Abdominal Wall Hernias

Introduction

  • The abdominal wall is a unique part of the body comprising of soft tissues – muscle and fascia (sheath like structure with a lot of strength).
  • There is no bony structure for support.
  • This distinctive composition makes it the ideal covering for our digestive system, as it allows for expansion following meals and in pregnancy.
  • Its other important functions are aid in breathing and straining.
  • This large expanse of unsupported soft tissue is prone to giving way, sometimes spontaneously, sometimes following an accident and often after a large surgical cut resulting in a hole in the soft tissue layers, through which contents of the abdominal cavity protrude out and become prone to injury. This condition is known as abdominal hernia
  • The treatment for this condition is surgically stitching close the defect in the wall. This is done after all contents of the hernia are gently released and positioned back inside the abdominal cavity.  Currently it is recommended that the suture closure of the defect be reinforced by a mesh*

Signs and symptoms

  • A painless swelling on the abdominal wall, which disappears on lying down and appears on standing or straining
  • The swelling can gradually increase in size, become non reducible, and cause pain and discomfort.
  • The common sites of hernia are
    • Umbilicus
    • In the midline above the umbilicus
    • Along any surgical scar on the belly
    • Sometimes on the side of the belly between the rib cage and hip bone

Diagnosis

  • Hernias are diagnosed by examining the patient complaining of above symptoms
  • Additional information to help prepare patient for surgery is gained by abdominal ultrasound and CT scan.

Complications

  • The worst complication of abdominal wall hernia is intestinal obstruction and strangulation. In this the blood supply to the intestine is cut off and it can become gangrenous. This condition is almost life threatening and a surgical emergency
  • Long standing hernias can causes thinning of the overlying skin resulting in its ulceration and necrosis. 
  • Long standing large irreducible hernias or very large hernias are challenging as the cavity of the belly may no longer be able to comfortably hold all the hernia contents, making it impossible simple closure of the hernial defect. In such situations the surgery becomes complex with added risks and is best discussed directly with the operating surgeon.

Treatment

Laparoscopic Ventral hernia repair (LVHR) –

  • The procedure of LVHR is performed through small keyholes in the abdominal wall.
  • All contents of the hernia are gently pulled back into the belly cavity. Any others adhesions to the abdominal wall are cleared around the defect
  • The size of the cleared hernial defect is measured and an appropriated sized mesh is chosen to cover the defect.
  • The hernial defect is closed with sutures
  • The mesh is rolled like a carpet and pushed into the cavity through a I cm port. It unrolls once it is inside.
  • It is then fixed over the closed defect using fixation screws or sutures.
  • Hospital stay is usually 2-3 days. In very large hernias hospital stay may be prolonged to 4-5 days
  • The patient may require a urinary catheter to keep the bladder empty, especially in lower abdominal hernias.
  • Patient may have to be on a soft diet till normal bowel movement is resumed.
  • The mesh provides additional strength to the repair as the tissues of the defect margin may not have the strength to provide a successful longterm closure.
  • A laparoscopic approach is a safe, sound and successful approach to repairing nearly all ventral hernias.
  • A very large mesh can be used to adequately cover the entire weakened area of the abdominal wall bringing down the chance of hernia recurring to one fourth that following open repair.

Post operative precautions

  • The patient maybe required to wear an abdominal wall binder for 2-3 weeks following surgery. This helps in decreasing pain and also support the healing tissues
  • The binder should be discontinued after 3 weeks to allow the tissues to gain their own strength.
  • Any weight gain increases risk of hernia developing again

*Mesh: This is a sheet made up of either modified plastic (non-absorbable) or synthetic/ biological material (absorbable) with strength equivalent or higher than that of the tissues of the abdominal wall. Non absorbable mesh provides long lasting strength to the repair, whereas absorbable mesh will provide strength for a limited period of time, before it gets broken down and absorbed by the body.