The article concerns abdominal, umbilical, and inguinal hernias. Other hernias, such as diaphragmatic hernias, are discussed in a different article.
A hernia is, in simple terms, an opening in the abdominal wall through which internal organs protrude into the subcutaneous tissue. They occur in typical locations where the abdominal wall is inherently weakened. These include the groin, where in men, vessels and the spermatic cord pass through the abdominal wall to the testicles. In women, only the round ligament passes through this area, making inguinal hernias less common. Instead, women are more likely to have a so-called femoral hernia, which also occurs in the groin but slightly lower than a classic inguinal hernia. Another weakened area of the abdominal wall is the navel and any scars from abdominal surgeries, especially if their healing was complicated.
In addition to a congenital predisposition resulting in the formation of weaker connective tissue, several factors that increase pressure in the abdominal cavity contribute to the development of a hernia. These typically include constipation, coughing, lifting heavy objects, and physical exertion associated with increased abdominal pressure. In men, prostate diseases that require straining during urination, and in women, pregnancy, can also lead to hernias. Hernias are also more common in obese individuals, where the abdominal wall is similarly weakened.
A separation of the abdominal muscles—diastasis—occurs through a mechanism similar to that of a hernia. It occurs only along the midline, typically above the navel, where the abdominal wall muscles on the right and left sides are connected only by a band of connective tissue from the sternum to the navel. Due to the aforementioned factors, this connective tissue band gradually widens from a normal width of about 1 cm to several centimeters. Diastasis can be easily observed when rising from a lying position, as a portion of the abdominal wall protrudes in varying sizes in the upper part of the abdomen, between the sternum and the navel. When lying still, it disappears again, but during examination, it can be felt that the edges of the abdominal muscles are spaced more than the mentioned 1 cm apart.
A hernia, as implied by the definition above, is the protrusion of internal organs through an opening in the abdominal wall into the subcutaneous tissue. This results in a noticeable bulge in the abdominal wall—typically in classic locations such as the groin, navel, surgical scars, and, rarely, in other areas. Initially, this bulge appears only under strain and increased intra-abdominal pressure. Gradually, the hernia enlarges, and the bulge may become permanent, especially while standing, whereas lying down in a relaxed position with bent legs allows the hernia to disappear—the organs return to the abdominal cavity. In larger hernias, particularly those that have been present for a long time, adhesions may develop, preventing the hernia from returning to the abdomen even when lying down.
A typical example is large scrotal hernias, which in men who do not address the issue for, say, 10 years, can reach enormous sizes, sometimes even down to the knees. In smaller hernias, particularly in obese individuals, the bulge may not be noticeable. Sometimes, even a doctor may not be able to palpate the hernia, and if there is a persistent suspicion of a hernia (pain in a typical location and ruling out other causes), further examination with ultrasound (sonography) may be necessary.
In addition to the described bulging, a hernia may cause discomfort, especially during exertion. When a hernia develops, particularly in the groin, a burning sensation may occur. Since some of the internal organs, most commonly the intestine, bulge through the hernia, dysfunction of these organs can arise. If the opening in the abdominal wall is narrow, it may compress the internal organs, leading to bowel obstruction, which can manifest as temporary constipation, bloating, and pain in the hernia area.
A specific problem is the incarceration of a hernia. This is a sudden event caused by the internal organ getting stuck or pinched in the hernia. This impairs the blood supply to the trapped organ, potentially cutting off its blood supply and leading to tissue death. When a segment of the intestine is incarcerated, it results in bowel obstruction. Both conditions manifest as severe pain in the hernia, which becomes firm and cannot be pushed back into the abdomen, even when lying down. Symptoms may include vomiting, abdominal cramps, and the inability to pass gas or have a bowel movement. This is an acute condition that requires immediate surgical intervention. If these symptoms occur or if there is any suspicion of a hernia, it is essential to seek medical help immediately.
If a hernia has already formed, it will not go away. Over time, it increases in size, can cause problems, and there is a risk of strangulation, which is why surgical intervention is recommended. There is no other way to resolve a hernia. A hernia belt, which pushes the hernia back and strengthens the abdominal wall, is recommended only temporarily, until surgery, or as a solution for seriously ill individuals who are unable to undergo surgery. The hernia belt is used for abdominal or umbilical hernias. Inguinal hernia belts are not recommended because their effectiveness is questionable and they are more likely to cause further complications, such as abrasions or chafing of the groin.
Hernia surgeries are among the most common operations we perform at Palas Athena. We specialize in laparoscopic hernia surgeries, but in certain cases, we also perform traditional surgeries. All surgeries require preoperative internal examinations to assess surgical risks and determine whether the patient is suitable for surgery in a same-day surgery setting. The operation is performed under general anesthesia. Only in very ill patients—typically older individuals—can an inguinal hernia be operated on under local anesthesia at the site of the surgery combined with analgesosedation (a pharmacological calming of the patient, which is not anesthesia), or under spinal anesthesia (the anesthetic is injected into the spinal canal in the lumbar region, and the patient feels nothing from about the halfway point of the body while remaining conscious; the effect lasts for several hours, after which sensitivity fully returns).
In laparoscopic inguinal hernia surgery, which we recommend for the vast majority of patients, access to the abdominal cavity is achieved through three small incisions (approximately 1 cm long) using special instruments. We pull the protruding organ back into the abdomen and cover the opening in the abdominal wall with a mesh. The mesh prevents the hernia from returning and, after it heals (the mesh is non-absorbable), it reinforces the groin, thereby preventing a recurrence of the condition. During one operation, it is possible to operate on one or both sides if the hernia is bilateral.
In conventional surgery—recommended only for very sick older patients who would poorly tolerate general anesthesia—we operate under local anesthesia combined with analgosedation or spinal anesthesia (as mentioned above). The operation is performed using a traditional oblique incision in the groin (approximately 10 cm long), through which we access the hernia after dissecting the layers of the abdominal wall. We then separate the hernia from other structures and return it to the abdomen. Here, too, we use a mesh (PHS), which we sew over the hernia opening to prevent the hernia from protruding again. The subsequent scarring around the mesh also strengthens the groin. Sometimes, in cases of significant tissue bleeding, we insert a drain, which is removed the following day.
Typically, if no complications arise, the patient arrives fasting on the day of the scheduled surgery and is discharged the following morning. Stitches are removed 8-10 days later, and 6 weeks after the operation, we recommend physical rest and not lifting anything heavy to ensure that the groin heals and strengthens properly.
Small umbilical hernias, up to about 2.5 cm in size, and when there is no significant diastasis (separation) of the abdominal muscles, are treated with traditional surgery. Under general anesthesia, a 3 cm incision is made below the navel to access the hernia, which is then returned to the abdominal cavity after dissection. The hernia opening is then closed by overlapping its edges in a roof-like manner, creating a doubling of the layers of the abdominal wall at this site, which strengthens it (Mayo repair). The skin around the navel, which must be freed during dissection, is reattached to the connective tissue of the abdominal wall, thus improving the cosmetic appearance of the navel.
If no complications arise, the patient goes home the following day, stitches are removed after 8-10 days, and it is recommended to avoid lifting anything heavy and to refrain from significant exertion for 6 weeks.
Surgery for larger umbilical hernias, hernias in scars from previous surgeries, and surgery for diastasis (separation) of the abdominal muscles: In the case of larger hernias and/or diastasis, we perform laparoscopic surgery under general anesthesia. The principle of the operation is to access the abdominal cavity through three small incisions (approximately 1 cm in size) using specialized instruments, where we free the protruding organs from the hernia and disrupt any adhesions with the abdominal wall. The edges of the hernial opening are then brought together with stitches, which are introduced through several tiny punctures (approximately 1-2 mm) using a special tool through the skin. The abdominal wall is subsequently reinforced with a mesh placed on the inner side of the abdominal wall and secured with stitches, which are again inserted through small punctures (approximately 1-2 mm) around the edges of the mesh. Thus, there are three smaller incisions from the instruments, each about 1 cm in size, and a series of small wounds, 1-2 mm in size, resulting from the stitches that pull together the abdominal wall and anchor the mesh. These tiny wounds do not require stitching and heal quickly and well. Additionally, after the surgery, we reinforce the abdominal wall with an abdominal hernia belt, which the patient wears for another 6 weeks to 2 months, depending on the size of the hernia. The hernia belt should be put on while lying down first thing in the morning, before getting out of bed, to ensure it is functional. It is removed only for washing and during sleep. After the surgery for these larger hernias, the length of hospitalization is 2-3 days. Stitches are removed 8-10 days post-surgery, and we recommend not lifting anything heavy and avoiding significant physical exertion for another 6 to 8 weeks, along with wearing the abdominal hernia belt.
During the surgery for extensive abdominal hernias, it may be necessary to return a large volume of internal organs that have protruded into the hernia back into the abdominal cavity. This can cause a significant increase in the volume of the abdominal cavity during and after the operation, which then presses against the diaphragm and lungs, potentially limiting breathing, especially in patients with other health issues (particularly lung diseases) and in obese individuals. This condition may persist for some time as the body adjusts to the new circumstances, and these patients require special attention and additional treatment.
