What to know about abdominal wall reconstruction

In this article, a consultant general surgeon explains why to treat hernias, especially reoccurring or exceptional ones, abdominal wall reconstructive surgery is one of the most effective methods.

What are hernias?

Hernias are portions of soft tissue that poke through a fault or weakness in the abdominal muscle or tissue wall. They are typically either a portion of the bowels or fatty tissue, although some types of hernias involve part of the stomach shifting out of place, such as the hiatus and diaphragmatic hernias, or the muscle itself poking through the tissue, such as in the leg.

 The kinds of the abdominal hernias are:

• Inguinal hernias are when fatty tissue or part of the bowel pokes through the groin and most commonly occur in men.
• Femoral hernias are also when a part of tissue or organ pokes through the groin, a little further down, but these are most common in women.
• Umbilical hernias are when fatty tissue or part of the bowel pokes through the stomach, near the belly button. They can occur in babies if the umbilical cord opening from birth is not properly sealed and when they occur in adults, they need surgical repair due to associated complications.
• Incisional hernia, where the tissue or organ pokes through a surgical wound that has not entirely healed, typically after open surgery.
• Spigelian hernia, where part of the bowel pokes through the side of the stomach, usually below the belly button.
• Epigastric hernias, where fatty tissue pokes through between the belly button and bottom of the breastbone.

A hernia is marked by a bulge, lump, or swelling that forms in the stomach area or at the top of the groin. Hernias can be painful at the touch or when straining, but some will not have much sensation and will be noticed from sight only.

Hernias tend to occur due to muscles losing structural integrity with wear and tear over time. Actions such as repetitive stretching and flexing weaken the muscles and thin them to the point of breakage, so that anything that puts pressure on those muscles can cause a hernia, such as pregnancy, coughing fits, straining on the toilet, and lifting heavy objects.

When is surgery used to treat hernias?

While some hernias may not cause pain and may not affect the patient’s life, some can be excruciating, and if left unaddressed can develop into complications a loss of blood supply due to the tissue getting stuck (strangulation), or a portion of bowel becoming blocked in the hernia (obstruction), which can lead to tissue death and infection.

Some patients may experience reoccurring hernias or be susceptible to them due to the weakness in their musculature.

Upon the evaluation of these risks, surgery may be recommended.

What is abdominal wall reconstruction surgery?

Abdominal wall reconstruction is just one technique to surgically repair an abdominal hernia. It has the added benefit of repairing and reinforcing the weakness where the hernia poked through, preventing reoccurrences in the future.

The surgery begins with the surgeons making an incision over the hernia so that they can locate the portion of organ or fatty tissue that is poking through – if it is an incisional hernia, then the new incision is made along the previous one. They may employ carbon dioxide gas to inflate the abdominal cavity, making the area more accessible for their tools and allowing them more flexibility and visibility in the abdomen. The herniated portion is then repositioned back in its proper place and secured, so that the surgeons can repair the muscle and tissue, which may include major muscles such as abdominis muscle, the external oblique muscle, the internal oblique muscle, and the transversus abdominis muscle.

Often, a bioprosthetic mesh is used, placed behind the abdominal muscles to support the muscles, provide structure, and perform as another layer through which a hernia cannot pass. They can be permanent or semi-permanent, and are shown to significantly reduce the risk of future reoccurrences.

It can be performed openly, laparoscopically, or robotically – the latter two use smaller incisions, which mean a faster recovery time, but there are cases that require the open technique, such as complex repairs. Abdominal wall reconstructions are performed under a general anaesthetic and can take up to six hours. 

What happens after abdominal wall reconstruction surgery?

After abdominal wall reconstruction, patients will likely feel sore which they can manage with painkillers. Patients may need to stay a few days in the hospital for observation and recovery, during which they will be fitted with drains to remove excess fluid, but they should be able to get back on their feet within a day of surgery. Patients are advised to not lift anything heavy for at least three weeks, with a tentative total recovery time of four months, but this can differ depending on the kind of hernia they had and the complexity of the repair.