- Hernias are weaknesses in the abdominal wall, which can allow fat or intestines to bulge through. The most common type occurs in the groin area and is called an inguinal hernia.
- Hernias can create problems when the intestine gets stuck, known as hernia incarceration or hernia strangulation. Hernia strangulation is a medical emergency that requires immediate surgical attention.
- The goal of hernia repair surgery is to close the hernia defect with minimal or no tension to ensure that it does not recur.
A hernia is a weakness or opening in the abdominal wall which often results in soft tissue such as fat or intestine protruding through the abdominal muscles and occupying the space under the skin. The mechanism of a hernia is like what happens with a bulge in a damaged tire, where the inner tube, normally contained by the hard rubber of the tire, extends through a thin or weakened place. The opening in the abdominal wall that leads to the hernia is also known as a hernia defect.
Inguinal hernias are the most common of all hernias and are also referred to as groin hernias. They occur near the crease between the lower abdomen and the upper thigh. When an inguinal hernia develops, intestine or fat may protrude through the defect in the abdominal wall, creating a bulge on the right or left side.
Signs and symptoms of inguinal hernias can include:
- Constant pain
- Discomfort during sitting or with activity
Sometimes, inguinal hernias cause no symptoms at all. Between 10 and 15 percent of men and 2 percent of women will develop inguinal hernias in their lifetime.
Ventral Hernias and Umbilical Hernias
Ventral hernias occur in the part of the abdominal wall above or below the umbilicus (belly button) and/or within the umbilicus itself, where they are called umbilical hernias. These hernias are less common than inguinal hernias, with some 10 percent of both men and women expected to develop either a ventral or umbilical hernia during their lifetime.
Spigelian Hernias and Flank Hernias
The Spigelian hernia, another rarer type of ventral hernia, occurs in the mid-abdomen but are more lateral than the belly button.
Flank hernias are hernias in the flank region (the side of the body, between the rib cage and the hip bone) and can present after trauma or spine surgery and cause bulging or discomfort.
Incisional hernias are a special kind of abdominal wall hernia that occur near prior surgical incisions where prior surgery has weakened the abdominal wall, or where infection in a healing surgical incision causes breakdown of the wound closure. About 25 to 30 percent of patients will develop an incisional hernia when a wound infection occurs after abdominal surgery.
Recurrent hernias are hernias which recur after an attempt at fixation. Even in the best of circumstances, hernias can recur due to the nature of the weakened abdominal wall.
Recurrent hernias are much harder to fix than other types of hernias due to previous surgical scarring, previous mesh, and inflamed tissue surrounding the hernia. Recurrent hernias should be evaluated immediately for possible repair.
Despite the name, Sports hernias are not actually true hernias, but represent a constellation of symptoms, typically groin pain or pressure without an obvious bulge, arising from muscle or tendon injury or weakness in the groin. These are caused by repetitive or quick motions from hip or pelvis twisting which can occur after playing competitive sports, hence the name. There are multiple muscles and tendons which attach onto the pubic bone, and these can get stretched, torn or pulled during sports such as football, hockey, baseball, soccer, and more. As there is no obvious hernia associated with this diagnosis, they are typically diagnosed by physical exam and history, and in more complex cases, x-ray, CT, MRI or ultrasound can be used to look for injuries.
Initial treatment involves rest and anti-inflammatory medications. Physical therapy is also useful in the management of these injuries. Surgery is typically reserved for severe or acute injuries and can involve releasing tendons of affected muscles, strengthening of the pelvic floor muscles, or re-attachment of tendons or ligaments.
Inguinal and ventral hernias may develop due to several factors, including obesity, aging, chronic cough such as with COPD, and strenuous physical activity requiring heavy lifting, such as construction work.
Certain rare conditions such as collagen vascular disease or genetic defects involving connective tissue may also cause abdominal hernias.
Intestine or other organs can get stuck inside of the hernia defect. This process is called hernia incarceration. When hernias become incarcerated, they can cause severe pain, and if the intestine becomes stuck, other symptoms such as nausea, vomiting, and diarrhea can develop. Some hernias are chronically incarcerated when they are present for so long, however if there is any concern, immediate evaluation is necessary.
When the stuck contents become damaged and extreme pain or other symptoms develop, this process is referred to as hernia strangulation. This is a surgical emergency which needs evaluation and surgical fixation right away to save whichever organs are stuck inside the hernia defect.
Surgical Hernia Repair
Anyone who has a hernia should undergo an evaluation for repair. Smaller inguinal and umbilical hernias without symptoms may be monitored without surgery, however every hernia should get evaluation by a hernia surgeon. Incisional hernias and large hernias should be repaired right away as they often enlarge over time. All candidates for hernia repair are evaluated to identify factors that can be modified to minimize the risk of complications, such as control of diabetes and smoking cessation.
The goal of hernia repair is to close the hernia defect with minimal or no tension to ensure that it does not recur. This occurs with or without mesh placement. Mesh is a surgical device used to help support the tissue around the hernia. Mesh can be either synthetic (manufactured polymer sheets), biologic (derived from human or animal tissue), or a mix of both. The secondary goal is to reduce the trauma of surgery by using minimally invasive approaches whenever possible and by ensuring that each patient is optimized.
Approaches to Hernia Repair
There are 3 different possibilities for repair approaches depending on the type of hernia and should be determined after a discussion between the patient and their hernia surgeon.
Open Surgical Repair
The surgeon makes an incision directly over the hernia defect and fixes the hernia from that incision, including mesh placement. This may be appropriate for smaller umbilical and ventral hernias and may be done under light sedation rather than general anesthesia. Open surgery may be necessary for larger or more complex hernias which are not able to be fixed minimally invasively.
The other two options are both considered examples of minimally invasive surgery:
Laparoscopic surgery is performed through several small incisions ranging from 5mm-12mm. The surgeon then uses long instruments to perform the surgery. The purpose of this is to approach the hernia from the inside-out, rather than outside-in. This approach is always performed while under general anesthesia. The surgeon inserts small tubes called cannulas through the abdominal wall at some distance from the hernia defect. The hernia is then fixed, and mesh can even be placed through these small incisions.
Robotic surgery is like laparoscopic surgery in that smaller incisions are used in order to fix the hernia, however instead of the surgeon operating with long instruments controlled by the surgeons hands, robotic instruments are placed inside the patient and the surgeon controls them from a console in the operating room. The robotic platform enables surgeons to have more precise movements, extended reach, and even the ability to perform more complex abdominal wall reconstruction compared to laparoscopic surgery.
Robotic surgery has been around for close to 2 decades however only in the past several years has its real utility in abdominal wall construction been realized. Patients that would normally need large open incisions which would necessitate a several day hospital stay with increased pain can undergo robotic surgery with the possibility of a one day or even same day discharge.
Specialized Hernia Repairs
Non-mesh inguinal (groin) hernia repair
While we recommend mesh reinforcement of inguinal hernias, in certain cases, non-mesh tissue repair can be an alternative. The technique mastered by our surgeons is the Shouldice technique, which is a 4-layer, sutured closure of the muscles and fascia of the groin and abdominal wall in order to repair hernias and strengthen the inguinal floor. While the recurrence rate is slightly higher without mesh reinforcement, the recovery is very similar.
Robotic Component Separation
In order to reconstruct larger hernia defects, muscle releases or component separations may need to be performed in order to bring the patient’s midline closer together. This involves either cutting the outermost oblique muscle, the external oblique, or the innermost oblique muscle, the transversus abdominis. By doing so it is possible to close hernia defects as large as 20-30 cm while preserving the function of the abdominal wall.
Hernias requiring component separation would normally require a large midline incision, however centers adept at robotic component separation may only require 4-6 smaller incisions on the abdominal wall. This allows for a quicker recovery and reduces the rate of complications.
Totally Extraperitoneal Hernia Repair
Typically minimally invasive ventral and umbilical hernia repairs would need to be performed trans-abdominally. This involves placing trocars or tubes inside the abdomen where it is filled with carbon dioxide and the surgeon works up on the abdominal wall. Using advanced optics, high level centers can perform these hernia repairs by operating within the layers of the abdominal wall themselves. This technique is called the enhanced-view Totally Extraperitoneal access (eTEP) hernia repair. This allows for direct visualization of muscle layers and a quicker and more robust repair than would be able to be achieved otherwise.
Some patients may have what is known as rectus diastasis, which is where the rectus muscles (the six-pack muscles) separate at the midline. This can occur with weight gain, with aging, and most commonly after pregnancy. These can also occur along with ventral or umbilical hernias. Even in the absence of hernias, rectus diastasis can be quite debilitating in those who suffer from it.
Repair of rectus diastasis involves bringing the ab muscles back together with the repair of any associated hernias at the same time. Traditional repair of rectus diastasis associated with a hernia involved a tummy tuck by a plastic surgeon, however advanced hernia centers can offer a minimally invasive approach for diastasis and hernia repair. This is referred to as a SubCutaneous Onlay Laparoscopic Approach (SCOLA) Repair. This approach involves 3 small surgical incisions in the lower abdomen and involves a re-approximation of the rectus muscles as well as repair of any associated hernias using long instruments or the robotic platform. This allows for a faster recovery without the need for skin excision.
If you are dealing with a hernia, the Columbia Hernia Center can help you. Our center is among the most advanced in the country, offering all options and techniques, including advanced robotic procedures and approaches. 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.