Arjun Shankar writes about hernias that occur in the midline of the abdomen – these are second in frequency only to groin hernias. Now that sutured repairs have been superseded by mesh there have been significant reductions in recurrence rates. The technological advances for midline hernia meshes allow them to be safely placed directly onto the bowel. These new meshes have a ‘non stick surface’ which makes placement on the bowel safe. The biological mesh is more impervious to infection and eventually becomes incorporated into the patients own normal tissue.
Midline hernias vary from small ones found within and adjacent to the umbilicus and complex hernias that may arise as a result of poor healing of a wound after surgery - incisional hernias. All of these hernias are repaired using meshwith the small ones done as day cases and sometimes under local anaesthesia.
Team of hernia experts
A hernia commonly occurs when a wound in the abdominal wall fails to heal. The subsequent protuberance of the underlying intestine through the defect may be very large indeed. Such cases need careful evaluation and often require the care of a team of surgeons including general abdominal surgeons and plastic surgeons. The operations may take hours to perform and the patient may have to stay in hospital for days with a requirement for intensive care support.
The story may not end even after the hernia has been repaired. The plastic surgeon may still need to perform a cosmetic reconfiguration of the overlying tissues akin to a ‘tummy tuck’. This partnership of reconstructive and aesthetic surgery usually results in a strong and cosmetically pleasing outcome.
Key hole repair of midline hernias
A Minimal Access Surgery (MAS) approach may be possible for selected patients with small midline hernias. Three ports are put in place and mesh secured with staples inside the abdomen over the hernial defect. These operations can be carried out as day cases and are likely to lead to reduced postoperative pain and infection rates.
This technique ishoweverreally only effective in smaller hernias because with no closure of the overlying defect the strength of the repair entirely depends on the mesh. The complication rates for midline hernia repairs exceed those for groin hernias and rise in proportion with the size of the hernia. Most wounds are closed with dissolving sutures although the larger cases may require metal clips.
Recurrence of midline hernias is more common than for those found in the groin. Another problem is that fluid may collect in the tissues underneath the skin – seromas – which may be particularly problematic in large hernias. In order to reduce this when repairing large hernias a small plastic tube (a drain) may be left in the space left behind after the repair is complete. This may stay for a few days until relatively dry at which time it can be removed.
The treatment of various types of hernia will vary depending upon the site and the nature of the problem although the principles of management are very similar. With improvements in technology and the establishment of specialist centres for hernia treatment patients should experience further improvements in outcomes.