Abdominal wall reconstruction is the practice of taking a dysfunctional abdominal wall due to hernia disease and putting it back together using advanced surgical techniques. Abdominal wall reconstruction is reserved for large, more complex, or recurrent hernias.
The abdominal wall
The abdominal wall is one of the most complex anatomic structures in the human body. Each of the muscles interconnect with each other, and the function of the abdominal wall is dynamic and complex in nature.
The major muscles that we attempt to reconstruct are the:
- Rectus abdominis
- External oblique
- Internal oblique
- Transversus abdominis.
Due to the complexity of certain hernias, repairing them with simple sutures may not be enough. In certain cases, a reconstructive procedure called a component separation may be necessary. This involves making incisions in 1 of the 3 oblique muscles in order to close the hernia. Long term studies have shown that this technique does not interfere with function of your abdominal wall and may be the only way to close large defects.
Abdominal wall surgery may be performed using:
- An open technique with traditional incisions
- Laparoscopic technique using small incisions
- Robotic technique using small incisions
Small incisions are generally preferred, but there are often reasons that make an open approach better, such as the difficulty in closing incisions, or the need to remove redundant tissue or skin.
There are several surgical procedures that fall under the category of reconstruction. These include:
Retro-rectus Rives Stoppa repair
This involves cutting the connective tissue, or fascia, around the ab muscles to flatten them and bring them together.
This technique attempts to re-approximate your rectus abdominis muscles and repair the hernia at the same time. Mesh is placed behind your ab muscles.
Anterior component separation
This surgery involves making a cut in one of your oblique muscles (the external oblique) so that your hernia can be repaired without tension. The incision into that muscle has no meaningful affect on your future core function after you heal.
With this approach, mesh is placed between the skin of the abdominal wall and the ab muscles.
Posterior component separation, or Transversus Abdominis Release (TAR)
This involves cutting the transversus abdominis muscle, the innermost of our oblique muscles.
This surgery is more complex than the Rives-Stoppa techniques, in that to assist with closing large hernia defects, a cut is made in one of your oblique muscles (the transversus abdominis) so that your hernia can be repaired without tension. This incision into that muscle has no meaningful affect on your future core function after you heal.
Mesh is placed between the lining of the abdominal wall and the ab muscles.
Mesh and abdominal wall reconstruction
There is much conversation regarding mesh in the media, mostly stemming from lawsuits regarding mesh for vaginal slings. In abdominal wall surgery, permanent or semi-permanent mesh has been proven through multiple studies to drastically reduce the risk of recurrence in the future, as it assists with scar tissue formation to form your “new” abdominal wall.
There is always a risk of synthetic or biologic mesh complications, such as infection, erosion, or chronic pain. These risks can be reduced by placing the mesh in a space which has no contact with bowel and using techniques which do not expose any abdominal wall nerves. This provides a natural barrier between any intestine and the mesh.
Immediately after surgery
You may have some mild upper abdominal or shoulder pain after surgery which can be normal since surgeons use carbon dioxide to fill your abdomen during surgery and this can get trapped. The gas is absorbed over the next 1-2 days but can be very uncomfortable in certain circumstances. Typically walking around and taking deep breaths can help absorb this air and reduce pain. However, if your pain is severe in nature and will not go away, or if you are concerned about a heart attack, let us know so that we can perform an appropriate workup.
You may have a feeling that it is difficult to swallow, and you may have a sore throat. The sore throat sensation is typically from intubation, or possibly even a gastric tube, depending on the procedure. This sensation goes away within a day. If your swallowing or sore throat becomes worse, let your doctor know.
You may feel that your breathing is difficult. Again, this may be from pain, or the surgery, but if you feel this is getting worse then alert your doctor.
During your post-surgery hospital stay
You will arrive in the Post-Anesthesia Care Unit (PACU) after your procedure, and as you wake up the nurses will check that you are tolerating liquids and will discharge you home when appropriate.
Due to the nature of this surgery, you may be in the hospital anywhere from 1-4 days or even more depending on how complex the hernia is.
During your stay you should walk or move about at least once every 2 hours along with a nurse or family member
You will be given a small, handheld device called an incentive spirometer to help you take slow, deep breaths. These breathing exercises help your lungs recover from surgery. Use your incentive spirometer ten times every hour. If you’re watching tv, a good approach is to use it during each commercial break.
For pain control, we will attempt to use non opioid therapy, however in larger cases this may be impossible due to pain from large incisions. You may start with a PCA (Patient controlled anesthesia) where you press a button to deliver pain medicine. From there we move to IV pain medicine, then oral pain medicine, and by that point you should be ready for discharge.
We will also give you medicine to help with blood clots (heparin or lovenox injection), medicine for nausea, as well as forms of medicine you were taking at home
Leaving the hospital
At discharge, you will receive any appointments and prescriptions as necessary. It’s a good idea to have someone stay with you during recovery.
When you arrive home:
- Remove loose rugs and cords that can be tripped over in your home.
- Do not consume any mind-altering medications or sleep aids without first speaking to your nurse or surgeon. These include: benedryl, klonopin, clonazepam, lorazepam, valium, diazepam, Ativan, flexeril, soma etc.
- If you are concerned that you may have a fever, or feel like you have the chills, take your temperature with your home thermometer. Anything over 100.4 F is considered a fever and anything less than that is normal for your body’s recovery. There is no need to take your temperature if you feel well.
You should aim to drink 1.5-2 liters (6-8 full glasses) of fluid (preferably water) daily. You should remain out of bed at least 6 hours during the day and walk around your home hourly while awake.
The reappearance of bowel movements might take up to 5 days after the surgery. Remember that walking is the most important factor in return of bowel function.
Follow up after surgery
Your surgeon will want to see you back for a follow-up visit 2-3 weeks after your procedure. If everything is normal there may not be a need to return again unless there is an issue.
While you should feel like your usual self after 6-8 weeks, your body will still be healing from the surgery for about a year. If you overdo it with physical activity and get a recurrence of some mild pain, reduce the inflammation with ice, Tylenol (if possible) and rest. If pain persists, make an appointment with your surgeon, or call your nurse. If you are worried, they are worried.
Complications of abdominal reconstruction are rare, and include but are not limited to:
- Pneumonia or telectasis (lung collapse)
- Wound infection, wound dehiscence (falling apart), abscess
- Urinary tract infection, inability to urinate
- Bowel damage
- Blood clots
- Chronic pain
- Need for additional surgery
When to call the office
Please call your doctor’s office if you are experiencing any of the following:
- Fever >100.4 which is sustained on 2 different readings. Temperatures less than this are normal after surgery, as the body heats up as it is healing
- Redness surrounding incisions, drainage from incisions that is green, yellow (solid yellow, clear yellow is fine), or foul smelling.
- Bleeding from your incisions that will not stop with pinpoint pressure (hold pinpoint pressure for 10 minutes first).
- Vomiting or persistent nausea which does not go away with time
- Inability to urinate more than 6-8 hours after surgery, or if you have the urge to urinate and also have pelvic pressure.
- We typically recommend trying to stand in a hot shower for 15-20 minutes
- Severe abdominal pain unrelieved by prescription medications or increasing in intensity
- Large amount bruising or discoloration over incisions or flanks
- If you feel that you are getting worse each day instead of better
When to go to the ER
Please call 911 and go to the nearest ER for the following:
- Chest pain
- Fainting spells
- Shortness of breath or difficulty breathing
- Trouble speaking, weakness on one side of your body or both, changes in your vision
- Uncontrolled bleeding from any incision
Please let your surgeon know once this has happened in case there is a surgical problem
Here are some useful tips you can use to make sure your recovery from hernia surgery goes as smoothly as possible, including information on diet, drain care, activity, pain management and more.
Diet after abdominal wall surgery
Stick to a light, soft diet for the first 2-3 days after surgery. This includes easily digestible foods like:
- Cottage cheese
- Scrambled eggs
Please keep your incisions clean and dry. Replace soaked dressings as needed.
If you only have glue or strips, you may shower 24 hours after surgery. Allow the water to run over the incisions and then pat dry, do not scrub. Do not pick off the glue or strips (Steri strips); these will fall off over the next two weeks.
Do not apply ointments to your incisions, and avoid soaking incisions (i.e. No baths, swimming, or hot tubs etc.) until healed after 4 weeks.
Notify your surgeon if there is discoloration, redness, swelling, pain, or drainage from your incisions.
For some cases you may have an abdominal binder placed. Please wear the binder while awake for 4 weeks total if given one.
These binders are typically machine washable, and additional ones can be purchased from pharmacies or online.
If you have a drain that you take home, remember it is sutured to your skin. You can prevent it from hanging or pulling by taping the tubing to the outside of your abdominal binder. Do not use safety pins for this.
Empty the drain 2-3 times daily and record the amount of fluid on the log that is given to you by the nursing staff when you leave the hospital. If you are not given a log, keep track of the amounts on a separate piece of paper.
The drainage will look like blood for up to three days. It will then begin to clear up and look more like fruit punch. Then it may become a clear yellow. Sometimes you will see thick strands of fat or clot run through it, and this is normal.
If the drain is clogged and not flowing, wash your hands, hold the drain near your skin (so as not to pull it out) and strip the drain by pinching and running your fingers down the tubing. This should unclog it. Be careful not to pull it out.
If the drain stops working, monitor for increased swelling around the site or in the abdomen. Sometimes you do not have any more fluid to empty and this can be a good thing.
Sometimes drainage/fluid will leak out of the opening surrounding the drain. This is ok, just keep it clean and dry. You can use saline and gauze or an alcohol swab to cleanse around it.
If the drain falls out or you accidentally pull it out, notify your surgeon’s office. Do not go to the emergency room. This may just be monitored.
The drain will typically be removed in the office at your 1-week follow-up appointment. Be prepared with Motrin, Tylenol and ice. Removing the drain may feel “weird” but typically does not hurt. We recommend you have someone drive you to this appointment.
Some key tips on activity after abdominal wall surgery include:
- Avoid lifting anything more than 15 pounds for 4 weeks.
- It is ok to walk up the stairs with the proper assistance (if needed).
- Do not drive if taking narcotic pain medications or while in moderate pain.
- Be sure to take focused deep breaths to help prevent lung collapse or pneumonia.
- Move around the house at least once an hour to prevent blood clots.
After 4 weeks you can slowly transition to your normal routine without restrictions. If you notice pain or discomfort, you may need an additional week or two.
Please take Tylenol or ibuprofen as needed for pain. You can take up to 1000 mg of Tylenol every 6 hours in a 24 hour period, and you can also take 400 mg of ibuprofen every 6 hours as well. You can alternate these pain medications every 3 hours as needed in order to achieve optimal pain coverage, however if only one medicine is needed, then there is no need to alternate.
Narcotic pain medicine may be taken on top of the ibuprofen or Tylenol but should be weaned off first.
Apply ice packs as needed for no more than 20 minutes at a time (20 minutes on, 1 hour off) for pain or swelling
Remember, your abdominal muscles are busy recovering. You may have some back pain as a result, especially if you had it prior. You can alternate ice and heat on your back.
Take a stool softener such as Colace (Docusate Sodium) if you are using a prescription narcotic or as needed for constipation. Colace is an over-the-counter stool softener. It works by making stools softer and less brittle. You may take 100 mg of Colace by mouth up to three times a day as needed.
Increase your physical activity if possible and drink 8 full glasses of fluids per day.
If you have not had a bowel movement in 4-5 days AND you are able to pass gas, you may try an over-the-counter liquid laxative of choice, (i.e. mineral oil, milk of magnesia, miralax or senna). You may also try prune juice or aloe vera juice.
Please do not strain or bear down too much to have a bowel movement. This can cause undue stress on your surgery sites. Take stool softeners in this case.
If you cannot pass gas after 3-4 days and are experiencing nausea, vomiting and abdominal distension, please call the office and come to the emergency room.
If you develop a persistent cough, please see your primary care physician right away. Coughs need to be controlled so as not to risk your repair.
More post-surgery restrictions and recommendations
Some activities to avoid post-surgery:
- No golfing, swimming or any other sports for 8 weeks
- No driving for 2 days after surgery, or while taking narcotic pain medication. Even severe pain by itself can distract you from driving
- No marijuana or tobacco intake for at least 4 weeks after surgery, but we recommend stopping the use of these lifelong for health purposes.
- No alcohol intake for at least 4 weeks after surgery. Alcohol can cause severe reactions when taken with narcotics or even large doses of Tylenol.
- No flying until at least 2 weeks after surgery. If there is an extremely important event, discuss this with our team.
Some activities we recommend:
- Make sure to move around at least once an hour while awake. Long walks are recommended, even if only inside your dwelling.
- Drink at least 1 protein shake/drink a day to supplement your protein intake. Protein is the most important piece of nutrition which helps with wound healing
- You can go for a light jog as tolerated after 2 weeks. If you are having discomfort, please rest.
- You can go back to work as soon as you are not taking narcotic pain medicine, or after 2 days. Some people even feel like they can return sooner!
If you’re dealing with a hernia or have need for abdominal wall surgery, the Columbia Hernia Center is here for you.
- Our team is highly experienced in all the most advanced treatment options, including enhanced recovery protocols for all our patients to help reduce complications from surgery and reduce the length of both your hospital stay and recovery.
- We also believe strongly that the best recovery begins before you ever enter the operating room. As part of this “pre-habilitation” approach, our team of specialists will check in with you every step of the way and make sure your body is optimized for your procedure ahead of time.
- We use permanent or semi-permanent mesh for all major abdominal wall reconstructions. This has been proven in the literature to drastically reduce the risk of recurrence in the future, as it assists with scar tissue formation to form your “new” abdominal wall. We also utilize techniques which do not expose any abdominal wall nerves to provide a natural barrier between any intestine and the mesh.
- Our precise attention to detail has allowed us to reduce the rates of chronic pain after surgery to less than 1%. We also pride ourselves in our ability to avoid post-operative narcotics.
- Our specialized pain management protocols have allowed us to avoid narcotics in over 95% of our minimally-invasive repairs.
- Our job doesn’t end after surgery. We’ll be with you throughout your recovery, monitoring your progress and answering any questions you have. If any complications come up, we’ll be there to get your recovery back on track.
To set up a consultation, please call us at (212) 305-5947 or use our online appointment request form. We look forward to answering your questions and meeting your hernia care needs.