Treatment of hernias of the anterior abdominal wall

The linea alba is an anatomical structure that is formed by the fusion of the fascia and aponeuroses of the muscles of the anterior abdominal wall. The linea alba is located along the midline of the abdomen (dividing it into two symmetrical halves) and is named so because of its white color, which is caused by connective tissue.

Normally, the linea alba has small openings through which blood vessels and nerve endings pass. These gaps are a “weak” point, and under certain conditions, internal organs and fatty tissue located in the abdomen can prolapse through them. Such protrusions are called hernias. Most often they are localized in the upper third of the linea alba.

How do hernias form?

Hernias occur in the area of “weak spots” of the anterior abdominal wall, under the influence of intra-abdominal pressure. Factors that cause its increase are called producing factors and include: physical activity, cough, childbirth and all those cases when the abdominal press tenses.

“Weak spot” is the area of the abdominal wall where the muscular aponeurotic part is most thinned. This may be the place of muscle attachment to the aponeurosis or physiological openings (inguinal rings, umbilical ring).

An increased risk of hernias is observed in people with predisposing factors: connective tissue weakness syndrome, damage to the nerves innervating the abdominal wall, as well as the presence of postoperative scars.

Possible consequences

Usually, for abdominoplasty with diastasis, people turn to doctors complaining of an unattractive figure, but this pathology is dangerous to a greater extent not because of the violation of aesthetics, but because of the negative consequences for health. In advanced forms, it can cause unpleasant complications:

pain in the back and abdomen, especially during exercise;
disruptions in the functioning of the digestive, respiratory and circulatory systems;
increased risk of hernia formation;
prolapse of internal organs.

No matter whether you are worried about an unattractive figure or painful symptoms, it is advisable to consult a doctor. You can order an examination at our surgical clinic in Novorossiysk, and a specialist will recommend treatment tactics. We offer the full range of services necessary to completely eliminate the pathology.

What does a hernia consist of?

All hernias, regardless of location and size, have a common structure and consist of the following components:

A hernial orifice is a defect of the anterior abdominal wall, mainly in the aponeurosis. Through them, the internal organs leave the abdomen and end up under the skin. If the hernial orifice is wide, then through it the contents can freely return to the abdominal cavity.
Hernial sac is a sheet of stretched peritoneum covering organs that extend beyond the abdominal cavity through the hernial orifice. The hernial sac is covered with several membranes, these also include subcutaneous tissue and skin.
The contents of the hernial sac are the internal organs or their individual parts that extend beyond the abdominal cavity through the hernial orifice.

Diagnosis of hernias

The diagnosis in most cases can be made based on a simple examination of the patient, when a protrusion is detected in typical places, increasing with physical activity. In unclear cases, the surgeon may use additional research methods.

Ultrasound of a hernia allows you to determine the size of the hernial orifice, distinguish small irreducible hernias from soft tissue benign tumors of the subcutaneous fatty tissue (for example, lipomas), and enlarged lymph nodes of the groin area. It is especially useful for inguinal hernias.

Herniography is used in case of unclear pain in the groin area (to exclude an externally invisible inguinal or femoral hernia), perineum (to exclude a perineal hernia) and in case of an inguinal hernia, if there is doubt about the presence of a hernia on the opposite side.
Computed tomography allows you to clearly determine the nature and size of the abdominal wall defect.

In recent years, due to the widespread introduction of new technologies and the latest scientific achievements and the use of modern plastic and suture materials, the quality of hernia repairs has significantly improved, and the number of relapses and postoperative complications has decreased.

An umbilical hernia is a pathological protrusion of abdominal organs through the umbilical ring, which can disappear or significantly decrease in size when the body is horizontal. This disease affects 6–10% of the population in adults and is more common in women.

Symptoms

The severity of symptoms of an umbilical hernia depends on many factors:

its size;
the presence of adhesions in the abdominal cavity;
the presence or absence of strangulation of the hernial sac;
general condition of the patient.

The very first symptom of a hernia is the appearance of a small protrusion in the navel area. There may not be any pain at first. At an early stage, you can even repair the hernia yourself, without a doctor. If adhesions appear, it will no longer be possible to straighten it. The duration of the process of adhesions formation varies from person to person, so some people have been accustomed for years to repair a hernia and move on without seeing a doctor, while for others, adhesions appear quite quickly.

Pain is not always present with an umbilical hernia in adults. It can appear during physical activity, coughing and standing in one place for a long time. Late stages may already be accompanied by nausea, vomiting, belching, constipation and difficulty urinating.

Treatment

The only treatment for umbilical hernia in adults is surgery. Surgery for an umbilical hernia may be postponed in uncomplicated forms of the disease in pregnant women or in cases of concomitant diseases aggravating the general condition of the patient (acute or aggravated chronic diseases, pulmonary or heart failure, etc.).

What types of hernias are there?

Depending on the anatomical location, external and internal hernias are distinguished. External ones include:

Umbilical hernia.
Inguinal hernia.
Hernia of the white line of the abdomen.
Postoperative hernia.
Paracolostomy hernia.
Lumbar hernia.
Perineal hernia.
Obturator hernia.
Hernia of the xiphoid process.
Sciatic hernia.

Hernias that form inside the abdominal cavity are considered separately. With such hernias, internal organs can be located in pockets of the peritoneum or penetrate into the chest cavity through the openings of the diaphragm.

Depending on the size of the hernia, they are divided into:

Small: hernial orifice less than 4 cm
Medium: hernial orifice from 4 to 10 cm
Large: hernial orifice larger than 10 cm

Hernias are also classified according to the degree of development:

initial - a small depression is identified in a weak spot of the abdominal wall - a triggering factor for the formation of a hernia;
canal - internal organs begin to sink into the hernial opening;
complete - the internal organs have passed through the hernial orifice and are located under the skin.

According to the clinical course, hernias are divided into:

reducible - the contents of the hernial sac move freely from the abdominal cavity to the hernial sac and back.
irredeemable.
strangulated - a condition in which the hernial orifice puts pressure on the structures of the released organ, which leads to disruption of its blood supply and can lead to necrosis. There are: elastic strangulation, fecal strangulation, parietal strangulation, retrograde strangulation, Meckel's diverticulum strangulation, Broca's hernia.

How common are hernias of the white line of the abdomen?

The most common hernias are inguinal and umbilical, while hernias of the white line of the abdomen are much less common. This type of hernia mostly affects women after pregnancy and young men who engage in heavy physical activity.

There are many reasons for the formation of white line hernias.

The most significant factor may be genetic predisposition. Inherited physiological and anatomical failure of the connective tissue structures of the body can lead to stretching of the linea alba, the formation of ectasia (expansion) of the rectus abdominis muscles, which subsequently entails thinning of the fascia; dilatations and gaps form in it, through which the formation of a hernia is possible.

Metabolic disorders, diabetes mellitus and other pathological conditions of the body that lead to changes in metabolic processes can cause depletion of the connective tissue structure of the white line. There are many diseases that can lead to a tendency to herniation, as well as effects that lead to an increase in pressure in the abdominal cavity: accumulation of fluid in it, heavy physical activity, pregnancy, difficult childbirth, chronic lung diseases, chronic constipation .

Stages of formation of a hernia of the white line

The formation of this type of hernia occurs in several stages.

At the earliest stage, usually invisible to the patient, preperitoneal adipose tissue protrudes through the slit-like defect in the connective tissue, forming a so-called preperitoneal lipoma.

Following this, the peritoneum is stretched and a hernial sac is formed, which can be palpated. Subsequently, at the stage of an already formed hernia, other abdominal organs are involved: omentum, loops of the small intestine, umbilical-hepatic ligament, transverse colon. At this stage of an already formed hernia, absolutely all components of the pathological process can be detected: the hernial orifice and the hernial sac with hernial contents. The risk of strangulation of a hernial protrusion, as a very dangerous condition, directly depends on the shape and size of the hernial orifice, the size of which can vary from several millimeters to several centimeters and take the shape of an oval, circle or even a rhombus; Moreover, the smaller the gate, the higher the likelihood that the hernia will suddenly be strangulated.

It is rare, but it happens that the type of hernia described in this article reaches large sizes; in their total mass they are relatively small. Often, the formation of a hernia does not occur beyond the stage of preperitoneal lipoma, which does not cause pain, and without the influence of aggravating factors does not evolve in progression and does not spread beyond the boundaries of the white line.

What are the symptoms of a hernia?

In the initial stages, a hernia may manifest itself as discomfort or slight pain during physical activity at the site of hernia formation. As the aponeurosis thins or the tissues of the anterior abdominal wall weaken, a painless protrusion appears, disappearing when pressure is applied to it. With each new episode of increased intra-abdominal pressure, the hernial orifice will increase in size, and the sac will stretch due to an increase in the volume of contents.

External abdominal hernias that occur without complications are characterized by such general symptoms as: the presence of a hernial protrusion, discomfort in the hernia area, dysfunction of the organs that make up the hernial contents.

Manifestations of hernia of the white line of the abdomen

The disease can be suspected if a small bulge is suddenly palpated in the midline of the patient's abdomen. Very often it does not cause pain and can be discovered accidentally by the patient himself or by the doctor during examination. Due to the fact that in a normal state the neoplasm, as such, may not cause pain, one of the indicators that allows one to suspect it is the appearance of pain during heavy work, after eating, or in other situations that lead to increased intra-abdominal pressure. An increase in pain may be associated with tension in organs and other structures fixed to the hernial sac, or as a result of strangulation of the contents of the hernial protrusion, which in turn requires emergency surgical intervention. Painful sensations can radiate to various areas of the chest, abdomen and back. When the muscles of the abdominal wall are relaxed in a horizontal position on the back, the hernial protrusion, and with it the pain, often disappears. In the event of such a formidable and extremely dangerous complication as a strangulated hernia, all the symptoms of an acute abdomen occur and general intoxication of the body increases: the temperature rises, piercing, intensely intensifying abdominal pain appears, nausea and vomiting, retention of stool and gases, and bloody discharge in the stool. , and the hernial protrusion can no longer be reduced in the supine position. Often the symptoms accompanying the disease are disorders of the digestive system such as nausea, heartburn, belching, associated with the entry of the digestive tract into the hernial sac.

Why is a hernia dangerous?

Any hernia is dangerous for the development of complications. The most serious complication of a hernia is strangulation. It occurs when the blood supply to the contents of the hernial sac is disrupted and tissue necrosis occurs.

An equally serious complication is intestinal obstruction. As a result of the prolonged presence of intestinal loops inside the hernial sac, they are compressed, the movement of intestinal contents through them is disrupted, and intestinal obstruction forms.

It is very important to understand that the development of complications can occur suddenly, against the background of complete well-being: on vacation, at the dacha, while traveling - in situations where qualified medical care is difficult to access or not available at all. Treatment of hernia complications requires emergency intervention, and delay can lead to a sharp deterioration in a person’s condition and significantly worsen the prognosis of delayed treatment.

Therefore, it is better to get rid of the hernia before complications develop.

Hernia treatment

It is only possible to completely get rid of a hernia through surgery. There are also conservative methods to alleviate the condition of a hernia, but their use is possible only if there are contraindications to surgery.

Contraindications to elective surgical treatment include severe concomitant diseases, malignant processes in advanced stages, acute diseases and pregnancy. It is important to note that complicated hernias must be operated on urgently for health reasons.

The smaller the size of the hernia, the easier the operation for both the surgeon and the patient. In turn, the treatment of giant hernias represents a major surgical problem and requires the use of non-standard approaches to its elimination.

Hernioplasty (hernia repair) is the name of an operation to “liquidate” a hernia with plastic surgery of a defect in the anterior abdominal wall.

Treatment methods

All hernias of the white line of the abdomen can be cured exclusively with surgery. Elective operations are performed for uncomplicated hernias. At the same time, it is possible to fully examine the patient and choose the optimal tactics for hernioplasty. Emergency operations are performed when complications develop (strangulated hernia), and in some cases several stages with delayed repair are required.

The choice of hernia repair method is determined based on the reasons for its formation, as well as the shape and size of the hernia. Sometimes it is impossible to carry out a full-fledged operation, in which case palliative interventions are limited. Such situations arise when the patient is old, in the presence of giant hernias, after closure of which suffocation may develop due to a sharp decrease in the volume of the abdominal cavity. Also, suturing is contraindicated in the early period after a strangulated hernia complicated by phlegmonous inflammation.

There are several ways to operate on hernias of the white line of the abdomen:

Fascial-aponeurotic plastic surgery. This method implements to the maximum extent the principle of stitching homogeneous tissues, which, under certain conditions, ensures their reliable fusion and reproduction of the natural anatomical relationships of the tissues of the abdominal wall.
This method is implemented in two ways:
- Simple suturing of the edges of the aponeurosis. This method is considered unreliable because it often causes relapses. Can be used in the treatment of young people.
The second method is suturing the aponeurosis with strengthening with muscle tissue . It is assumed that the muscle, due to its elasticity, will counteract the increase in intra-abdominal pressure. In practice, this method is also rarely used due to the technical difficulties of the operation. The main point is to preserve muscle function during muscle transplantation, and this is not always possible.
And the last method is plastic surgery using artificial reinforcing materials that strengthen the white line. Such techniques are used for recurrent hernias, for large hernias, for atrophic changes in the structures of the abdominal wall, as well as for multiple hernias of the white line of the abdomen. Polymer meshes are used as reinforcement. They are chemically inert, non-toxic, elastic and durable. Their use has made it possible to sharply reduce the likelihood of relapses and achieve good treatment results.

In addition to the traditional method of performing surgery using skin incisions, endoscopic technologies are increasingly being used. They involve carrying out all surgical procedures through small punctures. The advantage of this technology is that the intervention is less traumatic, has a good cosmetic effect and a quick recovery period. The disadvantage of this method is the need for special equipment and trained personnel. To date, this is not available in every clinic.

What are the methods of anterior abdominal wall plastic surgery?

Plastic methods can be tension or non-tension.

Tension is a type of plastic surgery performed using the patient’s own tissues. This method received this name because, in order to eliminate a hernia defect, the tissues must be “tightened” and sewn together. The resulting tension in the tissues can cause pain after surgery and result in a possible relapse. At the present stage of development of medicine, this method of closing hernias defects is significantly inferior to non-tension methods.

Tension-free plastic surgery involves the use of modern mesh prostheses to strengthen the anterior abdominal wall. The prosthesis is a polypropylene network, which, due to its flexibility, strength and high degree of tissue “germination”, has shown its reliability and safety when used in hernia repair. Mesh prostheses come in different sizes, from small ones with a diameter of 5 cm for umbilical hernias, to large ones of 50 x 50 cm for giant incisional hernias. Modern three-dimensional mesh systems make it possible not only to strengthen the hernia defect in the form of a “patch”, but to completely fill it, significantly reducing the risk of relapse. In some situations, a special mesh is installed, the surface of which is coated with a special composition that allows it to safely contact the abdominal organs and avoid the formation of adhesions between them.

The open hernia repair operation consists of several stages:

Isolation of the hernial sac. A skin incision is made above the hernial protrusion, the hernial sac is freed from the surrounding subcutaneous fatty tissue. The “hernial orifice” is distinguished.
The hernial sac is opened, the condition of the contents of the hernial sac is assessed, and if there are no complications, the contents are immersed in the abdominal cavity.
The hernial sac is excised, stitched and plunged into the abdominal cavity.
The integrity of the anterior abdominal wall is restored (plasty is performed).

Recovery after surgery

Recovery after surgery depends on the type of surgery. On average it takes 1-4 weeks.

With endoscopic ablominoplasty of diastasis:

the patient feels little or no pain;
complications occur extremely rarely;
physical fitness returns within a week;
almost no marks on the skin.

You can leave the hospital the very next day after the correction, but stress must be avoided for a month.

With standard abdominal abdominoplasty with suturing of diastasis:

the patient must remain in the hospital for several days;
there is often pain, so analgesics are prescribed;
stitches are removed after about 7-8 days;
It is necessary to abstain from physical activity for at least 3 months and not lift weights weighing more than 5-10 kg. After this time, you can return to your normal rhythm of life.

For all types of surgical intervention, wearing a bandage and/or surgical underwear is prescribed for at least 1 month.

Is it possible to operate a hernia without incisions using modern mesh prostheses?

Yes, you can!

At the moment, laparoscopic hernioplasty is the operation of choice for the treatment of various types of hernias. This operation is performed through punctures in the anterior abdominal wall. The surgeon inserts a video camera into the abdominal cavity and, using additionally inserted manipulators, releases the hernial sac from its contents. In the second stage, the surgeon separates the peritoneum of the hernial sac from the tissues of the anterior abdominal wall, dissects it and places a special mesh prosthesis on the hernial orifice. Then, the mesh is reinforced on top with the previously separated peritoneum.

Thanks to this, the prosthesis does not form adhesions with internal organs. This method of plastic surgery avoids tissue tension and greatly reduces the likelihood of relapse. The absence of large incisions on the anterior abdominal wall contributes to a comfortable course of the postoperative period.

Inguinal hernia

Classification

According to anatomical features, oblique, direct and combined inguinal hernias are distinguished. Indirect inguinal hernias can be of congenital or acquired origin.

Direct inguinal hernias are always acquired and are characterized by protrusion of the peritoneum into the inguinal canal directly through the inguinal space, outside the spermatic cord. Combined inguinal hernias are complex formations consisting of several hernial sacs that do not communicate with each other and exit through different hernial openings.

There are also reducible inguinal hernias (which can appear and disappear) and irreducible ones, the independent elimination of which is impossible due to the adhesion of the hernial sac to the hernial contents. A sliding inguinal hernia is said to exist if the hernial sac is formed not only by the parietal peritoneum, but also by its visceral layer covering the sliding organ. A sliding inguinal hernia may include the bladder wall, cecum, ovaries, tubes, uterus, etc.

If the inguinal hernia returns again after surgery, then it is regarded as recurrent.

According to the clinical course, uncomplicated and complicated inguinal hernias are distinguished.

Non-strangulated inguinal hernia;
Strangulated inguinal hernia.

With a strangulated inguinal hernia, the following clinical picture is observed:

sudden onset;
irreducibility;
sharp, gradually increasing pain;
nausea, hiccups, repeated painful vomiting;
retention of stool and gases;
serious condition of the patient;
tension, pain of hernial protrusion.

The presence of these clinical symptoms is an indication for emergency surgery.

Symptoms of inguinal hernia

Volumetric formations appear at the site of the hernial protrusion. Its sizes can be different - from a walnut to a chicken egg. A hernial protrusion can occur periodically and be easily reduced inwards - spontaneously or by the patient (reducible hernia), or it can be present constantly (irreducible hernia).
The patient begins to complain of periodic pain in the hernia area, which intensifies with physical activity and can radiate to the scrotum, sacrum, lower back and lower abdomen. Over time, the pain becomes chronic and quite severe.
There is a feeling of discomfort when walking.

Diagnostics

When examining patients with inguinal hernias, both groin areas are examined in a standing and lying position to identify (in unclear cases) asymmetry, even subtle, but giving some indication of the possible presence of a hernia.

Palpation of the superficial inguinal ring with insertion of a finger and simultaneous tension of the abdominal wall (coughing) gives a “shock symptom.”

Examination of the superficial inguinal ring in women is much more difficult than in men, and is possible only with loose skin and a significant expansion of the superficial inguinal ring.

Treatment of inguinal hernia

Treatment of inguinal hernias involves surgical removal of the defect in the abdominal wall. Closing the hernial defect and restoring the integrity of the abdominal wall can be done using local tissues - aponeurosis (hernioplasty with one’s own tissues) or a synthetic prosthesis (hernioplasty with the installation of a mesh prosthesis). Today, tension-free methods of inguinal hernia repair using a mesh graft are increasingly used in surgery. In this case, the hernial orifice is strengthened from the inside with a special polypropylene mesh, which subsequently serves as a frame for the germination of connective tissue and prevents the exit of internal organs. Tension-free hernioplasty reduces the likelihood of recurrence of an inguinal hernia. Treatment of inguinal hernias can be performed laparoscopically.  

Forecast and prevention of inguinal hernias

In the long term, recurrence of the inguinal hernia is possible. Relapses develop especially often after tension hernioplasty. In other cases, the prognosis for work ability and quality of life is favorable.

The goals of preventing an inguinal hernia include strengthening the muscles of the abdominal wall, combating constipation, quitting smoking, which leads to coughing, weight control, and wearing a bandage during pregnancy.

Hernia of the white line

A hernia of the linea alba appears as a painful protrusion anywhere along the midline of the abdomen.

Hernia of the white line of the abdomen (also known as preperitoneal lipoma) is a condition in which gaps form in the tendon fibers between the muscles along the midline of the abdomen, through which first the fat and then the abdominal organs emerge.

How does the postoperative period proceed?

After laparoscopic hernia repair, pain is practically not felt and is therefore easily controlled using tablet painkillers.

The only reminder of the operation was discomfort in the area of small punctures on the anterior abdominal wall.

In uncomplicated cases, discharge from the hospital occurs within 2-3 days. The time frame for returning to work, on average, does not exceed 10-14 days.

Traditional open surgery is characterized by pain in the postoperative period. However, carrying out comprehensive pain relief in a hospital allows you to reduce its severity and feel comfortable throughout the entire recovery period.

After discharge from the hospital, you will be advised to limit physical activity for a period determined by your attending physician based on the complexity of the treatment performed.

How is surgery to eliminate diastasis recti performed?

Before plastic surgery for diastasis recti, the patient needs to have an ECG and some tests. Three days before the operation, you need to exclude fatty, spicy and fried foods from your diet, do not drink alcohol, and stop smoking. All tests before hospitalization can be ordered at our clinic.

Abdominoplasty for diastasis of the rectus abdominis muscles is a very complex operation that takes place under anesthesia for 2-5 hours. The surgeon removes excess skin and fat, returns the abdominal muscles to their normal position, and can move the navel if necessary.

Taking into account the severity of diastasis, different types of surgery may be necessary:

endoscopic abdominoplasty – used to suturing muscles without removing excess skin. Plastic surgery occurs through small incisions, the seams are almost invisible after this. Approximate time – 2 hours;
mini-abdominoplasty - a small surgical intervention on the lower abdominal wall is indicated for normal body fat and good muscle tone. It is aimed primarily at removing excess skin; liposuction is allowed. Approximate time – 2 hours;
standard abdominoplasty – performed for obesity and severe stretching of the skin. This type of plastic surgery includes removal of skin stretch marks, excess fat, suturing of muscles, and possible displacement of the navel. Approximate time – 4 hours.

The sooner you seek the services of a surgeon, the less surgical trauma and the faster the rehabilitation period. Thanks to the proven technique and many years of experience of our doctors, you can count on excellent cosmetic results. With standard abdominoplasty to eliminate diastasis, the incision is made as low as possible so that in normal life it is hidden under underwear. When stitching, special threads are used so that the seam is almost invisible.

Who deals with surgical treatment of external abdominal hernias?

You can always contact the clinic of coloproctology and minimally invasive surgery for surgical treatment.

Qualified specialists regularly perform laparoscopic interventions for hernias of the anterior abdominal wall. In some cases, we also use traditional open surgery.

At KKMH, treatment of hernias is carried out both on a paid basis and under the compulsory medical insurance policy.

Sign up for a consultation by phone +7 (499) 11-03-222.