Abdominal Wall Hernia

Overview

What is it? An abdominal wall hernia is an opening in the abdominal wall muscles. Through this opening, part of the abdominal content, fat or both can protrude and cause a noticeable bulge.
Why it happens: From a mechanical point of view, the abdomen is a cavity enveloped by muscles and bones. The pressure of the cavity is transmitted equally to the walls of the cavity. If there is an increase in abdominal wall pressure which exceeds the pressure of the wall then the wall will rupture at its weakest point. This causes a hernia. Once a hernia has formed, it will continue to enlarge in size due to the increase in wall tension at that location. Increases in abdominal wall pressure can be caused by heavy weight lifting and heavy exercise but also from routine daily activities such as coughing, laughing, sneezing or being constipated.
Frequency: Approximately 40000 anterior abdominal wall hernia repairs are performed yearly in the UK. This figure accounts for all the subtypes of hernias described below.

Symptoms

Typically, abdominal wall hernias produce only mild symptoms. They are generally visible and can be seen as a lump or bulge beneath the skin. They may cause mild pain or discomfort, particularly when straining. However, if the hernia becomes strangulated the pain can be severe and may also be associated with nausea, vomiting or a colour change in the area of the lump. These symptoms require urgent surgical attention.

Diagnosis

In most cases a careful medical history and a physical examination will confirm the presence of a hernia and will define the exact type. Occasionally, it may be required to have some radiology imaging, either an ultrasound or a CT scan.

Treatment

There is no medication for hernias and therefore management is either watchful waiting (observing the hernia) or surgical repair. A support belt (hernia belt/corset type of support) may be used to keep the herniated organ inside the abdomen for most of the time however; this is only offering symptomatic control as essentially the hernia(the hole) in the abdominal muscles remains in place. Moreover, for types of hernias (for example Spigelian hernias or small umbilical hernias) belts do not usually work. There are many different options on how to repair an abdominal wall hernia. In all approaches, the principle remains the same –the contents of the hernia need to be reduced back in the abdomen and the hole needs to close. This can be achieved by a variety of options; the hole can close with stiches or by a covering mesh. It can also be achieved by an open approach (repair the hernia through a cut) or a minimally invasive/laparoscopic (key-hole) approach.
Open mesh repair of abdominal wall hernias – A mesh is almost always required when the hernia defect is above 2cm in maximum diameter. Over the last couple of decades there has been an emergence of new and more sophisticated meshes. We now have a wide variety of options with different properties and the suitable choice will depend on your needs, the type and the size of your hernia. Your surgeon will be able to offer you an individualized approach and a specific explanation of which mesh is right for you and for what reason.
Open non mesh repair of abdominal wall hernias – Patients with smaller defects and those who do not wish to have a mesh can be considered for an open repair of their abdominal wall hernia. The principle remains the same as with open mesh repairs –the hernia needs to be reduced and thereafter, closure of the hole is achieved with simple stiches rather than a mesh. As a rule, larger hernias are difficult to close without a mesh however a detailed discussion and a clear understanding of your options is very important in this type of surgeries. The first phase of the operation is very similar to the mesh repair –the herniated content needs to be reduced safely back in the abdomen. Thereafter in order to close the exposed hole stitches are used to approximate the muscles and prevent the hernia from happening again.
Laparoscopic repair of abdominal wall hernias – In this approach small incisions and a scope/camera are used. The exact position of the cut depends on the site and the size of the hernia. The surgeon inflates the abdomen with a special gas and enters the cavity with the use of the camera and small instruments. He then repairs the hernia working from the bottom of the hernia to the top. Once the content of the hernia is reduced a mesh is used to cover the hole. For some type of abdominal wall hernias this approach has a shorter period of post-operative pain and a faster recovery. For others, the benefits of a key-hole approach are less clear. Your surgeon will be able to discuss this in much detail prior to deciding which approach is best for you.
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Follow Up

If you had surgery for abdominal wall hernia

  • It is important to follow all your doctor’s instructions, take any medication prescribed regularly and keep your follow-up appointments.

  • Getting out of bed and walking is an important part of recovery and helps prevent complications.
  • You may have a drain and/or a pressure dressing after your operation. Your doctor and the nursing staff will give you detailed instructions on what to do before you go home.
  • Try avoiding heavy lifting and other strenuous activity. Ask your doctor what types of activities are safe and for a timed plan on when to resume your normal lifestyle. You should also ask when you can return to work which will depend on the type of your job.
  • Do not drive before you feel safe to emergency break – check with your insurance company for any small prints in your policy
If you have an abdominal wall hernia that is being watched
  • Consider having surgery sooner rather than later and make sure you are reviewed by a specialist.
  • take steps to avoid becoming constipated. Eat lots of fiber, drink plenty of fluids, exercise, and go to the bathroom when you feel the urge.
  • Try avoiding heavy lifting and other strenuous activity whenever possible.
  • A support belt might be of help particularly if you are experiencing mild symptoms.
  • Call your doctor if your hernia symptoms get worse or if the bulge becomes bigger.
Seek immediate medical attention if
  • You have a painful bulge that can’t be pushed back inside
  • If you have increasing pain, swelling, or redness
  • If you have nausea, fever, or vomiting along with hernia pain