What is a hernia?

A hernia, or abdominal wall hernia, is the protrusion of fat or viscera located in the abdomen from the abdominal cavity through a congenital or acquired gap.

The word hernia comes from the Greek and stands for the word bud, as it refers to protrusions on the trunk that resemble a bud. 

A prerequisite for the development of a hernia is a weak spot in the abdominal wall, which can be located at different sites. In most cases, this is already created during embryonic development. However, the weak spot can also develop much later, for example due to:

• a chronic lung damage with a strong cough
• a scar after an abdominal operation
• an increased pressure inside the abdomen due to e.g. pregnancies or even tumors.

Due to the constantly increased internal abdominal pressure, load-bearing abdominal wall layers can separate to such an extent that a bulge-like protrusion of the remaining abdominal wall layers results as a hernia sac.

Every true hernia has the 3 characteristic features.

• Hernia gap = This is the "hole" in the abdominal wall through which contents can pass.
• Hernia sac = Its inner lining usually consists of sliding peritoneum with hernial contents. If the hernia sac becomes trapped and does not slide back, it can cause severe pain and leads to emergency surgery if the bowel is trapped (incarceration).
• Hernia contents = Due to inflammatory reactions, a hernia sac may contain hernial fluid, but it may also be empty. Frequently, however, it contains portions of a large fatty apron covering the organs inside the abdomen (omentum majus) or portions of the small or large intestine. It may also contain freely movable organs, such as the ovaries, the appendix, or wall portions of the urinary bladder.

Often a hernia is an incidental finding and shows up as a small bump. In men very often in the groin and in women more often in the navel area or above the navel. Pain is rather the exception, it is more a feeling of pressure or a pulling pain during movement.

A hernia always occurs as a result of a chronic process of tissue change, i.e. one that lasts for years, or is created in younger people as a weak point in the abdominal wall. There is therefore no sudden rupture during a spontaneous movement, as is often assumed. 

In case of severe pain with nausea and / or vomiting, a doctor or emergency room should be consulted immediately. In men, the inguinal region may also have a torsion of the testicles as a separate clinical syndrome, which requires immediate therapy.

In the case of rather mild symptoms in the groin area after e.g. sporting activities, 2-4 weeks can also be discounted, since it is often a problem of the muscle groups in the pelvic area (adductors), which improves significantly with rest and taking anti-inflammatory drugs such as ibuprofen or diclofenac and does not require surgical therapy.

However, if there is a bump that recedes when the patient is lying down and recurs when the patient coughs while standing, a hernia is quite likely and should be evaluated by a surgeon.

In principle, it can be said:

• A hernia can only be treated by surgery and hernia bands are not a longer option for all patients who can be operated on, especially in the groin area.
• A hernia becomes larger and larger in the further years of life and is then more and more complex to operate.
• Surgery for a non-symptomatic hernia can be well planned and should be performed within the next 3-6 months after diagnosis.
• However, women with inguinal hernias should have surgery as soon as possible because you have a significantly increased risk of incarceration.
• The likelihood of incarceration, which is an emergency and requires immediate surgery, is about 6-8% in the upper abdomen and umbilical area and about 3% in the inguinal area.
• As a rule, it is not intestine that gets stuck, but fatty tissue of the abdominal cavity.
• Pregnant women with a suspicion of a hernia should see a hernia specialist for clarification.
• Sporting activities, as long as they do not cause any discomfort, can be continued without any problems, except for abdominal exercises (so-called sit-ups). In case of discomfort, consult a surgeon immediately.
• A rectus diastasis is not a hernia and is therefore not usually operated on.

Diagnosis of a hernia is usually made clinically by examination. A good tool is ultrasound, whereby small hernias can be easily detected, especially in women. In the case of large hernias, the diagnosis can be easily made without ultrasound.

In obese patients or complex conditions after several previous operations, magnetic resonance imaging (MRI) is the method of choice. Here it is important that a dynamic examination (Valsalva) is performed, in which the patient must push during the examination. Otherwise, small hernias cannot be diagnosed and the examination is useless. Imaging by magnetic resonance imaging (MRI) or computed tomography (CT) is useful for measuring large defects prior to surgical intervention.

Important: In patients with a new abdominal wall hernia who are older than 50 years and have not yet had a colonoscopy, this examination should definitely be performed before surgery as a preventive examination to rule out an intestinal tumor. Preventive colonoscopy is recommended for men over 50 years of age and for women 55 years of age, and the costs are covered by the statutory health insurance funds.

There are various surgical techniques that are individually adapted to the patient's findings and state of health. For all types of hernia, a distinction is made between operations with or without mesh insertion and the minimally invasive or open technique.

This individual choice is described as a tailored approach. Therefore, specialized hernia surgeons should always be proficient in various surgical procedures and perform them regularly.

The direct suture closure

The supporting connective tissue layer of the abdomen is called fascia and it is in this layer that the hernia gap is located. In the surgical technique of direct suture closure, the gap is securely closed with a suture that does not dissolve, using several sutures.

It is particularly important that no tissue is trapped in the gap to be closed. This procedure is used for smaller hernias under 1.5cm in the umbilical or upper abdominal wall area. Scar hernias, on the other hand, should always be treated with a mesh, as the risk of a new hernia (recurrence) is significantly greater here.

Mesh implantation

In the case of larger hernias over 1.5cm, risk factors such as obesity, chronic lung disease or connective tissue weakness, and in the case of scar hernias, a plastic mesh must be inserted for reinforcement. Otherwise, the risk of a new hernia (recurrence) is too great.

The nets are usually made of polypropylene or polyvinylidene fluoride plastic and are usually very well tolerated. All meshes have a tendency to shrink, so they should be used too large rather than too small. The mesh should overlap the edge of the hernia by at least 3cm for umbilical hernias and at least 5cm for incisional hernias to prevent recurrence if shrinkage occurs.

As a "planned" foreign body, all plastic meshes cause a reaction in the organism, forming an effusion around the mesh (seroma). In most cases, this is harmless and the body reabsorbs this fluid on its own within 2-5 months.

In very rare cases, a seroma must be punctured to drain the fluid. However, this should not be performed until 6 weeks after surgery at the earliest due to a high risk of infection. Even more rare is an infection around the mesh with pus formation due to an accumulation of blood with subsequent infection. In this case, a mesh must be removed again because there is no ingrowth.

Depending on the location of the mesh in the abdominal wall, there are different surgical methods.

New are mashes that dissolve slowly and thus lead to a permanent stability. The advantage is that patients do not have any foreign material in their bodies. The disadvantage is the extremely high price and the lack of long-term experience with these products in terms of stability and recurrence frequency. As a rule, these are used for infectious wounds in specialized hernia centers.

A further development in hernia surgery, in addition to the improved material properties, is the insertion of the meshes through the smallest possible incisions and the placement outside the abdominal cavity in order to avoid adhesions in the abdominal cavity.

• PUMP technique: This procedure is called Preperitoneal Umbilical Mesh Plastic (PUMP). In this procedure, umbilical hernias are treated with a mostly round mesh, which is 5-8cm in diameter and is not placed directly in the abdominal cavity (intraperitoneal position), but on the peritoneum. This ensures a correct, firm position and does not lead to the feared adhesions with the inner abdominal fat or the intestine. However, this technique is not always possible.
• MILOS technique: This technique is described as Mini Less Open Sublay and is a combination of open surgery and minimally invasive technique, a so-called hybrid surgery. The mesh is placed under the straight abdominal muscle in a so-called sublay position to prevent adhesion to the intestine. This proven procedure is currently the gold standard for surgical procedures of large abdominal wall hernias. The incisions are significantly smaller than in conventional surgeries performed in most hospitals. Important: Inguinal hernias are not operated on using this technique. Read more...
• ELAR-plus technique: In this technique, special emphasis is placed on the reconstruction of the rectus diastasis, i.e. the separation of the straight abdominal muscles. Through a small incision above the navel, the firm connective tissue sheath of the rectus muscles is incised and the midline is gathered.  A mesh is sewn in for reinforcement. The abbreviation ELAR stands for Endoscopic-Assisted Linea Alba Reconstruction plus Mesh Augmentation.

These days, modern anesthetics make surgery safe and less stressful for the patient. Nevertheless, it is important for the anesthesiologist and surgeon to recognize existing risk factors and to be prepared accordingly. Therefore, the following information is important before any surgery:

• Is there an infectious disease (hepatitis, TB, HIV).
• Are there any metabolic disorders such as diabetes mellitus or organ diseases (heart, liver, kidney, thyroid gland)?
• Are there any allergies or hypersensitivities (medication, antibiotics, iodine, latex)?
• Is there an increased bleeding tendency (nosebleeds, bruises from minor injuries)?If there was once a blood clot (thrombosis/embolism)
• If medication is needed regularly (especially blood thinners such as Marcumar, ASS, Plavix, Clopidogrel).
• Does the patient have a pacemaker or defibrillator?
• Have there ever been complications during a previous operation?

Complications can also occur during any surgery. We list here the most important ones related to hernia surgery.

• Allergies and intolerances: Open surgery usually involves a one-time administration of an antibiotic. Therefore, it is important to know if there is any drug intolerance. It is also important to know about any latex allergy, as these patients are the first to require surgery.
• Vascular, nerve and organ injury: Wherever a cut is made, something can also be severed. In terms of nerves, the fine cutaneous nerves in the groin are particularly worthy of mention here, which can lead to numbness or even pain after an injury. Organ injuries mainly affect the intestine. After previous operations, the removal of adhesions and a possible injury poses a particularly high risk.

• Bleeding and rebleeding: Patients on blood-thinning medications have a 4-fold increased risk of experiencing rebleeding. The type of medication is important. Kidney damage further increases the risk of a bleeding complication because the drug accumulates, making it last longer. In contrast, a bleeding complication in people who do not take blood thinners is very rare.
• Seroma (wound fluid): The formation of a seroma is very common and seen in various forms after hernia surgery. When plastic mesh is inserted, this foreign body reaction is quite pronounced. If a seroma forms, it should be left in place and observed. Usually the body reabsorbs the fluid within 4-6 weeks and nothing is seen. Under no circumstances should a seroma be punctured early, as there is then a risk of germs spreading from the skin, which can lead to infection.
• Wound pain: Pain after abdominal wall surgery is normal and especially distressing during movement. Therefore, all patients should also take their prescribed pain medication for the first 3-5 days. Operations of umbilical and incisional hernias are often more painful than minimally invasive operations of inguinal hernias. In some cases, discomfort may occur with weight bearing or prolonged sitting for up to 6 months after surgery.
• Wound infections: Proper infection with pus formation is very rare these days and rarely occurs with minimally invasive surgery. Therefore, the one-time administration of an antibiotic can be dispensed with during TAPP and TEP surgery. More common are wound healing problems (especially in obese patients), but these heal without further surgery.

You are welcome to book an appointment online in our appointment calendar DOCTOLIB under the specialty "Visceral surgeon and proctologist" with our doctors. We are looking forward to it.