Hernias preferentially develop where the abdominal wall has an anatomically predetermined weak point. This is easily understood at the navel. Here one notices already by palpation that the abdominal wall is quite thin. But not everyone develops a hernia during their lifetime, so other risk factors are required. A hernia develops preferentially when there is a disproportion between a high prere in the abdominal cavity and a too low strength of the abdominal wall tie. The result is that tie from the abdominal cavity through a weak point in the abdominal wall (hernia gap) bulges outwards. In the case of infantile inguinal hernia, such a hernia gap may already be congenital.
Scar hernia after abdominal surgery is a special case. The scar in the area of the abdominal wall is less stable than the original intact tie. The scar can gradually tear and lead to a hernia of the abdominal wall if the patient is exposed to the appropriate strain. This is often the case when there is a deeper wound infection after the abdominal surgery.
In addition to congenital tie weakness, there are risk factors that are ultimately associated with an increase in internal prere in the abdomen, such as
– heavy lifting (especially occupational) – severe obesity – chronic cough – chronic constipation – abdominal fluid in the presence of severe liver damage
When to operate?
The risk of a hernia is that the contents of the hernia can become trapped in the hernial opening and lead to an emergency situation. There is then severe pain because the tie (the contents of the hernia) is cut off. If a piece of intestine becomes trapped, this can lead to intestinal obstruction and intestinal perforation. Of course, emergency surgery should be avoided, as it is associated with more risks. Therefore, one tries to avoid such an emergency situation prophylactically with a planned procedure.
Often there is load-dependent pain in the hernia region, for example during heavy lifting, sneezing and pressing. As a result, patients are limited in their physical activity, so that surgery should be performed. Even without symptoms, a hernia should be operated on if it has grown in size during the course of the operation. Apart from cosmetic aspects, with increasing hernia size, the surgical treatment also becomes more complex and more prone to complications.
The risks and advantages of each operation must be weighed up individually and responsibly. This becomes plausible if one considers that the above-mentioned risk factors for hernia formation can be an expression of severe concomitant diseases (for example, liver cirrhosis with abdominal fluid, chronic pulmonary dysfunction). In such cases the operation becomes risky, possibly even dangerous or not feasible. We will be happy to advise you in consultation with your family doctor whether a hernia operation is advisable or necessary for you.
Principles of surgical treatment of abdominal wall hernias
The aim of the operation is a stable permanent closure of the hernia gap. Small hernia gaps with otherwise strong abdominal wall structures in the surrounding area can be closed directly with sutures (for example, a small umbilical hernia). In the case of larger hernia gaps and/or weak tie, however, there would be too much tension on the tie with the gathering sutures: the sutures would cut through the tie and thus provoke a new hernia (a "recurrence"). For these reasons, we then insert a plastic net into the abdominal wall for stabilization.
Depending on the individual situation, the plastic mesh can be inserted into different layers of the abdominal wall:
– "Onlay": insertion of the mesh between the subcutaneous fatty tie and the abdominal muscles "Sublay": insertion of the mesh under the abdominal muscles in front of the peritoneum "Intraperitoneal onlay" (IPOM): Insertion of the mesh into the abdominal cavity from the inside against the peritoneum with contact to the intestine
In any case, the size of the plastic mesh must be chosen so that the mesh clearly overlaps with the healthy and stable tie and can thus heal well. Thus, the mesh is always much larger than the actual hernia gap. In this way, the hernial orifice can be closed with as little tension as possible. This can prevent a recurrence of the hernia. In addition, we also use special plastic surgery preparation techniques to narrow very large hernial orifices.
Minimally invasive treatment of abdominal wall hernias
At our clinic we also offer the minimally invasive, laparoscopic insertion of a plastic mesh. While with the "open In the "minimally invasive" procedure, the skin incision is made directly in the area of the hernia procedure, an access to the abdominal cavity is created via small skin incisions far away from the actual hernia region. After loosening existing adhesions, the plastic mesh is inserted into the abdominal cavity, unfolded and fixed to the inside of the abdominal wall, i.e. to the peritoneum ("intraperitoneal onlay"), IPOM). A specially coated plastic net is used, which is allowed to rest on the intestine without damaging it. If the adhesions are so pronounced after a previous operation that they cannot be removed minimally invasively, open surgery must be performed.
The advantage of the minimally invasive procedure is that the extensive dissection of the individual abdominal wall layers in the hernia region is not necessary. In the case of large hernias, a circulatory disturbance in the abdominal wall can be avoided. A possible wound infection can be prevented. The disadvantage is that the special plastic nets required for this are extremely expensive and the hernia sac itself is not removed.
Minimally invasive treatment of inguinal hernia and thigh hernia
The inguinal canal is bounded by the inner and outer inguinal rings. In men, the vas deferens and testicular vessels pass through it; in women, only the uterine ligament passes through it. Inguinal hernias occur about five times more frequently in men than in women, whereas the gender ratio is reversed for femoral hernias. In the case of a thigh hernia, the hernia sac (the peritoneum) protrudes under the inguinal ligament next to the large vessels of the leg to the inner side of the thigh.
A distinction is made between "indirect" and "inguinal" hernias Inguinal hernia (in the area of the lateral inner inguinal ring) from the "direct" procedure Inguinal hernia (in the area of the outer inguinal ring located towards the middle). The direct inguinal hernia is the type of hernia typically acquired with aging.
In principle, all surgical procedures are available at our department. In a personal consultation, we will be happy to clarify which surgical procedure is most suitable for you. We distinguish between the
– minimally invasive procedures with plastic mesh insertion (TAPP, TEP) – open procedures with plastic mesh insertion (z.B. OP according to Lichtenstein) – open procedure without plastic mesh insertion (z.B. OP according to Shouldice, Bassini).
In adults, with a few exceptions, we perform the procedure minimally invasively as standard. Three small skin incisions are made in the middle or lower abdomen. lower abdomen. In the case of the so-called "TAPP the preparation takes place via the abdominal cavity, in the case of the "TEP" inside the abdominal wall. Both procedures involve closure of the hernial orifice by insertion of a plastic mesh between the peritoneum and the structures of the inguinal region. In the result, both minimally invasive methods are equivalent. The minimally invasive procedure is the method of choice when the hernia has recurred after previous open surgery. In addition, bilateral fractures can be treated simultaneously via the same access route.
The approximately 10×15 cm large and non-dissolvable plastic mesh is placed in such a way that all three possible hernia orifices (indirect and direct inguinal hernia, thigh hernia) are covered simultaneously. The probability of recurrence of the fracture is very low (about 1%). Late pain syndromes are somewhat rarer after the minimally invasive procedure than with the open surgical technique ("OP according to Lichtenstein").
In the open procedure ("OP according to Lichtenstein"), access to the inguinal canal is made through a single skin incision a few centimeters long in the groin. Here, too, a plastic mesh is sewn into the groin without tension. We prefer this procedure for very large hernias, for example if intestinal loops have prolapsed into the scrotum (scrotal hernia). The advantage of this method is that the procedure can be performed under local anesthesia even in patients with a high risk of anesthesia. The probability of recurrence of the hernia is significantly lower than with open procedures without mesh insertion (z.B. "OP according to Shouldice").
Plastic mesh should not be inserted in adolescents and young adults. In this case, if the tie is otherwise stable, the hernial orifice can be closed directly by suturing ("Bassini surgery") or "Shouldice").