If the hernia can be seen from the outside or if the protrusion that occurs during a hernia leads from the inside of the body towards the skin, it is referred to as an external hernia. If the hernia is inside the body (e.g. between the chest and abdomen), it is called an internal hernia. The most common external hernias are inguinal, umbilical, incisional, abdominal wall and thigh hernias, while the most common internal hernia is the diaphragmatic hernia. As soft tissue hernias do not regress but become larger over time, hernias should be treated with hernia surgery if the overall condition of the affected person allows for surgery.
The most common hernias and their surgical procedures are
These are described below.
The inguinal hernia is the most common form of hernia, accounting for 80 percent of all hernias. Men are affected nine times as often as women. In 10 percent of cases, the inguinal hernia occurs on both sides. The hernia is located above the inguinal ligament. In most cases, there is initially a painless protrusion in the groin. Pain often only occurs during physical exertion or when sitting for long periods. When lying down, the protrusion usually disappears again. Since, depending on the size of the hernia, the bowel may become trapped and sections of the bowel may die off, hernia surgery is essential.
Femoral hernias mainly occur in older women. Here, a hernia occurs below the inguinal ligament, so that the protrusion is usually visible on the inner thigh. Unlike inguinal hernias, femoral hernias are usually painful from the outset. And because parts of the intestine can also become trapped here, a femoral hernia is also treated using hernia surgery.
In most patients, an umbilical hernia does not cause any discomfort. However, this hernia causes a more or less noticeable protrusion in the area of the navel. As parts of the intestine can also be trapped in the umbilical hernia, this should also be treated with hernia surgery. Hernia surgery is already used for small umbilical hernias because incarceration can also occur here. Umbilical hernias that occur directly after birth, on the other hand, usually disappear spontaneously. If necessary, they are bandaged, but are not usually treated with hernia surgery.
An incisional hernia is a hernia of the abdominal wall that occurs in the area of surgical scars. Wound infections and wound healing disorders or multiple operations can promote the occurrence of an incisional hernia. However, connective tissue weaknesses or obesity can also contribute to incisional hernias. This causes organs in the abdominal cavity to bulge in the area of the surgical scar, which often leads to a pulling pain in the area of the scar. And because incisional hernias also become larger over time and harbor the risk of incarceration of parts of the intestine, hernia surgery should be performed.
If there is a diaphragmatic hernia , organs from the abdominal cavity can slide through the gap in the diaphragm into the chest cavity and become trapped. Strictly speaking, a diaphragmatic hernia is not a hernia, but an enlargement of the point at which the oesophagus passes through the diaphragm to the stomach. The enlargement of this normal predetermined gap can be caused by a weakness in the connective tissue or a prolonged increase in pressure in the abdominal cavity (e.g. pregnancy, obesity). This can lead to pain, especially after eating or when lying down, because gastric juice then flows back into the esophagus. Such a hernia also requires hernia surgery.
Hernias are usually treated surgically, unless there are serious reasons not to operate (e.g. poor physical condition). In the event of an incarceration of parts of the intestine, an emergency operation may even be necessary in the case of a hernia. Hernias can be operated on under local or general anesthesia. In the case of a hernia with incarceration, general anesthesia is usually preferred because the surgical incision can then be widened more easily if necessary.
In principle, different methods of hernia surgery can be distinguished. Firstly, a decision must be made as to whether the hernia is to be treated using open hernia surgery or closed hernia surgery. Closed hernia surgery is also known as laparoscopic hernia surgery - sometimes also referred to as keyhole surgery . Some surgeons also refer to this type of hernia surgery as minimally invasive hernia surgery.
In addition to this basic choice between open and closed hernia surgery , a decision is usually made as to whether hernia surgery should involve the insertion of a plastic mesh or whether this can be dispensed with. In hernia surgery, the plastic mesh serves to reinforce the closed hernia and generally leads to fewer recurrences (recurrence of the hernia in the same place). In the case of very small hernias that are closed with a direct suture as part of hernia surgery or in children and adolescents, the insertion of a plastic mesh can usually be dispensed with.
Mesh-free procedures are also usually used for large abdominal wall hernias - where the straight abdominal muscles have shifted to the side - because the large hernias are difficult to cover with a mesh. Which procedure is actually used depends on the type and size of the hernia and the age and condition of the person affected. Finding the most suitable procedure for the individual patient is the main concern when diagnosing and planning treatment for hernia surgery.
Depending on where the hernia is located and how large it is, it can be symptom-free or develop into a life-threatening inflammation. The first step is to determine exactly which hernia is present and how extensive it is. For this purpose, a thorough physical examination is carried out before any hernia surgery is performed. Other methods to determine the exact diagnosis are ultrasound and possibly a computer tomography. Sometimes X-rays are also taken with or without a contrast agent, such as the examination known as an X-ray hiatal hernia.
In addition, a consultation with the operating surgeon takes place before hernia surgery, in which the patient is informed about the planned operation and the most common complications of the operation and the post-operative course are explained. The type of anesthesia procedure planned (general or local anesthesia) should also be discussed with the anesthesiologist prior to hernia surgery.
As an inguinal hernia does not disappear on its own, it should be operated on. As with all hernias, there is a risk that parts of the intestine will become trapped and die. The surgical method chosen depends on the age of the affected person and the location and size of the hernia. In principle, there are three different methods of hernia surgery for an inguinal hernia: Shouldice surgery, Lichtenstein surgery and minimally invasive procedures using laparoscopy.
Inguinal hernia surgery according to Shouldice
In Shouldice surgery, the surgeon makes an incision in the groin region and exposes the hernia. He opens the hernia sac, pushes the hernia contents back into the abdominal cavity and sutures the gap with neighboring connective tissue. The Lichtenstein procedure is basically the same, except that the hernia is stabilized by a sewn-in plastic mesh during suturing. In the minimally invasive procedure, an endoscope (tube with mini camera) and the necessary instruments are inserted through small abdominal incisions and advanced to the hernia. Here too, the intestines are repositioned and the hernia is stabilized using a plastic mesh.
There are also two basic methods of hernia surgery for femoral hernias: the open method and the laparoscopic method. In open femoral hernia surgery, the hernia gap is closed with sutures after the hernial sac has been displaced or removed. However, this often results in tension, which causes pain and can lead to a recurrence. Laparoscopic femoral hernia surgery (minimally invasive) is performed using small incisions. The surgical instruments and an optical system with a video camera are inserted into the abdominal cavity through these small incisions and the hernia is exposed at its origin.
Femoral hernia surgery with plastic mesh
A non-absorbable (non-self-dissolving) polypropylene mesh is stretched over the hernial orifice and attached to the abdominal wall from the inside. The peritoneum is closed over it again. The scar tissue grows into the grid structure of the mesh and creates a new layer, which is usually more tension-free than if the skin had been sutured together directly. In all femoral hernia surgery procedures that involve the insertion of a mesh, it is important to ensure that the size of the plastic mesh is selected so that the mesh clearly overlaps with the healthy and stable tissue and can heal well. In an emergency situation with acute incarceration, open femoral hernia surgery with an inguinal incision is always chosen.
Depending on the size and age of the hernia, umbilical hernia surgery is also performed using either open hernia surgery or closed hernia surgery. In open hernia surgery for umbilical hernia, the abdominal wall is opened and the hernia sac is exposed through an incision. The contents of the hernia sac are then transferred back into the abdominal cavity. Closure is usually achieved by directly suturing the abdominal wall fascia (connective tissue layer). Sometimes this fascia is also sutured twice to make it more stable. In the case of larger umbilical hernias, closure can also be performed using a synthetic mesh.
In closed umbilical hernia surgery, access is gained through the abdominal wall via laparoscopy. Special instruments are used to close the hernial orifice directly. A plastic mesh can also be inserted here to provide more stability. Laparoscopic umbilical hernia surgery is a gentle surgical procedure that reduces pain after hernia surgery and lowers the rate of wound infections. In addition, patients are generally able to resume physical activity more quickly after hernia surgery using endoscopy.
In the case of a large incisional hernia, a pneumoperitoneum is often created prior to hernia surgery . This means that the abdominal cavity is pre-stretched over a period of several weeks by filling it with air every 2-3 days. This makes it easier to return the contents of the hernia sac (e.g. intestines) to their original position and reduces the pressure of the abdominal contents on the abdominal wall after hernia surgery.
In incisional hernia surgery, the muscle layers that have been pulled apart are sutured back together. In hernia closure by direct suturing, small incisional hernias up to a diameter of around two centimetres in patients without risk factors for recurrence (repeat hernia) are treated by direct suturing with a non-dissolvable suture. In the case of large gaps, existing risk factors for recurrence or repeated hernia surgery, a plastic mesh or ball patch is placed over, in or under the open area and connected to a layer of muscle. There are different methods of hernia surgery(sublay, inlay, onlay method) depending on the layer of the abdominal wall in which the mesh is inserted.
There are several methods of diaphragmatic hernia surgery, with fundoplication being the most common method. A sleeve is formed from parts of the stomach and placed around the lower part of the oesophagus. This reduces the backflow of acidic stomach contents into the oesophagus (reflux). The chyme, on the other hand, can be transported further from the oesophagus into the stomach. This operation is usually performed as a laparoscopy. In over 90 percent of those affected, fundoplication leads to a permanent cure. Young people with reflux disease in particular are spared the need to take medication for many years.
Another method of hernia surgery for diaphragmatic hernia is gastropexy, also known as fundopexy . During hernia surgery, the stomach is moved into its normal position and sutured to the anterior abdominal wall so that it can no longer move. In the third method of hernia surgery for diaphragmatic hernia, hiatoplasty (also known as hiatal stenosis), the diaphragmatic hiatus is simply sutured tighter. The edges of the diaphragmatic hiatus are then rejoined using special sutures. If necessary, a plastic mesh is stapled onto these sutures to reduce the risk of a new hernia.
Depending on the type of anesthesia and the surgical procedure, patients can get up immediately after hernia surgery or after a sufficient rest period. Longer periods of lying down after hernia surgery are unnecessary and should be avoided due to the risk of thrombosis with subsequent embolism. There should be no pain in the first few hours after hernia surgery, as local anesthesia is routinely applied to the surgical area both during surgery under general and local anesthesia. Mild painkillers can be used for pain that occurs later after hernia surgery.
The first dressing change takes place on the second or third day after hernia surgery. Depending on your workload, you will be able to work again two to three weeks after hernia surgery. Sporting activities should only be resumed three to four weeks after hernia surgery. Lifting heavy objects weighing more than ten kilograms should be avoided for around two to six months after hernia surgery. Sometimes the success of the operation is checked by a further examination after the hernia surgery, such as in the case of a diaphragmatic hernia by a repeat X-ray examination with contrast medium.
In addition to the general complications that apply to all operations, such as bleeding, infection, thrombosis and the risk of embolism, swelling in the operating area - caused by bruising or accumulation of tissue fluid - is relatively common in hernia surgery. However, this usually disappears shortly after hernia surgery. Slight pain in the operating area or sensory disturbances can also occur after hernia surgery, but these also generally disappear again.
Operating in close proximity to the bowel, bladder, vessels and nerves always poses a potential risk to these structures. However, injury to large vessels during hernia surgery is extremely rare. Recurrence of the hernia at the same site can occur with all hernia surgery procedures, but is less common when plastic mesh is used. Hardening and shrinkage in the area of the plastic meshes used are extremely rare in hernia surgery; allergies or rejection of the plastic meshes are practically non-existent.
