Advanced & Robotic Hernia Repair
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At Premiere Surgical Specialists, our Surgeons are experts in procedures to correct hernia defects in adults and children. With over 105 years of combined experience, we can perform open surgical, laparoscopic and robotic techniques to optimize patient outcomes with minimal down time.
What is a Hernia?
Quite simply, 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. This protrusion results in a typically noticeable bulge under the skin accompanied with discomfort, particularly when standing or straining. These defects may be congenital or can be acquired due to injury, previous surgery, or 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, and repetitive straining or lifting. Other risk factors include premature birth, male gender, family history, steroid use, chronic cough and smoking.
How is a Hernia Diagnosed?
Patients will frequently report a bulge in the groin area, at the navel or in an area of 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. In rare cases 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.
Hernia’s are usually readily diagnosed by a skilled physical exam. If you think you have a 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 helpful supplement to a physical exam. Ultrasound is a dynamic, real time and painless imaging tool that can be done while relaxed and/or straining to detect movement and protrusion in symptomatic areas.
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 during 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 experts at their diagnosis and proficient in their management. We specialize in both routine and complex surgical repairs and abdominal wall reconstructions. Types of hernia include:
The most common type of hernia is a hernia of the groin, called an Inguinal Hernia. Inguinal Hernias are more typical in male patients. With this type of hernia a protrusion will occur in the groin area and be associated with pain, especially when straining. These hernias can either be direct (occurring directly through the floor of the inguinal canal) or indirect (along the blood vessels and nerves exiting under the inguinal ligament). An indirect inguinal hernia is the more common type of inguinal hernia.
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Femoral hernia is a unique type of hernia occurring in the groin or inguinal area. Femoral Hernias occur more frequently in women than 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 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 and this allows hernias to develop alongside the blood vessels.
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An Umbilical Hernia occurs around the belly button of the patient. 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. 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 (a medical emergency) and thus should be treated when they are identified.
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An Epigastric Hernia occurs in the midline above the belly button in the tendon connecting the six-pack muscles. These hernias have a congenital origin but may become more apparent over time. They can also be acquired as aging and weight gain may lead to a thinning of the tendon as a result of stretching of these muscles. True defects may occur through this thin support structure and the defects may become quite large, requiring surgery.
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Spighelian & 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.
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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 and techniques 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.
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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 recumbency 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 lose 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.
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Hiatal & Diaphramatic 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.
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How Are Hernias Repaired?
Your surgeon may suggest lifestyle changes to ease the symptoms of a hernia, but surgery is considered the only way to permanently fix a hernia. For first time unilateral hernias, open repair is a viable option. This involves an open incision over the affected area and the implantation of a prosthetic mesh to cover the herniated defect. This is accomplished in an outpatient surgical setting under sedation and local anesthetic. Most patients are able to return to work about 2 weeks after surgery, but some can go back sooner. Patients are generally 80% recovered at two weeks and 90+% recovered at about six weeks. All patients do recover at their own rate and therefore postoperative care is always individualized.
Open Surgical Repairs
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 immersion bathing.
Minimally Invasive Repairs
Minimally invasive hernia repairs are an alternative approach to open hernia repair. These repairs are performed through small incisions under general anesthetic using traditional laparoscopic hand-held instruments or, more recently, by utilizing the da Vinci® Robotic Assisted Surgical System. These repairs offer the potential advantage of less postoperative pain, a quicker recovery, and less risk of infection. The surgeons at Premiere Surgical Specialists have been pioneering these repairs since the inception of these techniques in the early 1990’s. The repairs involve insertion of ports through small incisions in the abdominal wall, typically 3-4 in number, accessing either the pre-peritoneal space or the true abdominal cavity itself. These incisions are significantly smaller than through an open technique – for example, please see the image below:
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