A hernia is a weakness in the abdominal wall resulting in abnormal protrusion of abdominal contents (e.g. intestines) through the defect. Hernias enlarge over time and may become incarcerated (fail to reduce) or strangulated (loss of hernia contents due to lack of blood supply). A hernia should be surgically repaired. Although most hernias occur in the groin (eighty percent), they may also be located in the navel, upper-inner thigh, and along previous abdominal incisions.
Increased abdominal pressures caused by lifting heavy objects, coughing, substantial weight gain, or straining with bowel movements and the like may call a patient's attention to a hernia. Symptoms may include:
History and physical are the most useful tools in the diagnosis of a hernia. If clinical uncertainty persists after examination, an ultrasound or CT may provide your doctor with information showing bowel protruding through an abdominal wall defect.
Laparoscopic hernia repair may be considered in nearly all patients diagnosed with an abdominal wall hernia. Laparoscopic repair involves quarter-inch incisions through which a camera and instruments are placed. Open hernia repair requires a 3-5 inch incision. The abdominal wall defect is repaired with mesh and secured under direct vision of the laparoscope. Patients with hernias in both groins may be repaired through the same incision.
Many types of hernias can be safely repaired laparoscopically:
Patients recover sooner after laparoscopic hernia repair. Return to activities can occur within 2-3 days, compared to 2-4 weeks with an open approach. Pain experienced by the open technique is greater and longer-lasting. Wound infections occur less frequently with the laparoscopic technique.
The esophagus passes through an opening in the diaphragm (esophageal hiatus) as it courses through the chest to the abdomen, eventually ending at the stomach. This opening is usually adequate for passage of the esophagus and nothing else. However, patients that have a hiatal hernia have an enlarged opening. There are four different types of hiatal hernias described. The sliding hernia is the most common of the four, representing more than eighty percent of all hiatal hernias. The lower esophageal sphincter – the high-pressure zone near the junction of the stomach and esophagus – fails and allows stomach contents to reflux into the esophagus.
The symptoms associated with the hiatal hernia are variable but generally include:
Several studies are helpful to your doctor in making the diagnosis of hiatal hernia, including:
Laparoscopic Hiatal Hernia Repair and Nissen fundoplication is the procedure of choice for the repair of a hiatal hernia. Patients that have paraesophageal hernia which allows the fundus to be displaced into the chest above the GE junction, or patients with other abdominal organs (e.g. spleen, colon, liver) displaced into the chest, should be repaired urgently. The repair will help prevent complications such as bleeding, intestinal disruption, strangulation and the like. Elective repair is recommended only for patients that are asymptomatic and have a sliding hernia. This group of asymptomatic patients may also be followed by clinically seeking surgery only when symptoms arise.
In the past, open surgery was the only option for repair. This approach is associated with prolonged recovery time and a large painful incision. With the new minimally invasive approach, surgery is now a viable initial therapy even for patients who are asymptomatic.
The laparoscopic hiatal hernia repair and Nissen fundoplication is performed through five quarter-inch incisions through which a camera and instruments are placed. The hernia is reduced from the chest into the abdomen. This may require the separation of abdominal organs from the lung and middle chest structures. The hiatus is then re-approximated to the appropriate size. Some hernias are so large and tissues are so poor that prosthetic material must be used to prevent a recurrence. Hernia defects greater than 5 cm are buttressed with mesh. This significantly decreases the recurrence rate. After adequate repair of the hiatus, a new lower esophageal valve is constructed by wrapping a two-centimeter portion of the stomach around the lowermost portion of the esophagus. This collar is then anchored to the tough fibers of the diaphragm. The procedure typically lasts for two to four hours depending on the size and contents of the hernia. Patients are started on clear liquids the next morning and are discharged in the afternoon. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days.
Patients recover sooner after laparoscopic hiatal hernia repair and Nissen fundoplication. Return to activities can occur within 2-7 days, compared to 4-6 weeks with an open approach. Wound infections occur less frequently with the laparoscopic technique. Also, less pain has been reported with laparoscopy. Most importantly, greater than ninety percent of patients are symptom-free ten years after the procedure.
Large or complex abdominal wall hernias are a challenging surgical problem. Abdominal wall reconstruction is an advanced surgical procedure that restores the normal function of the abdominal wall. It is recommended for patients with advanced hernias and requires specialized surgical expertise. If not fixed properly, these hernias have a high risk of recurrence and complication.