What is a Hernia?
A Hernia is a defect (hole) in the muscles of the abdominal wall that hold your intestines safely inside. There are several different types of hernias but the three most common are: umbilical hernia (bellybutton), inguinal hernia (groin hernia) and ventral incisional hernia (hernia occurring in the scar of a previous surgery).
A Hernia can be a small lump that does not cause pain or discomfort or it can be painful and troublesome, especially during physical activity. Many people do not realize that the lump is abnormal and believe it to be a normal part of their body until a doctor finds it during routine examination. Sometimes hernias may not be readily visible due to excessive weight. The lump that is seen or felt is actually intra-abdominal fat and/or intestine or other organs that are pushing through the hole in the abdominal wall.
Are Hernias dangerous?
In general, hernias are not immediately dangerous and do not require emergency intervention or surgery. Many people may have a hernia for many months or years before it is recognized by themselves or their physician.
Traditionally, it was recommended to have hernias repaired as soon as possible to avoid potential complications of hernia incarceration or strangulation. Incarceration means that the hernia (the lump or bulge of intestines sticking out through the muscles) is stuck outside of the muscles and no longer can fall back into the abdominal cavity. In some situations, once the hernia is incarcerated, the risk of strangulation (blood flow being cut off to the intestines causing intestinal compromise) is increased.
In the past few years, surgical studies have shown that the risk of incarceration and strangulation events in the general population is low and therefore mandating surgical intervention solely based upon the concern of intestinal strangulation may not be warranted.
Our personal experience reflects the results of that literature as well. We perform several hundred hernia surgeries each year, electively, during the day. We are only called emergently at night to repair a hernia approximately once every other month.
Do I need to see a surgeon to consider hernia surgery?
Yes. If you have a hernia you should consider a consultative appointment with a surgeon experienced in the care of hernias. Although hernias, in general, are not typically life threatening, only an experienced surgeon can help inform you as to what risks may be associated with your specific hernia and overall medical situation.
Do I need to have hernia surgery if my hernia is not bothering me?
There are two reasons to consider elective repair of a hernia even if you are not experiencing pain at the present time.
- Hernias are generally easier to repair when they are smaller which often means a potentially easier recovery and less risk of complications. Bigger hernias sometimes require larger more complex operations which lead to longer recovery times and higher surgical risks.
- Recent studies have shown that patients with severe or chronic hernia pain who undergo repair are less likely to have full relief of their pain postoperatively as compared to patients who had their hernias fixed before they started having pain. Source: National Center for Biotechnology Information
As a general rule: Hernias do not require emergent repair but if you have recently discovered that you have a hernia you should start discussing the issue with your family and consider scheduling elective repair at a time that is least disruptive to your work and personal schedule.
Can my hernia be fixed with treatments other than surgery?
No. A hernia is a mechanical problem that requires mechanical repair. There are no herbs, unguents, creams, or medicines that will fix a hernia. Medical devices such as abdominal binders or trusses do not fix hernias. At best they may reduce pain associated with a hernia. Hernias never get smaller. Left untreated a hernia will continue to grow in size which is usually accompanied by an increase in pain.
What types of surgery are used to repair hernias?
Laparoscopic Repair (Laser surgery, camera surgery)
Three or four small incisions are used to place a camera and instruments inside the abdominal cavity in order to repair the hernia.
Laparoscopy has been revolutionary in decreasing the pain and discomfort associated with many surgical procedures. Gallbladder and colon surgeries that are performed with the camera more often result in quicker return to normal activities and are 100% recommended over open surgery when appropriate.
However, in Hernia surgery, laparoscopic repairs do not always have the same benefit in terms of decreasing pain and time to return to normal activities. Recent study has shown that post op pain is higher in laparoscopic patients in the first few months after surgery compared with open repairs with results being equal at one year. Source: National Center for Biotechnology Information
Open Repair (traditional surgery, Open surgery)
Open surgery is generally done through one surgical cut near the hernia itself. Open surgery is the original way to do surgery and has the longest scientific track record of results over the past several decades.
Should I have open or laparoscopic surgery to fix my hernia?
The decision as to which surgery a person should have for their particular hernia is a complex one based on many factors including the size and location of the hernia and the size, overall health and medical conditions of the patient. Both open and laparoscopic surgery have advantages and disadvantages and there is no single correct surgery for every patient. Discussion with an experienced surgeon regarding your particular hernia and medical condition is an absolute requirement for you to be able to come to an informed decision as to which surgery is the correct one for you.
What is Robotic Hernia Surgery?
Robotic surgery is an advanced form of camera (laparoscopic) surgery. Robotic surgery is based on placement of 3 small holes in the abdominal wall which allows a camera and two instruments to be placed inside the body in order to see and perform the operation. The robot does not perform the operation, your surgeon does. The robot simply holds the camera and instruments instead of the surgeon holding them directly. This allows for more precise control of the instruments movements.
Should I have Robotic Hernia Surgery?
Robotic technology allows many large operations that could previously only be performed “open, through a big cut” to now be performed as a minimally invasive surgeries with only series of small holes. This allows for decreased post operative pain and discomfort and quicker return back to normal activities.
Robotic surgery is generally preferable to an open surgery. However, not all patients or conditions are appropriate for robotic surgery. Advanced robotic hernia repair techniques are relatively new and many surgeons have only limited experience with these specific techniques. Anyone considering robotic hernia surgery should discuss their medical/surgical situation with a surgeon that has substantial experience and expertise in complex hernia repair and robotic surgery.
What is Abdominal Wall Reconstruction (AWR)?
Abdominal wall reconstruction is a term sometimes used to describe “hernia repair” or “hernia surgery.” AWR is a way of considering the abdominal wall, and the hernia in it, as a complete system. Rather than just “patching the hole,” AWR considers the way the entire group of muscles in the abdominal wall work together with repairs designed to take advantage of the natural mechanics and physics of the abdominal wall with the goal of restoring normal functionality of the abdominal wall while minimizing the risk of hernia recurrence.
What is hernia mesh?
There are hundreds of different brands and styles of mesh used in hernia repair. Some are very specific for certain types of hernias but in general there are only 3 basic types of mesh:
Permanent Synthetic (Plastic)
Permanent mesh is made from strong plastic polymers that are woven together to form a sheet or screen. Kind of like fishing line that has been woven together and sterilized or like window screen material. These materials are very strong, permanent and do not dissolve or go away. Synthetic mesh is inert and not “rejected” by the human body in the sense of a true allergic reaction. Most cases of “rejection” are really cases of mesh infection.
Mesh comes in different weights and weave patterns and some have special coatings to help protect the intestines. The ideal mesh for each hernia repair varies on the clinical situation for each specific patient. Synthetic meshes were developed in the 1950’s and have been used in clinical surgery regularly since the 1980’s. Synthetic mesh is the most common type of mesh utilized worldwide and has a long history of safe and effective use.
Mesh functions very much like rebar in the concrete used to build large buildings, bridges etc. It reinforces the otherwise relatively brittle scar tissue and helps disperse the forces and stresses from the hernia into the surrounding normal tissues in order to reduce the risk of the hernia coming back. Scientific studies have shown that the risk of a hernia recurring is reduced by 50% when mesh is used. Source: The New England Journal of Medicine
Biologics (Derived from human or animal tissues)
Biologic meshes are derived from human or animal tissues. Donated human skin was one of the first biologic meshes used in the early 2000’s. Human skin is only available in small sizes, is fairly expensive and tends to bulge over time, which makes it appear as though the hernia has returned. As a result, human skin is no longer commonly used for hernia repair. Biologic alternatives have been developed from various animal sources. The most common are derived from pig skin.
Biologic meshes are not permanent. They are supposed to dissolve over time and be replaced by strong tissue from your own body. They are designed to provide a scaffolding framework for the body so that new blood vessels and nutrients grow into the damaged area of the hernia and form new strong tissue that will resist hernia recurrence. Since these meshes are eventually absorbed by the body, they are supposed to be more resistant to infection causing them to be mostly utilized in complex patients with intestinal problems or pre existing infections.
Biologic meshes have been increasingly used in “normal” patients with simple uncomplicated hernias. The thought being that it would be better to use a mesh that eventually dissolves rather than something that is permanent. Unfortunately, the durability of biologics is much less than that of a comparable synthetic mesh and the risk of the hernia coming back is much higher when biologics are used. The average risk of a hernia coming back after repair with biologic is around 30%, but may be as high as 80%, compared to a 4% risk of recurrence when permanent mesh is used. Source: National Center for Biotechnology Information
Biologics should generally only be used in special circumstances or in the setting of a controlled research trial.
Temporary mesh is used during complex abdominal and intestinal surgery where there is excessive contamination or infection. Permanent mesh cannot be placed because of fear the permanent mesh may become infected. Once the body has recovered and the risk of infection is lowered, a permanent or sometimes a biologic mesh will be placed during a second surgery.
Is Mesh Safe?
Mesh overall is very safe when the correct mesh is used for the correct clinical circumstances and placed in the correct body space.
Ideally, a hernia should be repaired with a permanent synthetic mesh that has been designed to be strong enough not to break or rip under the stresses of the human body. The mesh should be woven in such a way so as to maximize its resistance to infection. The mesh should be placed in a location in the body that promotes the best tissue ingrowth, (which will decrease both the risk of recurrence and infection), and the mesh should be in a location that minimizes the risk of the mesh causing complications with normal body structures.
Internet and TV advertisements about mesh complications and “horror stories” should not be taken at face value. Many of these stories are unrelated to circumstances that surround routine hernia repairs.
Any manmade product that is placed into the human body may have complications that should be carefully weighed against its benefits during an educated conversation with your surgeon.
In regards to hernia surgery, mesh use is very safe and results in better outcomes overall as compared to hernia repairs without mesh.
Food and Drug Administration Information
Information on Surgical Mesh for Hernia Repairs
FDA wants to inform you about complications that may occur with the surgical mesh that is sometimes used to repair hernias, and to provide you with questions you may want to ask your surgeon before having this procedure. This is part of our commitment to keep the public informed about the medical products we regulate.Hundreds of thousands of hernia repair operations are performed each year both with and without surgical mesh, and patients generally recover quickly and do well after surgery.However, FDA has received reports of complications associated with the mesh. The complications include adverse reactions to the mesh, adhesions (when the loops of the intestines adhere to each other or the mesh), and injuries to nearby organs, nerves or blood vessels. Other complications of hernia repair can occur with or without the mesh, including infection, chronic pain and hernia recurrence.
Most of the complications reported to us so far have been associated with mesh products that have been recalled and are no longer on the market. For further information on the recalled products, please visit the FDA Medical Device Recall website.
We are continuing to analyze and evaluate incoming reports of adverse events, and are speaking with patients, surgeons and researchers. We will inform the public as new information becomes available.
Talking to your doctor
Before having a hernia operation, be sure to let the surgeon know if you’ve had a past reaction to materials used in surgical mesh or sutures, such as polypropylene.
There are also certain questions you should consider asking your surgeon:
- What are the pros and cons of using surgical mesh in my particular case?
- If surgical mesh will be used, is there special patient information that comes with the product, and can I have a copy?
- If surgical mesh will be used, what’s been your experience with this particular product, and with treating potential mesh complications?
- What can I expect to feel after surgery and for how long?
Reporting complications to the FDA
In order to help FDA learn more about possible problems with surgical mesh, it’s important that both physicians and patients report complications that may be associated with this product.
You can report any problems to the FDA’s MedWatch Adverse Event Reporting program either online, by regular mail or by FAX.
Online : MedWatch Online Voluntary Reporting Form (3500)
Regular Mail : use postage-paid FDA form 3500 available at: MedWatch Forms
Mail to MedWatch 5600 Fishers Lane, Rockville, MD 20852-9787
What problems may occur after hernia surgery?
In the immediate postoperative period, wound healing problems and infection are the most problematic. Wound problems include minor skin irritation or separation that requires no intervention. Sutures under the skin used for skin closure are designed to dissolve over a few weeks and go away completely. Sometimes the body may have a minor irritation reaction to this process resulting in small areas of skin separation or very small blisters. These require only a dry gauze or band-aid for covering. Triple antibiotic can be placed on the area daily as well.
Wound infections may range from minor redness requiring antibiotic or more involved infections that may require wound cleansing and packing or dressing changes. Deep infections may require placement of specialized drainage catheters and prolonged administration of IV antibiotics.
Hematomas are collections of blood following surgery. They are like a very thick bruise or blood clot under the skin and fat. These are not the type blood clots that travel to the heart or lungs. There usually is no treatment required for a hematoma. Hematomas are naturally reabsorbed by the body, within a few weeks.
Seromas are collections of clear plasma-like fluid under the skin, fat and/or muscles. Like hematomas, seromas generally are reabsorbed by the body within a few weeks after surgery. If a seroma is small, often nothing needs to be done. Larger seromas may require drainage if they are causing pain or if they are near mesh and could affect the integration of the mesh into the body.
Heart attack, stroke, renal failure, DVT, or Pulmonary embolus (blood clots in veins or the lungs) are all very uncommon occurrences but may happen after nearly any type of operation. Each persons individual risk of these or other complications is dependent upon many different things and should be discussed with your surgeon. Depending upon your personal medical situation, your surgeon may suggest further preoperative risk assessment discussion with your internist or cardiologist before scheduling elective surgery.
What long term problems may occur after hernia surgery?
Chronic pain and hernia recurrence are the most common long term issues with hernia surgery.
Significant chronic pain is uncommon after most hernia surgery and most pain will nearly completely resolve within a year of surgery as the body fully scars, heals, and incorporates the mesh. There are numerous nerves in the abdominal wall that may be affected by placement of the mesh and or the strings necessary to hold the mesh in place. Occasional, mild, intermittent, pain maybe experienced. This type of pain often responds well to a period of reduction in physical activity and/or over the counter administration of acetaminophen and ibuprofen type medications.
Hernia recurrence may occur at anytime. Studies have shown that the majority of recurrences occur within the first two years after surgery. 6- 8 years after surgery the risk of hernia recurrence levels off to a low baseline risk. Actual hernia recurrence risk percentages vary depending upon the type of hernia being fixed and the specific method used to fix it. Discussion with an experienced hernia surgeon regarding the published scientific literature as well as their own personal experience with a particular reconstruction technique should be undertaken prior to surgery.