Be Mindful of Hernias

Learn the facts and figures in this Q&A.

A hernia is a defect of the abdominal wall that allows a protrusion of an organ or structure. It’s a common ailment, with more than 1 million repair surgeries performed in the United States each year.

Adults and children can develop hernias as a result of heavy lifting, straining, coughing or any unusual stress that causes a sudden increase of intra-abdominal pressure.

Some hernias are congenital, or present at birth, whereas others develop as a result of a predisposition for hernia. And anyone who has surgery may experience a weakening of tissue at the incision site that could result in a hernia.

Because everyone is at risk, Florida Health Care News turned to David A. Napoliello, MD, a specialist in minimally invasive surgery, to learn more about hernia repair. Dr. Napoliello, who practices in Venice, Sarasota and Lakewood Ranch, is certified by the American Board of Surgery and is a fellow of the American College of Surgeons.

In this Q&A, the doctor describes hernias and procedures to repair them in greater detail. 

Q. Dr. Napoliello, what is the most common type of hernia? A. The most common type of hernia is called an inguinal hernia. It is a defect or weakness in the abdominal muscle wall through which intestine and fat layers protrude, forming a visible bulge in the groin area. 

To visualize the dynamics of it, think of a bicycle tire. The abdominal wall is like the thick outer wall of the tire. Should the tire get damaged, the inner tube can push through the weakened area or crack and form a small bubble. If the abdominal wall becomes weakened, the thinner, flexible tissue that lines the inside of the abdomen and holds the intestines in place, called the peritoneum, can bulge into the outer wall. In the tire, it is easy to see that the inner tube can become strangled by the pressure of the edges of the crack through which it is protruding. It is the same with a hernia. 

Q. What are some of the other common types of hernias? A. An umbilical hernia takes place when abdominal contents protrude through the naturally occurring tiny opening behind the belly button. Incisional hernias can take place when a previous surgery leaves an abdominal wall defect that allows the abdominal contents to protrude through it and bulge out. 

Q. How does a person know when he or she has a hernia? A. A person may suspect a hernia if he or she notices a bulge under the skin. Additional symptoms may include discomfort or pain during any of the following: lifting heavy objects, sneezing or coughing, straining while using the toilet, standing or sitting for long periods of time. Because delayed treatment can sometimes result in the intestine being trapped inside the hernia sac, resulting in gangrene, any bulge should be brought to a physician’s attention immediately so diagnosis and treatment can begin. If left untreated, some complications from hernias can be fatal. 

Q. Will a small hernia ever heal itself? A. No, a hernia does not heal itself or improve over time without intervention. The only exception to this may be small umbilical hernias in young children. 

Q. What treatments are available for hernias? A. Surgeons may choose one of several hernia repair techniques, depending on the patient and the size of the hernia. 

In the past, the only hernia repair option available was called a tension repair. In this open surgical procedure, the physician makes an incision at the site, pushes the protruding tissue back into place and stitches the tissue layers together. The potential disadvantages of this type of surgery are relatively long recovery periods, relatively high recurring rates and discomfort following surgery. 

Today, we can offer a variety of minimally invasive open, laparoscopic and robotic procedures. 

Q. Please describe the minimally invasive open procedures. A. Unlike the tension repair, minimally invasive open procedures are tension free because the stitches or sutures used do not put tension on the sides of the defect to keep it closed. Instead, special mesh patches are used that limit the size of the required incision. These procedures offer lower recurring rates, quick recovery and only minor discomfort following the surgery. Additionally, some approaches allow the patient to avoid general anesthesia. 

Q. Can you comment on laparoscopic surgery and robotic surgery? A. There are two main options for laparoscopic surgery. In the transabdominal approach, the physician makes a small incision and slides a thin telescope, called a laparoscope, through the abdominal wall into the abdomen. For the preperitoneal approach, the laparoscope slides in between the tissues of the abdominal wall. With both approaches, the doctor views the hernia and surrounding tissue on a video screen. 

Robotic surgery can be considered a type of laparoscopic surgery with better access and sewing techniques when needed, with the surgeon using a console nearby.

Q. What are the advantages of laparoscopic surgery? A. Depending on the patient, of course, there are several. Because it requires only small incisions, it will likely mean less pain and a shorter recovery time, and because the physician has the advantage of looking through the laparoscope, previously undiagnosed hernias may be discovered. Additionally, the laparoscopic approach allows us to manage recurrent hernias and optimize any repeat surgery because we do not have to go through the same incision site. 

Q. Can surgery be done on an outpatient basis? A. Yes, and it is usually performed in less than an hour. 

Q. Do you have a preference between the minimally invasive open procedure and the laparoscopic procedure? A. It depends on the patient. I specialize in minimally invasive surgery techniques and completed my fellowship in minimally invasive and advanced laparoscopic surgery. In fact, I was involved in training surgeons using the laparoscopic approach when it was first developed. I provide patients with information on open, laparoscopic and robotic procedures, and we make the decision together.

Q. Have there been any improvements to these surgical techniques in recent years? A. Definitely. Scientific improvements to hernia repair include the addition of very lightweight artificial meshes and biologic meshes such as processed skin grafts. Other improvements to decrease chronic pain associated with hernia repairs include the addition of absorbable tacking devices and dissolvable sutures, which help to decrease the risk of nerve entrapments and chronic pain. The surgical robot and revisiting no-mesh repairs are also highlights of current hernia surgery. 

Q. Once the surgery has healed, will the patient experience any diminished quality of life? A. No, most patients will be able to return to a normal routine. In fact, data show that within a week’s time, most people will feel well. Because I am conservative, I recommend that my patients avoid any physical strain for four weeks.

© FHCN staff article. js

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