abdominal hernias
Abdominal hernias are common conditions in which an internal organ or tissue pushes through a weak spot in the surrounding muscle or tissue wall, typically resulting in a bulge that can be visible or felt on the abdomen. Left untreated, hernias can lead to complications, making early diagnosis and treatment essential. Here, we will cover the three main types of abdominal hernias—inguinal, umbilical, and incisional hernias—exploring their causes, risk factors, potential complications, and treatment options.
Types of hernias
Inguinal Hernias
​
Inguinal hernias occur when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles around the groin area. This type of hernia is the most common abdominal hernia, especially in men. Inguinal hernias can be classified into two types: direct and indirect. Direct inguinal hernias develop when there is a weakening in the abdominal wall due to aging or strain, while indirect inguinal hernias are usually congenital and occur when the inguinal canal does not close properly after birth.
Umbilical Hernias
​
Umbilical hernias develop when tissue protrudes through the abdominal muscles near the belly button (umbilicus). They are common in infants but can also occur in adults. In infants, umbilical hernias may resolve on their own, but in adults, they are unlikely to close and typically require surgical intervention.
Incisional Hernias
​
Incisional hernias occur at the site of a previous surgical incision. They develop when the abdominal muscles are weakened following surgery, allowing tissue or organs to protrude through the incision area. Incisional hernias can develop weeks, months, or even years after the initial surgery.
Hernia Risk
Factors
Several factors can increase the likelihood of developing an abdominal hernia. Key risk factors include:
Age and Gender: Hernias are more common in older adults due to tissue weakness over time. Men are also more prone to inguinal hernias, while umbilical hernias are common in both genders, especially during infancy or with significant weight gain.
Genetic Factors: A family history of hernias can predispose individuals to developing one.
Chronic Coughing or Straining: Persistent coughing, such as from lung conditions or smoking, places repeated pressure on the abdominal wall, as does straining during bowel movements.
Obesity and Excessive Weight: Increased abdominal pressure from obesity can stress and weaken the abdominal wall, making hernia formation more likely.
Heavy Lifting: Occupations or hobbies that require heavy lifting put recurrent strain on the abdomen, increasing hernia risk.
Previous Abdominal Surgery: Scar tissue from surgery can weaken the abdominal wall, leading to incisional hernias.
Treatment
Watchful Waiting
When diagnosed with a hernia, some patients may consider delaying surgery in favor of “watchful waiting,” a conservative approach that involves monitoring the hernia without immediate intervention.
Downsides of Watchful Waiting
While watchful waiting may seem appealing for small, asymptomatic hernias, there are important considerations:
Risk of Hernia Enlargement: Hernias may grow over time, which can lead to increased symptoms or a more complex repair if surgery is eventually needed.
Possibility of Complications: The hernia may become incarcerated, where it gets stuck outside the abdominal wall, or strangulated, where the blood supply is compromised. Strangulation is a surgical emergency. Additionally, the bowel can become kinked and a patient could develop a bowel obstruction.
When Surgical Repair Becomes Necessary
Surgery is typically recommended if:
Pain or Discomfort: The hernia causes significant discomfort or pain during normal activities or exercise.
Increasing Size: The hernia is growing, which can raise the risk of complications.
Signs of Complications: Symptoms of incarceration or strangulation require urgent surgical intervention to prevent serious complications.
Abdominal Hernia Surgery
Inguinal hernias
​
Inguinal hernias can be repair with an open approach (a larger incision right on top of the hernia) or a robotic/laparoscopic approach (three tiny abdominal incisions). Open surgery is tried and true while robotic surgery is newer and has equivalently great outcomes​. An advantage of robotic repair is the ability to place a piece of mesh across four potential hernia holes which isn't as feasible with open surgery.
​​
​
Umbilical hernias
​
Similar to the above, umbilical hernias can be repair with an open or robotic approach. Small hernias (less than about 2cm) can be repaired with just sutures while larger hernias generally require mesh placement to reduce the changes of hernia recurrence. Additionally, these can be repair with robotic surgery to allow for a more precise and wide dissection which subsequently would allow for a larger piece of mesh if deemed necessary.
​
​
Incisional hernias
​
Like umbilical hernias, incisional hernias can be approached open or robotically. Open surgery often necessitate a much larger incision and can be more painful to recover from. Robotic surgery allows for tiny keyhole incisions that often lead to less postoperative pain. Mesh is almost always used, in order to reduce the risk of hernia recurrence.
What about Mesh?
There has been widespread discussion in recent years about the use of surgical mesh in hernia repair, with concerns primarily revolving around safety, potential complications, and the long-term outcomes of mesh implants. However, research has shown that when used appropriately, surgical mesh plays a crucial role in reinforcing weakened tissues and reducing hernia recurrence rates, which are key factors for successful hernia repair. Mesh use has become the standard in hernia repair.
Purpose of Mesh in Hernia Repair
Mesh is primarily used in hernia repair to provide additional support to weakened or torn tissue. Traditional tissue repair methods, where the surgeon sutures the defect closed, can be effective but are often associated with higher recurrence rates, particularly in larger or more complex hernias. Mesh reinforces the abdominal wall, acting as a scaffold for new tissue growth, which can significantly reduce the likelihood of hernia recurrence. Studies have shown that, in cases of inguinal hernias, mesh repair is associated with up to a 50% reduction in recurrence compared to non-mesh repairs.
​
Outcomes and Benefits of Using Mesh
Over the years, research has consistently demonstrated that mesh repair provides better long-term outcomes compared to non-mesh repair, especially for larger hernias and hernias in areas of the body prone to high tension. According to the International Guidelines for Groin Hernia Management, mesh repairs—particularly with minimally invasive techniques like laparoscopic surgery—are associated with faster recovery times, less post-operative pain, and lower rates of hernia recurrence. These benefits are particularly notable in procedures like laparoscopic or robotic repair of inguinal hernias, where mesh has become a widely accepted solution due to these improved outcomes.
​
Understanding the Risks and Controversies
While mesh offers significant advantages, it’s essential to acknowledge the potential risks. Complications like infection, chronic pain, and even mesh migration, though rare, can be serious. Fortunately, modern mesh materials and surgical techniques have evolved to minimize these risks. Many issues reported in earlier decades were associated with older types of mesh or inadequate surgical techniques. Today, most complications are minimized through advances in biocompatible materials and surgeon expertise. In fact The American Hernia Society (AHS) published an Advisory Statement supporting the use of appropriately selected mesh reinforcement for the vast majority of both inguinal and ventral hernias to reduce the risk of hernia recurrence.
​
For most patients, the benefits of mesh repair—such as lower recurrence rates and faster recovery—outweigh the risks. However, individual patient factors, such as hernia size, location, and overall health, play a role in determining the best approach. Consulting with an experienced hernia surgeon can provide clarity on whether mesh repair is the right option for you.
