Abdominal Wall Hernias
Hernia is a condition in which organs that should normally be in the abdomen protrude outward due to weakness in the anterior abdominal wall. It is most commonly seen in the groin area. Apart from this, it can also be observed in the navel, in the area of the old surgery site and on the side wall of the abdomen.
Anatomy
The anterior abdominal wall is composed of overlapping layers of muscle and connective tissue that contain and protect the intra-abdominal organs while facilitating movement and breathing. The abdominal wall muscles and layers form a cylindrical structure that starts under the ribs and extends below to include the inguinal region. This structure is fed by the ribs and lumbar veins..
Hernia Classification
Ventral hernia: It is the general name given to hernias that arise from the anterior abdominal wall, around the umbilicus, in the old operation site, on the side of the stoma.
Inguinal hernias: It is the name given to inguinal and femoral hernias that occur in the inguinal region.
Pelvic hernia: These are rare hernias that develop from the lowest part of the abdomen (pelvic region).
Flank hernia: These are abdominal side wall hernias that come out of the weakened back muscles.
In addition, anterior abdominal wall hernias can be examined under another classification as congenital and acquired hernias.
Inguinal hernias constitute the majority of anterior abdominal wall hernias.
Diagnosis
Patients usually present with pain and palpable swelling. It can be applied to an outpatient clinic or emergency. Physical examination is very important in the diagnosis of hernia. The diagnosis is mostly made by physical examination. However, additional imaging methods may be required to investigate the etiology or to determine the width of the anterior abdominal wall defect.
Treatment
If there is an emergency application, the hernia sac is not reduced and if the patient has an acute abdomen clinic, an emergency operation is planned. On the other hand, an elective operation is recommended to the patient due to his complaints and the possible danger of intestinal suffocation in outpatient applications..
Operation
Today, hernia operations can be performed as closed or open (conventional). If there is no obstacle for laparoscopy, namely: if there is no problem for the formation of intra-abdominal pneumoperitoneum, if there is no fistula on the anterior abdominal wall, if there is no operation that has been performed on the anterior abdominal wall many times, laparoscopic hernia repair can be planned for the patient. In the presence of the mentioned conditions or according to the surgeon’s experience and the patient’s request open surgery can also be planned. After closed surgery, patients usually have less pain and return to normal life faster. Therefore, laparoscopic hernia repair should be considered in the first place for patients.
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How is it done?
If inguinal hernia repair, one of the most common anterior abdominal wall hernias, is to be performed closed, two main types of surgery can be mentioned.
1.TAPP (Total abdominal preperitoneal repair)
It is the hernia repair performed by entering the abdomen (the space where the organs are located) with trocars placed through small incisions on the anterior abdominal wall and entering the anterior peritoneal cavity with incisions made from there. After the hernia sac is reduced from the inguinal region, the mesh (patch) is repaired and the incisions made in the peritoneum are closed again. If there is no problem in the postoperative follow-up, the patient can be sent to the home environment on the evening of the surgery. This type of surgery can be considered in the first place in patients who have had TEPP surgery before and have relapsed.
2. TEPP (Total extraperitoneal preperitoneal repair)
This time, with trocars placed in the anterior abdominal wall accompanied by small incisions, direct entry into the preperitoneal area and hernia repair performed directly from this area. In this type of surgery, a special trocar called a balloon trocar can be used for the dissection (opening) of the preperitoneal area (because it is a narrower area than the abdomen). .However, technical TEPP repair can be performed without this trocar.
3. Laparoscopic incisional and umbilical hernia repair
In these surgeries, the trocar insertion site changes according to the hernia area and its size. It is performed through the abdomen. The mesh (patch) type and size are adjusted according to the size of the anterior abdominal wall defect.
Especially if there is a recurrent hernia after open surgery, closed surgery can be considered in the repair. Because it will provide an approach to the hernia sac from a different and non-surgical plan, surgery will be able to relieve technically. However, of course, the patient’s characteristics (the situation that may prevent closed surgery) and the operator’s experience in decision making. will be effective.
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