Hernia Repair

A hiatal hernia is when a part of the stomach pushes up through the Hiatus, or an opening in the diaphragm for the esophagus to pass through, and into the chest area. Normally, the stomach sits below the diaphragm, a muscle that separates the organs in the chest from those in the belly. The esophagus, the tube that carries food from the mouth to the stomach, passes through a hole in the diaphragm. In people with a hiatal hernia, the hiatus becomes weak or stretched out, and the stomach pushes up through that hole.

There are 2 types of hiatal hernia:

• Sliding hernia - A sliding hernia happens when the top of the stomach, where the esophagus joins the stomach, squeezes up into the space above the diaphragm. This is the most common type of hiatal hernia. This can cause symptoms such as acid reflux, but does not generally cause damage to the stomach itself.
• Paraesophageal hernia - A paraesophageal hernia happens when the junction between the esophagus and the stomach stays below the diaphragm, as it should, but the top part of the stomach folds up and pushes up along the esophagus. This creates a pouch of stomach within the chest cavity. This is not very common, but it can be serious. If left untreated, this type of hernia can cause damage to the stomach by causing it to become trapped, and cutting off its own blood supply.

Causes of hiatal hernia

The exact cause for hiatal hernias is not known. Some people may develop a hiatal hernia after sustaining an injury to the chest or abdomen. Other people are born with a predisposition to develop a hiatal hernia.

In other cases increased, pressure in the abdomen, cause the hernia. This can include:

• Excessive coughing
• Pregnancy and childbirth
• Straining during bowel movements
• Substantial weight gain

Symptoms of a hiatal hernia

Some hiatal hernias do not cause any symptoms so do not need any treatment. We find these by accident, during imaging studies done for other reasons.

In other cases, hiatal hernias cause stomach acid to leak into the esophagus. We call this acid reflux or gastroesophageal reflux disease, or GERD. GERD can cause symptoms, including:

• Burning in the chest, known as heartburn
• Burning in the throat or an acid taste in the throat
• Stomach or chest pain
• Trouble swallowing
• A raspy voice or a sore throat
• Unexplained cough

Testing for hiatal hernia

If you have symptoms such as acid reflux or frequent heartburn, your doctor will order tests.

These tests can include:

• Barium Swallow study - A test where you drink Barium, a contrast material. It highlights the stomach and esophagus on an X-ray. We take X-rays as you swallow the contrast material. This gives us a functional picture of your esophagus and stomach.
• EGD (Upper Endoscopy) - A test where your doctor sticks a long, snake-like camera into your mouth, down your esophagus and into the stomach. This allows him or her to see the inside lining of your stomach, esophagus and the beginnings of your small intestine.
• Esophageal Manometry Test - A test which determines the strength and muscle coordination of your esophagus during swallowing.
• Esophageal PH testing - A test that looks at the PH level in your esophagus. This tests for stomach acid that is not normal in the esophagus, known as acid reflux.

In some cases, your doctor may need to test for heart disease. There are symptoms of heartburn or acid reflux can mimic the symptoms of a heart attack.

Treatment for hiatal hernias

Our treatment recommendation for hiatal hernias aims at managing your symptoms. We want to decrease the amount of acid reflux occuring in your esophagus. Chronic acid in the esophagus can lead to long term problems. It can even lead to pre-cancer and cancer of the esophagus.

The treatment in most cases will start with diet and lifestyle changes. If this does not work, your doctor may prescribe medications to decrease the amount of stomach acid you produce.

The hiatal hernia itself is not usually treated.

Surgery for hiatal hernias

If diet and lifestyle changes, or medications do not work, your doctor will need to do surgery. He or she will pull the stomach back down into the abdominal cavity. Then he or she will repair the hole in the diaphragm so the stomach does not slide up again.

We call this surgery Nissen Fundoplication. The surgery “wraps” the upper stomach around the esophagus. This prevents it from slipping above the diaphragm again. The surgery also repairs, or reduces the size, of the hole in the diaphragm.

Surgery can either be open surgery or laparoscopic surgery. Your condition might allow for a few different surgical techniques to repair your hernia. Your doctor will discuss these options with you based on your particular circumstances.

Risks

• Bleeding
• Infection
• Need for further surgery or other procedures
• Feeling of fullness or vomiting after eating
• Tear in the esophagus or stomach
• Recurrence of the hernia

Recovery after hiatal hernia surgery

We may hospitalize you for 2 - 5 days following surgery. As part of your care, your doctor might order a radiology procedure where you drink a contrast dye. This will allow him or her to evaluate your stomach and esophagus healing. We will watch your diet carefully. We'll start you on liquids then advance your diet as you are able to tolerate different kinds of food.

Inguinal or femoral (or groin) hernias happen where the thigh and body meet. Inguinal hernias are a bit higher on the groin than femoral hernias. Both types of hernias can form a sac that can hold a loop of intestine or a piece of fat pad, called omentum. These pushed out from inside the abdomen where they are normally found.

Both types of hernias can occur in men and women, but are more common in men.

Symptoms of a groin hernia

Groin hernias do not always cause symptoms. But when symptoms do occur, they can include:

• A heavy or aching feeling in the groin area. This generally progresses throughout the day after prolonged activity or standing.
• Dull pain in the groin that is worse when straining, heavy lifting, coughing.
• A bulge or lump at the groin, this may come and go, or may be there all the time.

Hernias can be very painful. They are even dangerous if the tissue in the hernia becomes trapped and is unable to slide back into the belly. Most of the time, the contents of the hernia can be “reduced,” or gently pushed back into the belly. Still, there are times when the hernia gets trapped and you can‘t push the hernia back in. If that happens, the trapped tissue can get damaged due to lack of blood supply. If the tissue does not get enough blood, it can become swollen and requires emergency surgery.

You should seek medical attention immediately if you have constant pain in the groin, or a bulging in the groin that you are not able to push back inside.

Testing for inguinal hernias

Often, we diagnose inguinal hernias through assessing symptoms and a physical examination. If the bulging is not obvious, your doctor will feel your groin area as you are standing. He or she will ask you to strain or cough to feel if the bulging occurs.

Your doctor may also order an ultrasound or a CT scan. These images help determine if you have other conditions causing your symptoms.

Learn more about our imaging services.

Treatment for inguinal hernias

Not all hernias need treatment right away. But many do need medical attention at some point, especially if there is bowel stuck in the hernia. Once you have a hernia, it will not go away on its own. If the hernia is not causing symptoms, it may not need to be fixed. The only way to fix a hernia is with surgery.

The right surgery for you will depend on a few factors, such as:

• The size of your hernia
• If this is the first time it is getting repaired or if it is recurrent
• Your general health

We offer open hernia surgery or laparoscopic hernia surgery.

Your doctor will discuss the type of surgery recommended for you and your hernia.

If you cannot have surgery, your doctor or surgeon might suggest you wear a device called a “truss.” This works like a belt or girdle. It goes over the hernia to hold the organs in place on the inside, preventing internal organs from becoming trapped in the hernia. Used the wrong way, a truss can actually do harm. Do not wear one unless your doctor or surgeon tells you to.

If you cannot have surgery, your doctor or surgeon might suggest you wear a device called a “truss.” This works like a belt or girdle. It goes over the hernia to hold the organs in place on the inside, preventing internal organs from becoming trapped in the hernia. Used the wrong way, a truss can actually do harm. Do not wear one unless your doctor or surgeon tells you to.

Open hernia surgery

During an open surgery, the surgeon makes an incision near the hernia. Then he or she gently pushes the bulging tissue back into place. Next, your surgeon sews the weak muscle layer back together so nothing can bulge through again. Your surgeon may also sew closed the sac pushed in from inside the abdomen, preventing any further tissue from pushing out.

In almost all cases, your surgeon will reinforce the area with a mesh patch. This is medical grade, plastic mesh material like a window screen, but softer and more flexible. Introduction of the mesh material allows for a tension-free repair of the hernia. It strengthens the muscle layers, and significantly decreases the risk of a hernia recurrence. Additionally, it allows for faster return to work and activities. The tissue layers and the skin will then close over top of the mesh.

If you had a loop of intestines stuck in the hernia, your doctor might need to remove that piece of intestine. This is especially true if the intestine is unhealthy due to lack of blood supply. Then he or she will sew the two ends of the intestine back together. Sometimes this requires a larger incision in the abdomen. This is generally only done in true emergency cases. 

Laparoscopic hernia surgery

We can also repair inguinal hernias through laparoscopic surgery. We place you under general anesthesia, so you are completely asleep. Using a small balloon and carbon dioxide gas, we create a space between two layers of the abdominal wall. We place mesh in this space, preventing the contents of the abdomen from pushing out through the weakened area.

Risks

Risks of this surgery include, but not limited to:

• Bleeding
• Infection of the mesh, which may require removal of the mesh
• Injury to the intestines or surrounding organs
• Injury to the blood supply to the testicle or to the Vas Deferens (the tube that brings sperm from the testicle to the penis) in men
• Recurrence of the hernia

Recovery after Hernia Surgery

In most cases, we complete groin surgery as an outpatient procedure. This is unless your intestines are trapped in the hernia. If you have trapped intestines, you may be in the hospital for 2 - 7 days or more.

We give you discharge instructions and pain medication to take at home as needed. You will be sore for about 1 - 2 weeks after surgery. We recommend you walk around your house several times per day after surgery. But you will want to take it easy for at least 2 weeks. You may have a lifting restriction of no more than 20 lbs for up to 8 weeks. Ask your doctor about your restrictions after surgery. Make sure to make any arrangements needed for your employer before having surgery.

If you smoke, you should stop smoking. It is best if you can quit at least 2 weeks before surgery, but anytime is a good time to quit. Quitting will help with your wound healing and your overall recovery. It also decreases your risk of a hernia recurrence.

An umbilical hernia is an opening between the abdominal muscles at the navel, or “belly button.” This happens when the umbilical cord scar fails to heal properly at birth.

Many umbilical hernias in newborns close in the first 12 to 18 months of life. Repair is rarely recommended until a child is approximately three years old.

Adults get umbilical hernias when the connective tissue and muscle stretch and weaken. This occurs due to increased intra-abdominal pressure from:

• Abdominal distension
• Ascites
• Obesity
• Pregnancy

Symptoms of an umbilical hernia

You will see a bulging area next to your umbilicus or navel. The bulge may be asymmetric and located slightly above, slightly below, or to one side of your navel. Many times fat from the inside of the belly becomes trapped into the hernia. Sometimes bowels or intestines are trapped in the hernia as well. Hernias can be sore to touch or may be painful with activity or with coughing or sneezing. Any increased abdominal pressure or straining abdominal muscles is uncomfortable. If you have trapped fat or bowel, hernias can cause persistent pain. If left untreated, they can also cause an infection.

If you have constant pain around your navel you should seek medical attention.

Treatment of Uumbilical hernias

Small hernias or those that are not causing symptoms do not need medical attention.

Larger hernias, those causing pain or those with bowel or fat trapped do need attention. An umbilical hernia will not resolve on its own, and may continue to enlarge over time. The only way to fix an umiblical hernia is with surgery to close the defect around the umbilicus.

Umbilical hernia surgery

The treatment for symptomatic umbilical hernias is surgery. Surgery can be open repair or laparoscopic, but most times they need open surgery.

In the open repair, we make a small incision over the bulging area. We repair the hole in the fascia, the strength layer of the abdominal wall. If the hole in the fascia is small, we pull the edges together with stitches. If the hole is larger, your surgeon may need to reinforce the repair with a mesh patch. The patch is made of medical grade, plastic mesh-type material like a window screen, but softer and more flexible. This strengthens the muscle layers, and significantly decreases the risk of recurrence of the hernia. Additionally, the patch allows for a faster return to work and activities. We close the tissue layers and the skin over top of the mesh. 

Risks

• Bleeding
• Infection of the mesh (which may require removal of the mesh)
• Injury to the intestines or surrounding organs
• Recurrence of the hernia

Recovery after umbilical hernia surgery

In most cases, we do umbilical hernia repair as an outpatient surgery. This is true unless you have trapped intestines in your hernia. If the intestines are trapped, you may be in the hospital for 2 - 7 days or more.

At discharge, we give you instructions and pain medication to take at home as needed. You will be sore for about 1 - 2 weeks after surgery. You should walk around your house several times per day after surgery. You will want to take it easy for at least 2 weeks. You may have a lifting restriction of no more than 20 lbs for up to 8 weeks. Ask your doctor about your restrictions after surgery. You should make any arrangements for work before having surgery.

If you are a smoker, you should quit smoking. It is best if you can quit at least 2 weeks before surgery, but anytime is a good time to quit. Quitting helps with your wound healing. It also helps your overall recovery, and decreases the risk of hernia recurrence.

Ventral hernias occur in the abdominal wall. They are holes, or defects, or areas of weakness in the fascia, the strong layer of connective tissue that covers the muscles of the abdominal wall. Ventral hernias can develop as a result of prior surgery (called incisional hernia) or spontaneously (umbilical, epigastric, or Spigelian hernias). They can be present at birth, or develop later in life.

Symptoms of ventral / incisional hernias

The most common symptoms include:

• An area of bulging in the abdominal wall, often in the middle or on the sides. They worsen when standing, heavy lifting, coughing or otherwise straining the abdominal muscles.
• Can have pain associated with area of bulging

If left untreated, the intestines or abdominal fat push through the hernia and get trapped. This causes a bowel obstruction or a blockage in the intestines. There is a loss of blood supply to that piece of intestines which causes permanent damage to the trapped tissue.

You should seek medical attention immediately if you have any of the following symptoms:

• Constant pain in the area
• Nausea or vomiting
• Increased abdominal distension
• Inability to have bowel movements

These can be signs of trapped bowel and may need emergency surgery.

Incisional hernias

Incisional hernias, by definition, develop at sites where an incision was made for some prior abdominal procedure. Hernias are due to failure of fascial tissues to heal.

Causes

Any condition that reduces wound healing will increase your risk for developing an incisional hernia. Such conditions include:

• Broken stitches
• Connective tissue disorders
• Excessive wound tension
• Infection
• Malnutrition
• Medications that suppress the immune system
• Obesity
• Smoking

Emergency surgery also increases the risk of incisional hernia formation.

Your risk of developing an incisional hernia is about 10 to 15 percent after abdominal surgery. This risk is higher if you have a wound infection after surgery.

Incisional hernias can increase in size to enormous proportions. Giant ventral hernias can contain a significant amount of small or large bowel. Incisional hernias can develop in the early postoperative period. They can also develop as late as 10 years after surgery. It is possible these may arise from previously undetected small hernias.

Indications for surgery

We recommend repairing most ventral or incisional hernias so they do not geting trapped in the hernia. Hernias will not go away on their own, and in most cases will continue to enlarge over time if left untreated. We leave some hernias untreated because the risk of undergoing surgery is higher than the benefit of fixing the hernia. You and your doctor will decide if your hernia needs repair and what type of surgery is best for you.

Surgery for ventral / incisional hernia repair

We use the same surgery techniques to repair a spontaneous ventral hernia and an incisional hernia. In some cases of incisional hernias, a patient will have a “Swiss Cheese hernia.” This is when there are many small holes in the fascia. We need to repair them all, either individually or as one large repair.

Open Surgery

During open surgery, the surgeon makes an incision near the hernia. Then he or she gently pushes the bulging tissue back into place. If there has been intestinal damage, that section is removed, and the two ends of your intestines are reconnected.

Next, your surgeon sews the weak muscle layer back together so nothing can bulge through again. In almost all cases, your surgeon will reinforce the area with a mesh patch. This is medical grade, plastic mesh material like a window screen, but softer and more flexible. Introduction of the mesh material allows for a tension-free repair of the hernia. It strengthens the muscle layers, and significantly decreases the risk of a hernia recurrence. Additionally, it allows for faster return to work and activities. 

In some cases the mesh is under the fascia layer, and in some cases the mesh is over top of the fascia layer. The soft tissue and skin layers are then closed over the mesh.

Laparoscopic surgery

We can also repair ventral or incisional hernais through laparoscopic surgery. We complete this surgery through small holes made in your abdominal wall using a camera and long instruments. We place mesh inside the abdominal cavity and secure it on the inner side of the abdominal wall.

Risks

• Bleeding
• Infection of the mesh (which may require removal of the mesh)
• Injury to the intestines or surrounding organs
• Recurrence of the hernia
• Need for further surgery or other procedures

Recovery after ventral / incisional hernia repairs

Your recovery time depends on the size of your hernia. We offer outpatient surgery for small hernias so you can go home the same day. Larger hernias, especially those involving trapped intestines, generally mean a stay in the hospital for 3 - 7 days, or more. We may place surgical drains in your abdomen to prevent fluid or blood from collecting around the mesh. You may need to go home with the drains in place.

Part of your treatment could include wearing an Abdominal Binder, to compress your belly. You will receive instructions to work on deep breathing exercises. These help to prevent pneumonia after surgery. If we prescribe antibiotics, you should take them to prevent an infection of the mesh.

We give you discharge instructions and pain medication to take at home as needed. You will be sore for several weeks after a large hernia surgery. You should walk around your house several times per day after surgery. You will want to take it easy for several weeks. You will be at about 80% recovery in 8 weeks, and full recovery will take 6-12 months. You may have a lifting restriction of no more than 20 lbs for 8 weeks or more as the muscle layers heal. Ask your doctor about your restrictions after surgery. You should make any arrangements needed for your employer before having surgery.

If you are a smoker, you should quit smoking. It is best if you can quit at least 2 weeks before surgery, but anytime is a good time to quit. Quitting helps with your wound healing. It also helps your overall recovery, and decreases the risk of hernia recurrence.

Your doctor may request you quit smoking several months before surgery. This will allow for the best possible recovery.