A hernia occurs when there is a tear or opening in the muscles of the abdominal wall. A small sac containing fat or intra-abdominal contents such as intestines protrudes through that opening. The repair of a hernia is called a herniorrhaphy. There are acquired hernias which are caused by straining over the years and congenital hernias which have resulted from a weakness in the abdominal wall present since birth. A hernia that cannot be reduced is incarcerated. If the blood supply of the hernia contents is compromised this is called a strangulated hernia. A hernia that develops at the belly button is called an umbilical hernia. Inguinal hernias develop in the groin. There are two basic types of inguinal hernias: direct and indirect. An indirect hernia follows the spermatic cord or round ligament where as a direct hernia protrudes directly through the muscles of the groin. Femoral hernias protrude through the femoral canal. A hernia that develops at an incision is called an incisional hernia. A ventral hernia can occur anywhere in the abdominal wall where there is a weakness. A hiatal hernia occurs when the stomach slides through the diaphragm into the chest.
A hernia can develop in anyone. Young, old, healthy or not, it makes no difference. Males are approximately five times more likely to develop groin or inguinal hernias. Femoral hernias are more common in females. The over all incidence of hernias in the adult male population is approximately five percent.
As a matter of fact there are. Lifting heavy objects, muscle strains, massive weight gains, chronic constipation, repeated attacks of coughing or chronic coughing and straining to urinate are just a few of the risk factors.
Generally a hernia can occur anywhere in the abdominal wall. If there is a weakness or defect in the abdominal wall a hernia can occur. The most common sight of a hernia is in the groin. Inguinal or groin hernias comprise 80 percent of all hernias. Hernias can also occur at previous abdominal incisions.
Frequently there are no symptoms. A hernia can be a fortuitous finding on a routine physical examination. More often however the hernias are symptomatic. The symptoms can include a bulge where the hernia is, pain in the area, a feeling of pressure or weakness in the area, a burning sensation, and a gurgling or squishy feeling in the area. A hernia can also present acutely. For instance heavy lifting in the yard or garden accompanied by sudden pain in the area of the inguinal or umbilical region could mean a hernia. Individuals who know they have a hernia should be aware of an incarceration. That means that the hernia cannot be pushed back can. Often incarceration can lead to strangulation. This is when the blood supply of what ever is in the hernia sac becomes compromised. This can be a life threatening condition that requires immediate medical attention.
There are many ways to repair a hernia. The conventional method: the hernia sac and defect are dissected out and the sac is either removed or reduced. Next using suture material, the muscle tissue surrounding the hernia defect is reapproximated.
Tension free repair using mesh: Once again the hernia defect and sac is dissected out and the sac either removed or reduced. The mesh is then inserted and covers the abdominal wall defect. Since the hernia is repaired without tension and minimal suturing used, there is a less pain. The mesh is a synthetic substance that has been around for years and is well tested. It is well accepted by the body’s natural tissues which grow into the mesh. Recovery is rapid and the likelihood of a recurrence is low.
The laparoscopic method: this is a similar to the tension free repair. A laparoscope which is a camera and light source is inserted in the vicinity of the hernia. The surgeon can then visualize the procedure on a television monitor. Surgical instruments are then inserted through separate incisions. The hernia defect and sac are dissected out and the hernia sac and its contents reduced back through the defect. Mesh is then used to cover the defect and is held in place with surgical tacs.
Robotic assisted surgery: Presently there is only one robotic device used for surgery. It is the da Vinci surgical system made by Intuitive Surgical Inc in Sunnyvale, California. Robotic-assisted surgery is a form of minimally-invasive surgery (MIS) that is performed through small incisions. Like the laparoscopic method, a high definition scope is used to three dimensionally visualize the surgical field. The surgeon sits at a console while viewing a high-definition, 3D image of the patient’s target anatomy. The surgeon’s hand, wrist and finger movements made at the console (outside of the surgical field) are translated into precise, real-time movement of surgical instruments attached to three or four robotic arms. Robotic-assisted surgery allows surgeons to perform many types of complex procedures with more precision, flexibility and control than is possible with conventional techniques.
Repairs are judged as good or bad depending on their recurrence rates. Obviously every surgeon strives to have a recurrence rate as close to 0% as possible. In reality however there is no such thing as a hernia repair that has a 0% recurrence rate. A tension free repair has a recurrence rate of approximately one half to 1%. A conventional repair, that is using suture material to close the hernia, can be associated with a recurrence rate as high as 10%. Recent studies have shown that a tension free repair using mesh as well as a laparoscopic or robotic assisted repairs have similar outcomes in terms of recurrence rates and complication rates. There are some patients that may be candidates for a laparoscopic or robotic assisted repair depending on the type of work they do, their body habitus and previous surgeries. Every patient is different and we try to tailor our recommendations based on the individual.
Most hernias do not reoccur. However, when they do, repair is usually done in the same manner as a primary hernia. Usually a synthetic mesh is used and is tacked or sutured in place. Most times a laparoscopic or robotic approach is used. It just depends on the patient and how many repairs they have had in the past.
Component separation technique is used for complex recurrent hernias, many of which have infected mesh. When the old mesh is infected it is always removed. Component separation means that the components of the abdominal wall are separated. Then a biologic mesh, synthetic absorbable mesh or a light weight mesh is placed between the muscle layers to effect the repair.