Surgery to repair a hernia is a common procedure -- more than half a million hernia repairs were done in the United States last year, according to the American College of Surgeons (ACS). Yet the decision to have the surgery isn't as simple as its frequency might indicate. In some cases, surgery may not be necessary. In others, where the patient is in pain or a portion of the bowel is protruding, surgery may need to be performed quickly. Your best course of action when diagnosed with a hernia is to work with a knowledgeable physician to determine what you should do.

A hernia develops when the outer layers of the abdominal wall are weak, allowing the inner lining of the abdomen to push through this barrier and form a sac. A portion of the intestine or abdominal tissue slips into this sac, filling the sac and often causing it to bulge out or protrude beneath the skin.

"When this happens, you usually see a bulge at the hernia site," says Rebecca Evangelista, MD, a general surgeon at The George Washington University Hospital."Or, you may see the bulge when you cough or laugh, as the inner lining is pushed through the opening with the strain of your action."

"It is important to note that the size of the bulge does not indicate the size of the defect of the abdominal wall," says Jason Brodsky, MD, a general surgeon at GW Hospital. "We can feel the bulge, but we can't always feel the defect, which can vary tremendously in size."

	Jason Brodsky, MD General Surgeon
	Rebecca Evangelista, MD, General Surgeon
	Juliet Lee, MD General Surgeon
	Fredrick Brody, MD Director of Minimally Invasive Surgery

Different Types of Hernia
The three most common types of hernia are:

Inguinal (groin): The ACS reports that inguinal hernias account for 80 percent of all hernias. These hernias occur at the groin and are most common in men. Usually, the bulge is seen at the crease where the thigh meets the torso. An inguinal hernia may occur when weakened abdominal muscles are strained from heavy lifting, sudden twists or pulls or even chronic constipation. A dramatic increase in weight can also place pressure on the abdomen and cause an inguinal hernia.

Umbilical: These hernias occur at the navel when an opening in the abdominal wall doesn't close as it should after birth. The hernia may first be noticed in a newborn, but it often closes by age two. Some hernias do not close, however, and a child may be referred for surgery. In adults, an umbilical hernia may occur if the area of the abdominal wall never closes fully and remains weak into adulthood.

"We sometimes see this in women after they have given birth. If that area of the abdominal wall is weak, the abdominal pressure of childbirth can cause an umbilical hernia," says Juliet Lee, MD, a general surgeon at The George Washington University Hospital.

Incisional: "This hernia is less common," says Dr. Lee. "It occurs in patients who have had prior abdominal surgery at the hernia site." Less than 10 percent of all hernias are incisional.

Symptoms Can Vary
Symptoms of a hernia include the visible bulge and a dull ache where the hernia exists. In some patients, a bulge may not be present, and they may only experience symptoms such as a dull ache or mild pain when lifting or straining.

"One sign of a serious complication of hernia is incarceration," says Dr. Brodsky. "This is when a portion of the bowel has gone through the opening and now can't get back inside, and as a result, the patient may experience severe pain and nausea. This is the main danger of a hernia."

When Surgery Is Necessary
Options for dealing with a hernia include observation and surgery. "There are no exercises you can do to correct a hernia," says Dr. Evangelista. "And there is no medication that will correct one, either. You really have two options: We can wait and observe the hernia or perform a surgical repair.

"Twenty years ago, surgeons routinely recommended surgical repair because of the risk to the bowel," says Dr. Evangelista. "Most literature shows around a 10 percent risk of bowel incarceration, but I think most surgeons would agree that anecdotally this risk is actually much lower. So, if a patient has a recognized hernia but no other symptoms, I will explain the options and risks."

Open Surgery Versus Laparoscopic Procedures
"The goal of surgery is to close the hole in the abdominal wall by either suturing the edges of the tissue together or placing a mesh covering over the opening," says Dr. Brodsky. Surgery to correct a hernia can be performed as an open or laparoscopic procedure.

"The preferred surgery for many physicians is the laparoscopic approach," says Dr. Lee. "During the laparoscopic procedure, three or four small incisions are made in the abdomen. A long scope with a camera at the end is inserted through one hole while surgical instruments are inserted through the other holes. The surgeon uses these instruments inside the abdomen to repair the hernia while watching a video screen."

One difference between the open and laparoscopic procedure is the placement of the mesh. During an open procedure, the mesh is sutured to the outside of the abdominal wall. During a laparoscopic procedure, the mesh is sutured to the inside of the abdominal wall.

The type of surgery chosen depends on several factors: the size of the hernia, physician preference and risk involved in placing a mesh covering at the hernia site. There are times when mesh cannot be used because of increased risk of infection.

"If the bowel has been compromised and we need to remove some of the bowel," says Dr. Brodsky, "we won't want to risk any infection by using the mesh. In those cases, which are infrequent, we will do a suture repair."

"When we do the laparoscopic procedure, we have a better chance of permanently fixing the hernia because we are putting the mesh on the inside of the abdomen," says Dr. Lee. "Additionally, we are able to see multiple defects along a long midline incision and thus are able to repair all the defects with mesh from the inside of the abdomen."

In most cases, the recovery process from an open or laparoscopic hernia repair is similar. Hospital stays can range from same-day release to a few days. "In selected cases, laparoscopic hernia repairs can offer a number of advantages over open procedures," says Dr. Brodsky.

To schedule an appointment with a surgeon who does hernia repairs, please call 1-888-4GW-DOCS.

Learn More! "Hernia Repair: What Is Your Best Option?" Oct. 12, 7–8:30 PM (Chick here for more details.)

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