Inguinal , Umbilical, Incisional and Ventral Hernia Repair

(Hiatal hernias are not covered in this handout, if you are seeing us because of a hiatal hernia please ask for a handout on GastroEsophageal Reflux Surgery).

What is a Hernia?

A hernia is a weakness or tear in the abdominal muscles which allows fatty tissue or an organ such as the intestines to protrude through the weak area. This can cause a noticeable bulge under the skin, and the pressure of tissue pushing its way through the weakened area can be the source of significant pain and discomfort. Symptoms can feel worse when you stand for long periods, during urination or a bowel movement, or when you lift heavy objects - when anything puts additional strain on the area.

Kinds of Hernias

Inguinal hernias

These occur in the groin (lower abdomen, just above the leg) in both male and female patients. They are the result of a weakness in the abdominal wall connective tissues in an area where the muscles become tendon. The only way to cure a hernia is with surgery. (P.S., the pronunciation of inguinal is ing' wa nal).

Femoral Hernia

Hernias in the femoral area, just below the groin crease, are more common in women than in men. Because they are so close to inguinal hernias, we generally treat these by an internal repair just as we would an inguinal hernia. (In fact, when we treat an inguinal hernia with a mesh patch, that patch covers the femoral area as well to prevent hernias forming here later.) Occasionally we will treat them with a plug technique from the outside.

Epigastric Hernia

This is another type of hernia that is more common in men than women. It occurs above the navel, in the upper-middle area of the abdomen.

Incisional Hernia

An incisional hernia is one that is located at the site of a previous surgical incision. These can develop weeks, months or even years after the initial surgery. These are often repaired with a mesh patch.

Umbilical Hernia

This type of hernia occurs in the naturally weakened area of the navel, where the umbilical cord was attached, and can affect women and men as well as children. Depending on the size of the hernia, this may be repaired either with sutures or a mesh patch.

Ventral Hernia

A ventral hernia is a generic term used to describe hernias of the abdominal wall other than inguinal hernias. So Epigastric, Incisional, and Umbilical hernias are all Ventral hernias. In addition there are uncommon kinds of hernias such as lumbar hernias that are classified as Ventral hernias. The term is useful because treatment options are fairly similar between different kinds of ventral hernias.

Hiatal Hernia

A hiatal hernia is a weakness in the diaphragm muscle that allows the stomach to move up into the chest. These kinds of hernias are often associated with gastroesophageal reflux disease (GERD). This pamphlet does not cover hiatal hernia repair but we have other material that does.

What Causes a Hernia?

Despite the folklore about heavy lifting being the cause of hernias, the reality is that most hernias are the result of a defect or weakness that exists long before the hernia appears; often the weakness in the abdominal wall is present at birth. The area can also be weakened by age, injury, or a previous surgical incision.

Heavy lifting or other strenuous activities can aggravate hernias, however.

Although hernias are more common in men than in women, they can develop in anyone. Risk factors include a number of things that can put additional strain on the abdominal wall, such as:

A chronic cough, such as smoker's cough

Obesity

Straining during bowel movements or while urinating

Pregnancy

Straining to lift heavy objects

Persistent sneezing, such as that caused by allergies

If the bulge flattens out when you lie down or push against it, you have what is called a reducible hernia; you are not in immediate danger, but the hernia should be evaluated by a physician. If the tissue protruding through the hernia is stuck and never flattens out, you have a nonreducible hernia; this is often painful and prompt medical attention is required. This may also indicate that part of the intestine is very tightly trapped -a strangulated hernia - and the intestine has become blocked. Symptoms of obstruction can include bloating, constipation, severe pain, vomiting and even shock. This condition is considered a medical emergency and immediate surgery will be needed to remove the blockage and repair the hernia. Even if you just suspect you have a hernia, see your doctor about it so that serious complications can be avoided.

Diagnosis of Hernia

A hernia is generally diagnosed on physical examination. In cases where the diagnosis may not be clear on exam, an ultrasound may be performed to help establish the diagnosis.

In about 10% of cases of inguinal hernias, another inguinal hernia will be found on the other side. Your surgeon will talk with you about whether to repair that at the same time.

When Is Surgery Needed?

Surgery is generally indicated when the hernia is causing enough discomfort that it impacts daily life, if the hernia is occasionally very tender, if the hernia is growing or at high risk of getting bowel stuck in the hernia (incarceration).

How Are Inguinal Hernias Repaired?

Traditional Tension Repair (Older Technique)

This technique is mentioned primarily so that you may understand better our current approaches, as we rarely use it currently for inguinal hernias. For this type of hernia repair the surgeon makes an incision in the abdomen over the hernia site, pushes any protruding tissue back into correct position within the abdominal cavity, and then stitches the hernia closed. A tension repair is used in some instances for children or if the hernia is extremely small. This technique however has several disadvantages. First, the level of discomfort following a tension repair is greater, and the recovery period is longer (about 4-6 weeks) than with a tension-free repair. In addition, there is an approximately 10-15 percent chance that the hernia will happen again. Its use has decreased in recent years and we rarely use it now.

Current Techniques Using an Internal Mesh or Patch

In most instances where surgery is indicated, we will recommend repairing the hernia using a mesh (also called a patch). This provides the most durable repair with the least amount of discomfort after surgery. The patches are permanent, nonreactive, typically made of polypropylene, and look somewhat like nylon windscreen. Some of the patches are anatomically contoured to fit in the groin area.

The patch is placed whenever possible behind (within) the abdominal wall. This allows pressure to hold the patch in place, instead of pushing the patch away. (Think of fixing a hole in a dam by putting a patch upstream, instead of downstream – you don’t need to be an engineer to understand that this will work better). Due to new techniques, it has become much easier to place the mesh in this location, with faster recoveries, less pain, and better long-term results.

The two most common techniques we employ are the Kugel technique and the laparoscopic technique. Both place a relatively large patch (up to nearly 4 by 6 inches in some cases) in this ‘upstream’ location – what we call preperitoneal location – in such a fashion that the patch covers not only the hernia hole but other areas in the groin where hernias can develop over time. The size, contouring, and reinforcement in the mesh permits us to place the mesh without the need of many sutures or staples to fix it in place, thus decreasing postoperative discomfort.

Both surgical techniques are mostly done under a general anesthetic, where you are completely asleep and feel nothing during surgery. (It is very difficult to get this preperitoneal space numbed up adequately with a local anesthetic.)

Minimally Invasive Open Preperitoneal Technique of Inguinal Hernia

In the open preperitoneal technique, a small 1.5-2 inch incision is made near the hernia bulge. The hernia is then identified and pushed back into the abdomen. The space between the abdominal wall and the peritoneum (think of it as the space between the drywall and the wallpaper) is freed up. A patch (aka mesh) make of is then placed into this opening so that it covers the hernia (the hole), as well as other potential hernia sites. Pressure holds the patch in place with only a few sutures. The skin is then closed with sutures and glue. The entire surgical procedure takes about 30-60 minutes.

Laparoscopic Inguinal Hernia Repair

Laparoscopy has made possible an advance called posterior hernia repair. The surgeon inserts a laparoscope, a thin instrument consisting of a lighted tube with magnifying lenses, through a small incision in the abdomen. Carbon dioxide gas is placed into the abdominal cavity to create a working space. The laparoscope enables the surgeon to examine the hernia and accurately place a mesh patch on the inside of the abdominal wall, not outside as with traditional mesh repair.

Through two other pencil-diameter incisions, special operating instruments are used to open up the space between the peritoneum and the abdominal wall (think wallpaper and drywall again), large enough to permit a mesh patch to be placed to cover the hernia hole and the other potential weak areas. The peritoneum is sewn back together again to keep the mesh in place; these sutures don’t cause pain. The carbon dioxide gas is removed and the very small incisions in the abdomen are closed (they are small enough that they don’t become hernias.)

We have not seen any major difference in postoperative discomfort or recovery time, or long term success, between the Kugel and laparoscopic approaches. Both approaches place a patch of similar dimensions in the same location. Therefore the decision as to which approach to use is more governed by the particularities of each hernia, and your surgeon will discuss with you which approach he would recommend.

Plug and Patch Repair of Inguinal Hernia

In the Plug and Patch repair, an incision is made over the inguinal hernia. Once the herniated tissue has been pushed back in, then an umbrella shaped mesh plug is placed into the hole and the edges of the umbrella shaped mesh are sutured to the edges of the hole. Then an additional flat piece of mesh is placed between two layers of the abdominal wall to provide a more broad-based reinforcement of the hernia repair.

External Mesh Repair of Inguinal Hernia (Used only in selected patients)

After making an incision, the surgeon uses a patch made out of flat (polypropylene) mesh and stitches it over the tissue surrounding the hernia. Results from this type of repair are good, with only a 3 percent recurrence rate.

Recovery is quick and there is less discomfort following surgery. This procedure can be done under local anesthesia, while you remain awake, avoiding the risks associated with general anesthesia, and can be done if you’ve had previous surgery in that area such as a prostatectomy. A disadvantage of this type of repair is that if the hernia is large, more stitches may be required to fasten the mesh, increasing the risk of nerve damage.
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Umbilical, Epigastric, Incisional, and Ventral Hernia Repair

These hernias in the abdominal wall are repaired by either open or laparoscopic techniques, and the decision on how to repair it is individualized to the patient. In either case, we will most likely use a patch to repair the defect from the inside rather than suture the edges of the defect together. This provides a stronger repair, because of the large patch underlay; less pain is often the case because the tissue is not pulled together under tension; quicker recovery is also seen because the patch is immediately strong and does not rely on tissue healing the same way that a sutured repair does. The following diagrams illustrate the inside view of a hernia with some fatty tissue pushing into the hernia (Figure 1); the patch being pulled up and centered over the hernia (Figure 2); and the patch being held in place with tacks (Figure 3).

Figure 1: Initial view of hernia

Figure 2: Patch being positioned under hernia

Figure 3: Patch being tacked in place

These hernia repairs are individualized and we will recommend the best technique and choose the most appropriate materials for your situation.

Benefits of Surgery

As we mentioned above, surgery is most often done when a hernia is causing pain and discomfort, or enlarging significantly. Studies have shown that over 90% of patients will experience relief of discomfort after they have recovered from their hernia surgery. Patients who have a significant amount of leg or testicle pain associated with an inguinal hernia may be less likely to improve fully after hernia surgery.

Risks of Hernia Surgery

Our techniques of inguinal hernia repair by placing a patch internally (such as the laparoscopic or Kugel repair) have been associated with a recurrence rate of less than 1% (in the first two years after surgery) and the development of persistent groin pain in less than 1% of patients. Other studies have shown that this technique is associated with a long-term recurrence risk of less than 2%. Other risks include swelling and pain in the scrotum or groin after surgery, development of a painful testicle, and prolonged recovery.

Ventral and umbilical hernia repair risks are primarily those of recurrence (which ranges from 2% to 10% depending upon the size of the hernia), injury to bowel during the surgery (less than 1%) and infection of the mesh requiring removal of the mesh (less than 3%).

Alternatives:

Currently there are no non-surgical techniques to fix hernias. A discussion with your surgeon will help you determine whether you would benefit from having your hernia repaired.

Prior to Surgery

You will receive a preoperative instruction sheet detailing what is required in the way of testing and preparation prior to your surgery. Please keep in mind to not eat anything after midnight prior to your surgery. You may have clear liquids (coffee and tea are NOT clear liquids) until 4 hours prior to your surgery time.

After Surgery

After surgery, you will spend a few hours in the recovery room and then most likely be discharged home the same day. You will need someone to drive you home from the surgery center.

When you go home you should keep an ice pack on the area of the hernia repair for 24 hours, be a ‘couch potato’ for 2 days, and then refrain from vigorous physical activity for the next week. In most instances you may return to unrestricted activities 10 days after surgery or as soon thereafter as your body and pain levels permit.

You will be given a discharge instruction sheet and a prescription for pain medication prior to leaving the surgery center. You will need to make an appointment to see us 2-3 weeks after surgery (sooner if you need to, we are always happy to see you sooner if questions arise.). Depending upon how you are recovering, further follow-up may not be needed beyond this.