Hernias

What is a Hernia?

A hernia is a breach, hole or gap in the normal barrier between the intra-abdominal organs and the tissue above muscles, called subcutaneous tissue. The primary risk of having a hernia is strangulation. Strangulation traps organ tissue that is normally inside the abdomen and the defect exerts a tourniquet-type effect which eventually cuts off the blood supply of the hernia. This will often lead to a surgical emergency within hours. If untreated, this strangulation can be fatal. Paradoxically, active people have a much higher risk of strangulation since activity can force the hernia outside of the body. Sedentary individuals are lower risk for the same reason. If a hernia is too small for organs to get stuck, it will mostly cause pain. Your surgeon will help you determine if this is the situation in your case. The medical community at large recommends elective hernia repair for all acceptable operative candidates. Patients deemed unacceptable risks for surgery can explore conservative, yet low yield treatments, such as support devices. In our experience, these treatments are not particularly helpful. Hernias (especially larger ones) can also disturb the correct alignment of the abdominal wall, causing asymmetric muscle function. Asymmetric muscle function is non-life threatening but an important consideration in younger, active patients. Unlike most other centers, we typically repair this in all of our patients. This is particularly important in individuals such as athletes who seek peak bodily function.

Hernia Symptoms

While some hernias have no symptoms, inguinal hernias (which are most common type) typically cause one or more of the following:

• Groin pain or discomfort that intensifies with pressure (when coughing, bending or lifting, for example)
• Weakness in the groin
• Pressure in the groin
• A bulge in the area on either side of your pubic bone
• Burning or aching at the bulge

What Causes a Hernia?

Hernias happen for many reasons and exerting too much pressure on the abdominal contents, or an acquired weakness in the abdominal wall are the most common. Obesity, heavy lifting, exercise, or other factors such as lung disease can cause pressure on the abdominal contents. Previous surgery, smoking, obesity and genetics can cause weakness of the abdominal wall. Hernias can also happen in very active individuals in what is called an “overuse injury”. This is similar to the way athletes develop arthritis earlier in life due to high activity. Hernias can occur in almost any areas of the body but are most common at inherent areas of weakness. These sites include the umbilicus (bellybutton), the groin in various areas, previous incision sites, and other areas on the abdominal wall.

Hernia Treatment Options

Surgical Hernia Repair

In general, there are several options available, but in our opinion, there is no “one size fits all approach”. In general, two major categories exist, mesh and no mesh hernia repair.

Mesh or No Mesh Hernia Surgery?

We are not advocates of mesh repairs in our practice. Data suggests over 50% of those implanted with mesh have significant issues resulting from the implant, such as chronic pain and infection or foreign body reaction to the mesh. In fact, a large part of our practice is based on the removal of previously implanted mesh and redo repairs. If we do implant mesh in our practice, we use what is called a biologic mesh. This is a specialized type of mesh that becomes part of your body, and infiltrated with your own tissue. Biological mesh is not widely used because it is far more expensive than conventional mesh. At City Surgical Care, we feel the benefits to our patients are worth the cost. The primary benefits include much lower risk of chronic pain and foreign body reactions and lower risk of infection. These two issues are the leading cause of post-operative mesh complications and the main indications for mesh removal after implantation. Even when we use biologic meshes, we minimize the size of the implant to ensure the risk of complications is as low as possible in order perform the most stable and successful repair.

Laparoscopic vs Open Repairs

We feel laparoscopic repairs are best for older, high-risk patients who cannot tolerate abdominal incision. Patients who are sedentary and not particularly concerned with perfect alignment of their core muscles are also good candidates. The vast majority of our patients do not fit into either of these categories. More commonly, we see patients after significant weight loss or multiple pregnancies, and are otherwise quite healthy and active. Patients after weight loss and pregnancies often have more complex defects that require more intensive repairs. In addition, the excision of excess skin and loose tissue and realignment of their abdominal wall musculature are common factors. For this reason, we utilize 2 separate types of incisions for all or our hernia repairs.

1. Simple hernia repairs are performed through a small belly button incision. In groin hernias, the incision is made below the waistline.
2. Complex hernia repairs with multiple problems or excess skin and tissue are addressed through a lower abdominal “tummy tuck” incision. Tummy tuck incisions address all issues in the abdominal wall at once. It can be much more difficult to address the abdominal wall through this incision, however we have become quite adept at this approach and feel that the overall result is hugely beneficial to the patient. In addition, we can remove any excess skin and tissue at this time that is either bothersome to the patient in terms of skin irritation, or that may impair wound healing, or prevent full exposure at the time of operation. The overall result is a much more aesthetically pleasing, functional, and strong abdominal wall.

We focus deeply on specialized repair to encompass all functional issues while at the same time improving aesthetic ones.

Muscle Flap Repairs/Component Separation Repairs

In some instances, a component separation repair is necessary. There are specific indications for this procedure, such as large or complicated defects, the presence of infection, or in recurrent hernias. Component separation repair is the gold standard hernia repair. It is a very specialized repair that we are adept at performing.

Risks of Hernia Repair Surgery

Any surgery or procedure has a theoretical risk of bleeding, infection, blood clots, and damage to adjacent structures. This is the same with hernia repair surgery. Prosthetic mesh complications confer a significant amount of risk, and for this reason we avoid them at all costs and use non mesh or biologic mesh repairs. More complex, more chronic, and redo hernias always confer a higher risk due to variants in anatomy and scar tissue, as well as a poor blood supply, however we have a significant amount of experience with redo surgery at City Surgical Care, in even the most high risk patients.

Risks of Not Repairing a Hernia

In most cases, hernias are not an emergency and repair is elective. However, the longer you wait to repair your hernia, the greater the risk of more serious problems occurring. In general, pain, tenderness, and bowel strangulation (in an emergency) are the risks. For these reasons, we believe almost all hernias should be repaired if identified. If, for some reason, you must delay repair, we always inform patients on how to avoid an emergency. In general, most hernias can be “reduced” at home, meaning you can push whatever is stuck, back in. This typically avoids emergency operations, but should be discussed with your surgeon, as this is not a long-term solution.

What to Expect After Hernia Repair Surgery

Depending on the type of hernia repair performed, your post-op course will vary. In laparoscopic or simple hernia repairs, you will have no drain. Incisions will be small. In general, pain will be mostly minor but can vary significantly based on unique circumstances. Dressings can come off in 24-36 hours and showering is ok after 72 hours. In more complex abdominal wall reconstruction repairs, redo hernias, and cases where skin excision is needed, drains are often left behind to collect fluid that may accumulate. Your nurse will teach you how to empty and record drainage. We typically remove drains and any external sutures or staples within one week. In larger cases we us a “vacuum dressing”, which is an active drain system that accelerates healing. Wound vacuums are typically removed within 2 weeks. Pain is moderate but eases off after 48 hours. Most patients are doing very well moving around after 24-48 hours. Showers are ok but patients should avoid baths until all drains are removed. In all cases, we encourage patients to move around and get back to normal as soon as possible. Activity can gradually increase at 2 weeks, and regular full activity at 5-6 weeks, depending on the procedure. Patients should not lift over 15-20 pounds under any circumstances for at least one month after a hernia repair. This is something some patients (such as those with small children) must plan ahead for. Lifting must be avoided because, like a bone repair, hernias are structural operations that need time to heal. Speak with your surgeon about your particular situation. In most cases, your doctor will prescribe 3-10 days of prophylactic antibiotics to prevent post-operative infection problems.

Hernia Surgery Cost New York & New Jersey

City Surgical Care is committed to helping patients receive the best care possible. The first step in the journey of effective care is always a medical consultation. Medical consultations are important because no two patients are exactly alike. In other words, consultations enable our doctors to understand each patient’s unique case, and determine the best treatment plan. Prior to booking a hernia consultation with our surgical practice, our team will collect your insurance information to determine if our providers accept your specific insurance plan. If we do not accept your medical insurance, we will inform you of any out of pocket costs associated with a hernia consultation and help you weigh your options. Either way, a doctor must see you before we can tell you what treatment for your condition will entail, from both a medical and cost standpoint. City Surgical Care treats patients in need of hernia repair surgery in our New York and New Jersey facilities. Contact us today to learn more about your treatment options for mesh and no mesh hernia repair.