hernienzentrum.berlin

The hernienzentrum.berlin with its friendly team of specialized doctors and nurses offers you individual and highly qualified diagnostics and surgical therapy of inguinal and abdominal wall hernias.

In order to always be up to date with the latest scientific developments, we regularly participate actively in national and international congresses. This enables us to offer you the best and safest therapy according to international standards at all times. We specialize in minimally invasive forms of therapy, so that you are quickly ready to return to work. 

With our location in Steglitz, we are your competent contact in Berlin, Potsdam and Brandenburg and would be happy to welcome you for a personal consultation in our practice rooms. 

PD Dr. Dietmar Jacob

An abdominal wall hernia is the protrusion of fat or organs located in the abdomen from the abdominal cavity through a congenital or acquired gap. The word hernia originates from the Greek and stands for the word bud, as it refers to protrusions that resemble a bud. 

A prerequisite for the development of a hernia is a weak spot in the abdominal wall, which can be located at different sites. In most cases, this is already created during embryonic development. However, the weak spot can also develop much later, for example due to chronic lung damage with a strong cough, a scar after an abdominal operation or increased pressure inside the abdomen due to e.g. pregnancies or even tumors.

Due to the constantly increased internal abdominal pressure, load-bearing abdominal wall layers can separate to such an extent that a bulge-like protrusion of the remaining abdominal wall layers results as a hernia sac.

Each hernia has 3 characteristic components:

1. Hernia gap = This is the "hole" in the abdominal wall, through which contents can pass through.
2. Hernia sac = Its inner lining usually consists of sliding peritoneum with hernial contents. If the hernia sac becomes trapped and does not slide back, it can cause severe pain and leads to emergency surgery if the bowel is trapped (incarceration).
3. Hernia contents = Due to inflammatory reactions, a hernia may contain hernial fluid, but it may also be empty. Frequently, however, it contains portions of a large fat apron covering the organs inside the abdomen (omentum majus) or portions of the small or large intestine. It may also contain freely movable organs, such as the ovaries, the appendix, or wall portions of the urinary bladder. In the case of a hiatal hernia, the stomach often slides into the thorax via a widening of the esophageal slit in the diaphragm (hiatal hernia).

Often a hernia is an incidental finding and shows up as a small bump. In men very often in the groin and in women more often in the navel area or above the navel. Pain is rather the exception, it is ehr a feeling of pressure or a pulling pain when moving.

A hernia always occurs due to a chronic, i.e. over years lasting, process of tissue alteration or is created in younger people as a weak point of the abdominal wall. Thus, there is no sudden tearing during a spontaneous movement, as it is often assumed. 

If there is severe pain with nausea and/or vomiting, a doctor or emergency room should be consulted immediately. In men, the inguinal region may also have, for example, a twisted testicle (torsion) as a separate clinical picture, which requires immediate therapy. 

In the case of rather mild symptoms in the groin area after e.g. sporting activities, 2-4 weeks can also be discounted, since it is often a problem of the muscle groups in the pelvic area (adductors), which improves significantly with rest and taking anti-inflammatory drugs such as ibuprofen or dicofenac and does not require surgical therapy.

However, if there is a bump that recedes when the patient is lying down and reappears when the patient coughs while standing, a hernia is quite likely and should be clarified by a surgeon.

In principle, it can be said:

• A hernia can only be treated by surgery and hernia bands are not an option for all patients who can be operated on, especially in the groin area.
• A hernia becomes larger and larger in the further years of life and is then more and more complex to operate on.
• Surgery for a non-symptomatic hernia can be well planned and should be performed within the next 3-6 months after diagnosis.
• However, women with inguinal hernias should have surgery as soon as possible because they have a significantly increased risk of incarceration.
• The likelihood of incarceration, which is an emergency and requires immediate surgery, is about 8% in the upper abdomen and umbilical area and about 4% in the inguinal area.
• As a rule, it is not intestine that gets stuck, but fatty tissue of the abdominal cavity.
• Pregnant women with a suspicion of a hernia should see a hernia specialist for clarification.
• Sporting activities, as long as they do not cause any discomfort, can be continued without any problems, except for abdominal exercises (so-called sit-ups). In case of discomfort, consult a surgeon immediately.
• A rectus diastasis is not a hernia and is therefore not usually operated on.

There are various surgical techniques that are individually adapted to the findings and the patient's state of health. For all types of hernia, a distinction is made between operations with or without mesh insertion and the minimally invasive or open technique. This selection is described as a tailored approach. Therefore, a specialized hernia surgeon should always be confident in various surgical procedures and perform them regularly.

The Direct Suture Closure

The supporting connective tissue layer of the abdomen is called fascia and the hernia gap is located in it. In the surgical technique of direct suture closure, the gap is securely closed with a thread that does not dissolve, using several sutures. It is particularly important that no tissue is trapped in the gap to be closed. This procedure is used for smaller hernias under 1.5 cm in the umbilical or upper abdominal wall area. Scar hernias, on the other hand, should always be treated with a mesh, as the risk of a new hernia (recurrence) is significantly greater here. 

Mesh Implantation

In the case of larger hernias over 1.5 cm, risk factors such as obesity, chronic lung disease or connective tissue weakness and in the case of scar hernias, a plastic mesh must be used for reinforcement. Otherwise, the risk of a new hernia (recurrence) is too great.

The meshes are usually made of polypropylene or polyvinylidene fluoride plastic and are usually very well tolerated. All meshes have a tendency to shrink, so they should be used too large rather than too small. The mesh should overlap the edge of the hernia by at least 3cm in umbilical hernias and by at least 5cm in incisional hernias to prevent recurrence if shrinkage occurs.

As a "planned" foreign body, all plastic meshes cause a reaction in the organism, resulting in an effusion around the mesh (seroma). In most cases, this is harmless and the body reabsorbs this fluid on its own within 2-6 weeks. In rare cases, a seroma must be punctured to drain the fluid. However, this should only be done after 6 weeks at the earliest due to a high risk of infection. Even more rare is an infection around the mesh with pus formation due to an accumulation of blood with subsequent infection. In this case, a mesh must be removed again, as there is no ingrowth.

Depending on the location of the mesh in the abdominal wall, there are different surgical methods.

New are meshes that dissolve slowly and thus lead to a permanent stability. The advantage is that patients do not have any foreign material in their bodies. The disadvantage is the extremely high price and the lack of long-term experience with these products in terms of stability and recurrence frequency. As a rule, these are used for infectious wounds in specialized hernia centers.

The navel is a natural weak point of our abdominal wall, which is why this type of hernia is very common.

As the child develops in the uterus, the blood vessels in the umbilical cord pass through the child's navel and ensure the supply of nutrients. After birth, the umbilical cord is cut and the umbilical ring closes. This may be partially omitted or widening may occur, which is favored, for example, by muscle and connective tissue weakness, pregnancy or obesity.

Umbilical hernias are common and most people have no problems with them except for the outward appearance. However, the size increases with age and so does the risk of entrapment (incarceration), which is about 8%. Therefore, it is recommended to have the umbilical hernia operated early, even in case of mild symptoms. As a rule, the operation is performed on an outpatient basis under general anesthesia in our surgery. Hospital treatment for minor findings is not necessary.

In the case of small defects of less than 1.5 cm, hernia repair can be performed without a mesh. For this purpose, sutures are used to close the defect, which do not dissolve, i.e. remain in the body forever.

In patients with abdominal wall weakness (rectus diastasis), a strong cough as in pulmonary diseases or obesity with a body mass index above 30, mesh insertion is recommended even for hernias smaller than 1.5 cm.

The meshes are usually 5-8 cm in diameter and can be placed either inside the abdomen as IPOM (Intraperitoneal Inlay Mesh) or on the peritoneum as PUMP (Preperitoneal Umbilical Mesh Plastic).

We recommend the keyhole technique only for larger hernias over 2 cm, because 3 incisions must be made on the lateral abdominal wall and this is only justified if the incision would be larger in the open technique. In addition, the mesh in this technique usually lies in the abdominal cavity, i.e. close to the intestine, which always leads to adhesions and, due to a significantly larger mesh size (at least 10x15cm), can also lead to significantly more adhesions.

This should be avoided if possible, even though recent studies show no long-term damage due to the adhesions.

Epigastric hernias are abdominal wall hernias above the umbilicus and are usually located in the midline. These are often small hernias, 1-2 cm in size, but can be very painful due to fatty impaction.

Between the straight abdominal muscles (Musculus rectus abdominus) there is a layer of connective tissue (Linea alba) in which gaps can form preferentially. This occurs preferentially in rectus diastasis, in which the linea alba can widen over 2cm to as much as 5 or 7cm. 

A rectus diastasis is increasingly observed in women who have given birth to 2 or more children or after multiple pregnancies. Men with a so-called "beer belly" also tend to have it and have more frequent hernias in this region.

The treatment for smaller hernias under 1.5 cm is closure with a suture that does not dissolve. Larger defects or hernias with a rectus diastasis must be covered with a plastic mesh that overlaps the hernia gap by at least 3 cm. 

The treatment can usually be performed on an outpatient basis.

Inguinal hernia is the most common type of hernia that we know and treat. More often the hernia occurs in men and especially in adolescence or in men over 50 years. 

The cause varies widely and is congenital in young men and usually connective tissue weakness in older people. Often only a small to large bump appears, which is painless and recedes when lying down. Complaints such as a pulling sensation are more likely to occur with physical exertion or when pressing, such as during bowel movements.

An inguinal hernia should usually be operated on, since the risk of entrapment of fatty tissue or parts of the intestine in the course of life is about 4% and then always results in an emergency operation.

We usually operate on inguinal hernias using a minimally invasive technique. We prefer the TAPP (TransAbdominal Preperitoneal Patchplasty) procedure, in which a 10x15cm plastic mesh is inserted through a laparoscopy with three small incisions under general anesthesia. This mesh does not dissolve and is usually not fixed in place to avoid nerve injury. 

Patients remain inpatient for one to two nights for monitoring and can immediately exercise normally. Swimming and running (jogging) can be done after 2 weeks, heavy physical activities and weight training only after 4 weeks. We prefer this procedure for our operations.

For patients who have undergone multiple abdominal or prostate surgeries, are taking blood thinning medications such as Plavix or Marcumar, or have a hernia that extends into the scrotum, we prefer the open Lichtenstein procedure. 

Here, a skin incision of about 6 cm is made in the groin and an 8x10 cm polypropylene mesh is implanted.  The in-patient stay is 1-2 days and patients can fully weight bear after 6 weeks. In healthy patients, the surgery can also be performed on an outpatient basis.

Young patients under the age of 25 or patients who do not want a mesh despite an increased risk of recurrence can be operated on using the Shouldice technique. This involves reinforcing the posterior wall of the inguinal canal with a double suture of a non-dissolving suture. This operation can be performed on an outpatient basis.