Hernias are acquired or congenital tissue breaches in the abdomen wall or diaphragm, but the term “breach” should not be understood as being like a broken bone. It is rather a weak area in the tissue (diaphragm or abdominal muscle) that can give way due to a certain predisposition or physical strain. Depending on the type of hernia, the peritoneum, parts of the stomach or gut can then squeeze through the hernial orifice formed in this way. If the hernial orifice is located in the abdominal muscle, the intestinal hernial sac that has pushed its way through can be felt from the outside as a protrusion and may also be visible, this is what is known as an external hernia. Internal hernias are formed by a weak area in the diaphragm; through which parts of the stomach push their way into the chest cavity.
Hernias do not always cause pain or any symptoms. In some patients with an external hernia only the protruding hernial sac under the skin can be detected. This externally displaced hernia can initially be pushed back in again. But, although this so-called repositioning relieves the pain originally caused, the hernia is not healed. On the contrary, the hernia can become larger over time and this in turn makes an operation more likely. Internal hiatal hernias, on the other hand, generally lead to pain after eating or when lying down.
A hernia will always be painful if intestinal loops protrude outwards through the hernial gap and become trapped. This can interrupt the blood supply to segments of the gut. This situation of a trapped hernia is always a medical emergency. In order to restore the circulation, it must be operated on quickly and this is the only way to prevent the tissue from dying off and to avoid any peritoneal inflammation.
The types of hernia that are treated surgically are:
As a ‘watch and wait’ strategy does not heal a hernia, the causes of the breaches still remain and conservative measures, such as pushing it back in again and wearing hernial trusses are inadequate, the option of a surgical treatment of the hernia should be discussed with a hernia specialist as soon as possible.
Methods of hernia surgery
Hernia surgery is a specialization of visceral surgery, i.e. the branch of medicine that deals with operations on the internal organs. Experts in hernia surgery move the sections of tissue in the hernial sac back into the abdominal cavity and close the hernial orifices either by suturing or using an artificial mesh that should reinforce the weak area in the tissue. Another breach can thus be prevented.
Open surgery and minimally invasive surgical methods as well as methods with or without mesh implants differ from one another in principle. The method used depends, in particular, on the expertise of the operating surgeon, the resources available to him/her, the size and type of hernia, and on factors relating to the individual patient.
Minimally invasive hernia surgery indicates all the treatment methods used by a hernia specialist, which involve the smallest possible skin incisions and are thus are the gentlest treatment possible. In contrast with an open hernia operation, minimally invasive hernia surgery does not cause any large scars and the recovery time is accelerated by the protection of the surrounding tissue.
What surgical options are there for hernias? Hernia specialists are able to respond to this question with well-founded advice. Which is the right surgical method depends on the respective type of hernia and its degree of severity. The patient’s age and general state of health as well as the surgeon’s experience also play an important role.
In minimally invasive techniques, which are also called keyhole surgery or endoscopic surgery, only small skin incisions each of one centimeter in length are required, through which the operating surgeon introduces the surgical instruments and thus operates directly on the hernia while protecting the tissue as much as possible. If the endoscopic intervention is carried out via the abdominal cavity, this is also known as laparoscopic surgery. An endoscope or laparoscope includes an optical unit and working probes. Such a minimally invasive hernia operation is carried out under a general anesthetic.
The principle of a hernia operation is always the same: the repositioning of the hernial sac and the closure of the hernial gap. If an artificial mesh is to be introduced, this is another decision that is made by the hernia specialist together with the patient. This type of mesh closes the hernial gap and reinforces the tissue in the area where the hernia has been.
Tried-and-tested minimally invasive procedures for an inguinal hernia, for example, are:
- TAPP: laparoscopic transabdominal mesh repair, i.e. the operation is carried out via the abdominal cavity
- TEP: endoscopic preperitoneal mesh repair, i.e. the operation is carried out in the intermediate layer between the peritoneum and muscle wall, the abdominal cavity is not opened
Immediately following the operation, the pain is alleviated by medication and the area operated on is cooled using cooling pads. In general, hernia patients can already be mobilized just a few hours after the minimally invasive procedure in the hospital, i.e. they are allowed to get up again and walk a few steps. This also prevents thrombosis and aids the circulation. After a few days, patients are mostly discharged from the hospital, and it is recommended that daily activities can be resumed three to five days later.
Physical exertion should likewise be avoided, such as straining hard when defecating. “Stay pain free” is not just a well-meant wish from your doctor, but at the same time the measure of your personal level of activity following the operation. If you cannot feel any pain, then the level of exertion is fine; but you should be cautious when embarking on activities.
Minimally invasive hernia surgery has the advantage that patients are normally mobile again more quickly and the wound healing is completed faster. Hernia patients who have had minimally invasive operations are generally able to work again after two to four weeks. The treating physician will give detailed advice on individual progress following a hernia operation.
The general risks of a minimally invasive hernia operation include hemorrhages, wound healing disorders, infections and thrombosis. The hospital and nursing staff can minimize these risks by taking the appropriate care and precautionary measures. Swelling, bruising and retention of tissue fluid in the area operated on can also occur with minimally invasive hernia surgery.
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