The Center for Abdominal Wall Reconstruction at Creighton University Medical Center is led by Dr. Robert Fitzgibbons, a world leader in the treatment of abdominal wall hernias. The Center offers evaluation and treatment for a variety of complex hernias including sports, umbilical, incisional and epigastric hernias.

Sports Hernias

The term “sports hernia” is confusing, even to physicians, because by definition the patient doesn't actually have a hernia. It is discussed under the general topic of hernia because they occur in the groin, and when operation is required the procedure is very similar to a standard hernia repair. But the cause of the hernia is not a hole with a neck and a sac, but rather just weakened or stretched tendons or muscles in the groin area, which leads to pain that interferes with function. The diagnosis is essentially one of exclusion when a patient presents with groin pain and no obvious cause by physical examination or x-ray studies. There is considerable interest in sports hernias because they commonly occur in high profile athletes whose occupations are significantly impacted by the condition.

Umbilical Hernias (C)

Umbilical hernias occur through or just to the side of the belly button. The latter are referred to as paraumbilical hernias. Umbilical hernias are treated according to the age of the patient.

Umbilical Hernia Repair

The majority of hernias occurring in children younger than two years will heal spontaneously; therefore, watchful waiting is the rule, and only symptomatic hernias are repaired. In children older than two years and in adults, surgical correction is required, with the type of repair employed depending on the size of the hernia. If the defect is small (< 1 inch), a direct suture tissue repair may be performed. For larger umbilical and paraumbilical hernias, particularly those in adults, a mesh repair is preferred. Patients with very large hernias, previous failed repairs, or those who are very obese, are particularly suited for laparoscopy because a large prosthesis can be placed on the organ side of the hole in the abdominal wall, overlapping the hole widely.

Incisional Hernias (B)

Incisional hernias, by definition, occur through previous abdominal incisions. The term “ventral hernia” is often used interchangeably with incisional hernia but this is really not accurate because any hernia in the front part of the abdomen is ventral, e.g., umbilical or epigastric. The basis of the hernia is separation at the site where the abdominal muscles were reapproximated (re-attached) after an abdominal operation. There may be a single hole, or a so-called Swiss cheese hernia, where there are multiple holes. There are many causes, including impaired wound healing on the part of the patient due to chemical and molecular imbalances, infection at the time of the original operation, poor surgical technique in closing the original incision, genetic factors, cigarette smoking, excessive coughing, and obesity just to name a few.

Incisional hernias can be unsightly, painful, alter a patient’s lifestyle and employment opportunities, and carry a risk of incarceration and/ or strangulation. In some patients there are minimal or no symptoms and the hernia is easily pushed back into the abdomen (reduced). Watchful waiting is an acceptable strategy in this group. Hernia belts are worn by some patients but they probably do little to prevent enlargement or complications, although they do provide support.

Incisional Hernia Repair

The only way to repair an incisional hernia is surgery. It will not heal on its own. In contradistinction to groin hernias, where operative repair results in a very low hernia recurrence rate, incisional hernia repair has a very high failure rate. For this reason incisional hernia repair has evolved significantly in the last 10 years from one which was formerly dominated by simple one or two layer suture techniques to today where there are so many approaches that it is even difficult for surgeons, let alone primary care physicians or patients, to determine what is best. Simple suturing for conventional open surgery has been replaced by the use of prosthetic material in nearly all adult patients. Laparoscopy is now commonly recommended for incisional hernias but has specific risks which must be assessed in individual patients to make sure the operation is safe.

Epigastric Hernias (A)

This hernia protrudes though the narrow strip of fascia which connects the two rectus muscles in the middle of the abdomen (the linea alba ). They can occur anywhere from the navel to the breast bone. In the majority of these patients, the fibers of the linea alba in the area of the hernia are defective, leading to the hernia. Twenty percent of these patients experience multiple hernias. Most are less than one half inch in diameter and contain only fat from the space between the lining and the muscles of the abdomen, known as the preperitoneal space.

When symptomatic, patients complain of a painful nodule in the upper midline which can be quite uncomfortable because the necks of these hernias are small and can tightly constrict the preperitoneal fat. At this stage there is no sac and therefore no risk of strangulation of abdominal contents.

Epigastric Hernia Repair

Repair by slightly widening the neck and pushing the fat back into the preperitoneal space (i.e., reducing the hernia), and simple closure of the defect cures the symptoms. These hernias are prone to recur, with rates as high as 10%. Some surgeons therefore prefer to place a postage stamp-sized piece of prosthetic material in the preperitoneal space to reinforce the repair. Left untreated, an epigastric hernia can become large enough to develop a peritoneal sac into which intraabdominal contents can protrude. The hernia then must be treated as if it were an incisional hernia.

Abdominal Hernia Locations

A. epigastric B. incisional C. umbilical D. direct E. indirect F. femoral

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