Ventral Hernia

Abdominal Hernia

A hernia is a protuberance of an organ or its fascia through the cavity wall where it normally is contained. One of its more common types is abdominal hernia.


It usually builds up in the abdominal wall, where a region fails and weakens, through which the intestines and other contents of the abdomen may protrude.

These hernias consist of the peritoneum encircling the abdominal organs, along with fats and intestinal portions. They may either be present upon birth from partial closure of abdominal wall, or may be acquired from increased pressure against an abated muscular area. [1, 2, 3]

What are Ventral Hernias?

Definition : Ventral hernias are abdominal hernias predominantly found along the midline of the abdomen. These may be found as a birth defect, from an incomplete closure of the abdominal wall, or from an incision of a previous abdominal surgery. [2, 3]

These types of hernias are found to be fairly common. On a recent survey done at Scotland, 120 patients were diagnosed of having ventral hernias within a span of just 3 months. [4]

Picture 1 : This is an example of ventral hernia, with bulging on the midline of the patient’s abdomen.
Image Source: www.surgery.wisc.edu

Types of Ventral Hernias

Several types of ventral hernias exist, with each having a different location and etiology.

Incisional Hernia

This type of ventral hernia bulges through a surgical scar or a previous incision site. Mostly appearing after 5 years, it can even occur soon after the procedure, or even decades after. A third of those who have undergone abdominal surgery, such as appendectomy, often develop this. Among 5 out of a thousand patients develop these hernias at the laparoscopic port site, however, more patients, 150 out of a thousand people, are likely to have them after a previous open abdominal incision. [2, 5, 6]

Primary Umbilical Hernia

Occurring spontaneously in the abdomen, this can be either be a congenital condition, occurring after birth, present over time from muscular weakness, or an antecedent of a past incision site. [7]

Epigastric Hernia

This hernia type bulges in the midline and is usually located within 5 to 6 cm above the umbilicus. Present in 3 to 5% of the population, it can occur with or without a previous abdominal incision. [6, 7]

What Can Cause an Increased Risk of Ventral Hernias?

Aside from having a family history and being congenital, ventral hernias can also be acquired. A number of factors can increase one’s chance of having these ventral hernias. They are the following:

  • Open abdominal procedures weakening the abdominal muscles
  • Continuous and more frequent coughing bouts
  • Heavy lifting
  • Pregnancy
  • Diabetes mellitus
  • Prolonged corticosteroid use
  • Infection at a previous surgical incision
  • Large abdominal incisions
  • Episodes of relentless vomiting
  • Obesity
  • Chronic constipation and severe straining upon defecation
  • Cigarette smoking
  • Pulmonary disease
  • Nutritional deficiencies
  • Overexertion
  • Sleep apnea
  • Enlarged prostate and conditions causing straining on urination [3, 6, 8]

Signs and Symptoms of Ventral Hernia

  • Ventral hernias produce a lump or a bulge in the abdomen. Its size usually increases through a period of time. It may disappear upon lying down and eventually recur and enlarge when one stands, lifts a heavy object, or pressure is placed on the abdomen. [2]
  • A ventral hernia is reducible if it diminishes in size as response to manual pressure or upon lying down. It is irreducible or may even be incarcerated if reduction fails and an intestinal part bulges through the hernia sac. When strangulated, the intestine is ensnared in the hernia pouch, decreasing its blood supply and thus is a cause for a medical emergency. [8]
  • Manifestations of these types of hernia include a distended and bloated looking abdomen, and abdominal pain upon lifting object, coughing, standing too long, and straining. If the hernia is incarcerated, more severe abdominal pain, constipation, vomiting and nausea, can be experienced. However, when strangulation of the hernia is eminent, severe, excruciating abdominal pain is noted, along with tachycardia, high grade fever, protracted vomiting and profuse sweating. [2, 6, 9]

Diagnosis of Ventral Hernias

A comprehensive history and complete physical examination are both required to evaluate for the presence of these types of hernias. The patient is examined in both standing and supine positions. A Valsalva maneuver is done to demonstrate its shape and determine its size.

He may also be asked to strain or cough during examination to further visualize the hernia bulge. [2, 10, 11]Diagnostic examinations such as complete blood test and chemistry, urinalysis, ultrasound, and Computed tomography (CT) scan can also be performed to confirm the presence of such hernias. [7]

Nonsurgical Management of Ventral Hernias

This option is only suggested to asymptomatic hernia patients. Aside from watchful observation and waiting, trusses and belts can be used. These equipments are applied to the hernia, correctly fitted and with an adequate amount of pressure. With a goal of achieving hernia control, patient found them to be either an uncomfortable or a sufficient contraption for symptomatic control. [12]

Surgical Treatment for Ventral Hernias

Episodes of vomiting and sharp abdominal pain with a sudden onset may indicate bowel obstruction and incarceration. These warrant immediate surgical repair and treatment. This is done by suturing the muscle, with a use of another muscle or tissue flap, or by inserting a mesh as reinforcement for the hernia site closed. It may be performed either through an open hernia repair or by laparoscopy, depending on the size and location of the hernia. [7]

Open Hernia Repair

This type of hernia repair is done as the surgeon makes an incision in close proximity to the site of the hernia. The bulge is then pushed back within the abdomen, and then closed with a suture, a tissue flap, or a mesh. This is usually done among patients with infections and strangulated intestines. [13]

Picture 3 : A photo of an open hernia repair using a mesh.
Image Source: www.medscape.org

Open ventral hernia repair (VIDEO)

Laparoscopic Hernia Repair

This is considered to be the better option for surgical management of ventral hernias, because of lower infection rates and shorter duration of hospital stay. In this method, several incisions or small punctures are made in the abdomen, through which trocars or hollow tubes are inserted. Placed thru these trocars are surgical tools inflating the abdomen with carbon dioxide for further visualization of the hernia. Finally, a mesh is then used to suture and clip the hernia site. [7, 14]

Picture 4 : A photo showing a laparoscopic repair of the hernia, with trocars inserted for further visualization.
Image Source : www.justlaparoscopy.com

Prognosis

If untreated, ventral hernias can cause the intestines to be obstructed or incarcerated. These may cause problems with the entire human body, initially thru digestion, and thus be a surgical emergency, or furthermore, lead to mortality. [15]After repair, hernia can still recur. Based on a study done, ventral hernias can return for 41 of the 1,000 patients repaired using a mesh, and for 430 of the 1,000 patients where open, non-mesh repairs were instituted.

The risk of recurrence increases with a previous hernia repair, a prior abdominal surgery, and an infected hernia. Thus, immediate follow up with the surgeon is advised when there is continuous abdominal pain and swelling, high grade fever, vomiting, and swelling, redness, or bleeding of the incision site post-operatively. [7, 16, 17]

References:

  1. Hernia. Collins English Dictionary – Complete and Unabridged 11th edition.
  2. http://www.ucsfhealth.org
  3. http://www.localhealth.com
  4. Courtney, C,et al. Ventral Hernia Repair: A Study of Current Practice. Hernia. 2003 March.; 7 (1): 44-6.
  5. Helgstrand, F, at al. Troca Site Hernia After Laparoscopic Surgery: A Qualitative Systematic Review. Hernia. 2011; 15:113-121.
  6. http://www.patients.dartmouth-hitchcock.org
  7. Selected Readings in General Surgery. Hernia. 37 (8)
  8. Malangoni, M, et al. Textbook of Surgery. Philadelphia, PA: Saunders, 2008.
  9. http://www.ehow.com
  10. http://www.wisegeek.com
  11. http://www.mdconsult.com
  12. Cheek, C, et al. Trusses in the Management of Hernia Today. British Journal of Surgery. 1995; 82:1611-1613
  13. Saureland, S, et al. Laparoscopic versus Open Surgical techniques for Ventral or Incisional Hernia Repair. The Cochrane Collaboration. 2011.
  14. Hwang, C, et al. Laparoscopic Ventral Hernia Repair is Safer Than Open Repair: Analysis of the NSQIP data. Journal of Surgical Research. 2009; 156: 213-216.
  15. http://www.smarterpatient.com
  16. Brill, J, et al. Long Term Outcomes with Transfacial Sutures Versus tacks in Laparoscopic Ventral Hernia Repair: A Review. The American Surgeon. 2011; 77: 458-65.
  17. Forbes, S, et al. Meta-Analysis of Randomized Controlled Trials Comparing Open and Laparoscopic Ventral and Incisional Hernia Repair with Mesh.

Published on by under Diseases and Conditions.
Article was last reviewed on September 11th, 2016.



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