we learn by continuous quality improvement innovations. We cannot guarantee any result but we do guarantee to do the best we can for our patients. We are not quitters.