Hiatus Hernia Repair (Abdominal)
Hernia correction is among the most commonly performed operations today, as it can affect people irrespective of age and gender and usually occurs without warning. As such, it’s important to learn what a hernia is, how to recognize it, and what you should do about it.
What is a hernia?
A ‘hernia’ is formed when an organ pushes through a gap or weak area in the muscle or tissue around it, protruding into other parts of your body. If you find a soft bump protruding from your belly, thigh or lower abdomen, especially after exercise or strain, it is likely a hernia. Don’t worry, hernias are not necessarily life-threatening - but they can be very unpleasant and lead to future complications if not treated immediately!
Pain can vary, but it is likely to cause some pain when the surrounding muscles are exerted, or when you cough or go to the bathroom. Hernia can produce both sharp, stabbing pains and dull aches. The pain typically intensifies through the day and is worst in the evening. Standing can also intensify the pain. If you suspect that you may have a hernia, see a doctor immediately. It’s a common injury, something your doctor sees on a daily basis, so there’s no reason to panic!
Risk factors and prevention
Hernias can unfortunately occur in anyone, regardless of age or physical fitness. However, there are some factors that can increase your risk, such as smoking, prior surgeries that involve incisions in the abdominal wall, weakening of the abdominal wall due to lack of exercise, obesity, pregnancy, improper posture while lifting something, and so on. Aging also accounts for weakness in the fascia and abdominal wall. If you tick one or more of these boxes, be extra careful! Ideally, one should maintain good core body strength, good posture, and proper discretion and form when exercising or otherwise exerting oneself. Overexertion during exercise can cause a hernia, as well as things like persistent coughing or constipation, which causes sudden strain or pressure in your abdomen. Stay healthy!
Common types of hernia, their causes and treatment
This is the most commonly occurring type of hernia (around 70%), and usually occurs in men as they tend to naturally have weaker abdominal walls around the groin. In fact, many have small gaps from birth where the inguinal canal has failed to close properly after the testicles descend.
The inguinal canal serves an important function - in men, it allows the spermatic cord to connect the scrotum and abdomen, securing the testicles, and in women it is home to a ligament that helps secure the uterus.
An inguinal hernia occurs when, due to strain, an organ from the abdomen - usually the bladder or small intestine - tears through the abdominal wall and protrudes into the inguinal canal. The main danger here is something called ‘strangulation’, which is when blood supply to part of the intestine is cut off due to pressure. This can cause terrible pain and requires immediate surgery.
This is a groinal hernia that occurs more often in women than men, and is located just below the crease of the groin. This hernia occurs in the femoral canal, which houses the femoral artery running from groin to thigh. In the case of a hernia, tissue from the abdomen is forced into the thigh through this opening. As pain due to this hernia is felt in the groin region, it can easily be mistaken for an inguinal hernia and can be hard to diagnose physically due to its usually small size. Often, it is only found when part of the intestine has become trapped in the femoral canal and caused ‘strangulation’, which requires emergency surgery.
This type of hernia occurs when the intestine forces its way through the site of a prior surgical incision made in the abdominal wall. This incision may not have healed correctly, or may just have left a weak spot in the muscle and tissue. Incisional hernias can occur even many years after surgery, so it pays to be cautious! They usually occur along vertical incisions, and tend to be larger and more painful.
They are more likely to occur in those who have suffered infection after surgery, leading to incomplete healing, or those who are overweight or elderly, suffer from chronic lung problems leading to continuous coughing, or have had multiple surgeries using the same incision. Those on steroid medications are also at risk.
This hernia occurs around the navel. The umbilical ring is a ring of tissue that forms around the area where the umbilical cord enters the body of the fetus, and usually seals itself before birth. However, if it doesn’t close, it’s a prime spot for a hernia. The intestines or fat can force their way through the opening, causing the belly button area to look swollen.
Umbilical hernias are very common with children around birth - however, they’re usually not painful, and will close off on their own. At other times, they occur when the child is older, due to strain while crying or performing bowel movements.
These hernias can also afflict adults of both sexes, either because their umbilical ring never closed before birth, or due to weakening of the abdominal wall due to pregnancy, violent coughing over periods of time, or obesity and inactivity.
Your diaphragm separates your chest and your abdomen. There is a gap in your diaphragm, called the hiatus, which allows your esophagus to pass through and connect to your stomach. When hiatal hernia occurs, your stomach is forced through the opening.
Most commonly, the stomach and lower part of the esophagus enter the chest through the hiatal opening. This is called a sliding hiatal hernia. However, sometimes a paraoesophageal hernia occurs. Here, only part of the stomach is forced through the hiatus, next to the esophagus. This can be dangerous, as like with inguinal hernias, ‘strangulation’ is an issue - the blood supply to the stomach could be slowed or cut off.
Although hiatal hernia sounds quite frightening, many people show no symptoms. Others may suffer from heartburn due to reflux, or a feeling of fullness. With larger hiatal hernias, chest pain, difficulty swallowing, and symptoms of gastrointestinal bleeding (blood in vomit or stool) may occur.
As there is no bulge, hiatal hernias must be diagnosed via endoscopy, or with barium swallow X-ray that allows the doctor to view the area internally.
Hernias can only be corrected through surgery. In some cases, umbilical hernias (in infants) and inguinal hernias (in men) that cause absolutely no symptoms may not need repair. However, this is a decision only to be taken by your physician!
Two types of surgery are available for hernia repair - open surgery and laparoscopy.
This is the traditional method of dealing with hernias, and the only option for larger ones. Normally, you will be placed under general anesthesia. If the hernia is quite small, your surgeon may use local anesthesia with medication to help you relax.
Open surgery is very straightforward - you are placed under anesthesia, and an incision is made in the area of the hernia to correct it. The hernia is separated from the area it is protruding into, and pushed back through the hole it came from. Then, the gap is securely stitched up behind it. Sometimes, mesh is added to strengthen the area and prevent a recurrence. This mesh or ‘patch’ technique is a much newer method and invaluable in the case of incisional hernias, which had a very high chance of recurrence due to repeated incisions and suturing in an already weakened area. Until it became possible to place the surgical mesh through laparoscopy, open surgery was the only possibility for incisional hernias.
Open surgery leaves a larger scar than laparoscopy, but in the case of inguinal hernias it occurs very low on the abdomen and is not likely to be very visible. As this method is more invasive, it can take several weeks to make a full recovery. Ask your surgeon if laparoscopy is an option for your particular hernia and trust him to choose the best surgery for you.
You can find many helpful personal accounts of experience with open hernia surgery online.
This method is extremely effective in treating smaller hernias, and leaves a much smaller scar than open surgery. Chances of infection are minimal, and the recovery period is much shorter and less painful.
Your surgeon will put you under general anesthesia, and your abdominal cavity will be inflated with CO2 gas for better visibility. Next, a laparoscope (a tiny camera with a light to illuminate its surroundings, mounted on the end of a narrow tube) is inserted through a small incision and used to examine the hernia. Then, using special miniature instruments, your surgeon corrects the problem through similar tiny incisions (in total, 3-6). He will either suture the gap through which the hernial sac protrudes, or place mesh in the gap to block it off and support the surrounding flesh. This mesh encourages tissue to grow around it, eventually causing the gap to close.
Preparing for surgery
Once you are diagnosed, your doctor will run through your surgical options with you. Then they will review your surgical and medical history, ask you questions about your diets, supplements and medications, perform any necessary lab tests, and conduct a physical exam. Based on the above, additional tests may be needed.
Bring a full list of all medications and supplements you are taking and clarify if you need to stop any of them before the surgery. It is vital that you be very honest with your doctor - including telling him details about your smoking or drinking habits, or if you think you might be pregnant.
Here are some things to keep in mind:
Make sure you have someone to take you to the hospital and back home! Even for an outpatient procedure, you can NOT drive after anesthesia.
Be very clear about which medicines and foods you need to avoid the week/day of the surgery.
If you smoke, try to severely restrict this the week of the surgery.
Wear and carry loose clothing. You won’t want anything chafing against your fresh surgical incisions!
Leave all jewellery and valuables at home as you will need to remove them for the surgery.
Pack an overnight bag even if you’re an outpatient - in case of complications you will need to stay at the hospital.
Recovery from surgery
You should fully recover from the anesthesia an hour or two after the surgery. Laparoscopic hernia surgeries are usually an outpatient procedure, which means that most likely, you will go home the same day. Smaller open surgeries may be the same. For larger open surgeries, you will spend a few days in the hospital.
Once you get home, it will take you a few days (for laparoscopic surgery) and a few weeks (for open surgery) to recover. Make sure you strictly follow any post-operative care your doctor has recommended, and take all medications on time. Your doctor will prescribe you pain medications to keep you comfortable. You can also apply clean ice packs to the area to reduce swelling.
Make sure you eat healthy, stay hydrated, and get up and walk around the house often (to keep your circulation up). Do not overexert yourself with housework, heavy lifting, or gym visits!
If you suffer from fever, nausea, vomiting, very severe pain, bleeding, and urine or stool issues, contact your doctor immediately. Make sure you attend all follow-up appointments and checkups so that he/she can ensure that you are recovering well!
And don’t be too upset if you have a hernia - as Dwayne ‘The Rock’ Johnson said after recovering from not one but THREE simultaneous hernias, “It was a really nice blessing to slow down. It was almost God's way of saying, 'Well, now you're going toke a break.’” Stay positive, stay educated, trust your doctor, and everything will turn out alright.