Hernia Surgery

Inguinal (Groin) Hernia Repair

Approximately 600,000 hernia repair operations are performed annually in the United States. Many are performed by the conventional “open” method. Some are performed using a small telescope known as a laparoscope.

How do I know if I have a hernia?

The common areas where hernias occur are the groin (inguinal), the belly button (umbilical), and the site of a previous operation (incisional). It is usually easy to recognize one. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting. The pain may be sharp and immediate, or a dull ache that gets worse toward the end of the day.

What causes a hernia?

The wall of the abdomen has natural areas of potential weakness. Hernias can develop there or elsewhere due to heavy strain on the abdominal wall, aging, injury, an old incision, or a weakness present from birth. Anyone can develop a hernia at any age — both men and women. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting, persistent coughing, or difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate.

How the repair is performed

Use of a truss (hernia belt) is rarely prescribed, as it is usually ineffective. Most hernias require a surgical procedure, done in one of two ways.

1. Open repair

Done from the outside through a three- to four-inch incision in the groin or the area of the hernia. The incision extends through the skin and subcutaneous fat to reach the level of the defect. The surgeon may use a small piece of surgical mesh to repair the hole. This is usually done with a local anesthetic and sedation, but may be performed under spinal or general anesthesia.

2. Laparoscopic repair

A laparoscope — a tiny telescope connected to a special camera — is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen. Other cannulas are inserted to work inside. Three or four quarter-inch incisions are usually necessary. The hernia is repaired from behind the abdominal wall, and a small piece of surgical mesh is placed over the defect and held in place with small surgical staples. This operation is usually performed under general anesthesia, occasionally under regional or spinal anesthesia.

Advantages of the laparoscopic repair

Laparoscopic hernia repair fixes tears in the abdominal wall using small incisions, telescopes and a patch (mesh). It may offer a quicker return to work and normal activities, with decreased pain, for some patients. Only after a thorough examination can we determine whether it is right for you — the procedure may not be best for some patients who have had previous abdominal surgery or who have underlying medical conditions.

Recovery

Most hernia operations are performed on an outpatient basis, so you will probably go home the same day. Following the operation you will be monitored in the recovery room for one to two hours until you are fully awake; once you are awake and able to walk, you will be sent home.

With any hernia operation you can expect some soreness, mostly during the first 24 to 48 hours. You are encouraged to be up and about the day after surgery. With a laparoscopic repair you will probably be able to get back to your normal activities within a short amount of time — showering, driving, walking up stairs, lifting, working and sexual intercourse. Call and schedule a follow-up appointment within two weeks after your operation.

Ventral & Incisional Hernia Repair

Approximately 90,000 ventral hernia repairs are performed each year in the United States. Many are done by the conventional open method; some are performed robotically.

What is a ventral hernia?

A ventral hernia usually arises in the abdominal wall where a previous surgical incision was made. In this area the abdominal muscles have weakened, resulting in a bulge or tear. The inner lining of the abdomen pushes through the weakened area to form a balloon-like sac, and a loop of intestine or other abdominal contents can push into it. If those contents get stuck within the sac they can become trapped, or “incarcerated” — which could lead to serious problems requiring emergency surgery.

Ventral hernias can also develop at the belly button (umbilicus) or any other area of the abdominal wall. An incision in your abdominal wall will always be an area of potential weakness; hernias can develop there due to heavy straining, aging, injury, or an infection at the site following surgery. They can occur immediately after surgery or not become apparent for years.

How the robotic repair is performed

Robotic hernia repair fixes tears or openings in the abdominal wall using small incisions, laparoscopes and a patch (screen or mesh) to reinforce the abdominal wall. A laparoscope with a television camera attached is inserted through a cannula, allowing our team to view the hernia from the inside. Other small incisions are used for instruments to remove scar tissue and insert surgical mesh. The mesh is fixed under the hernia defect to the strong tissues of the abdominal wall and held in place with special surgical tacks and, in many instances, sutures. Usually three or four incisions of a quarter to a half inch are necessary. The operation is usually performed under general anesthesia.

The traditional alternative is an open repair through an incision in the abdominal wall, which may go through part or all of a previous incision. The surgeon may sew your natural tissue back together, but frequently mesh is required for a sound closure.

Advantages of the robotic repair

Results may vary depending on the type of procedure and each patient's overall condition. Common advantages may include:

• Less post-operative pain
• Shortened hospital stay
• Faster return to a regular diet
• Quicker return to normal activity

Only after a thorough examination can we determine whether a robotic ventral hernia repair is right for you. It may not be best for patients who have had extensive previous abdominal surgery, hernias in unusual or difficult locations, or certain underlying medical conditions.

Recovery

Most of these operations are performed on an outpatient basis, so you will probably go home the same or the following day — though some patients need admission for a day or more, depending on the extent of the procedure and your general health. Post-operative discomfort is usually mild to moderate, and patients frequently require pain medication.

You are encouraged to engage in light activity at home; we will determine the extent of activity, including lifting and other physical exertion. Most patients get back to normal activities in a short period of time. Occasionally patients develop a lump or swelling where the hernia had been — frequently fluid collecting in the space the hernia previously occupied. Most often this disappears on its own; if not, we can aspirate it with a needle in the office. Typically patients schedule a follow-up within two to three weeks after the operation.

Hiatal Hernia Repair

Hiatal hernia repair is surgery to correct a bulging of stomach tissue through the muscle between the abdomen and the chest — the diaphragm — into the chest cavity.

What is a hiatal hernia?

When the opening (hiatus) in the diaphragm is too large, some of the stomach can slip up into the chest cavity. This can cause heartburn — gastroesophageal reflux, or GERD — as gastric acid flows back from the stomach into the esophagus.

When repair becomes necessary

• Severe heartburn
• Severe inflammation of the esophagus from the backflow of gastric fluid (reflux)
• Narrowing of the opening through the diaphragm (esophageal stricture)
• Chronic inflammation of the lungs (pneumonia) from frequently breathing in (aspirating) gastric fluids

How the repair is performed

Under general anesthesia, the stomach and lower esophagus are placed back into the abdominal cavity. The opening in the diaphragm is tightened and the stomach is stitched into position to prevent reflux. The upper part of the stomach (the fundus) may be wrapped around the esophagus — a fundoplication — to reduce reflux.

Recovery

Depending on the extent of the repair and your general health, patients may spend several days in the hospital after surgery. A tube may be placed into the stomach through the nose and throat (a nasogastric tube) during surgery and may remain for a few days. Small, frequent feedings are recommended as you resume eating.

Abdominal Wall Reconstruction

Some hernias are not a single, simple defect. A hernia that has been repaired before and come back, a very large defect, a hernia in a patient who has had multiple abdominal operations, or one complicated by previous mesh infection needs more than a patch — it needs the abdominal wall rebuilt.

Abdominal wall reconstruction is the term for those complex repairs. Because the right technique depends entirely on your anatomy, your previous operations and your general health, we do not describe a single standard approach here. What we can tell you is that these cases are planned individually, often with imaging beforehand, and that they are the kind of case our surgeons are trained for.