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Epigastric and Parambilical Hernia Repair
These hernias appear above the "belly button" and come through a defect in the midline linea alba- the fusion between the left and right rectus abdominis muscles (the "six pack" muscles). In epigastric hernias, typically intra-abdominal fat squeezes through a small hole in the linea alba. These hernias can be exquisitely tender but, due to the very small size of the defect, the risk of bowel herniation or incarceration is low. Paraumbilical hernias are usually larger than epigastric or umbilical hernias usually and require repair because of the risk of bowel contained within them becoming incarcerated or strangulated.
Both epigastric and periumbilical hernias can be repaired as an open or laparoscopic operation depending upon the individual presentation. Using the same principles of tension free hernia repair, epigastric and periumbilical hernias over 2 cm in diameter should be repaired using mesh placed behind the abdominal wall muscles. Surgery involves repair of the area of weakness and return of the abdominal contents back into their normal position. Small to moderate epigastric and periumbilical open hernia repairs can be performed under local anesthetic as an outpatient procedure. Laparoscopic repair may be indicated for patients with large defects, occult hernias, or larger body habitus.
Spigelian Hernia Repair
This is an uncommon type of ventral hernia that appears at the edge of the rectus abdominis muscle (the "six pack" muscles) where it fuses with the lateral oblique muscles.
Spigelian hernias can be repaired as an open or laparoscopic operation depending upon the individual presentation. Using the same principles of tension free hernia repair, Spigelian hernias should be repaired using mesh placed behind the abdominal wall muscles. Open Spigelian hernia repairs can be performed under local anesthetic as an outpatient procedure. However, this type of hernia is occasionally difficult to appreciate and laparoscopic repair may be indicated for patients with occult hernias or larger body habitus.
Incisional Hernia Repair
Whenever an incision is made into the abdominal cavity, the resultant scar even when fully healed, may not to be as strong as the original abdominal wall. If there is tension on the closure or problems with wound healing, the abdominal wall musculature may separate creating an incisional hernia. These hernias more frequently develop the setting of obesity, coughing, straining, infection, malnutrition, steroid or chemotherapy administration, and emergency surgery.
An incisional hernia can develop any time after surgery, most however become evident within 2 years of the initial operation. These hernias gradually increase in size and may become progressively more symptomatic. The size of an incisional hernia can vary significantly. Small hernia defects pose a greater risk of incarceration and strangulation while larger hernias may become progressively more symptomatic and increase in size over time. Medical evaluation of an incisional hernia is strongly advised.
Incisional hernias vary widely in size and complexity. A detailed surgical consultation is required for evaluation and determination of the correct treatment in each individual case. Small hernias may be approached open or laparoscopically depending on the location and contents. Larger hernias often require an abdominal wall reconstruction to lower the risk of recurrence. Effective surgery must follow the principles of a "tension free" repair with placement of mesh behind the abdominal wall muscles as these hernias develop in many cases as a result of too much tension at the original abdominal closure. Each case is reviewed individually to determine the optimal method of repair. Laparoscopic repair is often feasible for smaller defects. Larger repairs may combine a laparoscopic approach to reconstructing the abdominal wall with an open technique to reinforce the abdominal muscles and close the defect.
Complex cases such as those with infection, prior failed repairs, coexisting ostomies, loss of abdominal domain, are all individually evaluated and repair is personalized to maximize the chance of successful repair. Review of prior operative reports and prior abdominal wall imaging is often helpful to help tailor each operation and should be brought to the initial consultation or submitted for review.