Abdominal Wall Hernia Surgery: Innovative Surgical Techniques for Abdominal Wall Hernias and Incisional Hernias

Abdominal wall hernia surgery is one of the most common surgical procedures in industrialized nations. This condition affects about four percent of the population. Men between the ages of 40 and 50 are particularly likely to be affected. There is also a congenital form that affects children, which can often be corrected through surgery as well.

Abdominal hernia surgery is the standard treatment for hernias of the abdominal wall.

An abdominal wall hernia does not heal on its own. Even in mild cases, it is possible to push the hernia sac back so that the intestines are in their correct position.

However, the risk of recurrence is increased. The muscle defect can enlarge due to the pressure exerted by the hernia sac.

Without immediate abdominal wall hernia surgery, the risk of complications also increases. For example, protruding parts of organs can become trapped, leading to painful and dangerous circulatory problems. If a portion of the intestine is involved, there is a risk of life-threatening intestinal obstruction.

Timely treatment of an abdominal wall hernia prevents this risk. Only emergency hernia surgery can resolve the obstruction.

Development of an Abdominal Wall Hernia

The peritoneum is the innermost layer of the abdominal wall. It covers the organs—the intestines, liver, stomach, and spleen. The peritoneum secretes a fluid that acts as a lubricant. It prevents uncomfortable friction when organs move against one another.

Doctors refer to a hernia (hernia / fracture) of the abdominal wall when the peritoneum bulges outward through a gap in the muscle. Organs can also slip outward into this sac of tissue (hernia sac). The standard treatment is abdominal hernia surgery.

When does an abdominal wall hernia occur?

Surgical procedures for abdominal wall hernias are so common because the abdominal wall is not uniformly structured.

A hernia usually develops at an anatomical weak spot, such as in the area of the navel.

A weak abdominal wall promotes the formation of hernias, for example due to:

This is caused by:

a congenital weakness of the connective tissue or
decreasing tissue strength with age

The trigger for the hernia—and thus for the subsequent hernia surgery—is usually unusually high pressure in the abdominal cavity.

This pressure can be persistent due to injuries, tumors, or fluid accumulation, such as in cases of:

liver cirrhosis or
chronic lung diseases

It can also occur when pressure rises briefly, such as when coughing, straining, or lifting heavy objects. Being overweight, by the way, is an additional risk factor.

The situation is different for children who require surgery for abdominal wall hernias. In these cases, the opening through which the peritoneum slips is usually congenital.

Following abdominal surgery, surgery for an abdominal wall hernia may be necessary, as scar tissue is more susceptible to hernias. Patients should be especially cautious if their surgical wounds have become infected. Again, being overweight is an additional risk factor.

Internal hernias are also possible. They are rare and require abdominal hernia surgery.

Fractures in various areas of the abdominal wall

The type of treatment for abdominal wall hernias also depends on the exact location of the hernia.

Hernias most commonly occur in the groin area and are called inguinal hernias. They mostly affect men because, in the embryo, the testicles descend through the inguinal canal. The canal sometimes does not close completely afterward. Most abdominal hernia surgeries are therefore performed in the groin area.

Femoral hernias, on the other hand, are more common in women. They develop below the inguinal ligament.

Another typical site for a hernia is the area around the navel, known as an umbilical hernia. Surgery for an abdominal wall hernia in this area also serves to reinforce the abdominal wall to prevent future hernias.

Umbilical hernias in children are a special case. This is the only type of hernia that can heal on its own within the first two years of life. Therefore, surgery is not necessary in some cases.

A hernia in the upper abdomen (epigastric hernia), which occurs between the sternum and the navel, is much less common. It almost always requires abdominal hernia surgery.

An incisional hernia, on the other hand, can occur anywhere in the abdominal wall—depending on the location of the scar from a previous surgery.

Symptoms of Abdominal Wall Hernias

People with small hernias often barely notice them because symptoms only appear during physical exertion. They unknowingly delay surgery.

For example, patients may experience a feeling of pressure that can turn into a pulling or stabbing pain as soon as they tense their abdominal muscles.

Typical situations include:

Coughing fits
straining during bowel movements, or
Lifting heavy objects

At this stage, surgery for an abdominal wall hernia is not yet absolutely necessary. However, a hernia will not resolve on its own. Therefore, without treatment, those affected can expect their condition to worsen over time.

In addition, mobility—and thus quality of life—is limited for those affected. They try to avoid painful situations; however, surgery for abdominal wall hernias becomes more complex as the hernias enlarge.

If the hernia grows, the pain eventually becomes chronic. Those affected feel unwell, often suffer from bowel movement issues, and can feel the hernia from the outside.

Abdominal wall hernia surgery can no longer be avoided at this point. Otherwise, in the worst-case scenario, abdominal organs that have slipped through the hernia may become strangulated. This can lead, for example, to a life-threatening intestinal obstruction. In this case, emergency surgery is necessary.

Doctors therefore recommend having abdominal hernia surgery performed early and on a scheduled basis to prevent this situation.

Abdominal Wall Hernia Surgery

Experts will only refrain from performing abdominal wall hernia surgery if the procedure poses too high a risk to the patient. This is the case, for example, with chronically ill patients.

If fluid accumulation due to liver cirrhosis is causing the hernia, doctors carefully weigh whether abdominal hernia surgery is reasonable.

The decision for or against surgery depends on:

the size of the hernia and
its exact location

In other words: How likely are life-threatening complications?

Abdominal Wall Hernia Surgery

Examinations Before Abdominal Wall Hernia Surgery

A comprehensive diagnostic evaluation is, of course, performed before abdominal hernia surgery, in part to determine the exact location of the hernia.

The physical examination begins with the patient standing. The patient must cough or strain while the doctor palpates the area and usually feels or even sees the hernial sac. The same examination is also performed with the patient lying down.

Before abdominal wall hernia surgery, additional ultrasound images (sonography) are taken to identify which organs are protruding through the hernia.

This allows the doctor to determine the urgency of the procedure. The larger the hernia and the more organ tissue protrudes, the sooner the abdominal hernia surgery must be performed.

In some cases, such as with umbilical hernias or internal hernias, a computed tomography (CT) scan is also performed.

Preparations for Abdominal Hernia Surgery

Abdominal wall hernia surgeries are among the most common procedures and can be performed without complicated preparations. The patient does not need to arrive at the hospital until the day of the surgery, when doctors will draw blood. They must not eat, drink, or smoke for six to eight hours before the scheduled surgery.

An anesthesiologist will discuss with the patient which type of anesthesia is appropriate. Whether general anesthesia is necessary or local anesthesia is sufficient depends on the type of abdominal hernia surgery.

If general anesthesia is used, an ECG must also be performed beforehand. In any case, the patient will be given sedatives in advance. In addition, the relevant area of the body will be shaved before the abdominal wall hernia surgery.

Surgical Techniques for Abdominal Wall Hernia Surgery

There are various approaches to abdominal wall hernia surgery.

The basic goal is to permanently close the existing opening through abdominal hernia surgery. Only in the case of small, uncomplicated hernias can this be done exclusively with sutures.

In many cases, it is necessary to use a synthetic mesh during abdominal wall hernia surgery to stabilize the affected area. This is used not only for larger hernias but also for older patients whose connective tissue is more elastic.

The mesh used must be significantly larger than the resulting opening. This allows it to fuse well with the body’s own tissue.

Its position can vary greatly:

“Onlay” describes the placement of the mesh between the subcutaneous fat and the abdominal muscles.
If, during abdominal hernia surgery, the mesh is placed beneath the abdominal muscles but in front of the peritoneum, doctors refer to this as a “sublay.”
“Intraperitoneal onlay” (IPOM) is the technical term for a mesh placed within the abdominal cavity that presses against the peritoneum from the inside.

Which procedure is used for abdominal hernia surgery depends on:

The size and location of the hernia
Other issues, such as adhesions caused by scar tissue
The type of hernia (primary hernia or recurrent hernia)
The patient’s age

Mesh-free procedures for abdominal hernia surgery

Abdominal wall hernia surgeries are relatively rarely performed without additional mesh. This type of abdominal hernia surgery is primarily used in children and adolescents, as well as for very small hernia openings.

For example, the Shouldice method is commonly used for inguinal hernias. In this procedure, the surgeon reinforces the posterior wall of the inguinal canal with the patient’s own tissue. However, this type of abdominal wall hernia surgery is only possible if the tissue is sufficiently strong.

The Mayo fascial duplication technique is used for very small hernias at any age. Simply put, the surgeon sutures the overlapping edges of the abdominal wall layers together to restore stability to the tissue.

In cases of large tears in the abdominal tissue, the rectus abdominis muscles may be displaced to the side. The solution here may be the Ramirez abdominal wall flap repair.

In this procedure, doctors separate bundles of muscle fibers and reposition them to close the gap in the abdominal wall. This is a technique used in abdominal wall hernia surgery that can be performed via an open incision or using a minimally invasive approach.

Abdominal Wall Hernia Surgery with Mesh Repair

A mesh used in abdominal hernia surgery provides additional stability and is intended to reduce recurrence rates.

The most common procedure for inguinal hernias is the open abdominal wall hernia surgery according to the Lichtenstein method. In this procedure, surgeons close the defect using an onlay mesh, sometimes combined with sutures.

Another treatment option is called the “plug and patch” technique. During this inguinal hernia surgery, the surgeon uses the sublay technique to suture a kind of “umbrella” into the hernia defect. The surgeon then places a mesh onlay into the inguinal canal.

Doctors also use mesh for larger umbilical or incisional hernias to stabilize the abdominal wall, which is under significant tension.

An alternative abdominal hernia surgery for large incisional hernias is the sublay technique. In this procedure, doctors excise the scar tissue and hernia sac, then close the resulting gap with a mesh. They place the mesh on both sides beneath the rectus abdominis muscles.

It is also possible to perform abdominal hernia surgery using a minimally invasive (laparoscopic) approach, which involves only small incisions.

Through these incisions, doctors insert a small camera, a light, and instruments into the patient’s abdominal cavity. This type of surgery is performed under general anesthesia. The methods are called TAPP (transabdominal preperitoneal mesh placement) and TEPP (total extraperitoneal hernioplasty).

During these abdominal hernia surgeries, the surgeon closes the hernia defect beneath the peritoneum using a synthetic mesh. The two procedures differ in terms of the surgical approach. In TAPP, the surgeon operates through the abdominal cavity. In TEPP, the access is between the peritoneum and the abdominal wall.

The IPOM method, on the other hand, is used for incisional or umbilical hernias. During this abdominal hernia surgery, the surgeon inserts the mesh laterally and places it over the defective area from the inside.

Postoperative Care After Abdominal Hernia Surgery

After abdominal wall hernia surgery, patients must take special care to rest and avoid overexertion. Although standing and walking are possible on the first day, it is better to lie down initially.

Physical activity can then be gradually increased. After two weeks, all normal daily activities should be possible again, such as driving, cycling, and hiking.

Depending on the type of surgery (open or minimally invasive), light office work may be possible after just a few days.

Patients should wait three to four weeks before resuming sports, depending on the intensity of the activity.

One special consideration is lifting heavy objects weighing more than ten kilograms. Patients who have undergone abdominal wall hernia surgery must wait ten to twelve weeks before doing so.

Otherwise, patients do not need to take any special precautions after abdominal wall hernia surgery. With a protective bandage over the wound, patients can wash and shower as usual. A doctor will remove the stitches about nine to twelve days after the abdominal hernia surgery.

Possible Complications

Like any surgical procedure, abdominal wall hernia surgery can lead to unwanted complications. For example, nerve damage may occur, which patients may experience as chronic pain.

Wound infections, testicular damage, and blood clots are also possible after abdominal hernia surgery. In addition, the doctor must consider the risks of general anesthesia before deciding to perform abdominal wall hernia surgery.

Furthermore, a hernia may reoccur (recurrence) later on, requiring doctors to repair it with another abdominal wall hernia surgery.

FAQ

How does a gap in the abdominal wall develop?

An abdominal wall hernia develops due to a weak spot in the abdominal wall. Through this hernial opening, abdominal contents or fatty tissue can bulge outward.

What role do the abdominal muscles play in a hernia?

Weakened or injured abdominal muscles increase the risk of abdominal wall hernias because they no longer provide sufficient support for the internal organs.

What are incisional hernias, and why do they occur?

Incisional hernias develop after abdominal surgery in the area of the old surgical scar. The abdominal wall is weakened in that area, allowing hernia sacs to form again.

Does every hernia sac require surgical treatment?

Not every small hernia causes immediate symptoms. However, if the hernia sac becomes increasingly prominent or there is a risk of incarceration, surgical intervention is necessary.

What happens in the event of an intestinal obstruction caused by an abdominal wall hernia?

If abdominal organs, such as sections of the intestine, become trapped in the hernia opening, an intestinal obstruction can occur. This is a medical emergency requiring immediate surgery.