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Hernias

The abdominal wall is made up of three layers of muscle laterallly, and two vertically oriented muscles in the central portion of the abdomen. All of the muscles of the abdominal wall are arranged to give the maximum amount of support to our internal organs, and to help keep our bodies straight and erect. The fascia of the muscle is the tough fibrous covering which connects the muscle to it’s neighbors, and blends to form strong connections for the muscle to the skeleton. Despite the design of our bodies, there are areas in the abdominal wall which are more prone to developing weaknesses than other areas. The groin is one such area, and the umbilicus is another. A hernia is essentially a defect or hole in the abdominal wall. This defect allows fat, or even bowel, from inside of the abdomen to protrude through the wall creating a bulge and often discomfort. A risk inherent in bowel herniation, is the entrapment of the bowel with the possible disruption of blood flow to the segment involved. This could result in bowel death and the need for bowel resection. Hernias may occur anywhere within the abdominal wall, and may appear after particularly strenuous activity, such as heavy lifting. Hernias may also develop in the abdomen where surgical incisions have been made. Whether a hernia is congenital (one which a person is born with), acquired through over-exertion, or the result of surgical incision, the treatment is essentially the same. The hernia contents must be reduced (pushed back into the abdomen), and the defect repaired. Modern hernia surgery is based on the principles of tension-free repair techniques. Basically, this comes from the understanding that holes in the abdominal wall can rarely just be sewn closed. To do so, inevitably places the closure under tension, and the repair eventually fails. The use of synthetic mesh to support closures and cover abdominal wall defects, allows for a repair without tension, and therefore a strong and durable reconstruction. There are many types of mesh in various geometric designs, all intended to accomplish this reconstruction with the greatest durability and the least amount of stress to the patient’s body.

There are basically two approaches to any given hernia repair, open or laparoscopic. The open approach involves a small incision over the hernia defect, reduction of the hernia contents, and repair of the defect with an appropriate mesh for that given hernia. The latest developments in mesh design often make this the best choice for inguinal (groin) hernias. The patient requires only some mild sedation and local anesthesia to accomplish an excellent repair using very few internal sutures. Umbilical hernias may also be repaired in this manner. These hernias may also be approached laparoscopically, utilizing very small incisions and a video camera to gain access to the undersurface of the defect. Larger hernias in the central abdominal wall are perhaps best approached laparoscopically. This method allows for the complete visualization of the defect(s), the accurate placement of mesh, and the opportunity to secure the mesh effectively, and thereby promote healing and improve durability. The incisions are small, and therefore, there may be a reduction in post-operative pain, particularly when repairing large central hernias, which would otherwise require long incisions to approach. The duration of a hernia operation varies with the location and size of the defect, as well as the approach chosen for repair. Almost all hernia repairs are performed as outpatient procedures. Recovery time after surgery will also vary with the extent of the surgery required to repair the defect. There is almost always some degree of physical activity limitation after surgery in order to allow opportunity for healing prior to stressing the repair. The degree of limitation will depend upon the nature of the activity in which a person is usually involved, and the extent of the surgical repair. With modern surgical techniques and materials, the risk of recurrent herniation is quite low.


All content copyright 2010, Alan F. Jacks, MD, PA
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