Ventral Hernia refers to the ventral surface of the body (abdominal wall) and not a specific type of hernia. Therefore there are many locations here where we see hernia formation. These hernias are considered spontaneous and are not related to a prior surgical incision. They tend to occur in areas that are recognized as natural anatomically “weak spots” on the muscular abdominal wall. The manner in which these are repaired is typically indistinguishable from the incisional hernia repairs but the mechanism behind their formation can be different.
Umbilical Hernia
These types of defects in the “belly button” are very common. This area of the abdominal wall is very thin. None of us have muscle in the midline of the abdomen and consequently this are is vulnerable to hernia formation. In fact this umbilical ring is actually open to allow passage of the umbilical vessels from the mother into the fetus. After birth begins to close as the rectus muscles grow towards each other to leave a fibrous area where the opening used to be. Some children are born with an umbilical hernia that gradually closes over the first 5 years. In cases where it doesn’t close surgery is appropriate.
In some situations one could say that the umbilicus is a hernia waiting to happen. Particularly when we add mechanical stress to this area from issues like obesity, abdominal distension, pregnancy and heavy lifting/straining/constipation. These hernias occur more often in women with a 3:1 ratio. Patients typically present with a soft mass in the region of their belly button that comes and goes. It is typically more painful with coughing, lifting or straining. People often report that their “IN-EY” has become an “OUT-EY” and they want it fixed because it is cosmetically bothersome and others can see it though their clothing.
In many cases these defects are very small, pose no realistic risk and virtually asymptomatic. We literally would have to make the hole bigger to be able to fix it with our sutures and meshes. Obviously these do not require surgery and are safe to watch.
We know from surgical studies that simple suture closure of umbilical hernias can create a lot of tension on the surrounding tissues and as a consequence 50% of the types of repair result in the development of a recurrent and usually larger hernia defect. As a consequence if we decide to fix an umbilical hernia we are usually going to place a small piece of mesh behind the umbilicus to provide a durable tensionless repair. We are able to hide the scar in the natural curve of the umbilicus so when it is all healed it would be difficult to know that anything was done
Epigastric Hernia
These occur as a defect in the midline of the abdominal wall between the umbilicus (belly button) and the lower tip of the sternum called the xiphoid process. Because of their location high on the abdominal wall incarceration or bowel obstruction is rare. They do typically present as an uncomfortable bulge or lump. They tend to occur more often in males and in middle-aged patients.
Spigelian Hernia
These are rare hernias that develop along the semilunar line of the abdominal wall. This area is weak because the posterior sheath of the rectus muscle is missing at this level. These defects form lateral to the rectus muscle and are notoriously difficult to diagnose on physical exam because the herniated contents slides between muscle groups and doesn’t necessarily rupture through them. These hernias are dangerous and up to 20 % of them will present as an incarceration. They are easily repaired with a laparoscopic approach in experienced hands.
Flank Hernia
Although the defect is anatomically outside of the abdominal wall these hernias are typically considered to be a type of abdominal wall hernia. Most are related to prior surgery- particularly for kidney and spine approaches so they are often considered “incisional hernias” too. These types of hernias are often related to denervation of the muscles in this are from the original surgery. The muscles atrophy, tissue thin and then a bulge results.
Spontaneous disruption of the tissues in the lumbar region results in a palpable posterolateral mass that gets larger with straining and coughing. Complaints of back pain are not unusual. This is an anatomically complex region in that the hernia ruptures in a zone bordered the ribs, the spine and the iliac bone. Utilization of mesh is basically mandatory to bridge the gap. Expertise is critical or chronic pain will result do to mesh fixation on these sensitive areas. Fortunately it does lend itself to a laparoscopic repair in most cases.
Diastasis Recti
This is a very common source of patient referrals to our office. Patients are often very worried because the have a “big” hernia that needs to be fixed right away. Fortunately this is almost always a benign situation that just needs a brief physical exam and some education.
None of us have muscle in the midline of our abdomen. Our abdominal wall is essentially a series of overlapping muscles on the left and the right sides. These sides are mirror images of each other that are wrapped in fibrous layer we call fascia. This fascia is fused in the midline to unite the two sides much like the way we button a shirt. This zone of fusion is called the linea alba or “white line”. This line is not typically very wide but it is very strong. A normal separation between the two sides is approximately 2cm or about ¾ of an inch.
This area can become much thinner, weaker and wider with obesity and pregnancy. When this midline structure widens the rectus muscles on either side mover further apart and a “diastasis” or separation occurs. Thus the term: diastasis recti. As this tissue thins a bulge in the midline of the abdomen is noted with the patient’s rectus muscles contract as they strain or exercise. It is not unlike squeezing two ends of a long balloon and watching the middle bulge outward. Doing a sit up from a supine position is notorious for creating the bulge that creates the anxiety that creates the referral to a surgeon.
These occasionally dramatic bulges are not true hernias because there is no hole. If there is no hole there can be no incarceration of tissue or bowel so repair is not “necessary”. Some women have found that postpartum exercises guided by a physical therapist to strengthen the abdominal wall are helpful at diminishing the size of the bulge. Others may opt for plication of the thin abdominal wall with an abdominoplasty or “tummy tuck “ from a plastic surgeon. This is a major procedure and may require a long recovery.
We do occasionally “repair” a diastasis recti problem laparoscopically. We reserve these repair for patients that are having pain. Many of these people have physically demanding job and the pulling and stretching of this thin tissue can be very uncomfortable and dramatically decrease their quality of life. Reinforcement of the thinned linea alba/diastasis recti with a lightweight mesh dramatically decreases pain in this region. The mesh is attached to the healthy thicker muscles on either side of the defect effectively bridging the weak area and redistributing the forces out the undamaged tissues. As the repair heals and the mesh becomes incorporated into the abdominal wall the linea alba has been thickened and the process of the rectus muscles retracting away has stopped.