Abdominal Wall Hernia Repair
Foreword by Mr. Abu-Own
I have an interest in the repair of groin and abdominal wall hernias. Abdominal wall hernias that I routinely repair include: umbilical and paraumbilical hernias, incisional hernias, epigastric hernias and occasionally spigelian and lumbar hernias.
Most abdominal hernias are repaired as a day case (go home same day) under general anaesthetic. But some (e.g. large incisional hernias or other complex hernias) may require you to stay overnight after the operation.
This page has been designed to provide you with some background about abdominal wall hernias, the nature of the surgery, what to expect throughout the process and the potential risks. An aftercare page has also been included to provide patients with more information about recovery and getting back to normal daily activities.
What is a hernia?
A hernia is a “bulge” in the groin or abdomen, which develops because of an abnormal protrusion through a weakness in the abdominal wall. They can occur at any age and in many different locations. The protrusion contains a cavity (the hernial sac) which can be empty or it can fill with abdominal contents (bowel or fat).
Typically, hernias are more obvious when standing or straining, such as when coughing, lifting heavy items or digging, as the increased pressure in the abdomen can force bowel into the sac.
Hernias usually develop over time for no obvious reason, although in some people there may be an inborn weakness in the abdominal wall. Occasionally, a strenuous activity will cause a lump to appear suddenly for the first time.
What common types of abdominal wall hernias are there? How are they treated?
Abdominal wall hernias produce a bulge in the abdomen rather than the groin. There are various different types that occur in different locations in the abdomen. They are all treated in a similar way: return the abdominal contents back to their normal position, repair the weakness in the abdominal wall, with or without reinforcement by a mesh.
Some of the most common types include:
Paraumbilical and Umbilical Hernias: The umbilicus, or belly button, is a natural weakness in the abdominal wall where hernias commonly occur.
A paraumbilical hernia (para means next to) is an area of weakness
around your umbilicus that
adults develop. Not to be confused with an umbilical hernia, which is an area of weakness
within the umbilicus and is more common in
Although they are are often small, paraumbilical hernias in adults are considered high priority for surgical repair as the risk of serious complications such as strangulation (see next question) are higher than most other types of hernia. Paraumbilical hernia repair is a surgical procedure commonly performed to correct the weakness in the abdominal wall or to close an opening near the umbilicus that has allowed abdominal contents to protrude. Surgery involves a cut in the umbilical area, usually underneath the belly button (smiley face incision) or above the belly button. The herniated tissue is pushed back inside the abdominal cavity. The hole in the abdominal wall may be closed with permanent sutures (stitches) or with a mesh.
Umbilical hernias in young children usually get better on their own before the child reaches 1 year. If the hernia is very big or hasn’t gone away by the time your child reaches 4 years, then a surgical repair is usually recommended.
Incisional Hernia: An incisional hernia occurs due to a weakness of the abdominal wall directly at, or in the region of a previous surgical incision. This may cause a bulge and/or pain and discomfort.
Surgery involves return of the abdominal contents back into their normal position and repair of the area of the weakness. A mesh may be placed to give it added strength.
Most incisional hernia repairs can be done as a day case (go home on the same day), but procedures for large incisional hernias may require patients to stay overnight after the operation.
Epigastric Hernia: An epigastric hernia occurs due to a weakness or opening in the muscles of the upper abdominal wall, on a line between the breast bone and the umbilicus (belly button). This results in a bulge in the abdominal wall which may cause pain or discomfort.
Surgery involves return of the abdominal contents back into their normal position and repair of the area of weakness. A mesh may be placed to give it added strength.
What problems do abdominal hernias cause?
Hernias may simply appear as a painless bulge that enlarges when standing or coughing, but often they cause an aching discomfort or a dragging sensation. Over time, it may gradually become bigger and more uncomfortable.
Occasionally, the contents of the hernia may become trapped in the weak point in the abdominal wall. This can cause bowel obstruction with severe pain, nausea and vomiting (incarcerated hernia).
There is also a small chance that the hernia may strangulate. This means that the bowel becomes squeezed to the extent that it cuts off the blood supply to the portion of bowel in the hernia. This serious complication is very painful and requires emergency surgery.
The risk of strangulation may be greater with smaller abdominal hernias and with paraumbilical hernias in adults.
Does it need treatment if it's not causing any problems?
It is usually advised that provided you are fit for the operation, abdominal wall hernias should be repaired to prevent the complications (above) from arising; even if it is not currently bothering you.
What types of treatment are available?
Unlike groin hernias, abdominal wall hernias are usually repaired under general anaesthetic.
The operation can be performed
laparoscopic (keyhole). Mr Abu-Own will discuss the benefits and drawbacks of each with you and help you decide which is the best option for your individual case.
Mr Abu-Own may or may not use a mesh to provide extra reinforcement. If a mesh is to be used, antibiotics are administered during the operation. Suitability for mesh may be suspected before the operation, but it is often difficult to tell in advance so the final decision is usually made during the operation.
What are the risks associated with abdominal hernia repair?
Serious complications from abdominal hernia repairs are rare.
Mr Abu-Own will discuss with you in person the possible complications of your particular type of abdominal hernia repair.
Examples of such complications include, but are not limited to:
Wound haematoma (old blood collecting under the closed wound)
Wound or mesh infection
Recurrence of the hernia
Seroma (a collection of fluid between the skin and the muscle/mesh)
Deep vein thrombosis (DVT) and pulmonary embolism (PE) (uncommon)
Bowel injury or peritonitis (very uncommon)
Need to return to theatre for further surgery (very uncommon)
Before the operation
You will attend a pre-admission clinic where you will be seen by a Preoperative Assessment Nurse Specialist.
At this clinic, you will be asked about details of your medical history. Any investigations and tests require will be arranged. This is a good opportunity for you to ask any questions about your admission for the operation, but please feel free to discuss any concerns you have at any time.
You will be asked if you are taking any tablets or other types of medication - these might be ones prescribed by a doctor or bought over the counter in a pharmacy. It helps us if you bring details, or the packaging, with you of anything you are taking.
It is very important that you tell us if you are allergic to any medications or dressings/plasters.
You will be admitted on the day of your operation. Abdominal wall hernia surgery is usually performed as a day case procedure, meaning that you will be able to go home on the same day. We might occasionally recommend you stay in hospital overnight. This will be discussed with you when you are seen in clinic.
All abdominal wall hernia repairs require general anaesthetic.
Your anaesthetist will visit you on the ward. They will review your medical history. In particular, you will be asked about your medications and any health problems that you have. They will also ask you about previous anaesthetics you have had and whether you had any problems with these (for example, nausea). You will be asked if you are allergic to anything. They will also want to know about your teeth, whether you wear dentures, have caps (crowns) or a plate. Your anaesthetist may examine your heart and lungs.
You may be prescribed medication to take shortly before your operation. This is known as the 'pre-medication' or 'pre-med' - it relaxes you and may help send you to sleep.
A general anaesthetic is usually performed by giving you an injection of medication into a vein through a thin, plastic tube (cannula), usually placed in your arm or hand. If a local anaesthetic is used, it is given by injection under the skin in the area of the incision.
While you are unconscious and unaware, your anaesthetist remains with you at all times, monitoring your condition and controlling your anaesthetic. At the end of the operation, your anaesthetist will reverse the anaesthetic and you will regain awareness and consciousness in the recovery room, or as you leave the operating theatre.
During the operation
Open repair: This involves an incision in the abdomen, freeing up the hernia sac and replacing it inside the abdominal cavity. The abdominal wall may be strengthened with the aid of a sheet of Prolene mesh - which does not dissolve - directly behind the weak area. This prevents the bulge of the hernia from returning.
The mesh is made of the same material as the permanent suture (stitches) we commonly use to repair blood vessels. You will not be aware that it is there.
The wound is closed with dissolving stitches under the skin. A number of different dressings may be then used, including showerproof dressings.
Laparoscopic repair: This involves an incision near your navel and two or three further incisions. Each incision is about 1 cm long. Through these, the abdomen is inflated with carbon dioxide gas which is completely harmless. If a mesh is used, it is placed directly behind the weak area, as with the open repair.
At the end of the operation, before you wake up, the wounds in your abdomen will be treated with local anaesthetic so that when you first wake up there should be very little pain. Some patients have some discomfort in their shoulders, but this wears off quite quickly.
The cuts made will be covered with small waterproof dressings.
After the operation
After your operation, you will wake up in the recovery room. You might have an oxygen mask on your face to help you breathe. You might also wake up feeling sleepy.
You will have a thin, plastic tube in one of the veins in your arm, attached to a bag of fluid called a drip.
People can often feel sick after an operation with general anaesthetic, and they may vomit. If you feel sick, please tell a nurse and you will be offered medicine to make you more comfortable.
Local anaesthetic is usually injected into the wound(s) to minimise pain immediately after surgery and this lasts for 4-6 hours. You will be given pain relief medication to take home for you to take if required. As the discomfort subsides you will need less pain relief but you may need to take the pain killers for 2-4 weeks.
If you have had a laparoscopic repair you may have some discomfort and a pulling sensation around the navel which will last 7-14 days.
You will be able to drink immediately after the operation and if this is all right and you do not feel sick, you will be able to eat something.
After your operation we will try to get you up and about as soon as you are comfortable. You will be allowed home when you are comfortable, have had something to drink and eat, and have passed urine.
You are not insured to drive unless you are confident that you can brake in an emergency, and turn to look backwards for reversing, without fear of pain in the wound. This takes about 10-14 days for most people. If in doubt you should check with your insurers. A good test is to sit in a stationary car and practise doing am emergency stop. If you are not inhibited because of any pain or discomfort, then you are probably safe to drive.
If you have had an open repair, it is safe to perform light exercise immediately after your operation, but it is sensible to avoid anything strenuous for 4-6 weeks. However, the only thing to hold you back will be discomfort and, if the wound is not hurting, you can do whatever you like.
You will be able to return to your normal daily activities gradually. You should be able to return to office work within two weeks and manual work within 4-6 weeks. You will be given a certificate to cover the time off work that you require.
The two pain relief medications most commonly prescribed after hernia surgery are paracetamol and codeine (or paracetamol and ibuprofen). You should be aware that codeine can commonly cause constipation and drowsiness. All medications are supplied with an information leaflet which lists possible side effects — please read this for more details.
Mr Abu-Own routinely sees his patients at least once following a hernia repair, around 2-4 weeks after the procedure. Your ward nurse will let you know. For self-funding patients, this is included in your pre-agreed all-inclusive procedure price.
When to seek medical advice after the operation
In the period following your operation you should seek medical advice if you experience any of the following problems:
increasing pain, redness, swelling or discharge;
difficulty in passing urine;
high temperature over 38°C or chills; or