HERNIAS

Paul Montero, MD
Kevin Rothchild, MD
Assistant Professor
Surgery
University of Colorado Denver

MS3 Didactic Series

Surgical Consultation Requested

42 y/o male
CC: abdominal pain
HPI: Was lifting a box last month, noted a tearing pain and
eventually an associated, enlarging lump just above umbilicus
which is soft. No n/v/c/d/f. Pain is constant, stable, moderate,
and does not radiate. Exacerbated by exertion, sneezing.
PMHx: GERD, HTN, Obesity
PSHx: open Nissen fundoplication 2004
SHx: no ETOH, ppd tobacco x 12 years
FHx: diabetes, obesity

Physical Exam

98.7 78 142/85 16 94% RA

59 224 lbs BMI: 33
A+Ox3, NAD, CTA B, RRR, No
Edema, EOMI, No icterus
Soft, reducible, mildly tender bulge
in previous midline incision. Skin
intact and healthy.

What is a Hernia?

What is a Hernia?

A defect, weakening, or hole in the abdominal

wall where it should not be (from the latin for
rupture)

Areas of weakness: umbilicus, hiatus, inguinal canal

Previous incision
There are also internal hernias (rare)

Famous Hernias: inguinal (direct, indirect,

pantaloon), umbilical, ventral, femoral, hiatal,
flank, spigelian, obturator

Hernia Locations

Hernias

4-5 million laparotomies performed in the US each year

Reported incidence of ventral hernia is 2 25%
150,000-500,000 hernias repaired annually in U.S.
Hernia repair is the most commonly performed surgery
worldwide

Choi et al. Annals of Surgery 2012

Breuing et al. Surgery 2010

Hernia Imaging

US, CT

What complications can occur from

Hernias?

What complications can occur from

Hernias?

Natural History: slowly get bigger, never go away

on their own (*there is one exception)
Symptoms: pain, obstruction, unsightly bulge,
impeded function
Incarceration
Strangulation
Erosion of hernia sac through
weak

skin

What factors mitigate Hernia

formation/enlargement/recurrence?

What factors mitigate hernia

formation/enlargement/recurrence?
Weakened tissue

Force applied to tissue

What factors mitigate hernia

formation/enlargement/recurrence?

Weakened tissue
Smoking
Age
Steroids
Immunosuppressive Meds
Collagen disorders
Surgical Wounds

Force applied to tissue

Heavy lifting
Obesity
Constipation
Coughing
Difficulty urinating

What factors mitigate hernia

formation/enlargement/recurrence?

Weakened tissue
Smoking
Age
Steroids
Immunosuppressive Meds
Collagen disorders
Surgical Wounds

Force applied to tissue

Heavy lifting
Obesity
Constipation
Coughing
Difficulty urinating

What are the management options

for a Hernia?

What are the management options for

a hernia?

Observation

Support (truss, binder)

Repair

What are the Surgical Techniques used

for Hernia Repair?

What are the Surgical Techniques used

for Hernia Repair?
Open Repair
Laparoscopic Repair
Mesh
Type
Location of Placement

What are the Surgical Techniques used

for Hernia Repair?
Open Repair
Laparoscopic Repair
Mesh
Type
Location of Placement

Factors to Consider:
Size of hernia
Location of hernia
# of hernias
Patient Comorbidities
Experience of Surgeon
Mesh availability

Types of Mesh

Synthetic:
Absorbable: polygalactin 910 [Vicryl], polyglycolic acid
[Dexon]
Non-absorbable: polypropylene [Marlex, Prolene], and
expanded polytetrafluoroethylene [ePTFE, Gortex]

Biologic:

From Sabiston Textbook of Surgery, 19th Ed 2012

Mesh: Location of Placement

From Sabiston Textbook of Surgery, 19th Ed 2012

Laparoscopic Repair

http://www.youtube.com/watch?v=-g9wfx6m9LA

Additional Reading:
Luijendijk et al. NEJM 2000

Heniford et al. Annals of Surgery 2003