Ventral hernia (epigastric and Spigelian hernia)
What is a Ventral hernia?
A hernia occurs at a site of weakness in the abdominal (tummy) wall. The content of the abdominal cavity (fat and bowel) bulge through the defect or weakness creating a lump.
Ventral hernia includes both Epigastric hernia and Spigelian hernia.
Epigastric hernia are common and appear between the umbilicus (belly button) and the lower part of the sternum (breast bone). They are usually on the midline.
Spigelian hernia are less common and form at the outside edge of the rectus muscle.
Ventral hernia can occur at any age in adulthood. They do however tend to be more common in people who are overweight. Other factors that contribute to development of a ventral hernia include anything that increases abdominal pressure, such as chronic coughing, constipation, strenuous exercise and heavy lifting.
Symptoms of a ventral hernia
Most people will notice either a bulge or pain.
Epigastric hernia are most common in young to middle aged adults. Pain and tenderness over the hernia are the common reasons for presentation.
Spigelian hernia are often quite difficult to diagnose and patients frequently complain of localised but intermittent pain.
This is often exacerbated by lifting and straining. The pain can range from a dull aching sensation though to sharp severe pain. The pain and discomfort can limit a person’s activity and this may result in time off work. Over time ventral hernia tend to increase in size and become more uncomfortable.
Most of the time the hernia will be diagnosed based on clinical examination findings and no furthers tests are required. On rare occasions an ultrasound scan or abdominal CT scan are needed to confirm the diagnosis and help plan surgery.
Complications of a ventral hernia
Complications can occur with a ventral hernia. An incarcerated hernia means the hernia is no longer reducible, in other words the hernia is unable to be pushed back inside. When this occurs more serious complications become more likely.
Strangulation is a term for when the contents of the hernia become tightly “trapped” within the hernia and they lose their blood supply. A strangulated hernia is a potentially a serious and life threatening complication. At times the intestine can become trapped within the hernia, which can lead to bowel obstruction, another potentially life threatening complication. If you have very painful hernia, which is either “stuck” or is red or tender seek medical attention as soon as possible.
Treatment of Ventral hernia
A ventral hernia will not heal by itself. The only way to get rid of a hernia is by surgery. This is a routine day case operation that Mr May performs at the Duchy Hospital, Truro.
The purpose of surgery is to reduce symptoms such as discomfort or a bulge, but also to reduce the risk of possible complications of the hernia such as bowel obstruction or strangulation. The larger the hernia the more likely these are to occur. However life threatening complications are still rare.
Open ventral hernia repair
An “open” approach involves an incision underneath over the hernia. The size of the incision depends on factors such as size of the hernia and amount of abdominal wall fat, but for a small hernia the incision is sometimes only 2-3cm in length.
The hernia defect in the abdominal wall is identified, and contents are reduced (returned to the abdomen). Occasionally the contents of the hernia are excised.
The hernia will then be repaired by either placing a plastic mesh (often polypropylene) underneath the muscle layer, termed a “sublay repair”, or by closing the defect with sutures. The mesh, although inside the muscle layer, remains outside of the peritoneal (abdominal) cavity.
Laparoscopic or keyhole repair of a ventral hernia
A “laparoscopic” or keyhole approach involves entering the abdomen, with 3 incisions on the side of the abdomen. One is for the camera, and 2 others are for the surgical instruments.
Using keyhole instruments, the tissue underneath the hernia sac is cleared from around the hernia.
A special mesh is placed over the hernia defect with a good amount of overlap all around and it’s then secured to the abdominal wall using staples or sutures. The mesh is designed so it does not stick to bowel, but the mesh will be within the peritoneal cavity.
Ventral hernia repair is usually carried as a day case procedure at the Duchy Hospital. An open repair can be carried out under local or general anaesthetic. However laparoscopic repair can only be performed under general anaesthesia.
Your specialist surgeon Mr Denzil May will discuss with you the risks and benefits of the different surgical options.
Should a ventral hernia always be repaired?
If a ventral hernia is very small and asymptomatic it may be left alone. There are small risks associated with surgery and the aim of the surgery is reduce the symptoms of discomfort or an unsightly bulge.
Symptomatic ventral hernia would usually be offered repair with the aim of alleviating symptoms and improving quality of life.
Open or keyhole repair of your ventral hernia?
Open repair of ventral hernia has been used for many years with good effect. It will be usually be offered for both very small (a small neat incision) and very large hernia (too large for keyhole repair).
The medical trials comparing each have shown very little difference in outcome. The risks and benefits of each approach will be discussed with you in the outpatient clinic at the Duchy Hospital.
Risks and Complications of surgery
Generally speaking ventral hernia repair is very safe with a low risk of complications.
Following surgery most patients will experience some discomfort and some minor swelling at the operation site. Patients will be given painkiller medication for this, and this is usually only necessary for the first few days after surgery. There may also be some bruising that will last for a few days. There is a small risk that patients may not be able to pass urine following surgery, if this occurs a temporary catheter is usually required.
Complications of the operation include:
A wound infection involves the scars, which then become hot, red, swollen and painful. There is sometimes discharge from the wound. Some wound infections require a short course of antibiotics, more rarely a further operation is required. Wound infection is more common with open repair than with keyhole repair.
Mesh infection is rare. However when a mesh becomes infected it is more difficult to treat. Often this requires a prolonged course of antibiotics, sometimes intravenously. If the infection does not resolve the mesh may need to be removed with an operation. Mesh infection is less common with laparoscopic repair compared to open repair.
Minor bruising is common following hernia surgery. Significant bleeding is very rare. Any bleeding is controlled at the time of the operation, but afterwards there is small chance bleeding can occur. This can lead to a haematoma either related to the wound or inside the abdomen. Should this occur it tends to resolve gradually over a few weeks. It is possible, albeit extremely unlikely that a blood transfusion is required. Sometimes further surgery is required.
Whenever bowel is handled there is small possibility of damaging the bowel. In open ventral hernia surgery this can occur rarely but is more common with laparoscopic surgery. It is still however rare. Recognised injuries will be repaired during the operation. If this is not recognised further surgery may be required.
Seroma and persistent lump
A seroma is a collection of fluid at the site where the hernia used to be. This is more common after keyhole repair, as the hernia sac is usually left in place. A seroma can be confused with a recurrence of the hernia, but over time will slowly resolve. Very occasionally a seroma will need to be aspirated with a needle.
There is no method of hernia repair that can give a 100% guarantee that it won’t recur. Ventral hernias recur at a rate of about 2-3 % per year. If it does recur a repeat operation is often required.
General risks of surgery and anaesthesia
Modern anaesthetics are very safe. Most people are not affected. Rarely some patients develop a reaction to the anaesthetic, or develop a blood clot in the leg (deep vein thrombosis) that can go to the lung (pulmonary embolism). Patients at risk of this are given compression stockings (TEDS) to wear. Very rarely patients may suffer a heart attack or a stroke as result of anaesthesia and surgery.
After your operation
Following discharge from hospital the area around the hernia operation may be sore for the first few days. You will be given painkiller medication, take these as prescribed. The wound would usually be closed with dissolvable stiches which do not need to be removed. You can shower and bath after 24 hours. Spare dressings and instructions will be provided on discharge.
There are no restrictions on diet following surgery. However it’s advised, for the first 3-5 days to eat relatively light and bland food, and avoid fizzy drinks.
After surgery it is best to walk and mobilise gently, and gradually build up to normal activity as you feel able and pain allows. You should avoid heavy lifting for the first 4 to 6 weeks following surgery. Providing you have no discomfort it is ok to do cycling, swimming and running within about 2 weeks of surgery.
You should be able to drive after about 7-10 days. You must be able to look over your shoulder as normal, and perform an emergency stop without pain or discomfort. If in doubt practice this first before driving.
Going back to work depends on your job. Most patients who have sedentary jobs are able to return to work by about 2 weeks. If your job involves heavy lifting or manual labour then 4-6 weeks off work is required.
Complications after discharge are unusual. After private surgery we will phone you on a daily basis for the first few days. You will be given emergency contact details, which you should call if you think something may be wrong.