Prof. Dr. Mike Ralf Langenbach is a leading figure in the field of hernia and reflux surgery. Since taking office as Chief of Surgery in the fall of 2019, he has led the Department of General, Visceral Surgery, and Coloproctology at the Evangelical Hospital in Lippstadt with remarkable dedication and professional expertise. His extensive expertise covers a broad spectrum of surgical procedures, with a particular focus on hernia surgery and the treatment of reflux diseases.
Drawing on his many years of experience, Prof. Dr. Langenbach, together with his highly qualified team, performs hundreds of hernia surgeries each year. In doing so, he employs both proven and innovative surgical methods to provide his patients with long-term relief. His close collaboration with the latest medical technologies and the application of state-of-the-art procedures make him a leading expert in his field. In addition, Prof. Dr. Langenbach is distinguished by his additional qualifications in proctology and minimally invasive surgery.
His broad expertise and versatile skills enable him to develop individually tailored treatment plans that are tailored to the specific needs of each patient. As chief of surgery at one of the region’s largest acute care hospitals, which treats approximately 18,000 inpatients per year, Prof. Dr. Langenbach goes beyond purely surgical care. He places great emphasis on interdisciplinary collaboration and a holistic approach to patient care. The well-being of the patient is always at the center of his efforts.
His passion for medicine and his exceptional dedication have made Prof. Dr. Langenbach a highly respected member of the medical community. His ability to explain complex medical issues in an understandable way, along with his empathy and compassion, make him a trusted point of contact for his patients and their families.
In his clinical work at the Evangelical Hospital in Lippstadt, Prof. Dr. Langenbach has had a decisive influence on and further developed the field of hernia and reflux surgery. His commitment to research and teaching, as well as his numerous scientific publications, underscore his outstanding standing in the medical community. Prof. Dr. Mike Ralf Langenbach is undoubtedly an outstanding figure and a key player in the field of hernia and reflux surgery.
The editorial team at Leading Medicine Guide took the opportunity to speak with Prof. Dr. Langenbach about the treatment of umbilical hernias.
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An umbilical hernia is a condition in which tissue or organs protrude through a weak spot or gap in the abdominal wall near the navel. This weak spot develops when the muscles or connective tissue around the navel fail to close properly, which normally occurs during fetal development.
“The main cause of an umbilical hernia is genetic predisposition—specifically, the composition of the collagenous connective tissue responsible for the tissue’s strength, elasticity, and structure. This results in a natural weakness in the abdominal wall, making it easier for tissue or organs to protrude through the navel. Being overweight is also a major factor and quite common, as the extra weight increases pressure in the abdominal cavity, weakens the connective tissue, causes metabolic changes, and impairs healing. People with a chronic cough or smokers, who often cough in the morning, can also increase pressure on the abdominal cavity, causing existing weak spots in the abdomen to open up and form a hernia. Women have a higher risk after pregnancy due to stretched tissue, especially if they have had multiple pregnancies. People with diabetes also have a higher risk of an umbilical hernia, as they generally have poorer tissue regeneration. “Heavy lifting—usually for work-related reasons—without proper technique can also increase abdominal pressure and cause an umbilical hernia,” explains Prof. Dr. Langenbach at the start of our conversation, going on to describe in detail why tissue and organs can protrude outward:
“An umbilical hernia develops precisely because of a weakness in the abdominal wall around the navel, which causes tissue from the abdominal cavity to protrude outward through this opening. This protruding tissue forms a hernial sac that may be visible under the skin. Typically, the contents of the hernial sac consist of abdominal organs or abdominal fat, which normally reside within the abdominal cavity. These tissues can exert additional pressure on the abdominal wall due to the factors mentioned above—such as being overweight, pregnancy, or physical exertion—thereby increasing the risk of an umbilical hernia. The hernial ring allows the hernial sac to protrude outward and form a hernia. The size of the hernial sac and the severity of the umbilical hernia can vary depending on the size of the hernial ring and the volume of the contents within the sac. It is important to note that a small umbilical hernia often causes more severe pain than a large one, as it tends to compress more nerves, is more prone to incarceration, and can displace more easily.”
Umbilical hernias can usually be diagnosed through a physical examination and, depending on their size and severity, treated either through monitoring, the use of special abdominal belts, or, in more severe cases, surgery to repair the hernia. For people at increased risk due to weight, age, or other pre-existing conditions, it is particularly important to undergo regular medical examinations to detect and treat an umbilical hernia early.
An umbilical hernia is closely related to the fascia, as the fascia plays an important role in the structure and strength of the abdominal wall. Fascia are connective tissue structures that envelop and support the muscles, organs, and other tissues in the body. In the abdominal region, a layer of fascia surrounds the abdominal muscles and, together with the muscles, forms the abdominal wall. If a weak spot or gap develops in this abdominal wall, as is the case with an umbilical hernia, this means that the fascia in this area is also compromised. The weak spot or gap in the fascia allows tissue or organs to protrude through the abdominal wall, leading to the development of a hernia.
In recent years, modern surgical techniques have advanced significantly to make the treatment of umbilical hernias more effective and less invasive. One of the most advanced methods is laparoscopic hernia repair, also known as minimally invasive or keyhole surgery.
In this technique, special instruments and a camera are inserted through tiny incisions in the abdominal wall to repair the hernia. Compared to traditional open surgery, the laparoscopic method offers numerous advantages. These include a faster recovery, less postoperative pain, minimal scarring, and a shorter hospital stay. “Here in Lippstadt, we typically perform minimally invasive surgery and use synthetic mesh for stabilization, which is placed inside the abdominal cavity to support the hernia, prevent it from recurring, and ensure nothing can slip through again. The meshes promote healing by reducing the strain on the tissue and distributing the tension. In the past, the hole caused by the hernia was simply sutured shut—which resulted in more pain for patients, and the recurrence rate was also significantly higher. The synthetic meshes used today are made of polypropylene and polyester and are very well tolerated. In addition, during minimally invasive surgery today, surgeons simultaneously attempt to remove the hernial sac that has protruded outward and suture the fascia over the mesh, which also results in a good cosmetic outcome externally,” explains Prof. Dr. Langenbach, adding:
“Minimally invasive procedures are performed under general anesthesia. CO₂ is introduced into the abdominal cavity, causing it to inflate like a balloon. Trocars (tubes) and a video camera are then inserted to examine the abdominal cavity from the inside and determine the surgical approach; two incisions are made to accommodate the instruments. The collagen-coated mesh can then be implanted and secured with absorbable staples (the meshes integrate into the abdominal cavity, and after a few months, the mesh would be visible on imaging at most as a grid-like structure). The patient usually gets out of bed on the same day as the surgery, can walk around, and eat and drink normally. The mesh is usually slightly noticeable and causes a bit of pain when moving; pain medication can be taken if needed. On day two, a blood sample is taken for a follow-up check, and the patient can be discharged. The patient should then avoid lifting more than 2–10 kilograms for the next two to four weeks, but normal daily activities are not a problem. Complications are rather rare. In a few cases, an infection may develop around the mesh—in such cases, treatment with antibiotics is attempted first. If that doesn’t help, the mesh must be removed, as otherwise the bacteria cannot be eliminated from the body.”
At the Evangelisches Krankenhaus Lippstadt gGmbH, approximately 300 hernia surgeries are performed each year, of which about 100 are umbilical hernias. Prof. Dr. Langenbach has observed an overall increase in umbilical hernias, as people are unfortunately gaining weight, which increases abdominal pressure.
Another innovative technique is robot-assisted hernia repair, which is performed in Lippstadt.
“Since mid-2022, we have been performing many surgeries for internal hernias using the da Vinci robot, particularly large hiatal hernias (about 15–20 per year). This is the area in the diaphragm where the esophagus enters the abdominal cavity, where the stomach is located. There are some patients in whom the entire stomach slips into the lung cavity. They usually go to a pulmonologist first because they often have difficulty breathing. However, the shortness of breath is actually caused by the hiatal hernia, which lies twisted above the diaphragm. We work very closely with a pulmonologist who regularly refers patients to us from all over Germany, and many patients also come to us on referral through the Leading Medicine Guide portal. “We also perform reflux surgeries using the da Vinci robot, as well as complicated cases, because it simply allows us to identify the problem much more effectively,” explains Prof. Dr. Langenbach regarding robot-assisted surgery.
Surgery with the da Vinci robot offers similar advantages to laparoscopic surgery, but with the added benefit of an even more precise repair. However, robot-assisted hernia repair requires specially trained surgeons and appropriate equipment, which is not available in all medical facilities. The choice of the optimal method depends on various factors, including the size and type of hernia as well as the patient’s overall health.
An incarcerated (strangulated) umbilical hernia is a medical emergency that requires immediate medical attention.
“In an incarcerated hernia, the hernial sac that has bulged through the abdominal wall becomes pinched or trapped, leading to a severe restriction of blood flow. This can lead to tissue damage and necrosis, requiring immediate surgery to repair the hernia and save the tissue. It is not without risk, as it can also cause perforations in the intestine. As the saying goes, “You mustn’t let the sun go down on an incarcerated hernia.” Patients then arrive at the hospital as emergency cases, suffering from pain. Often, a CT scan and MRI are performed to check whether intestinal contents are trapped—though this is sometimes visible even without imaging. If this is the case, the surgery can only be performed as an open procedure and not as a minimally invasive one. In contrast, a non-incarcerated umbilical hernia does not carry such an acute risk. In this case, the hernial sac can protrude through the abdominal wall without becoming strangulated or trapped, which would lead to an interruption of the blood supply. “Treatment of a non-incarcerated hernia can usually be postponed until the patient is a suitable candidate for elective surgery to repair the hernia and reduce the risk of complications,” says Prof. Dr. Langenbach regarding this specific condition.
Preventive measures to avoid umbilical hernias aim to reduce pressure in the abdominal cavity and strengthen the abdominal wall.
A healthy lifestyle plays an important role in preventing umbilical hernias. This includes a balanced diet and regular physical activity to maintain a healthy body weight and reduce pressure in the abdominal cavity. “Being overweight or obese can increase abdominal pressure and raise the risk of umbilical hernias. Specific exercises to strengthen the abdominal muscles—aimed at reinforcing the abdominal wall and supporting weak spots—are highly recommended. Especially in men, an apple-shaped belly—or “beer belly”—significantly increases the risk of an umbilical hernia, as abdominal pressure is particularly high in such cases,” recommends Prof. Dr. Langenbach. If you are at increased risk, it may be advisable to consult a doctor about additional preventive measures and screening procedures to detect and treat potential problems early on.
Strengthened abdominal muscles can help prevent the development of umbilical hernias or reduce the risk of a recurrent hernia after surgery. Some recommended exercises for strengthening the abdominal muscles:
Planks: This exercise aims to strengthen the entire core, including the abdominal muscles. By stabilizing yourself in a push-up position on your forearms and keeping your body in a straight line, the abdominal muscles are activated and strengthened.
Crunches: Crunches are targeted abdominal exercises that work the rectus abdominis muscles. By lying on your back, bending your knees, and lifting your shoulders slightly off the floor, the abdominal muscles are engaged and strengthened.
Leg Raises: This exercise focuses on the lower abdominal muscles. By lying on your back and raising your legs, the lower abdominal muscles are engaged and strengthened.
Russian Twists: This exercise works the lateral and oblique abdominal muscles. By sitting on the floor, bending your knees, and rotating your upper body, you strengthen the lateral abdominal muscles.
It is important to perform these exercises regularly and correctly to effectively strengthen the abdominal muscles and reduce the risk of an umbilical hernia. However, people at higher risk for umbilical hernias should consult their doctor before starting an exercise program to ensure that the exercises are appropriate for them.
Hope for the Future
“Robotics is ultimately nothing more than minimally invasive surgery in which the surgeon controls the robot to guide the instruments. The major advantage is that the instruments—even with their many degrees of freedom—are far superior. They allow you to reach places that would be completely out of reach manually. In the coming years, the technology will certainly continue to evolve, and AI (artificial intelligence) will also play a greater role here—for example, by using installed software with stored CT or MRI scans to better assess risk areas during surgery. “Theoretically, it’s also conceivable that the surgeon could be located somewhere entirely different from the robot and control it remotely,” predicts Prof. Dr. Langenbach, adding a critical note: “Further developments in research and technology are always necessary, but the broader context should also improve—particularly on the political front, where policymakers simply need to make a stronger commitment. Hospitals are generally becoming financially weaker and are under immense pressure. The focus on financial gain should decrease, and we should once again prioritize the patient’s best interests. There needs to be more clarity here, and politicians shouldn’t be handling financial matters through the back door at the expense of doctors. For example, da Vinci surgeries aren’t receiving additional funding, even though they’re the better option for many patients,” says Prof. Dr. Langenbach, and with that, we conclude our conversation.
Thank you very much, Professor Dr. Langenbach, for your candid remarks and the interesting insight into the multifaceted field of hernia surgery!
