Hernia Surgery

A hernia is the protrusion of a portion of the body through the wall or space that contains it. Abdominal wall hernias occur when fat or bowel protrudes through the muscle and fascia of the abdominal wall. As the inside muscles of the wall or lining of a cavity is weakened and the organs meant to stay within that cavity slip out. A bulge or small balloon-like sac is created and is sometimes palpable and/or visible.


Male and female patients are both susceptible to getting hernias. Causes can vary from congenital (born with it), developmental or as a result of life’s activities that wear on muscle tissue as people age.

A hernia will not get better over time nor will it ever go away by itself. The development of a hernia is correlated to stress on the abdominal wall or a pressure within the abdomen. Contributing factors to hernias include:

Types of Hernias

The most common and familiar hernias are abdominal, but they do occur in other parts of the body as well.


Symptoms vary depending on the type of hernia. Generally, symptoms of hernias result from the discomfort caused by the dimension of the hernia and its contents. The diagnosis is often easily made on physical examination. Some hernias may show no symptoms at all. They can occur at any age. However, hiatal and paraesophageal hernias are diagnosed by X-ray, CT or upper endoscopy.

Incarcerated Hernia

An incarcerated hernia may not be an immediate medical emergency but has the potential of becoming one and must be addressed by a physician. With an incarcerated hernia, a piece of the intestine that protrudes through an abdominal opening in the abdominal wall becomes stuck in that opening. The blood supply to the intestine may become reduced and the intestinal tissue begins to die. In this situation the incarcerated hernia becomes strangulated. Incarcerated hernias cause painful swelling and a tender bulge under the skin. Other symptoms often include anorexia, nausea, vomiting, and fever. Emergency surgery can be required for an incarcerated hernia. Your surgeon will place the intestine back into the abdomen and repair the weakened area in the abdominal wall. Incarcerated hernias can cause bowel obstruction and must be evaluated by a physician.

Strangulated Hernia

A strangulated hernia is a life-threatening emergency and must be urgently dealt with. Strangulated hernias refer to hernias where the blood supply is cut off. Should this occur, any tissue in a hernia, such as part of the intestine, can become ischemic (blood supply cut off) and die. Immediate surgery is essential to save the herniated tissue. Unlike regular hernias, strangulated hernias are irreducible, always painful, tender to the touch and are sometimes accompanied by nausea, vomiting, and fever. There is usually a feeling of malaise. A strangulated hernia can cause small bowel obstruction.


Hernias are usually diagnosed by a medical examination and prior medical history. Ultrasound and computerized tomographic scanning is also often used to aid in the diagnosis. Urinalysis may be ordered to rule out other problems including a urinary tract infection.

Choosing Surgery

Most hernias will become larger over time and will not permanently resolve on their own. However, there is a small risk of a medical emergency occurring if part of the bowel gets trapped within a hernia. Not all hernias have to be repaired, but surgery should be considered if:

Medical Treatment

Medical treatment can be offered for paraesophageal and hiatal hernias. Treatment options include prescription strength antacids. Many times patients consult with a gastroenterologist for the management of their symptoms. If these modalities are unsuccessful, surgical treatment is explored.

Surgical Treatment

The only treatment for most hernias is the surgical repair of the defective muscle. Hernia repair is one of the most frequently perform operations. Over 600,000 procedures are performed annually in the United States. It is highly effective and has only a 10% overall recurring rate. Different hernias have variable recurrence rate. Surgical repair is performed either laparoscopically with minimally invasive technique and fiber optic instruments or with the conventional or traditional open technique.

Laparoscopic Hernia Repair

The laparoscopic “minimally invasive” technique is performed under a general anesthesia and most often done on an outpatient basis. A harmless gas is utilized to inflate the abdomen. This provides our surgeon with room to work in the abdomen and an unobstructed view. This can be uncomfortable to the patient so a general anesthetic is used to prevent discomfort.

A laparoscope (a telescope-like instrument with a viewing camera) is inserted through a small incision at the navel. Other long-handled surgical instruments are inserted into the abdomen through several small incisions. The camera on the laparoscope transmits images from the abdomen to a high definition viewing screen in the operating room which guides your surgeon in the procedure. Your surgeon will gently pull the body part back into its proper place and position a mesh patch over the weakness in the abdominal wall. Sutures are then used to reinforce and secure it. The abdomen is then deflated, the small incisions are closed with sutures or surgical tape and the procedure is completed.

There are many benefits to performing this procedure laparoscopically:

Traditional Open Hernia Repair

With the open technique, our surgeon makes an incision several long near the hernia. Once he sees the herniated area, it’s gently pushed back into its proper place. A piece of mesh is implanted underneath the strong fascial tissue covering and reinforcing the area of weakness and secured with sutures. This is often performed as an outpatient procedure and under local anesthesia. There are however instances where general anesthesia or regional or spinal anesthesia is required.


Hernia repair is a relatively safe surgical procedure and complications are rare. As with any surgery, there exists the potential risks of bleeding, infection, chronic pain, blood clots, injury to the intestine, testicular area or other nearby structures, as well as a potential possible allergic reaction to the anesthesia.


There are various steps that can be taken to try to avoid the reoccurrence of a hernia:

What to Expect After Surgery

When to Call the Doctor After Surgery

Umbilical Hernias

An umbilical hernia will create a bulge or soft swelling near the navel (umbilicus). This will occur because intestine, fat, or fluid pushes through a weak spot in the belly where the umbilical cord passes through the abdominal wall (navel) and creates a sac at the belly button. Hernias can occur in the weak area at any time from birth through late adulthood, as the weakness continually bulges and opens and abdominal contents protrude through it. Umbilical hernias present the same risks of incarceration and strangulation as other hernias.


Umbilical hernias are common in infants. Premature babies and those with low birth weights are more prone to hernias. The bulge may only be noticed when the baby cries, coughs or strains. When the baby is calm or lying on his or her back, the bulge may disappear. Most often they will shrink and close on their own by the time the child is 3 or 4 years old. Generally, umbilical hernias are painless in children.


In adults, umbilical hernias are generally acquired because of too abdominal pressure. They have a tendency to get larger over time. They are a general result of health problems that create excessive pressure in the belly. Factors contributing to this are excess weight, pregnancy, too much fluid in the belly (ascites), chronic cough, constipation, or an oversized prostate gland.


Umbilical hernia repair is generally treated with outpatient surgery. While having fa ew risks, it is far more risky to avoid treatment. Left untreated, there is a risk of strangulation, which means that blood supply to the tissue is cut off because part of the intestine or fat is trapped. Then any tissue in the hernia, such as part of the intestine, can become ischemic (blood supply cut off) and die quickly. Immediate surgery is essential to save the herniated tissue

This is usually an outpatient procedure and the patient usually goes home the same day as the surgery when it is not due to strangulation. The following steps are part of the surgical procedure to repair an umbilical hernia:

Ventral and Incisional Hernias

A ventral hernia is a protrusion of an organ inside the abdomen such as the intestine or the bowel. The protruded organ comes out through the cavity, pushes the muscle layer of the abdominal wall and is visible from the outside as a bulge in the abdomen. It can cause much discomfort and is a curable condition. Surgery is usually the main treatment for the majority of ventral hernias because they will most likely worsen if not treated.

A ventral hernia usually arises in the abdominal wall where a previous surgical incision was made (ventral incisional hernia). It occurs in the area around the previous incision where the abdominal muscles have weakened and a bulge or a tear occurs.

Ventral hernias are more common as a person ages. Persistent coughing, difficulty with bowel movements and urination or frequent need for straining will increase the likelihood of a ventral hernia forming.


In addition to the bulge in the abdomen other signs and symptoms of a ventral hernia includes:


There are many causes of ventral hernias. The most common are:


Most often ventral hernias are painless, even when the bulge is touched. However, pain may occur when a person:


Should a hernia become incarcerated, then a great deal of pain occur and immediate medical attention and treatment is required. The incarceration occurs when the protrusion does not enter back into the original cavity it came from. Necrosis (death of body tissue) may then occur in very severe cases. The blood supply to the protruded part of the organ gets cut off and the organ tissues die due to the lack of nutrition. This can lead to a strangulated hernia and severe pain. If a ventral hernia becomes incarcerated then the patient can suffer from:

A ventral hernia is considered a serious condition and should be treated without delay in order to prevent life-threatening symptoms and strangulation. It can be repaired with surgery that is performed either laparoscopically or the open traditional way.


The possibility may exist for your surgeon to push a ventral hernia back into the abdomen without performing surgery. Should surgery be required and performed laparoscopically, 5 -6 several small incisions will be made in the abdomen. A scope and tools are inserted through these incisions to repair the hernia. If the surgery is performed with an open procedure, then the abdominal wall is surgically opened to repair the hernia.

When located, the tissue surrounding the hernia is exposed. Extra fat or tissue will be removed. The muscles and abdomen wall are then closed.

The mesh that is used is made of a man-made or natural material may help support the wall of the abdomen. This may be placed in front of, on, or inside the lining of the abdomen. In some cases, the incision from a large hernia may be covered with a skin flap. A skin flap is a muscle or tissue that is taken from a nearby area of the body (chest). (If a stoma exists where a hernia occurs, it may have to be closed, and a new one created. A drain may be inserted to remove extra fluid. Additional information regarding the laparoscopic procedure and open procedure is available near the top of this page)

Home Care

After the surgical repair, the condition can be further treated at home by:

Inguinal Hernias

An inguinal hernia is a protrusion of abdominal cavity contents through a weak area at the inguinal ring. The opening to the inguinal canal is located in the groin. Soft tissue which is usually part of the intestine also called the small bowel, protrudes through a weak point or tear in the muscles of the lower abdominal wall. An inguinal hernia can appear as a bulge on one or both sides of the groin and can be painful when coughing, bending or lifting a heavy object.

Most inguinal hernias are a result of the muscle wall not closing as it should before birth, leaving a weak area in the belly muscle. Pressure on that area can cause tissue to push through and bulge out. The bulge may appear over a period of time extending from weeks to months. It can also appear suddenly after heavy weight lifting, coughing, straining, bending or even laughing. The hernia can be painful, but some often cause the bulge without pain.

Inguinal hernias can occur from infancy through adulthood. Men, because of their anatomical structure, are much more susceptible to developing an inguinal hernia.

An inguinal hernia will not get better on it’s own, and at some time, could possibly lead to life-threatening complications. Surgical repair is generally recommended for an inguinal hernia that is painful or continues to increase in size.

The repair of an inguinal hernia is one of the most frequently performed surgical procedures. Most hernia patients will have surgery to repair the hernia even if they don’t have symptoms because most doctors believe it is in the best interest of the patient to have the surgery. This will also avoid the potentially dangerous possibility of strangulation, where the intestine gets trapped inside the hernia. If the hernia is small, painless and easily pushed back into the belly, then surgery may not be necessary.


The symptoms of inguinal hernias include:

Indirect Inguinal Hernia

Indirect inguinal hernias are congenital (present since birth) and are more common in males because of the way a male develops in the womb. A weakness in the tissue in the inguinal canal is the cause of this type of hernia.

The inguinal canal extends from the abdomen to the groin. During fetal development in the male, the testicles, spermatic cords, and blood vessels descend through the canal into the scrotum. In females, the inguinal canal is the channel for ligaments that keep the uterus in place. The entrance to the canal at the inguinal ring does not always close after birth and a weakness can be left in the abdominal wall. Fat or part of the small intestine can slide through this weakness into the inguinal canal and cause the hernia. The inguinal channel usually closes up before birth but a defect in the closure is indicative of a weakness that can result in a hernia.

Indirect inguinal hernias can occur at any age but as one ages and the tissue becomes weaker the chance of it happening increases. They occur more often in men than women and are more common than direct hernias. Premature infants have a greater susceptibility to having an indirect inguinal hernia because there is less time for the inguinal canal to close.

Direct Inguinal Hernia

Direct inguinal hernias can form as the connective tissue of the abdominal muscles degenerate during the adult years and cause a weakening of the muscles. Fat or the small intestine will slide through the weak muscle into the groin. Direct inguinal hernias will develop over time as continuous stress is placed on the weakened muscle. They can only occur in the male. Several factors can create pressure on the weakened abdominal muscles and make the condition worse:

Indirect and direct inguinal hernias generally slide back and forth through the inguinal canal. With gentle massage, they can usually be moved back into the abdomen.

Incarcerated and Strangled Hernias

An incarcerated inguinal hernia is a hernia that gets stuck in the groin and is unable to be massaged back into the abdomen.

Swelling causes the hernia to be incarcerated. This can also lead to a strangulated hernia wherein the blood supply going to the incarcerated small intestine is jeopardized. Strangulated hernias are serious and do require immediate medical attention.

If the strangulated hernia is not treated severe infection, nausea and vomiting can occur. The condition can then become life-threatening if surgery is not immediately performed. The affected intestine could die and then that potion of the intestine would need to be removed.


The symptoms of a strangulated hernia include:

The inguinal hernia is diagnosed through a physical examination. The doctor will feel the hernia as it moves into the groin or scrotum. He may be able to gently massage it back into its proper place in the abdomen.

When inguinal hernias become enlarged, cause symptoms or become incarcerated in adults, they require surgical treatment. In infants and children, inguinal hernias are usually operated on to prevent the hernia from incarcerating. The surgery can be performed laparoscopically or the open traditional way.


If the hernia is small, a wait and see approach may be taken. If the hernia is large and painful, surgery is usually necessary to repair the hernia and prevent serious complications and relieve discomfort. There are two types of surgical procedures for hernia repair.


Five to six small incisions are made in the abdomen and a fiber-optic tube with a tiny camera is inserted into the abdomen through one of the incisions. Small instruments and a surgical mesh are inserted into the abdomen through the other incisions. A video camera is used as a guide for your surgeon to perform the procedure. The synthetic mesh is used to repair the hernia by attaching it to the strong tissue in the abdominal wall. Special surgical tacks, and in some instances sutures, are used to hold it in place. (Three to four ¼ inch to ½ incisions are required for the process). The laparoscopic procedure is discussed in further detail as well as the advantages of laparoscopic hernia repair near the top of this page.


This is commonly known as the”open” method of hernia repair. An incision is made in the groin and the protruding intestine is pushed back into the abdomen. The weakened or torn muscle is then repaired by being sewn together. A synthetic mesh is often used to support or reinforce the weakened area (hernioplasty), Additional information on this procedure is available near the top of this page.

Diagram of a Hiatal Hernia

Hiatal Hernias

A hiatal hernia is a different type of hernia that presents in a different way. It occurs in the chest area and will affect the digestive system. It is an anatomical abnormality where part of the stomach protrudes through the diaphragm and up into the chest. In most cases, a hiatal hernia will not cause any symptoms. If pain or discomfort is experienced, it can be due to the reflux of gastric acid, air or bile. Other symptoms, though not present in all cases, include shortness of breath (the hernia’s effect on the diaphragm), dull chest pains, and heart palpitations (irritation of the vagus nerve).

The esophagus or food tube normally passes down through the chest, crosses the diaphragm and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. The esophagus then joins the stomach just below the diaphragm. When an individual has a hiatal hernia, the esophageal hiatus opening (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest.

Other factors possibly contributing to hiatal hernia occurrence include:

Most hiatal hernias in adults have developed over the years and are usually found in people who are 50 or over, obese and smokers. By age 60, up to 60% of people will have a hiatal hernia to some degree. However, they are occasionally seen in infants where they have most probably been present since birth.

When to Seek Medical Care

Hiatal hernias are divided into two categories; sliding or paraesophageal.

Sliding Hiatal Hernias

Sliding hiatal hernias are the most common forms of hernias. Most are not associated with any symptoms. As the hiatal hernia increases in size, the likelihood of symptoms will occur. These symptoms are almost always the symptoms of gastroesophageal reflux disease (GERD).

The junction of the esophagus and stomach (gastroesophageal junction) and part of the stomach protrudes into the chest. This junction may remain permanent in the chest, but most often, it will jut into the chest only during a swallow. The herniated part of the stomach will fall back into the abdomen once the swallow is completed.

Hiatal Hernias and Gerd

The hiatal hernia often interferes with the barrier (lower esophageal sphincter) which prevents acid from refluxing from the stomach into the esophagus. Patients suffering from GERD more often will have hiatal hernias than those not suffering from GERD.

The symptoms associated with GERD and the resulting hiatal hernia are:

When hernia symptoms are severe and chronic acid reflux is involved, surgery may be recommended. Chronic reflux can cause severe damage to the esophagus and even lead to esophageal cancer.

The esophagus normally has a neutral pH, which means that it is neither acidic nor alkaline. The stomach produces acid for the digestion of food. A muscular valve separates the esophagus and stomach. This valve is commonly referred to as the anti-reflux valve, or gastroesophageal valve (GEV).

When operating properly this valve between the esophagus and stomach opens to allow food to pass after swallowing. GERD (gastroesophageal reflux disease)is caused by acid that escapes from the stomach through this one-way valve located at the top of the stomach and may travel all of the way back into the throat. The stomach acid passes into the esophagus, producing symptoms of heartburn and acid regurgitation. Damage to the lining of the esophagus may occur, as well as damage to the lungs if the acid is inhaled.

Two changes that promote acid reflux will occur when a hiatal hernia is present:

The pressure at the gastro-esophageal junction decreases. The sphincter will slide up into the chest and the diaphragm will remain in its normal location. The pressure that is normally generated when the diaphragm overlaps the sphincter and the pressure generated by the sphincter no longer overlap. The gastro-esophageal junction and the stomach are pulled up into the chest with each swallow. The sharp angle where the esophagus and the stomach join becomes less sharp and the valve like effect is lost. This too will promote acid reflux.


An endoscopy, upper GI series or high-resolution manometry are the procedures used to determine the presence of a hiatal hernia. If present, it will appear as a sac between the esophagus and the stomach. This sac is delineated by the lower esophageal sphincter above and the diaphragm below. It can sometimes be problematic because the hernia may only be visible during swallowing.


The treatment for patients suffering from a hiatal hernia is usually the same as for those suffering from GERD. Sliding hiatal hernias rarely cause problems on their own other than contributing to acid reflux if they are not treated. If GERD becomes severe and is unresponsive to medication surgery will often be performed.

During surgery, the hiatal hernia is removed in a procedure similar to the one used for the repair of paraesophageal hernias (see paraesophageal hernia treatment below). An added feature to this surgery is wrapping part of the upper stomach around the lower sphincter to augment the pressure at the sphincter and prevent further acid reflux.

This is a hiatal hernia defect or wide opening in the diaphragm. This opening can be repaired with stitches or mesh.

This is a mesh repair of the diaphragm. Typically mesh is used for large hiatal or paresophageal hernia repairs where tension in the tissues is present.

Risk Factors Causing Hiatal Hernias

Increased abdominal pressure caused by:

Paraesophageal Hernias

A paraesophageal hernia is a protrusion of the stomach through the diaphragm into the chest cavity. This surgery is performed to correct the defect in the diaphragm that allows it to occur. When the stomach herniates(bulges) upward into the chest it may move around or even twist on itself. Paraesophageal hernias occur when the stomach moves up along the side of the swallowing tube or esophagus. They are generally larger than sliding hiatal hernias, which are a direct upward protrusion into the chest.

Normally, the esophagus (food pipe) goes through a hiatus (small opening) in the diaphragm. The diaphragm is a muscular wall that separates the chest and
abdomen (stomach). With PHR, the hiatus in the diaphragm is too large or the muscles around the hiatus are too weak. A sac can squeeze through this large opening and position itself next to the esophagus. This herniated sac may contain a portion of the stomach. When this herniated sac gets trapped in the chest, it causes stomach acid to back up into the esophagus and damage the esophagus. The hernia may range from less than an inch of the stomach to one that includes all of the stomach and sometimes, other organs as well. The opening of the diaphragm may be very small or up to 4-5 inches in diameter. Patients with paraesophageal hernias will most likely suffer from heartburn, reflux, regurgitation or many of the other symptoms associated with GERD. In the most serious situations, the stomach may develop ulcers, bleeding or twisting that could result in decreased blood flow and perforation of the stomach.


A paraesophageal hernia can strangulate a portion of the stomach above the diaphragm resulting in esophageal or GI tract obstruction. The tissue can even become ischemic (a decrease in the blood supply to the organ) and necroses (tissue death). A very large herniation can cause the inflation of the lung to restrict, resulting in pain and breathing problems.

If left untreated and the hernia is associated with GERD, complications can include bleeding, perforation of the esophagus, and a greatly increased risk of esophageal cancer

A paraesophageal hernia is commonly repaired with the laparoscopic technique. During the surgery, the stomach is replaced back down into the abdomen. The opening in the diaphragm is made smaller and stitches or mesh material will be used to close or decrease the size. Closure of the diaphragm may include the use of mesh. The procedure is combined with either a partial Toupet or a complete (Nissen) fundoplication.

Benefits of the Paraesophageal Hernia Repair

Risks of the Paraesophageal Hernia Repair

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