Hernia Treatments
With our specific area of expertise, there are actually countless treatment options even for the same type of hernia. What makes our hernia experts special is their extensive training allows them to tailor their approach for each individual patient based on their medical and surgical history paired with their wants and needs. We believe this approach leads to better outcomes compared to other surgical groups which may not have the extensive training our experts have. Let’s discuss the options you have for treating your hernia.
Surgical Hernia Repair
Anyone who has a hernia should undergo an evaluation for possible repair. Smaller inguinal and umbilical hernias without symptoms may be monitored without surgery, however incisional hernias and larger hernias should be repaired right away as they often enlarge over time. All candidates for hernia repair are evaluated to identify factors that can be modified to minimize the risk of complications, such as control of diabetes and smoking cessation.
The goal of hernia repair is to close the hernia defect with minimal or no tension to ensure that it does not recur. This most commonly occurs with the placement of mesh. Mesh is a surgical device used to help support the tissues around the hernia to increase the success of repair and more importantly to reduce the chances of recurrence. Mesh can be either synthetic (manufactured polymer sheets), biologic (derived from human or animal tissue), or a mix of both. The secondary goal is to reduce the trauma of surgery by using minimally invasive approaches whenever possible and by ensuring that each patient is as optimized as possible.
Approaches to Hernia Repair
There are 3 different possibilities for repair approaches depending on the type of hernia and should be determined after a discussion between the patient and their hernia surgeon.
Open Surgical Repair
The surgeon makes an incision directly over the hernia defect and fixes the hernia from that incision, including mesh placement. This may be appropriate for smaller umbilical and ventral hernias and may be done under light sedation rather than general anesthesia. Open surgery may be necessary for larger or more complex hernias which are not able to be fixed minimally invasively.
The other two options are both considered examples of minimally invasive surgery:
Laparoscopic Surgery
Laparoscopic surgery is performed through several small incisions ranging from 5mm-12mm. The surgeon then uses long instruments to perform the surgery. The purpose of this is to approach the hernia from the inside-out, rather than outside-in. This approach is always performed while under general anesthesia. The surgeon inserts small tubes called cannulas through the abdominal wall at some distance from the hernia defect. These tubes are the “working ports” we place instruments inside of. The hernia is then fixed, and mesh can even be placed through these small incisions.
Robotic Surgery
Robotic surgery is similar to laparoscopic surgery in that smaller incisions are used in order to fix the hernia, however instead of the surgeon operating with long instruments controlled by the surgeons hands, robotic instruments are placed inside the patient and the surgeon controls them from a console in the operating room. The robotic platform enables surgeons to have more precise movements, extended reach, and even the ability to perform more complex abdominal wall reconstruction compared to laparoscopic surgery.
Robotic surgery has been around for close to 2 decades however only in the past several years has its real utility in abdominal wall construction been realized. Patients that would normally need large open incisions which would necessitate a several-day hospital stay with increased pain can undergo robotic surgery with the possibility of an overnight stay or even same day discharge.
Specialized Hernia Repairs
Non-mesh inguinal (groin) hernia repair
While we recommend mesh reinforcement of inguinal hernias, in certain cases, non-mesh tissue repair can be an alternative. The technique mastered by our surgeons is the Shouldice technique, which is a 4-layer, sutured closure of the muscles and fascia of the groin and abdominal wall in order to repair hernias and strengthen the inguinal floor. While the recurrence rate is slightly higher without mesh reinforcement, the recovery is very similar.
Robotic Component Separation
In order to reconstruct larger hernia defects, muscle releases or component separations may need to be performed in order to bring the patient’s midline closer together. This involves either cutting the outermost oblique muscle, the external oblique, or the innermost oblique muscle, the transversus abdominis. By doing so it is possible to close hernia defects as large as 20-30 cm while preserving the function of the abdominal wall.
Hernias requiring component separation would normally require a large midline incision, however centers adept at robotic component separation may only require 4-6 smaller incisions on the abdominal wall. This allows for a quicker recovery and reduces the rate of complications.
Totally Extraperitoneal Hernia Repair
Typically, minimally invasive ventral and umbilical hernia repairs would need to be performed trans-abdominally. This involves placing trocars or tubes inside the abdomen where it is filled with carbon dioxide and the surgeon works up on the abdominal wall. Using advanced optics, high-level centers such as the Columbia Hernia Center can perform these hernia repairs by operating within the layers of the abdominal wall themselves. This technique is called the enhanced-view Totally Extraperitoneal access (eTEP) hernia repair. This allows for direct visualization of muscle layers and a quicker and more robust repair than would be able to be achieved otherwise. This technique can sometimes avoid going inside the abdomen all-together.
Rectus Diastasis
Some patients may have what is known as rectus diastasis, which is where the rectus muscles (the six-pack muscles) separate at the midline. This can occur with weight gain, with aging, and most commonly after pregnancy. These can also occur along with ventral or umbilical hernias. Even in the absence of hernias, rectus diastasis can be quite debilitating in those who suffer from it.
Repair of rectus diastasis involves bringing the rectus (Ab) muscles back together with the repair of any associated hernias at the same time. Traditional repair of rectus diastasis associated with a hernia involved a tummy tuck by a plastic surgeon, however advanced hernia centers can offer a minimally invasive approach for diastasis and hernia repair. This is referred to as a SubCutaneous Onlay Laparoscopic Approach (SCOLA) Repair. This approach involves 3 small surgical incisions in the lower abdomen and involves a re-approximation of the rectus muscles as well as repair of any associated hernias using long instruments or the robotic platform. This allows for a faster recovery without the need for skin excision.