What is Ventral Hernia?
Ventral hernias are a type of hernia that occur in the abdominal wall but not in the groin or upper stomach area. These account for roughly 350,000 surgeries each year. General surgeons often perform these common surgeries to repair the defects in the abdominal wall. If you are in suitable health for the operation and you have a hernia causing symptoms, or there’s a high risk of complications from the hernia, then surgery is usually recommended. Ventral hernias can significantly affect everyday life and sometimes can result in hospital stays or even be life-threatening.
What Causes Ventral Hernia?
Ventral hernias, or bulges of tissues through an opening in the muscles of the abdomen, can be either acquired or present at birth (congenital). Acquired ventral hernias are the ones that most surgeons typically treat. However, some people live with ventral hernias that were present from birth for several years before getting them surgically fixed.
Acquired ventral hernias generally happen for several reasons. They can be due to a previous surgery, which results in what’s known as an incisional hernia. Other causes include physical trauma or continuously putting stress on the naturally weaker areas of your abdominal wall. Places like the belly button (umbilicus), a line called the semilunar line, area around a surgical hole created for waste removal (ostomy sites), lower abdominal areas on both sides (bilateral inguinal regions), and an opening in the diaphragm for the esophagus (esophageal hiatus) are generally weaker and prone to hernias.
Being obese can also contribute to causing hernias because it stretches and weakens the tissue (fascia) of your abdomen. Specifically, frequently gaining and losing weight can weaken these tissues over time, increasing the risk of hernias.
Risk Factors and Frequency for Ventral Hernia
In 2006, there were 348,000 cases of ventral hernia repairs in the United States, which cost about $3.2 billion. This put a significant strain on the healthcare system, with most of the cost coming from emergency repairs or complications after surgery. Following surgery, patients also run a certain risk of developing a hernia. The risk of getting a hernia depends on the type of surgical procedure done.
- There is a roughly 10% chance of a hernia after a midline laparotomy surgery.
- About 5% of patients may develop a hernia following a transverse muscle splitting incision.
- The risk drops to less than 1% following a laparoscopic repair.
Signs and Symptoms of Ventral Hernia
An abdominal wall hernia often presents symptoms such as pain, swelling, or a sense of fullness at the hernia site. These symptoms can change depending on a person’s position or straining effort, also known as the Valsalva maneuver. In more severe cases, where a hernia is trapped or cut off from blood supply, the area might turn red or appear asymmetrical. While the diagnosis of an abdominal hernia is generally done through a physical exam and patient’s history, it can be tricky in obese patients as obesity can limit the effectiveness of the exam. Hence, it’s crucial to examine the patient in various positions as hernias can shift based on body movements or position.
When evaluating patients with ventral hernias, healthcare professionals should ask certain specific questions in order to get a comprehensive understanding of the patient’s condition. These include:
- When did the patient first notice the hernia?
- Were there any events that might have triggered it?
- Has the patient experienced associated symptoms such as pain, redness, constipation, nausea or vomiting?
- What’s the size of the hernia bulge and does it change in size? If it does, what triggers the change?
- Does the patient have a history of previous hernias?
- Has the patient recently gained or lost weight?
- What’s the patient’s occupational, dietary, exercise, smoking, and drinking habits?
- Is there a family history of connective tissue disorders, which might increase the risk of hernia development?
This thorough assessment helps to identify potentially problematic hernias and to plan appropriate treatment.
Testing for Ventral Hernia
If you’re suspected of having a hernia and the physical examination is unclear or inconclusive, your doctor may order additional tests such as an ultrasound, a CT scan, or an MRI. These tests can provide detailed images of your abdomen and aid in confirming the diagnosis or planning for surgery.
Before any surgical procedure, a preoperative medical check-up is a crucial step to make sure you are fit for surgery and anesthesia. The doctor typically follows a set of specific guidelines for this process. Even though open ventral hernia surgeries can be done without inducing full unconsciousness, it’s usually preferred to achieve complete relaxation during the surgery to avoid any complications and achieve the best possible results.
The risks of hernia repair surgeries can vary a lot. A small umbilical hernia might involve minimal risk, while a significant reconstruction can have considerable risks. For example, patients with lung disease or a history of prolonged smoking might be advised to undergo lung function tests before surgery.
It’s also important to carry out any required screening checks before undergoing abdominal surgery. For instance, it would be less than ideal to perform surgery for colon cancer on a patient who had recently undergone a hernia repair. Part of the preoperative routine includes advising patients to stop taking specific medications like antiplatelet and anticoagulation drugs. These medications can increase the risk of forming a blood clot during or after surgery, which can lead to more severe issues like infection.
Treatment Options for Ventral Hernia
Ventral hernias are commonly treated through surgical procedures. While hernias without symptoms are generally addressed through planned surgery, those that are strangled need immediate medical attention. If a hernia is imprisoned but not strangled, it’s not an urgent surgical situation, but patients should consult with their healthcare provider about the pros and cons of surgery. If the risk is reasonable, surgery should be planned as soon as feasible. If, for some reason, someone is not fit for surgery, alternative measures like special belts, supports, or corsets can be used to manage their hernia, though these are not as effective.
Various surgical methods have been developed over time to repair hernias. The fundamental principle behind these procedures is that they should not create tension and they often include the use of a mesh for added support. Different types of mesh and different placement strategies are options available, depending on the specific condition. Smaller hernias usually undergo a basic surgery without mesh.
Comparing laparoscopic hernia repair surgery and open surgery methods, the laparoscopic approach tends to decrease overall complications, reduce hospital stay, and quickens return to normal activities. In some cases, recurrence rates can also be slightly lower with laparoscopic repair, but it does have some risks such as earing potential for abdominal organ injury and technical difficulty.
Robotic surgical repairs are gaining popularity due to the improved maneuverability during surgery. This method allows for smaller incisions and easier closure of the defect, making it more convenient from a technical point of view. However, robotic surgeries can be more expensive and time-consuming than laparoscopic procedures and no definitive studies have shown its superiority yet.
In cases where defects are large and cannot be easily closed without tension, a technique known as component separations is used. The technique varies and generally involves placing a mesh and careful cutting and movement of abdominal muscles to close the gap. These cases can be quite lengthy and technically challenging.
A parastomal hernia is a specific type of hernia that arises near a stoma (a surgically created opening) on the abdominal wall. It’s estimated that up to 30% of patients with stomas can develop these hernias. To prevent hernia formation, one option is to place a prophylactic (preventative) mesh when the stoma is created.
The choice of mesh for hernia repair is often up to the surgeon and can be either synthetic or biologic. Synthetic meshes have come a long way and have proven to be quite reliable, but they can still become infected and present the risk of recurrence. Biologic grafts create a similar foreign body reaction and can form adhesions, but they are less likely to get infected. However, they can be quite expensive and are generally used in infected or contaminated surgical sites.
What else can Ventral Hernia be?
When a doctor is trying to figure out if a patient has a hernia, they should also consider other conditions that could be causing the symptoms. These conditions are:
- Diastasis recti (separation of the abdominal muscles)
- Abscess (a collection of pus)
- Muscle strain
- Seroma (a pocket of clear fluid that sometimes develops after surgery)
- Wound hematoma (a collection of blood outside of a blood vessel)
- Lymphadenopathy (swollen lymph nodes)
- Soft tissue malignancy (cancer in the soft tissues)
- Rectus sheath hematomas (bleeding into the sheath of the rectus abdominis muscle)
What to expect with Ventral Hernia
Recovery after ventral hernia repair surgery can vary from person to person. The conditions during the initial surgery are usually the best way to predict if there will be complications after the procedure. Emergency surgeries for severe hernias that require removal of a portion of the bowel are often linked to a higher risk of complications and chance of the hernia coming back. This is largely due to the surgical area becoming at least mildly contaminated, which means that synthetic mesh shouldn’t be used.
The wound class is a key factor in estimating the risk of complications from a surgery and should be recorded in the patient’s surgical records.
A ‘clean wound’ (class I) refers to an incision where there’s no inflammation, no breach in sterile conditions, and no contact with the respiratory, digestive, and urinary systems.
A ‘clean-contaminated wound’ (class II) pertains to an incision where the respiratory, digestive, or urinary tract is accessed under controlled conditions, with no contamination evident.
A ‘contaminated wound’ (class III) is an incision where there may have been significant violation of sterile conditions, such as spillage from the digestive tract, or where acute, non-pus-filled inflammation is found. This also includes open wounds from injuries that have been open for more than 12 to 24 hours.
A ‘dirty or infected wound’ (class IV) identifies an incision where there may have been organ perforation, acute inflammation with pus encountered during the surgery, or for wounds resulting from trauma where treatment is delayed, or there’s fecal contamination or tissues with diminished vitality.
Possible Complications When Diagnosed with Ventral Hernia
After a ventral hernia repair, there’s a chance it could reappear, but this chance has been lowered extensively with the introduction of a support piece called a mesh. Different methods of repair carry different risk percentages. If repaired with a laparoscopic method using mesh, there’s a 10-12% risk. An open surgical method using mesh carries a 13-15% risk, and an open surgical method without mesh has an 18-20% risk.
Infection in the mesh after a ventral hernia repair is a serious concern. It generally needs a second, more complex surgery and raises the risk of hernia recurrence. Certain factors can raise the risk such as a high body weight index, lung diseases like COPD, previous abdominal aortic aneurysm repair, earlier infection at the surgery site, type of mesh, long surgery duration, the mesh not fully covered by tissues, injury to intestines during surgery and surgical site infections. If the mesh gets infected, it often needs to be removed, but it’s possible to deal with the infection using antibiotics.
Breathing problems can develop after a ventral hernia repair, because the repair affects the volume of the abdominal cavity. This increases the pressure on the diaphragm which can cause poor oxygen circulation and need for breathing assistance. Some clinics have protocols in place to prevent health issues after these tough surgeries. Strategies backed up by evidence to prevent breathing problems include proper pain management using PCA, regional blocks or epidurals, early walking after surgery, and not always using nasogastric tubes. Despite the lack of support from evidence, deep breathing exercises, incentive spirometry, and CPAP are often used.
Common Risks and Complications:
- Recurrence of ventral hernia
- Infection in the mesh after hernia repair
- Breathing problems after ventral hernia repair
- Second, more complex surgery due to mesh infection
- Raised chances of hernia recurrence due to mesh infection
Recovery from Ventral Hernia
For the first week after surgery, patients should not lift anything that weighs more than 10 pounds (4.5 kilograms). In the second week, the weight limit is raised to 20 pounds (9 kilograms). Over a 6 week period, patients can gradually increase their physical activity until they’re back to normal.
It’s crucial to minimize the use of narcotics during the recovery period due to their addictive potential and their tendency to cause constipation. Pain management can involve a combination of medications, such as acetaminophen, anti-inflammatory drugs, neuropathic medications, muscle relaxants, along with narcotics. This approach has been found to reduce reliance on opiate pain medications.
Additional techniques such as regional blocks, long-lasting local anesthetics, and nerve blocks after surgery can also help to reduce opiate usage. To prevent straining and bloating, patients are often recommended to take stool softeners and laxatives during the recovery period.
Usually, patients are not restricted in what they eat after surgery, but a diet rich in fiber is recommended. Patients can take showers 24 to 48 hours after surgery.
Giving patients instructions after surgery multiple times throughout their treatment and recovery has been found to be helpful. Providing literature on the topic can also be beneficial. Research across various medical fields has shown that educating patients can help prevent complications after surgery.
Preventing Ventral Hernia
Preventing acquired ventral hernias, which are bulges or gaps that appear in your abdominal wall, can be tricky. This is mainly because we’re trying to prevent incisional hernias – hernias that can appear at the site of previous surgeries. Making sure patients follow instructions for care after surgery is not always possible, and this is where most risks arise.
When closing up a surgical wound in the abdomen, doctors have to be really diligent. They need to make sure they use enough stitches for the size of the wound – in fact, they need to make sure the length of the sutures (the stitches used) is more than 4 times the length of the wound. It’s also important that the stitches are placed in a certain way along the wound, and that they go deep enough (between 5 and 10 mm).
Doctors also need to make sure that they’re not pulling the stitches too tight when they’re closing up the wound. They need to close all large surgical openings (those larger than 10mm). Even though it’s rare, hernias can sometimes occur at surgical openings smaller than 10mm, which is why larger sites should always be closed up. Figuring out the best suture to use when closing larger surgical wounds is currently a topic of further research. There are numerous papers, however, recommending slowly absorbable or non-absorbable single strand sutures for closing incisions.
The use of sutures that don’t dissolve might have lesser chances of causing a hernia, but they can also increase the risk of long term pain and unusual drainage from abnormal connections between the tissues (a.k.a. fistulas) to the suture. Single strand sutures are known to have a lower risk of infection compared to multi-strand sutures.
One of the biggest ways to prevent a ventral hernia is to stop any infections in the wound in the first place. Wound infections can greatly increase the chances of a hernia, and also increase the likelihood of mesh infections, which are serious and often require another surgery. Surgeries performed using small tubes and a camera (laparoscopic surgeries) have shown lower infection rates compared to traditional open surgeries. It’s also been found that patients who take steps to improve their health before surgery like quitting smoking, eating healthier, losing weight, exercising, and managing blood sugar are less likely to get infections.
Additionally, there are several steps we can take right before and during surgery to minimize the chances of an infection. These include giving antibiotics before surgery, making sure the patient’s body temperature doesn’t drop too much, using sterile tools and techniques, and preparing the skin properly before the operation. However, wearing abdominal binders (a band you wrap around your abdomen) hasn’t really been shown to reduce the risk of hernias. The only proven benefit is that patients feel more comfortable wearing them.
