There are 5 types of ventral abdominal wall hernias.
1. Paraumbilical/Umbilical Hernias
The weakness in the abdominal wall here is the umbilicus. As a foetus the umbilical cord joins a foetus to the mum so that food can be delivered to the growing baby. The weakness here persists. Truncal obesity is the greatest cause of adult-onset hernias, but the weakness is common and eventually can be opened to allow a hernia to develop. These hernias are common and can present in anyone. Pregnancy in women is a common cause of an adult onset paraumbilical hernia.
Repair is straightforward but recurrence is relatively high for this hernia type and repairs can only really be attempted 2-3 times. It is important to modify the modifiable risks before repairing this kind of hernia: Smoking and a BMI >33 are contraindications to a planned (elective) repair. Women that develop these after childbirth should wait until they have completed their family to have them repaired or they return with each pregnancy. The difference between an umbilical and a paraumbilical hernia is important in certain circumstances, but the repair method and approach is the same for both. A true umbilical hernia comes through the tiny umbilical aperture present since birth. Paraumbilical hernias come through a new defect at the side of this aperture that develops later in life. Some older patients with a ‘true umbilical’ hernia need investigating before with imaging and or bloods to be sure we understand any additional cause for it and how this might impact on the advice we give you.
We recommend and offer umbilical hernia repair under LA and sedation. Past patients have loved this approach and the great results generated. We can test the repair whilst making it and patients are walking in and out within hours with a quicker recovery to fuller activities and sport than inguinal hernias.
2. Epigastric/ventral hernias
These are more complex to explain, but not more complex to repair.
They arise in the midline between the umbilicus and the xiphisternum. There is no natural weakness, but it is an area without muscle between the layers of aponeurosis so damage in this site is more common. They can exist in one or both layers of aponeurosis. If they only come through the anterior aponeurosis then no peritoneum is poking through, so some argue they are not technically a hernia, but the fat that pokes through can get trapped and cause symptoms in the same way as a hernia can.
An important differential diagnosis is called a divarication recti when the space between the 2 rectus abdominus muscles is widened by increased intra-abdominal content. This can be a pregnancy in women, but it is common in men with a bit of a beer belly. The distinction here is that no defect is noted in the aponeurosis and so peritoneum is not poking through. These are not a hernia. Some plastic surgeons repair these for cosmetic reasons, but weight loss and core exercise programmes will substantially improve them making surgery unnecessary in the vast majority.
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We aim to repair your hernia within 2-3 weeks of your consultation with our expert Consultant Surgeon
3. Spigelian (also known as Lateral) Hernias
These are quite uncommon, rare even. (American websites refer to them as lateral hernias). The anatomy to explain these is quite complex. They occur just before the internal oblique and transversalis muscles fuse and become adherent to the corner of the pelvic brim at a bony point you can feel laterally on yourself just lower than the belly button called the ASIC – anterior superior iliac crest. It is harder to explain why these occur, but my assumption is that close to where a non-fixed point becomes fixed it has more shearing force exerted on it. These hernias also come through muscle rather than aponeurosis. Muscles weaken and become part replaced by fatty tissue as we age making damage more likely over the years. As abdominal pressures increase with activity and/or weight gain the pushing of the abdominal contents against the muscle wall can cause parting of the muscle fibres so peritoneum can eventually extend through the layers of the abdominal wall. The defect pushes through the transversalis, internal oblique and finally the external oblique muscles. They can be very hard to spot clinically or on imaging as they do not always push all 3 layers causing symptoms with very few clinical signs to help make the diagnosis.
At Hernia Clinic Hampshire despite Spigelian or lateral hernias being uncommon we see and repair probably as many in a year as most general surgeons will repair in a career. This has helped us gain a clearer understanding of where to find them and how to advise on your recovery after repair.
These can be repaired under local anaesthetic and sedation too in patients better suited to this approach.
4. Incisional Hernias
These occur through an old surgical incision. They can happen soon after surgery within the first year while the wounds are healing and re-modelling, or later in life. In the first year the wound remodelling gains strength over time but is never as strong as it was before the incision was made. The more times the same incision is opened the weaker it’s final strength will be. Additional to this smoking prevents strong connective tissue causing weakening and higher BMI especially truncal accumulation of that additional weight also puts more pressure on the abdominal wall so that breakdown occurs at the weakest point – often an old incision. The defective area is often near the old incision site not in it and has multiple defects that all need repairs.
Repair of an incisional hernia is more complex and needs imaging and usually a general anaesthetic rather than an local anaesthetic with sedation as the amount of surgery needed is often more than anticipated pre surgery. It is particularly important to use a hernia support belt recovering from this operation.
5. Parastomal hernias
These are like an incisional hernia and come around a stoma. The risk factors are the same, but these are very common in people that have a stoma and very difficult to resolve. The most effective solution is to re-site the stoma and close the old, herniated stoma site. But they then frequently recur at the new site.
Hernia Clinic Hampshire do not repair parastomal hernias because the best strategy is re-siting the stoma and we do not do that kind of surgery. There are an increasing number of available parastomal hernia supports that work well in many. We advise you contact your stoma nurse for help and advice.
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- No referral letter needed from your GP
- Contact us directly to arrange an appointment with this week
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- Top Consultant level surgeon with hernia specialist anaesthetist
- Surgery usually takes less than 1 hour and you can expect to leave within 2 hours of your surgery
- Fast recovery and full advance on how to get the best outcome from your surgery. Follow up included in self funded package
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