ADVANCED

SURGICAL &

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hernia repair specialists

Diaphragm Hernias

Diaphragm hernias are opening(s) that can occur in the diaphragm muscle, and generally occur at a natural opening, such as the hiatus where the esophagus travels through into the abdominal cavity. These are known as hiatal hernias. Diaphragm hernias can also form in other areas of the muscle such as what occurs with a Morgagni Hernia, Bochdalek Hernia, or Traumatic hernia (rupture from blunt force). The most common type of diaphragm hernia is the Hiatal Hernia.

Hiatal Hernia

What is a hiatal hernia?
The diaphragm is a sheet of muscle that separates the abdomen from the chest cavity. It has an opening in the middle called the hiatus. The food pipe, or esophagus, runs through the hiatus in order for it to enter into the stomach. When the hiatus is enlarged, the stomach can bulge up into the chest causing symptoms such as heartburn, regurgitation, reflux, chest pain, and trouble swallowing.

There are several types of hiatal hernias (aka paraesophageal hernias):
The first type of hiatal hernia is called a sliding hiatal hernia. This is the most common type of hiatal hernia and is a result of the lower esophagus and top of the stomach sliding up together into the chest through the hiatus.

Other, less common types of hiatal hernias are called paraesophageal hernias. These occur when a section of the stomach goes up into the chest next to the esophagus, or when other organs such as colon, intestine, or spleen go up through the hernia defect into the chest. These types of hernia can be more dangerous because they are not always associated with symptoms and can result in the stomach tissue becoming twisted off from its blood supply resulting in “strangulation” of the stomach. In most cases, however, people have mild symptoms such as heartburn or gastroesophageal reflux disease (GERD) due to the structural changes associated with the hiatal or paraesophageal hernia.

What causes a hiatal hernia?
There are many factors that can result in a hiatal hernia, but for most patients, the cause is unknown. It is possible that some people are simply born with a short esophagus or a large hiatus, or develop these conditions over time due to weakened tissue, or chronic scarring of the lining of the lower esophagus from acid reflux resulting in contraction or shortening of the overall esophageal length. Other causes include increased intra-abdominal pressure in the abdomen due to conditions such as obesity, pregnancy, chronic cough or straining during bowel movements. Experts also predict that patients who have gained a considerable amount of weight are at risk for hiatal hernia development, along with people over the age of 50 and people that are smokers.

What are the symptoms of a hiatal hernia?
It is not uncommon for people to have no symptoms associated with their hiatal hernia. When symptoms do occur, they normally consist of heartburn and gastroesophageal reflux. Other symptoms may include pain or discomfort in the stomach or upper abdomen, chest pain, a harsh or sour taste in the back of the throat, as well as bloating and even excessive belching.

Chest pain due to a hiatal hernia feels very similar to that experienced during a heart attack. It is crucial to seek evaluation and treatment immediately so that you can be correctly diagnosed and treated.

Symptoms of a strangulated hiatal hernia or associated obstruction include the inability to have a bowel movement (constipation), the inability to pass gas, or development of nausea and vomiting.

How is a hiatal hernia diagnosed?
A barium swallow study, which is a specific X-ray procedure, can enable the proper evaluation of the esophagus to correctly diagnose a hiatal hernia. Other ways to diagnose a hiatal hernia are by CT scan or esophagoscopy (EGD). The esophagoscopy is a procedure where an endoscope, a long-thin flexible medical video camera, is inserted through the mouth into the esophagus and stomach and allows the examination of the upper digestive system.

How are hiatal hernias treated?
Hernia surgery is not necessary when patients do not have any symptoms associated with their hiatal hernia. Although some mild symptoms such as bloating or stomach displeasure and heartburn can occur, there are ways a hiatal hernia may be treated through healthy lifestyle changes. These changes include maintaining a healthy weight, limiting fatty, acidic, and caffeinated foods, along with avoiding alcoholic beverages and quitting smoking. It is also recommended that the person avoid eating at least 2-3 hours before going to bed and elevating their head while sleeping to reduce the amount of acid exposure into the lower esophagus. Other treatments include taking over the counter antacids to chemically neutralize stomach acid, thereby reducing heartburn symptoms.

When is hernia surgery necessary?
Patients who suffer the following conditions along with a hiatal hernia may be required to undergo surgical repair:

  • Gastroesophageal reflux or GERD with symptoms including regurgitation, difficulty swallowing, and/or heartburn that is no longer responsive to acid-blocking medications.
  • Strangulated hernia or obstruction – symptoms including the inability to have a bowel movement or pass gas, severe pain with eating, or persistent nausea and A strangulated hernia is an emergency situation, and often requires an emergency operation.

There is no guarantee that the hernia will not return after surgery. The best way to reduce your chances of recurrence are to avoid smoking, maintain a normal weight, and avoid any abdominal stressors such as straining, heavy lifting, and chronic cough. Repairing recurrent hernias (those that have occurred after previous repair) are exceedingly complex difficult cases, and the chance for definitive (lasting repair) goes down with each subsequent repair. Your first chance at repair is therefore the best one, so it is in your best interest to reduce as many personal risk factors for recurrence as much as possible before the first operation, and maintain a healthy lifestyle afterwards.

Abdominal Wall Hernias

What is an abdominal wall hernia?
An abdominal wall hernia is a defect, or abnormal opening, in the muscle or connective tissue layers that make up the abdominal wall. The abdominal wall is what keeps your internal organs inside and protected from the outside world. The abdominal wall extends from the bottom of the breastbone (sternum), down to the pubic bone, and outwards on both sides around to your back. When an abnormal opening, or gap, develops in the abdominal wall it is called a hernia. Intra-abdominal structures can then become entrapped in the opening, leading to pain and even life-threatening situations requiring emergency surgery. Inguinal (groin), Umbilical (belly button), Femoral, Ventral, and Incisional hernias are all subtypes of abdominal wall hernias.

What causes an abdominal wall hernia?
A weakness in the layers of the abdominal wall is what is responsible for the formation of a hernia. This can be a natural weakness, for example those that commonly occur in the groin or belly button, or can develop at a weak point in a healed incision from prior surgery, called an incisional hernia.

What are the symptoms of an abdominal wall hernia?
Usually pain associated with a bulge are the first signs of an abdominal wall hernia. These can occur in the groin, at the bellybutton, or through a prior incision site from surgery, even years after the scar has healed.

How are abdominal wall hernias diagnosed?
Abdominal wall hernias are sometimes diagnosed by the patient who feels a bulge and is sometimes associated with pain. If this is the case, the hernia needs to be confirmed by a physician exam. Hernias can also be diagnosed on imaging studies such as CT scan. If you think you have a hernia, see your doctor right away. If the bulge is associated with severe pain accompanied by persistent nausea and vomiting, and inability to pass gas or stool you may have an intestinal obstruction where a loop of intestine has become stuck (incarcerated) at the hernia defect. This is a serious emergency situation–proceed to your nearest emergency room immediately.

How are abdominal wall hernias treated?
Abdominal wall hernias are treated with surgical repair, and depending on the size of the defect opening and other factors associated with your individual medical profile are often repaired with hernia mesh. These procedures are done either through an open incision or laparoscopically (through small incisions) depending on the type of hernia and work required for repair.

Why should I have my hernia fixed?
If you suspect that you have an abdominal wall hernia, and it is causing you pain or discomfort, you should see your primary doctor for an exam and confirmation of the hernia. You can then request a referral to a hernia repair specialist, such as the surgeons at Advanced Surgical and Bariatrics of NJ. All symptomatic hernias in general should be repaired.

What is hernia repair mesh?
Hernia repair meshes are generally similar to the material used to make mosquito nets. However, hernia meshes are highly developed materials engineered specifically for use as sterile medical devices used for abdominal wall reinforcement. Due to ongoing advances in technology, hernia meshes are an intense area of ongoing research and development and therefore require proper selection by a surgeon with specialty training in hernia repair materials. The hernia specialists at Advanced Surgical & Bariatrics of NJ can meet with you for consultation and provide you with more information on which mesh is best for you and why.

Definitive hernia repair
There is no guarantee that a hernia will not return after surgery. The best way to reduce your chances of recurrence are to avoid smoking and achieve a normal body weight prior to surgery. You will also need to avoid abdominal stressors such as straining, heavy lifting, chronic cough, and weight regain after surgery. Repairing recurrent hernias (those that have occurred after previous repair) are exceedingly complex difficult cases, and the chance for definitive (lasting repair) goes down with each subsequent operation. Your first hernia surgery therefore represents your best chance at achieving a lasting repair, so you will need to reduce as many personal risk factors for recurrence as much as possible before your first operation and maintain a healthy weight and lifestyle afterwards.

Inguinal Hernia

What causes an Inguinal Hernia?
Everyone has natural weak point(s) in various areas of the abdominal wall due to their normal anatomy. One of these areas is in the groin (inguinal region). For children, hernia development can be congenital, but adults can develop this type of hernia as a result of strenuous activities, chronic cough, or chronic straining from difficulties with bowel movements or urination.

Symptoms of an Inguinal Hernia
Usually pain associated with a bulge in the groin is the first sign of an inguinal hernia. It can be a sharp pain or an ache that gradually gets worse as the day proceeds. Signs that the hernia is entrapped or strangulated are tenderness, redness of the overlying sking, severe unceasing pain, and the bulge not being able to be reduced or pushed back in. These are serious symptoms that must be treated immediately.

Laparoscopic Inguinal Hernia Repair
The surgeons at Advanced Surgical and Bariatrics of NJ specialize in the laparoscopic approach to inguinal hernia repair, which offers patients a shorter recovery and sooner return to work and daily activities. Laparoscopic inguinal hernia repair with mesh is also associated with a lower risk of long-term chronic pain after repair versus the traditional open approach. At Advanced Surgical and Bariatrics of NJ, our surgeons will examine you and decide if the laparoscopic approach is right for you.

How is the Procedure Performed?
There are two general options for inguinal hernia repair: the open approach and the laparoscopic approach. The open approach requires a three to five inch incision in the groin area. The hernia defect is identified and repaired using a piece of surgical mesh. Local anesthetic and sedation as well as spinal anesthetic or a general anesthetic are used for this procedure. In a laparoscopic hernia repair, 3 small incisions are made where a small thin camera called a laparoscope and two working instruments are inserted through the abdominal wall. The layers of the abdominal wall are separated and the space is maintained with carbon dioxide gas. This grants the surgeon access to the hernia defect and the surrounding tissues and allows for dissection and placement of the mesh. Laparoscopic inguinal hernia repair is done under general anesthesia.

What complications can occur?
For laparoscopic hernia repair, primary complications associated with the operation are not common. There is a low risk of injury to blood vessels, nerves, the bladder, the intestines, nerves or the spermatic cord leading into the testicle. Your individual risk for these complications be reviewed with your surgeon at Advanced Surgical and Bariatrics of NJ during your consultation for surgery. For many patients after open or laparoscopic repair, there can be swelling and bruising of the abdominal wall and scrotal region. This is normal and will steadily decline and resolve completely with time. Despite the low rates of recurrence of the hernia after it has been repaired, a hernia can come back at any time. At Advanced Surgical and Bariatrics of NJ we encourage our patients to review and ask questions about specific risks, complications, and how to best reduce their risk of recurrence after repair.

Incisional Hernia

What causes an incisional hernia?
An incisional hernia is one that forms in a previous incision from prior surgery. The incidence of a hernia forming in a previous abdominal scar is about 20%, and is even higher in people who are obese or who are active smokers. The hernia defect itself can form anywhere along the scar tissue of a previous incision, and can be very small to large and complex. Incisional hernias can develop slowly over many or can even occur years after surgery. The underlying cause is usually due to inadequate healing or excessive pressure on the abdominal wall scar.

Who is at risk for incisional hernias?
Conditions that increase strain on the abdominal wall such as obesity, pregnancy, peritoneal dialysis, liver disease, chronic straining/lifting, chronic cough, or chronic difficulties with bowel movements or urination are risk factors for hernia formation. Also smoking, advanced age, malnutrition, poor metabolism, steroid medications, chemotherapy, and hematoma or infection after a prior surgery put a patient at a higher risk of developing an incisional hernia.

What are the symptoms?
Pain is usually the first symptom a person will have with an incisional hernia, regardless of whether or not they have a bulge at the incision site or the abdomen. Once the bulge is present, it can increase in size and gradually cause more symptoms such as nausea and vomiting. If internal organs such as intestine becomes entrapped in the hernia defect, this can be life-threatening if left undiagnosed and untreated.

How is an incisional hernia treated?
The surgical repair of an incisional hernia is largely dependent on reducing or eliminating the tension present at the surgical site. The method that is preferred by most hernia surgeons is a tension-free method and is used by most medical centers. This procedure involves the placement of a mesh patch. Once the mesh is sewn into the area, it bridges the weakened area that is beneath it. The mesh becomes firmly integrated into the abdominal wall as the area heals, and continues to protect the organs of the abdomen.

How is incisional hernia repair performed?
The procedure can be done in two different ways, either by a laparoscopic approach or by a conventional open repair. In a laparoscopic incisional herniorrhaphy, small incisions are made and a tube-like camera and instruments are used to place the mesh. In the conventional open repair procedure, the hernia is accessed through a larger abdominal incision. If intestines are trapped in the hernia (incarcerated), or if they have become twisted off from their blood supply (strangulated) this often requires part of the intestine to be removed with the remaining ends reconnected (resection and anastomosis). The approach to repair depends on many factors, and operative planning often requires preoperative imaging such as CT scan. The surgeons at Advanced Surgical and Bariatrics of NJ will meet with you to discuss your best options. The main advantage of laparoscopic incisional hernia repair is reduced risk of mesh infection.

Femoral Hernia

A femoral hernia can appear as a grape sized lump in the inner or upper part of the thigh or groin. This lump is usually painful and may even disappear when you lie down, however straining of the muscles can cause the lump to reappear.

What causes a femoral hernia?
A femoral hernia can occur when fatty tissue or part of an intestine, protrudes through into the groin area at the top of the inner thigh through a weak spot in the surrounding muscle wall of the abdomen and into the femoral canal.

Femoral hernias tend to occur more frequently in women due to the wider shape of the female pelvis. While more common in older women, femoral hernias are highly rare in children.

As stated earlier, the hernia can appear suddenly when the muscles of the abdomen are strained. Those who suffer from constipation can aggravate the hernia and cause it to appear suddenly. Femoral hernias have also been linked to obesity, those with heavy coughs and those who carry or push heavy loads.

Why is surgery needed?
The operation pushes the bulge back into place and helps to strengthen the abdominal wall. Femoral hernia repair is a necessary procedure, since this type of hernia, if untreated, has a high risk of intestinal strangulation, which is a potentially life-threatening condition where a section of the intestine can become stuck in the femoral canal and cut off from the blood supply, which causes the tissue to die. Femoral hernia surgery will rid you of your hernia and prevent these complications from happening.**

How is the surgery performed?
Femoral hernia repair can be performed one of two ways. It can be done through open surgery where one large cut is made in which the lump can be pushed back into the abdomen, or through laparoscopic surgery. This is a less invasive method where several small incisions are made to repair the hernia. In most cases, you should be able to return home the same day as your surgery.**

What are the risks of having surgery?
Femoral hernia repair has very few risks, however 1% of femoral hernia cases reported a return of their hernia after the operation. Complications of femoral hernia repair are extremely rare, however they can include the development of a lump under the incision site, difficulty passing urine, narrowing of the femoral vein, injury of the bowel, weakness (temporarily) of the leg, and damage to nerves which can lead to pain or numbness in the groin area.

Umbilical Hernia

What is an umbilical hernia?
An umbilical hernia is a protrusion, or abnormal bulge, that can be felt or seen over the belly button. This condition develops when a portion of the intestine protrudes through the muscle of the abdominal wall.

Umbilical hernias in children are caused by an opening in the abdominal wall that is present at birth. The bulge can be seen and felt all the time or only when the child is crying, coughing, or straining during bowel movements. This protrusion may disappear when the child is relaxed.

One in every six children has an umbilical hernia, and it can affect both boys and girls equally. This condition is more common among African-American children than Caucasian children and low birth weight and premature infants have a higher risk of developing umbilical hernias. Umbilical hernias also often occur in adults, and should be repaired if they are causing symptoms of pain or intestinal entrapment.

What are the symptoms of an umbilical hernia?
The most common symptoms associated with umbilical hernia are pain and a bulge. Usually symptoms are stable over time, but often the bulge can become larger or can involve entrapment of internal organs such as intestine. Anyone with a known umbilical hernia who develops persistent nausea and vomiting with severe abdominal pain and inability to pass gas or stool may have intestinal entrapment (incarceration or strangulation) resulting in is a potentially life-threatening situation. This is a medical emergency which requires immediate evaluation; proceed to your nearest emergency room without delay.

What causes an umbilical hernia?
The abdominal organs are formed on the outside of a baby’s body during their development in the womb. These organs return to the abdominal cavity around the 10th week of gestation. If the wall of the abdomen fails to close around the abdominal organs, an umbilical hernia can form.

On occasion, the intestines can become trapped in this muscular defect, which causes umbilical pain and tenderness. This is condition is called an incarcerated hernia and must be evaluated immediately to prevent the cause of damage to the intestines. Symptoms of an incarcerated hernia include severe pain and redness of the bulge.

When should an Umbilical hernia be repaired?
In children, most umbilical hernias will go away on their own by age 3 or 4. This is why it may be recommended to wait until your child has reached this age to consider surgical repair. If, however, the defect is greater than 2cm in diameter, it will need to be surgically repaired. In adults, any symptomatic umbilical hernia should be evaluated for repair.

The Surgical Procedure
If it is determined that your child will need to undergo umbilical hernia repair, a small incision will be made at the base of the belly button where the bulging intestine can be identified. Then the intestine can be pushed back into its proper place, while the hernia sac is removed. Multiple stitches are put in place around the muscle wall to prevent another hernia. The skin around the belly button will be then sewn down and attached to the underlying muscle so that the belly button looks like an “innie” instead of an “outie.” Most children are able to return home within a few hours after surgery, however children with certain medical conditions and premature infants may need to remain under observation for one night.**

For adults, the decision to repair an umbilical hernia with mesh depends on the size of the hernia defect found at the time of surgery. The surgeons at Advanced Surgical and Bariatrics of NJ can evaluate you and provide more details at your consultation visit.

**The information on this website is not an alternative to medical advice from your regular physician. Our health advice is not intended as medical diagnosis or treatment; consult your regular physician before beginning the bariatric process. This site is for educational purposes only, and does not replace the need for a formal consultation with a surgeon before undergoing a surgical procedure or receiving treatment. The content/images on this website are not a guarantee of individual results. Individual results may vary.