What is a hernia and how does it happen?
A hernia is a breach, hole or gap in the normal barrier between the intra-abdominal organs and the tissue above muscles, called subcutaneous tissue.
Hernias happen due to a variety of causes, most of which have the common theme of either exerting too much pressure on the abdominal contents, or an acquired weakness in the abdominal wall. Pressure on the abdominal contents can be caused by obesity, heavy lifting, exercise, or other factors such as lung disease. Weakness of the abdominal wall can be genetic, but in today’s society, is most often caused by previous surgery, smoking or obesity. Hernias can also happen in very active individuals as what is called an “overuse injury”, similar to the way athletes develop arthritis earlier in life due to high activity.
The most common sites of hernias are at inherent sites of weakness, such as the umbilicus (bellybutton), the groin in various areas, previous incision sites, and other areas on the abdominal wall, although truthfully, they can occur in almost any areas of the body.
What are the risks of having a hernia?
The real risk of having a hernia, is strangulation, or trapping of organ tissue which should normally be inside the abdomen, and the defect exerting a tourniquet type effect which eventually cuts off the blood supply of the hernia, causing a surgical emergency. When this happens, it typically progresses to an emergency in several hours, and is often fatal if left untreated.
Paradoxically, more active people have a much higher risk of this happening due to their activity level being more likely to force the hernia outside of the body. Sedentary individuals are lower risk for the same reason.
Smaller hernias that are too small for organs to get stuck typically case mostly pain, and your surgeon will help you decide if this is the case in your situation.
The medical community at large recommends elective hernia repair for all acceptable operative candidates. If a patient is deemed to be unacceptable risk for surgery, some conservative but low yield treatments are options, such as support devices, but have not been particularly helpful.
There is a non-life threatening risk as well to not repairing hernias, especially larger ones, which is particularly important in the younger, more active patient, that is typically our clientele, and that is a hernia disturbs the correct alignment of the abdominal wall, causing asymmetric muscle function. We typically repair this in all of our patients, something not done at most other centers. This is particularly important in the person set on achieving peak function.
What are the options for surgical hernia repair?
Mesh or no mesh hernia surgery?
We are not advocates of mesh repairs in our practice. Data suggests over 50% of those implanted with mesh have significant issues resulting from the implant, such as chronic pain and infection or foreign body reaction to the mesh. In fact, a large part of our practice is based on the removal of previously implanted mesh and redo repairs.
If we do implant mesh in our practice, we use what is called a biologic mesh. This is a specialized type of mesh that becomes part of your body, and infiltrated with your own tissue. The reason this mesh is not widely used in practice, has much to do with cost reasons. It is far more costly than conventional mesh, but we feel the benefits are worth the cost.
The two major benefits include much lower risk of chronic pain and foreign body reactions as well as lower risk of infection. These two issues are the main cause of almost all post- operative mesh complications and the main indications for mesh removal after implantation. Even when we use biologic meshes, we minimize the size of the implant to ensure that the risk of any issue is low as possible in order to do the most stable and successful repair.
Laparoscopic vs open repairs
In our opinion, laparoscopic repairs are most useful on older more high-risk patients who cannot tolerate an abdominal incision, or those who are sedentary and not particularly concerned with perfect alignment of their core muscles.
The vast majority of our patients do not fit into either of these categories, as we see largely patients after a significant amount of weight loss, after multiple pregnancies, and are otherwise quite healthy and active. Patients after weight loss and pregnancies often have more complex defects that require more intensive repairs, as well as the excision of excess skin and loose tissue, as well as full realignment of their abdominal wall musculature to get back to their active lives.
For this reason, we untilize 2 separate types of incisions for all or our hernia repairs.
- Simple hernia repairs are done through a small belly button incision, or a small incision below the waistline in the case of a groin hernia .
- Complex hernia repairs with multiple problems or excess skin and tissue are addressed through a lower abdominal “tummy tuck” incision, in order to address all issues in the abdonimal wall at once.It can be much more difficult to address the abdominal wall through this incision, however we have become quite adept at this approach and feel that the overall benefit is hugely beneficial to the patient. In addition, we can remove any excess skin and tissue at this time that is either bothersome to the patient in terms of skin irritation, or that may impair wound healing, or prevent full exposure at the time of operation. The overall result is a much more aesthetically pleasing, functional, and strong abdominal wall.
NYC Surgical Associates is one of the only centers in the world that focuses so deeply on a specialized repair to encompass all functional issues while at the same time improving aesthetic ones.
Muscle Flap Repairs/Component Separation Repairs
In some instances, a specialized repair called a component separation repair is performed. There are specific indications for this procedure, such as large or complicated defects, the presence of infection, or in recurrent hernias. This is the gold standard hernia repair, and a very specialized repair that we specialize in at NYC Surgical Associates.
What are the risks of hernia repair surgery?
Any surgery or procedure has a theoretical risk of bleeding, infection, blood clots, and damage to adjacent structures. This is the same with hernia repair surgery. Prosthetic mesh complications confer a significant amount of risk, and for this reason we avoid them at all costs and use non mesh or biologic mesh repairs.
More complex, more chronic, and redo hernias always confer a higher risk due to variants in anatomy and scar tissue, as well as a poor blood supply, however we have a significant amount of experience with redo surgery at NYC Surgical, in even the most high risk patients.
What are the risks of NOT repairing my hernia?
In general, risk of pain, tenderness, and bowel strangulation in an emergency are the risks, and reason why almost all hernias should be repaired if identified. They are not an emergency in most cases, and are elective operations, however, the longer you wait to repair your hernia, the greater the risk of problems occurring.
If, for some reason, you must delay repair, we always inform patients on how to avoid an emergency. In general, most hernias can be “reduced” at home, meaning you can push whatever is stuck, back in. In most cases this avoids emergency operations, but should be discussed with your surgeon, and is not a long-term solution.
What should I expect after my hernia repair surgery?
Depending on the type of hernia repair performed, your postop course will be variable.
In laparoscopic or simple hernia repairs, you will have no drain. Incisions will be small. In general, pain will be mostly minor but can vary significantly based on unique circumstances. Dressings can come off in 24-36 hours and showering is ok after 72 hours.
In more complex abdominal wall reconstructive hernia repairs, redo hernias, as well as when skin excision is needed, often drains are left behind to collect any fluid that may accumulate, and the nurse will teach you how to empty and record that drainage. In some bigger cases, we use what is called a “vacuum dressing” which is an active drain system that helps accelerate healing. Pain is moderate but eases off after 48 hours. Most patients are doing very well moving around after 24-48 hours.
In all cases, patients are encouraged to move around and get back to normal as soon as possible. Typically drains come out in one week, as well as any external sutures or staples. No baths should take place until all drains are removed, but short showers are ok. If a wound vacuum is placed, typically we need to return to the operating room to remove it in 1 to 2 weeks.
Activity is increased gradually starting at 2 weeks, and regular full activity at 5-6 weeks, depending on the work done. No lifting over 15-20 pounds is permitted under any circumstances for at least the first month after any hernia repair and this is something some patients need to plan ahead for, such as those with small children. This is because, like a bone repair, a hernia is a structural operation and needs time to heal before you can place force upon it.
Speak with your surgeon about your particular situation. In most cases, 3-10 days of prophylactic antibiotics are prescribed to prevent post-operative infection problems.