The abdominal wall has three muscles on each side of the torso, and two paired muscles that run up and down from the breastbone (the xyphoid) to the pubic bone. The muscles on the sides are the transversus abdominis, the internal oblique, and the external oblique muscles (from deep to superficial). The up and down “6-pack” muscles are the rectus abdominis muscles.
General surgeons most commonly enter the abdomen through an incision that runs vertically around the navel or umbilicus, and this incision is called the midline laparotomy. Therefore, the most common hernia treated by Dr. Dumanian is the midline incisional hernia located between the rectus abdominis muscles.
Some midline incisional hernias are too big to repair by simply moving the rectus muscles back into their original position and holding them together with simple stitches. In the components separation hernia technique, also called the “separation of parts procedure”, the tight external oblique muscles on both sides of the abdominal wall are cut, to allow the paired rectus muscles to be brought together in the center. The external oblique muscle is not removed, but rather is weakened with a surgical incision. Dr. Dumanian is a pioneer in the safe performance of the components separation hernia technique, and has performed close to 1000 of these procedures.
Surgeons put sutures into the muscles when a hernia is repaired. However, the tension on the stitches causes them to cut through the abdominal wall like a cheese cutter. The greater the forces on the sutures, such as due to chronic coughing, heavy lifting soon after surgery, and patient heaviness, the more likely the sutures will pull through normal tissue. Dr. Dumanian’s strategy is to distribute forces to limit or avoid suture pull through.
In most surgeries, Dr. Dumanian will use a mesh to distribute forces and to limit or avoid suture pull through. Meshes have allowed Dr. Dumanian to lower hernia recurrence rates to the 0-5% range.Dr. Dumanian is an authority on the use of meshes for reinforcement of the abdominal wall. He has published results on hundreds of his repairs, as well as on his technique for “perforator preservation” to the skin for decreased complications with the components separation procedure. Dr. Dumanian will use a biologic mesh only on rare occasion to help with an abdominal wall closure due to his concerns about the durability of these biologic meshes.
Unfortunately yes. However, Dr. Dumanian has an extremely low mesh removal rate. You can look at Dr. Dumanian’s NSQIP numbers for 2012-2013, showing no deep infections, and a 3% superficial infection rate for a year of abdominal wall surgery.
There are theoretical problems with the use of mesh including bowel adhesions, scar formation, infection, and chronic pain. Dr. Dumanian has not seen these problems to any large degree. Not using the mesh leads to a recurrent hernia about 25% of the time. The use of mesh to reinforce any hernia repair is an important decision that Dr. Dumanian will have to make during surgery.
Patients who have had bariatric surgery often develop hernias. These hernias are repaired with the same techniques outlined above. This includes using mesh, and sometimes the components separation technique. 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 in an abdominoplasty at the time of your hernia procedure.
You may already have a draining area and a mesh infection from a previous hernia repair. 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 patients with infected abdominal wall mesh.
Any hernia on the front of the abdominal wall is a ventral hernia. The term “ventral hernia” includes most incisional hernias, inguinal hernias, epigastric hernias, and umbilical hernias. You can see that “ventral hernia” is a relatively non-specific identifier for hernias.
An abdominal hernia is a bulge or protrusion at a weakened area in the abdominal muscles, allowing the intestines or other internal tissues to be palpable through the skin.
The hernia may occur at an old surgery site, through muscle weakened by a pregnancy, or in an area weak since birth. Some life situations can contribute to hernia formation such as being overweight, chronic coughing, straining with bowel movements or lifting heavy objects.
Once the hernia has appeared it will not resolve on its own. In fact, with the passage of time the hernia will tend to get bigger and more painful. Some hernias are at increased risk for developing an obstruction of the bowels–a serious situation.
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.
In the most simple situations, the surrounding muscles are stitched together to eliminate the weakness. The most durable repairs use mesh in some way to prevent recurrences.
You should avoid aspirin products for one week prior to surgery. You should eat and drink nothing after midnight the night before 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 the day prior to surgery and use a laxative. The purpose of these steps is to rid the bowel of as much content as possible, which facilitates the hernia repair surgery.
Your recovery course is very much dependent on the size and complexity of you hernia repair and your overall health. The smallest hernia repairs around the belly button may be performed as an outpatient. A few 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 seven days in hospital with six to eight weeks of recovery time away from work. Patients who do heavy lifting may need restrictions for work for many months.
If you have had the hernia for a considerable length of time and if it is of the larger size, you may experience a 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. These symptoms may persist for several weeks following the repair, but with time, they will improve. Despite the surgical pain, most patients feel better after the repair due to the restored higher intra-abdominal pressure.
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.
Low impact activities like walking, swimming, and using an elliptical trainer are allowed and encouraged to aid recovery. Core exercises, Pilates, and planks are also encouraged once you begin feeling better. Weight lifting and jogging should be avoided for four to six months depending on the type of repair. Visit our blog to learn more about exercising after hernia 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 “Spanx” are all useful for lower abdominal incisions such as abdominoplasty because of the compression they provide and the fact that they stay in place. A particularly firm support can be obtained from a 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 in Chicago can be found on the internet. Binders can be worn for most of the day immediately after your abdominal surgery. After the drains are removed, you are allowed to wear girdles, bicycle pants, and Spanx. The garments should be worn for the first several weeks. Dr Dumanian will advise you when the garments are no longer needed. Visit our blog to learn more about what to wear after hernia surgery.
