Abdominal Wall Surgery addresses the following conditions:
- Wounds After Intraabdominal Surgery
- Medium and Massive Hernias
- Umbilical Hernias
- Hernias Associated with Ostomies / Parastomal Hernia
- Rectus Diastasis After Pregnancy
- Hernias After Massive Weight Loss Surgery
- Addominal Wall Reconstruction Articles by Dr. Dumanian
Dr. Dumanian also offers cosmetic abdominal surgery.
View pre and post-operative photos involving a Abdominal hernias.
May contain graphic images.
Abdominal Wall Surgery and Repair
The abdominal wall comprises the stomach muscles and the skin, and they serve to hold in the intestines, stomach, and liver. Hernias occur when there the abdominal wall muscles no longer contain the intestines, stomach, and liver. This can occur due to a natural stomach muscle weakness, such as in the groins and the umbilicus. Ventral hernias occur after a surgeon has made an incision into the abdomen, and the initial repair of the stomach muscles has not remained intact. Reasons for the development of hernias after surgery include postoperative infections, large patient size and obesity, smoking, lifting too soon after repair, and wound healing issues such as steroid use. Dr. Dumanian specializes in the repair of large ventral hernias, and has published extensively on this topic.
The abdominal wall has 3 muscles on each side of the torso, and two paired muscles that run up and down from the breast bone (the xyphoid) to the pubic bone. In the most common type of ventral hernia, the two paired up and down stomach muscles are no longer attached to each other, and move away from each other. In the separation of parts procedure, through a separate short incision, the tightest of the 3 side muscles is cut, to allow the paired stomach muscles to be brought together in the center. The side muscle that is cut is not removed, but rather is weakened. In over 200 surgeries, no one seems to notice the weakened function of that stomach muscle. Dr. Dumanian often uses a permanent mesh to reinforce the central repair. In his hands, this serves to dramatically lower the hernia recurrence rate. There are theoretic problems with the use of this mesh, including bowel adhesions, scar formation, and infections. Dr. Dumanian has not seen these problems. Not using the mesh leads to a recurrent hernia about 25% of the time. Recurrent hernias can have their own problems, including bowel adhesions and obstructions. The use of mesh to reinforce the separation of parts hernia repair is an important decision, and will be made by Dr. Dumanian at the time of surgery.
There are many types of hernias, and there are several types of hernias that Dr. Dumanian does not tend to treat. Diaphragm hernias are not visible externally. For these patients, the stomach is put back into the abdomen after it has slid into the chest. This is best done by a general surgeon. Inguinal hernias are located in the groins, and also are typically treated by general surgeons.
Additional Resources: Book Chapters by Dr. Gregory Dumanian
Abdominal Wall Surgery: Conditions and Information
The first step in an abdominal wall reconstruction is for the surgeon to attempt to heal any open wounds that remain after the last abdominal surgery. Often, local wound care with dressings is all that is needed to get wound closure.
Some small and deep wounds are due to retained stitches that had been used to suture the abdominal wall muscles. Getting rid of the sutures often allows the wound to close by themselves. This is often done in the office, and sometimes in the operating room. The risk to this procedure is creating a hole in the intestines while looking for the suture. To decrease the chance of this happening, Dr. Dumanian will often get a CT scan to see if the bowel is near the open wound.
Some patients with large open wounds require skin grafts to achieve a healed wound. The skin grafts are taken from the leg, and placed on the surface of the open wound. The procedure typically is successful. Dressings and protection of the newly skin grafted area is needed for a few weeks after surgery.
Large wounds that develop after abdominal surgery often mean that a hernia will develop for that patient. When the open wounds are treated and the skin is healed, the internal scar tissue softens, and a weakness of the abdominal wall becomes obvious. The hernia that results becomes bigger with time. The time to fix the hernia is when the hernia is becoming larger, because that means that the internal scar tissue has mostly gone away.
View pre and post-operative photos involving a massive hernia.
May contain graphic images.
View pre and post-operative photos involving a medium hernia.
May contain graphic images.
Massive hernias are repaired using the same techniques as used for smaller hernias. People with massive hernias more often require the use of either permanent or biologic mesh to help close the abdominal wall. The surgeries take longer, and require longer hospital admissions. The hernia recurrence rate may even be a little higher. Dr. Dumanian will need a CT scan for planning the procedure, to make sure there are no other hernias or bowel problems that would need to be addressed.
One problem with fixing the most massive hernias is with the lungs. Putting the intestines back within the abdominal wall may put pressure on the diaphrams and the lungs, making breathing difficult after surgery. Patients with long smoking histories, emphysema, or a previous tracheostomy may have the greatest problems after surgery. Your doctor may conclude that the hernia is too risky for your lungs to repair.
Some patients with massive hernias have associated problems with the intestines. These patients may need bowel removed at the time of the abdominal wall reconstruction. If this is necessary, Dr. Dumanian would work with a general surgeon to perform the reconstruction.
A weak area of the abdominal wall occurs at the umbilicus, or belly button. The area is weak, because of the way that babies are formed in the uterus and the umbilical cord. Umbilical hernias do not tend to become overly large, but they can be bothersome and painful. There is also a small risk that a loop of intestine becomes caught outside the abdominal wall and the bowel loop can strangulate and die. This is a rare but potentially very serious condition.
There are two very different ways to repair umbilical hernias. One method makes an incision around the belly button, and uses stitches or even a piece of mesh to reinforce the weak area. This procedure is typically done by a general surgeon. A completely different method of repair involves an incision near the pubic hair, lifting the skin, and bringing the entire length of the stomach muscles together from the breast bone (the lower aspect of the sternum) to the pubic bone. The umbilical hernia is therefore repaired essentially over a much longer area, rather than stitches just at the hernia site. This repair involves both the hernia repair, and the same techniques used for an abdominoplasty, or tummy tuck. Part of the procedure is paid for by your insurance plan, but there are extra charges to the patient for the surgeon's fee and for the operating room for the cosmetic aspects of the procedure.
Some of the most difficult hernias to repair are the hernias associated with ostomies, or exit sites of the bowel. This could include colostomies, ileostomies, or ileal conduits for patients who have had their bladders removed. In general, Dr. Dumanian attempts to repair the site where the colostomy exits the abdominal wall. This involves decreasing the abdominal pressure with the separation of parts procedure, weakening the abdomen a bit to there is not as much pressure on the bowel at the stoma exit site. It also involves the re-repair of the stoma exit site, usually with a piece of mesh. Of course, use of mesh has its own potential complications including possible infection and need for removal. Dr. Dumanian will need a CT scan for planning the procedure, to make sure there are no other hernias or bowel problems that would need to be addressed.
In certain instances, the stoma will need to be moved from one side of the abdomen to the other. If this is the case in your situation, you would be referred back to your original surgeon, or else a similarly trained surgeon at Northwestern Memorial Hospital.
Pregnancy can cause the two stomach muscles (the rectus abdominis muscles) to be stretched apart from each other. This causes a significant shape change to the abdominal wall, even for very slender patients. Because the tissue between the muscles has been permanently stretched, no amount of exercise will restore the shape of the abdomen. There is also no risk to this condition, because the inner aspect of the abdominal wall is smooth. This means that bowel can not find its way into a hernia and potentially strangulate.
Rectus diastasis is repaired through the surgical technique of an abdominoplasty, or tummy tuck. This skin is lifted near the pubic hair, and elevated to the level of the breast bone. The muscles are tightened in the midline where the tissue had been stretched by pregnancy. Permanent stitches are often used. Some amount of restretching of the muscles after the repair can occur.
The condition of a rectus diastasis can hurt, and many years ago the repair of the stomach muscles was covered under many insurance plans. This is not the case anymore. The repair of a rectus diastasis is considered cosmetic surgery, and is not a covered expense by insurance plans.
Some women are just as concerned about the FUNCTIONAL issues of having a rectus diastasis as they are about the cosmetic issues. When the rectus muscles are no longer attached to each other in the midline, they no longer contract effectively. The upper arms and trunk do work, and need to push off against a pressurized abdomen. With rectus diastasis, a lack of coordinated muscle contraction and the expanded size of the abdominal cavity works against effectively raising intraabdominal pressure. With going up stairs, exercise, or other acts of daily living, a rectus diastasis causes other parts of the body such as the back to work harder. Repair of the rectus diastasis, therefore, often gives patients better use of the torso, and often improves mild lower back pain if it is present.
Patients who have had bariatric surgery often develop hernias. These hernias are repaired with the same techniques outline above. This includes using mesh, and the separation of parts procedure. Excess skin that occurs after weight loss surgery is often removed during the same hernia operation. However, this is a cosmetic procedure, and would not be covered by your insurance. Speak with Dr. Dumanian at the time of your meeting if you would be interested to remove extra skin at the time of your hernia procedure.
Dr. Dumanian is an expert at all types of cosmetic surgery of the abdomen and the trunk, and performs them frequently. This includes liposuction of the abdomen and flanks, mini-tummy tucks, and full tummy tucks (full abdominoplasty). Speak with Dr. Dumanian if you are a good candidate for one of these procedures, and what would be the risks and benefits in your specific situation.
The decision whether to use mesh or not is complicated, and you will need to discuss this with Dr. Dumanian. Using a permanent mesh decreases the recurrence rate of a new hernia developing. However, meshes also can become infected, cause adhesions to the bowel and bowel blockages, or cause holes in the bowel to develop. In general, Dr. Dumanian feels that the benefits of using mesh and the associated decreased hernia recurrence rates outweigh the risks in many situations. Mesh is used typically at the same time as the separation of parts procedure.
For some patients, the risks of an infection are too great to use a permanent mesh, but some sort of abdominal wall reinforcement is still required. Biologic meshes are best thought of as a kind of "leather." The materials are taken either from human cadavers or from animals, thoroughly processed to remove cells or any chances of infection, and then packaged for use. When these materials are used in an abdominal hernia repair, your own tissues gradually incorporate this biologic mesh, and replace it with your own cells. They seem to avoid some of the other problems seen with permanent meshes, namely infections and adhesions. However, they also are associated with higher hernia recurrence rates. Speak with Dr. Dumanian if he plans to use either permanent or biologic mesh.
From a previous hernia repair, you may already have a draining area and a mesh infection. This is a serious situation, and typically requires the complete removal of the mesh. Depending on the type of mesh that was used for you, Dr. Dumanian may need to perform a complete abdominal wall reconstruction after the mesh is removed. In other instances, the mesh is removed at one operation, a hernia slowly redevelops over time, and the hernia is then repaired when there is no infection present. Dr. Dumanian has extensive experience in treating patient with infected abdominal wall mesh.
What Is An Abdominal Or Ventral Hernia?
An abdominal hernia is a bulge or protrusion at a weakened area in the abdominal muscles. For many patients the bulge is visible but not painful. Other patients will have varying degrees of discomfort.
What Causes A Hernia?
The hernia may happen at an old surgery site, through muscle weakened by a pregnancy, muscle weak from the time birth or for no apparent reason. Some life situations can contribute to a hernia such as being over weight, chronic coughing, straining with bowel movements or lifting heavy objects.
What Will Happen If The Hernia Is Not Repaired?
Once the hernia has appeared it is not likely to resolve on its own. In fact, with the passage of time the hernia will tend to get bigger, often with increasing pain.
What Is The Purpose Of The CT Scan?
It will help determine the size and extent of the hernia and if any of your intestines are protruding into the hernia. If so, there is the potential for a more serious situation where the intestines become caught in the hernia. The scan will also help your surgeon determine the best way to repair the hernia.
How Are Ventral Hernias Repaired?
In the most simple hernias the surrounding muscles are stitched together to eliminate the weakness. In larger and more complicated hernias it may be necessary to add a mesh material to the muscle area which creates a stronger repair.
What Is A 'Separation Of Parts' Repair?
For some complex hernias additional small incisions are made on either side of the abdomen to allow access to the muscles there. The muscles in that area are weakened slightly which takes pressure off the main hernia repair. This actually adds to the strength and endurance of the hernia repair but does not weaken your overall abdominal strength.
Is There Any Prep Needed Before The Surgery?
You should avoid aspirin products for one week prior to surgery. You should eat and drink nothing after midnight the day of surgery. You will need to report to the designated surgery area at the assigned time.
Your doctor may request you consume only clear liquids for 2 days prior to surgery and use a liquid laxative the afternoon and evening before ( see details at the end ). The purpose of these steps is to rid the bowel of as much content as possible, which makes the hernia repair surgery much easier.
Can A Hernia Recur?
Abdominal hernias can recur. Much depends on your individual situation. Carefully following the post operative guidelines will help minimize the chances of a reoccurrence.
How Long Will Recovery Take?
Your recovery course is very much dependent on the size and complexity of you hernia repair and your overall health . Simpler, smaller hernia repairs may only require a day or two in the hospital followed by two to four weeks at home before returning to your job. Larger more complex repairs may require up to 7 days in hospital with six to eight weeks recovery at home.
What Can I Expect During Recovery?
If you have had the hernia for a considerable length of time and if it is of the larger size, you may experience a very tight feeling in your abdominal area following the repair. It may feel as if you cannot take a deep breath or eat more than a few bites of food at a time. You may actually feel like you can't eat anything for several days after the repair. These symptoms may persist for several weeks following the repair, but with time they will improve.
When Can I Exercise And What Kind?
Once you are at home and feeling better, you will be able to resume some physical activities. After several weeks you will be allowed to lift the equivalent of a small bag of groceries. After several months you will be allowed to lift the equivalent of a large bag of groceries.
Activities like walking, swimming and an elliptical trainer are allowed and encouraged. Weight lifting will not be possible for several months and jogging for up to a year. You will need to avoid exercises targeting the abdominal muscles for at least one year.
What should I wear after abdominal surgery?
After hernia repair, abdominoplasty, and other abdominal surgeries including liposuction, it is comforting to wear an external support. The garment provides some compression to the skin and soft tissues to help with pain, smooth out and improve healing, and reduce swelling. The garment serves as a reminder of the recent surgery, and not to do any heavy lifting.
Garments or binders that wrap around the body are most useful for upper abdominal hernias. Girdles, bicycle pants, and “spanxs” are all useful for lower abdominal incisions such as abdominoplasty because of the way they wrap around the hips. A particularly firm support can be obtained from the Columbian garment known as a “faja”. This garment is used for cosmetic improvement of the abdomen, as well as after abdominal wall surgery. Stores that sell the faja can be found in Chicago on the internet.
Binders can be worn most of the day immediately after abdominal surgery. Girdles, bicycle pants, spanx, and fajas are best worn after the drains are removed. The garments should be worn most of the day for the first several weeks. Dr. Dumanian will tell you when the garments are no longer needed.
NY Times Article: "Rediscovering a Shortcut to an Hourglass Figure"
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- Abdominal Wall Tumors and Reconstruction
- Abdominal Wall Reconstruction Chapter
- Challenging Abdominal Wall Defects
- Enterocutaneous Fistula
- Hernia Repair And Meshes 2009
- Hernias in the Obese Population
- Infected Mesh
- Loss of Domain
- Open VS Laparascopic Hernia Repairs
- Perforator Preservation and Hernia Repair
- Reconstruction of the Pelvis and Perineum