Conditions We Treat

Below is a list of conditions most commonly treated at the Stony Brook Center for Abdominal Core Health and Complex Hernia Repair

Hernia 101

What Is a Hernia?
In very broad terms, herniation is a condition when an organ or tissue is misplaced from its normal anatomic position through an opening.

Our specialty at the Hernia Center is hernias of the abdominal wall. To better understand what a hernia is, why they are formed and how we can fix them we need to briefly review the structure of our abdomen.

Layers of the Abdominal Wall

Most hernias happen within our abdominal wall. The abdominal wall consists of multiple layers: skin and fatty tissue on the surface, fascia (a robust fibrous connective tissue) and muscles under that, and the peritoneum, the innermost layer.

Fascia and muscles are the layers that provide support to our abdomen and keep internal organs, such as the intestines and stomach, inside. The peritoneum is a thin and slippery membrane that covers all internal organs located inside the abdomen and the abdominal wall itself. It works like a nonstick coating on a pan preventing the intestines from sticking to each other and the abdominal wall.

Structure of the Hernia

Hernia means “rupture” in Latin. Rupture, or the thinning out of the fascia and/or the muscles creates a weak spot. Initially, the weak spot is small (hernia defect) but with time it can become larger. Any internal (intra-abdominal) structure, such as fatty tissue or intestine, can protrude through this defect. Very small hernias often contain just a small lump of fat, which is often harmless, but can cause intermittent pain. When the defect becomes large enough, a loop of intestine can protrude through. A herniated organ or tissue will form a capsule or hernia sac. It can be difficult to assess what the size (diameter) of the defect is based on hernia appearance alone. Some hernias look like a mushroom, with a relatively small defect and narrow “stalk” or “hernia neck”, and larger “cap”. Others may have wider defects, but less prominent herniation. That is why we often obtain a computed tomography (CT) scan (“CAT scan”) to better evaluate the unique anatomy and determine the best surgical option. Hernia's with wider defects (despite being less pronounced) will need more extensive surgery.

If you already have a relatively recent (within the last 6 months) CT scan  – please bring the CD disk with you to your appointment so your doctor can review the images.

Why Did I Develop a Hernia?

In addition to an anatomic factor (congenital or acquired “weak spot” in the abdominal wall), increased intra-abdominal pressure (IAP) can also lead to a hernia. For reference, normal pressure is around 0-5 cm of water. High pressure in the abdomen pushes out intra-abdominal content (fat, intestines) through those weak spots. Here are some factors that increase the pressure in the abdomen:

• Excessive body weight (typical intra-abdominal pressure range in individuals with morbid obesity is 10-15 cm of water – three times more than normal)
• Chronic cough, constipation or straining with urination (e.g., related to prostate disease)
• Improper lifting of very heavy weights
• Pregnancy
• Certain diseases, associated with buildup of fluid in the abdomen (such as liver cirrhosis or certain types of cancer)

We always try to normalize intra-abdominal pressure prior to hernia repair, particularly of large complex hernias. Even 20 to 30 pounds of weight loss matters as it frees up intra-abdominal space to fit the herniated organs. Our weight loss specialists (dieticians, endocrinologists and bariatric surgeons) are here to help you to achieve the desired weight. This will not only make your hernia repair more robust, but also will help to control many chronic medical conditions, such as hypertension and diabetes.

Types of Hernias by Location

Some weak spots in the abdominal wall are congenital. Examples of such weak spots are groin canal (inguinal canal), which contains blood vessels of testicles and the vas, and navel (belly button, or umbilicus). Congenital hernias may close (heal) spontaneously in childhood. Sometimes they do not close and become symptomatic in adulthood. With age and decreased muscle tone, especially with persistently elevated intra-abdominal pressure, other weak areas may develop, for instance in the flank and lumbar regions. And traumatic injury, for instance, a severe motor vehicle crash, can damage abdominal wall and subsequently lead to a traumatic hernia.

Another major group of hernias are incisional. Any incision made through the abdominal wall after healing will never achieve the same strength as an intact tissue. Therefore, almost a third of all midline surgical incisions will eventually form an incisional hernia. The location of incisional hernias can be very different, but it always follows the previous surgical scar. Even a small surgical incision can lead to a hernia.

What Happens if I Have a Hernia? Can I Live With It?

There are several potential scenarios. Let’s order them by increasing severity and urgency.

1. It can wait several months -- Hernias that do not contain vital organs (such as the intestine), and do not cause pain, may not need immediate surgery. Such hernias typically contain just a lump of fat (so called preperitoneal fat or omentum). The main problem with such silent non-bothersome hernias is that they grow, as do all other hernias. The size of defect in abdominal wall muscle and fascia will inevitably grow with time. How fast it will grow depends on the individual and on multiple factors. Everything that increases pressure inside the abdomen will promote hernia growth. Down the road, a small silent hernia (without symptoms) very likely will become large and start causing pain. The content of a larger hernia most likely will include not only a harmless lump of fat, but a loop of small or large intestine. Additionally, repair for a large hernia is more challenging, and recurrence rates are higher. More involved surgeries create higher stress on body, too.

A reassuring sign is being able to push the hernia back inside. Such hernias are called “reducible.” This means that the hernia content is free and can move inside the abdomen (reduce) and come back (herniate). Contrary to reducible hernias, “incarcerated” hernias cannot be pushed back inside. If the hernia contains just a lump of fat, it does not make your situation more urgent. A “Fat plug” can stay in the hernia for years and prevent other critical structures from entering the hernia. Of course, a hernia containing incarcerated fat still can (and will) grow and now it is large enough to accommodate something more important, such as bowel.

2. It Should Be Repaired Within the Next Few Months -- Hernias that cause symptoms (such as pain or discomfort), hernias that are growing rapidly and hernias that contain a vital organ (most frequently a loop of intestine) should be addressed sooner, rather than later. Two potential troubles can happen with bowel-containing hernia: obstruction and strangulation. Obstruction happens because the bowel is kinked inside the hernia sac. The relatively narrow neck of the hernia can obstruct normal passage of liquid intestinal content (succus) towards the rectum. Sometimes, patients develop chronic, long-standing partial bowel obstruction from incarcerated hernias containing a loop of bowel. These patients may suffer from various gastrointestinal symptoms, such as constipation, bloating, and abdominal pain. Hernias that contain the large intestine (colon) may make endoscopic evaluation of the colon difficult (colonoscopy).

As opposed to chronic partial obstruction, acute bowel obstruction is a true surgical emergency. Symptoms of acute bowel obstruction are nausea and vomiting, significant bloating and decreased frequency (or lack) of gas or stool passage. Hernias are the number one cause of bowel obstruction in patients who did not have abdominal surgery before. If you develop these concerning symptoms, you must come to the nearest emergency room without delays and most likely will require an emergency operation. This is a life-threatening situation.

3. It Must Be Addressed Now -- Strangulated hernias and hernias causing bowel obstruction are surgical emergencies. Patients with acute bowel obstruction from a loop of intestine kinked in the hernia sac will often develop nausea, vomiting, abdominal distention and pain; decreased frequency of bowel movements and gas. From fluid losses within dilated loops of bowel, patients can become dehydrated and develop significant fluid and electrolyte imbalances or kidney failure. If acute bowel obstruction is indeed caused by hernia (and not by intra-abdominal scar tissue or adhesions, for instance), these gastrointestinal symptoms will be often associated with painful and irreducible hernia (incarceration). In any case, anyone with suspected bowel obstruction must immediately present to the nearest emergency room for evaluation and treatment. In cases when the bowel in the hernia is still viable (not dead) a quality hernia repair is often possible. When segment of the bowel is dead, the surgeon will remove it and connect two healthy ends together. In such cases, mesh placement is usually avoided, which leaves only tissue-based repair options (repair by sewing together folds of the patient’s own tissues). Such repairs, particularly in cases of larger hernias, are less robust and lead to higher recurrence rates. In the future, patients who develop recurrent hernia might need definitive repair with mesh. At times, when placement of definitive permanent mesh is too risky, the surgeon may use slowly absorbable mesh to buttress the repair. Of course, it is always better to avoid such emergencies and repair the hernia in elective settings, when high quality repair is possible, and the patient is not sick.