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Patient Info
Dear Patient,
Of all chronic diseases, herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with
congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum
(hernial sac), possibly together with parts of the intestines, protrudes.s are the most common. For example, in
Germany each year some 275,000 people develop an inguinal herniaThe most common type of hernia with hernial
orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term:
[no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal
hernia. and almost 100,000 people abdominal wall herniaLatin term: hernia ventralis. Hernia of the abdominal
wall. s. Hernias develop because of disease-induced gaps in the abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. or diaphragmDome-shaped
muscle plate protruding into the chest cavity, which is secured to the sternum, costal arches and lumbar spine. The
diaphragm forms a partition between the chest cavity and abdominal cavity. It is the most important respiratory
muscle; its muscle fibres contract when breathing in and relax when breathing out. through which a hernial
sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents.
composed of a lining called the peritoneumA smooth layer of connective tissue that lines the abdominal cavity and
covers most of the internal organs. can protrude because of the internal abdominal pressureThe pressure
prevailing inside the abdomen; this can be raised through coughing or pressing.. Abdominal structures, such as
intestinal loops, can enter this hernial sac, hence every hernia in principle poses a risk of constriction and
life-threatening strangulation of internal organs. The risk of strangulation is around between 1–3 % per year. For
that reason every effort should be made to carry out hernia surgery at an early stage.
Despite the high frequency of such surgical hernia procedures, unfortunately, the overall results for Germany on
the whole are not at all satisfactory. For example, the recurrenceRelapse or onset once again of a disease. rate
and the rate of chronic pain following inguinal hernia surgery is above 10 %. For that reason surgeons who are
especially experienced in hernia surgery have come together in the non-commercial company Herniamed to
develop and implement specific quality standards for treatment of hernias. The cornerstone of this endeavour is
strict quality assurance with documentation of all details related to the hernia operations performed and evaluation
of treatment results over a period of 10 years. That hernia surgical techniques can be improved through strict
quality assurance is something we know thanks to scientific studies carried out in Scandinavia.
This Patient Info document is one element aimed at treatment of hernia diseases in line with the dictates of quality
assurance. It is intended as a means of giving you, the patient, an overview of the various examination and
treatment possibilities for hernia, so that you are optimally informed about your disease. However, it is, of course,
not intended as a substitute for a talk with your doctor. But the information presented here will help you and your
doctor decide during a medical consultation on the best form of treatment for your condition
On behalf on the Herniamed Quality Assurance Study, I hope your treatment will prove a success and wish you
speedy recovery!
Prof. Dr. med. Ferdinand Köckerling
Study Director
Herniamed Quality Assurance Study
c/o Klinik für Chirurgie
– Visceral- and Gefäßchirurgie
Zentrum für Minimal Invasive Chirurgie
Neue Bergstraße 6
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D-13585 Berlin
Tel.
Fax
+ 49 (0) 30/130 13 2151
+ 49 (0) 30/130 13 2154
1 Hernias
1.1 A few statistics
HerniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes.s are a widespread phenomenon. Accordingly, around 27 % of men and 3% of
women will suffer from an inguinal herniaThe most common type of hernia with hernial orifice above the inguinal
ligament in the region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. at some stage of their
life. Based on estimates released by international hernia societies, some 20 million people worldwide underwent
inguinal hernia surgery in 2007. In Germany around 275,000 inguinal hernia procedures and just under
100,000 abdominal wall herniaLatin term: hernia ventralis. Hernia of the abdominal wall. operations are carried out
each year. Both children and adults of any gender or age can be affected by this condition.
In abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle layers)
enclosing the abdominal cavity. surgery there is a disease-induced gap in the abdominal wall through which the
peritoneumA smooth layer of connective tissue that lines the abdominal cavity and covers most of the internal
organs., and possibly internal abdominal organs, can protrude. In inguinal hernias the opening is situated in the
region of the inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal
region through the abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring.
The lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the female, the round
ligament of the uterus pass through the inguinal canal., while in diaphragmatic herniaHernia in the region of the
diaphragm. See also hiatal hernia.s it is located within the diaphragmDome-shaped muscle plate protruding into the
chest cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition
between the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle fibres
contract when breathing in and relax when breathing out.. Every type of hernia poses a risk of constriction and
life-threatening strangulation of organs, in particular of the large intestine. The risk of strangulation is around 1–3 %
per year.
Hernias should always be operated on since the congenital (present at birth) or acquired gap in the abdominal wall
will not close on its own. If a hernia is operated on at any early stage, it generally poses no danger. Hence, in
principle surgery can be equated with a cure for the disease.
Hernia operations are routine procedures that are performed very often and for many years now. In recent years
the surgical techniques have been continually improved, hence there is an optimal form of treatment available for
each individual case.
1.2 A look at the anatomy
In order to understand why herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with
congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum
(hernial sac), possibly together with parts of the intestines, protrudes.s occur, we need to take a closer look at the
anatomical structures of the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity., inguinal canalLatin term: canalis inguinalis. A canal
measuring 4 to 5 cm long, running in the inguinal region through the abdominal wall. It originates at the internal
inguinal ring and leads into the external inguinal ring. The lymph vessels and, in the male, the spermatic cord with
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the seminal duct and, in the female, the round ligament of the uterus pass through the inguinal canal. and
diaphragmDome-shaped muscle plate protruding into the chest cavity, which is secured to the sternum, costal
arches and lumbar spine. The diaphragm forms a partition between the chest cavity and abdominal cavity. It is the
most important respiratory muscle; its muscle fibres contract when breathing in and relax when breathing out..
1.2.1 The abdominal wall
The anterior abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity. is bordered at the upper end by the rib cage and at the lower end by the
inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a fascia in the lumbar region, which, inter alia,
is fused with the aponeuroses of the oblique abdominal muscles and the transverse fascia.. It is composed of
different layers of tissue lying on top of each other and enclosed on the outside by the skin. Situated immediately
beneath the skin is fat tissue (subcutaneous adipose tissue), beneath that various muscle layers with associated
tendon plates (also called "aponeuroses"). The abdominal wall musculature includes the three lateral abdominal
muscles which, with their wide and flattened tendons providing elastic support, like a corset, to the abdominal
contents. There is also the anterior rectus abdominis muscleLatin term: musculus rectus abdominis. The rectus
muscle runs in two straight lines from the chest to the pelvis. It is subdivided by several intermediate tendons.
(rectus muscle) running down the midline of the body and containing a tendinous cover called the rectus sheathA
covering, composed of the tendinous plates of the anterior abdominal muscles, of the rectus abdominis muscle
(Latin term: musculus rectus abdominis) which runs down the midline of the body.. This, too, is closely intertwined
with connective tissue structures of the abdominal wall and helps retain the abdominal contents in position.
Beneath the muscle layers is, in addition to connective and adipose tissue, the peritoneumA smooth layer of
connective tissue that lines the abdominal cavity and covers most of the internal organs.. It serves as a smooth
lining covering the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between the
diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum. and
enclosing the majority of internal organs. [Fig. 1]
Fig 1: The anatomy of the abdominal wall
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1.2.2 The inguinal canal
The inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region
through the abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The
lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of
the uterus pass through the inguinal canal. is a canal measuring around 4 to 5 cm in length and traversing the
abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle layers)
enclosing the abdominal cavity. from the top to the bottom in the inguinal region. Within it are nerves and lymph
vessels as well as, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament
(one of the ligaments serving to secure the uterus within the pelvis). In terms of anatomy, the inguinal region is a
weak point of the abdominal wall since in some parts of it the muscle-tendon layer is very thin. [Fig. 2]
Fig. 2: The anatomy of the inguinal canal
1.2.3 The diaphragm
The diaphragmDome-shaped muscle plate protruding into the chest cavity, which is secured to the sternum, costal
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arches and lumbar spine. The diaphragm forms a partition between the chest cavity and abdominal cavity. It is the
most important respiratory muscle; its muscle fibres contract when breathing in and relax when breathing out. is a
muscular plate that separates the chest and abdominal cavities from each other. It is secured to the breast bone
(sternum), rib cage and lumbar spine, projecting into the chest cavity in the form of two domes. In addition to a
number of smaller gaps, the diaphragm has three large openings: oesophageal hiatusLatin term: hiatus
oesophageus. Opening in the diaphragm through which the oesophagus passes. for the oesophagusGullet.
(gullet), aortic hiatusOpening in the diaphragm through which the aorta as well as lymph (lymphatic) vessels run.
for the aortaLargest artery in the body. (the main blood vessel in the body) and, finally, the opening for the inferior
vena cavaLatin term: vena cava inferior. Large blood vessel running through the vena cava orifice of the diaphragm
from the abdominal cavity into the chest cavity.. These natural openings are potential sources of herniaDerived
from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal
wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the
intestines, protrudes.s through which, in the event of disease, organs or structures can be displaced from the
abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between the diaphragm and
pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum. into the chest. Hernias
passing through the oesophageal hiatus are also called hiatal herniaDiaphragmatic hernia protruding through the
oesophageal hiatus.s. [Fig. 3]
Fig. 3: The anatomy of the diaphragm
1.3 What is a hernia?
1.3.1 Structure
Derived from the Greek word “hernos” (bud, sprout, protrusion), the term herniaDerived from the Greek word
“hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm
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(hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes.
means an opening, for example in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose
tissue as well as muscle layers) enclosing the abdominal cavity., through which the peritoneumA smooth layer of
connective tissue that lines the abdominal cavity and covers most of the internal organs., possibly together with
parts of the intestines, can protrude. This opening can be of congenital or acquired origin. The medical designation
for this opening is hiatal orifice and the protruding peritoneum is called the hiatal sac, and any organ structure
contained therein is called the hernia contentsThe components of the abdominal cavity, such as intestines or
greater omentum, contained within the hernial sac.. The hernial openings can be situated in the abdominal wall, in
the vicinity of surgical scars, in the diaphragmDome-shaped muscle plate protruding into the chest cavity, which is
secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition between the chest cavity
and abdominal cavity. It is the most important respiratory muscle; its muscle fibres contract when breathing in and
relax when breathing out., inguinal region, floor of the pelvis, abdominal cavityLatin term: cavitas abdominalis. The
region of the trunk situated between the diaphragm and pelvis containing the abdominal organs. The abdominal
cavity is lined with the peritoneum. and even in the muscles of the back.
As such, a hernia is made essentially of the following three parts [Fig. 4]:
·
Hernial orificeGap in the abdominal wall or in the diaphragm through which the peritoneum, possibly
together with parts of the intestines, protrudes.: Disease-induced gap, for example in the abdominal wall.
Depending on its location, it runs through different tissue layers (muscles, tendons, scar tissue, etc.). The location
of the hernial opening determines how the hernia will be designated, for example, one uses the term inguinal
herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the region of the lateral or
medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral
inguinal hernia and medial inguinal hernia., umbilical hernia (close to the navel), incisional herniaHernia occurring
after an abdominal operation in the region of the surgical scar. (in the region of a surgical scar), diaphragmatic
herniaHernia in the region of the diaphragm. See also hiatal hernia., etc.
·
Hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents.: Projection of the peritoneum protruding through the hernial opening. On the outside the hernial
sac is covered by subcutaneous adipose tissue and skin. These layers are called the hernia coveringStructure
enclosing the hernial sac with subcutaneous adipose tissue and skin. .
·
Hernia contents: The hernial sac is either empty or – as in the majority of cases – filled with the hernia
contents. The hernia contents can be made of different components, for example of intestinal loops and/or parts of
the greater omentumLatin term: omentum majus. An adipose and connective tissue layer lined with the peritoneum
and covering the small intestine. The greater omentum is responsible for immune defence in the abdominal
cavity. (this is an apron-like peritoneal structure made of fat and connective tissue which is normally spread across
the intestinal loops). The hernia sac generally contains a fluid called hernia waterFluid contained within the hernial
sac, promoting sliding of the hernia contents., promoting sliding of the hernia contents.
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Fig. 4: Structure of a hernia
1.3.2 Causes
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. can have different causes. Essentially, a distinction is made between congenital
and acquired herniaHernia with hernial orifice and hernial sac situated at a location on the abdominal wall where
there is acquired weakness. The reduction in the strength of the abdominal wall may be due to: impaired collagen
synthesis, raised internal abdominal pressure, overweight, pregnancy.s.
1.3.2.1 Congenital hernias
Here the herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired
gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly
together with parts of the intestines, protrudes. sac is present in some cases at birth as an anlage. In the case of a
congenital inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia., for example, a
finger-shaped protrusion of the peritoneumA smooth layer of connective tissue that lines the abdominal cavity and
covers most of the internal organs., projecting through the internal inguinal ringOrigin of the inguinal canal on the
inside of the abdominal wall situated above the inguinal ligament. into the inguinal canalLatin term: canalis
inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the abdominal wall. It originates
at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels and, in the male, the
spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass through the inguinal
canal., serves as hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents.. In the congenital umbilical herniaHernia protruding in infants or young children through the, as
yet, incompletely closed umbilical ring (congenital hernia), and occurring in adults due to a weakness in the region
of the navel (acquired hernia). the hernial sac projects outwards through the incompletely closed umbilical
ringRing-shaped opening in the tissue around the navel. (a ring-shaped opening in the tissue around the navel). In
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general, congenital herniaHernial orifice and hernial sac are present as an anlage already at birth.s occur already
during infancy or at a young age.
1.3.2.2 Acquired hernias
In acquired herniaHernia with hernial orifice and hernial sac situated at a location on the abdominal wall where
there is acquired weakness. The reduction in the strength of the abdominal wall may be due to: impaired collagen
synthesis, raised internal abdominal pressure, overweight, pregnancy.s a hernial orificeGap in the abdominal wall
or in the diaphragm through which the peritoneum, possibly together with parts of the intestines, protrudes. with
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is
formed at certain weak points of the body, example in the abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. when there is a lack of
abdominal wall strength or in the vicinity of surgical scars because of incomplete scar formation. One important
cause is a defect in collagenStructural protein of the connective tissue. metabolism. Since collagen is responsible
for the connective and supporting tissues of the body, any disruption in its production leads to connective tissue
instability and reduced scar strength. The risk of development of a defect in collagen metabolism, and hence of
connective tissue weakness, increases with age. Hernias can also occur due to a sharp rise in the internal
abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through coughing or pressing.,
as in the case of chronic cough due to lung disease, chronic constipation leading to increased pressing during
bowel movements or if regularly carrying heavy loads. Other risk factors are pregnancy and overweight. In a few
rare cases no reasons can be definitively identified for onset of a hernia.
1.3.3 Complications
HerniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes.s can lead to a number of physical and aesthetic defects. Strangulation of the
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. in
the hernial opening gives rise to a dangerous situation. This is called incarcerationConstriction of tissue, for
example of hernia contents such as greater omentum or intestinal loops in the presence of hernias. Due to swelling
following blood congestion and oedema there is a risk of death (necrosis) of the constricted organs. and results in
local blood congestionLocal accumulation of blood. and leakage of fluid into the tissues (oedemaWater
accumulation in tissue; accompanied by swelling of the tissue.). Tissue swelling leads to virtual strangulation and
impaired blood flow of the organ structure enclosed within the hernial sac. If, because of its size, it is no longer
possible to push back the hernial sac into the body, there is a risk of death (necrosisTissue death due to
irreversible failure of cell functions (cell death).) of its contents, for example strangulated intestinal loops, if surgery
is not promptly carried out. This situation causes the patient severe pain and constitutes an acute emergency
warranting immediate hospitalisation or emergency treatment.
Strangulation of a hernia poses a threat of tissue death and calls for immediate surgery.
1.4 Different types of hernias
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. can occur at different body sites. Different types are identified, depending on
where the hernia opening is situated. [Fig. 5]
The most important types of hernias:
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Epigastric herniaA hernia of the
upper abdomen whose hernial
orifice is situated in the region of
the linea alba.
Hernia in the midline of the upper abdomenTummy, belly.
Umbilical herniaHernia protruding Hernia in the navel region
in infants or young children
through the, as yet, incompletely
closed umbilical ring (congenital
hernia), and occurring in adults
due to a weakness in the region of
the navel (acquired hernia).
Incisional herniaHernia occurring Hernia in the vicinity of a scar left after a previous operation
after an abdominal operation in the
region of the surgical scar.
Inguinal herniaThe most common Hernia in the inguinal region
type of hernia with hernial orifice
above the inguinal ligament in the
region of the lateral or medial
inguinal fossa (Latin term:
[no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis).
See also lateral inguinal hernia
and medial inguinal hernia.
Femoral herniaLatin term: hernia
femoralis. A hernia passing
through the lacuna vasorum.
Special form of inguinal hernias descending to the thigh
Parastomal herniaA parastomal
Hernia in the presence of an artificial intestinal outlet (stoma)
hernia is an incisional hernia in the
vicinity of an artificial intestinal
outlet (endostoma).
Hiatal herniaDiaphragmatic hernia Diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia. at the s
protruding through the
the oesophagusGullet. enters the abdomen
oesophageal hiatus.
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Fig. 5: Different types of hernias and their localisation
1.4.1 Epigastric hernia
An epigastric herniaA hernia of the upper abdomen whose hernial orifice is situated in the region of the linea alba.
is a hernia in the midline of the upper abdomenTummy, belly. (between the breast bone (sternum) and navel). The
hernia opening is situated in the region of what is known as the linea alba. This is a tendinous strip formed from the
tendinous skin of the lateral abdominal muscles. The hernial sacEvagination of the peritoneum that protrudes
through a hernial orifice. It may contain hernia contents. may contain components of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity., and in rare cases also
parts of the small intestines. Risk factors for onset of an epigastric hernia are connective tissue weakness,
increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
coughing or pressing. (e.g. in the event of chronic cough and strong pressing because of constipation), overweight
and frequent carrying of heavy loads. In general, epigastric hernias can be seen and/or felt. It may, or may not be,
accompanied by pain. If affects men and women equally.
1.4.2 Umbilical hernia
Around 5 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are umbilical herniaHernia protruding in infants or young
children through the, as yet, incompletely closed umbilical ring (congenital hernia), and occurring in adults due to a
weakness in the region of the navel (acquired hernia).s. Often, they are of a congenital nature and thus manifest
already in infancy or at a young age. In adults mainly acquired herniaHernia with hernial orifice and hernial sac
situated at a location on the abdominal wall where there is acquired weakness. The reduction in the strength of the
abdominal wall may be due to: impaired collagen synthesis, raised internal abdominal pressure, overweight,
pregnancy.s are seen, attributable – for example in pregnant women or persons engaging in heavy physical work –
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to increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
coughing or pressing..
Since the tissue of the abdominal navel is, by nature, less stable than that of the surrounding tissues, the navel
represents a natural weak point in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose
tissue as well as muscle layers) enclosing the abdominal cavity.. In the umbilical hernia, the hernial sacEvagination
of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. protrudes through the
umbilical ringRing-shaped opening in the tissue around the navel.; this is a ring-shaped opening in the tissue
around the navel. The hernia manifests as a swelling in the navel region, and may be painful. The hernial sac may
contain lymphatic or fat tissue from the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum., and in some cases also parts of abdominal organs. Whereas strangulation is virtually never seen in
congenital umbilical hernias, this is by all means possible in the case of acquired umbilical hernias occurring in
adults. Therefore the latter cases should be operated on immediately. In most cases, a congenital umbilical hernia
heals spontaneously, hence surgery is generally not needed.
1.4.3 Incisional hernia
Incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar.s occur after open
surgical procedures on the abdomenTummy, belly. in the region of the surgical scar. This type of hernia is seen
after some 10 % of all abdominal operations. Based on data from the German Federal Statistical Agency, around
50,000 incisional hernia surgical procedures are carried out each year in Germany (!).
Incisional hernias arise because of a lack of strength of the surgical scar. Contributory factors include wound
infection, bleeding, impaired wound healing, patient’s poor general and nutritional status, special diseases such as
diabetes or cancer, overweight, medications (in particular cortisone preparations), long-standing nicotine
consumption as well as defective collagenStructural protein of the connective tissue. metabolism. Incisional hernia
generally presents within one year of abdominal surgery. The main symptom is a visible or palpable protrusion in
the region of a still relatively fresh abdominal surgical scar.
Even if an incisional hernia does not give rise to any complaints, it should nonetheless be operated on since it
could cause dangerous complications, in particular strangulation of intestinal components. However, the original
surgical scar should be first allowed to heal, something that in general takes around six months after the
procedure.
1.4.4 Inguinal hernia
Inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the region of the
lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also
lateral inguinal hernia and medial inguinal hernia.s account for around 75–80 % of all hernias and are thus the most
common type of hernia. Around 27 % of men and 3 % of women will develop an inguinal hernia at some stage of
their life. Thanks to a narrower inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long,
running in the inguinal region through the abdominal wall. It originates at the internal inguinal ring and leads into the
external inguinal ring. The lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the
female, the round ligament of the uterus pass through the inguinal canal., women on the whole are less commonly
affected than men.
A distinction is made between medial (= direct) and lateral (= indirect) inguinal hernias.
1.4.4.1 Medial/direct inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. is always acquired. It
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accounts for around 30–40 % of all cases of inguinal hernias and affects in particular men of advanced age. The
hernial opening is situated in the area of what is known as Hesselbach’s triangle, a muscle-free region of the
inguinal fossa. The hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents. runs medially to the blood vessels of the lower abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. (medial = parallel to the
midline of the body). It protrudes vertically, that is through a direct pathway, through a region of the abdominal body
with acquired tissue weakness.
1.4.4.2 Lateral/indirect inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. can be either of
congenital or acquired origin. It accounts for around 60–70% of all cases of inguinal hernias and affects men in
particular. It occurs mainly on the right side of the body (49 %), less commonly on the left side (36 %) or on both
sides (15 %). Lateral inguinal herniaAlso called indirect inguinal hernia. A lateral inguinal hernia can be either of
congenital or acquired origin. It runs through the inguinal canal, with the internal inguinal ring as hernial orifice.s do
not project directly through the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity., running instead – indirectly – through the inguinal
canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the
abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels
and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass
through the inguinal canal.. The internal inguinal ringOrigin of the inguinal canal on the inside of the abdominal wall
situated above the inguinal ligament., which is the entrance to the inguinal canal in the region of the lateral inguinal
fossaExternal inguinal fossa., serves as hernia opening. The hernial sacEvagination of the peritoneum that
protrudes through a hernial orifice. It may contain hernia contents. then protrudes towards the outside at the
external inguinal ringThis is also known as the superficial inguinal ring (Latin term: anulus inguinalis superficalis).
The opening in the inguinal canal on the outside of the abdominal wall above the pubic tubercle, formed by an
opening in the tendon of the external oblique abdominal muscle (Latin term: musculus obliquus externus
abdominis)., which is the outlet of the inguinal ring.
In females, the lateral inguinal hernia can reach as far as the labia majora and, in males, as far as the scrotum. The
terms labial and scrotal herniaLatin term: hernia scrotalis. Lateral inguinal hernia whose hernial sac stretches as far
as the scrotum.s are used, respectively, to denote these conditions.
1.4.5 Femoral hernia
Around 7 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are femoral herniaLatin term: hernia femoralis. A hernia
passing through the lacuna vasorum.s. This special type of inguinal herniaThe most common type of hernia with
hernial orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term:
[no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal
hernia. is virtually always acquired and affects mainly women (around 80 % of cases). Risk factors are, in addition
to female gender, advanced age, history of pregnancy / pregnancies as well as overweight. The hernia opening of
femoral hernias is situated beneath the inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a
fascia in the lumbar region, which, inter alia, is fused with the aponeuroses of the oblique abdominal muscles and
the transverse fascia. in what is known as the lacuna vasorum, which is the entry site for the blood vessels and
nerves supplying the thigh.
Often, a femoral hernia is diagnosed only at a very late stage, or indeed commonly only when complications are
already present. This is due to the fact that the patients concerned feel only a diffuse pressure pain beneath the
groin, or indeed no pain at all. In obese patients, in particular, it is often difficult to see or feel a femoral hernia in
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the form of a swelling below the groin. Hence it is often diagnosed only when the hernial sacEvagination of the
peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is already strangulated within
the hernia opening. By that stage, there is a risk of the hernial sac (for example intestinal loops) not being
adequately supplied with blood, thus posing a risk of necrosisTissue death due to irreversible failure of cell
functions (cell death). (tissue death). For that reason a femoral hernia should always be operated on as early as
possible.
1.4.6 Parastomal hernia
Parastomal herniaA parastomal hernia is an incisional hernia in the vicinity of an artificial intestinal outlet
(endostoma).s are hernias occurring beside (Greek term para = beside) an artificial intestinal outlet (stoma). The
opening in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity., which is needed to construct the stoma, serves as the hernia opening
through which the hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents., possibly with parts of the intestines or greater omentumLatin term: omentum majus. An adipose
and connective tissue layer lined with the peritoneum and covering the small intestine. The greater omentum is
responsible for immune defence in the abdominal cavity., protrude outwards. Up to 50 % of all stoma patients are
affected by a parastomal hernia, thus making it the most common complication associated with an artificial
intestinal outlet.
A parastomal hernia occurs if the scar in the region of the stoma (opening) is not sufficiently strong. Contributory
factors are impaired wound healing, bleeding and wound infections, in addition to the patient’s poor general and
nutritional status, special diseases such as diabetes or cancer, overweight, medications (in particular cortisone
preparations), long-standing nicotine consumption as well as defective collagenStructural protein of the connective
tissue. metabolism. The symptoms of a parastomal hernia are palpable defects in the affected tissue or a
protrusion in the region of the artificial intestinal outlet, occurring when coughing or pressing.
1.4.7 Hiatal hernia
If the oesophageal hiatusLatin term: hiatus oesophageus. Opening in the diaphragm through which the
oesophagus passes. is expanded because of a congenital or acquired weakness of the surrounding tissue, a
diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia. can occur at this site. In such a
hiatal herniaDiaphragmatic hernia protruding through the oesophageal hiatus. there is partial or complete
displacement of abdominal organs into the chest cavity. Depending on the size of the hernia, different types are
identified.
The most common type is the axial sliding herniaHiatal hernia, where the stomach is pushed upwards, with
the entrance to the stomach (cardia) being displaced into the chest cavity., where the stomach is pushed
somewhat upwards, resulting in the entrance to the stomach together with the cardiaThe part of the oesophagus
leading into the stomach; entrance to the stomach. (the site where the oesophagusGullet. enters the stomach)
being displaced into the chest cavity. Often, a sliding hernia causes none, or few, complaints. Hence it is commonly
diagnosed only by chance. However, if the muscular closure mechanism between the oesophagus and stomach
does not function properly because of displacement of the stomach, there can be refluxBackflow of gastric juice
into the oesophagus. (backflow) of stomach acid into the oesophagus. This, in turn, gives rise to irritation of the
oesophageal mucosa causing reflux diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric
juice into the oesophagus with onset of heartburn as well as swallowing disorders. withthe typical symptoms of
heartburn, swallowing disorders and pain in the upper abdomenTummy, belly.. If hiatal hernia causes such
complaints, attempts are made first of all to treat this by means of conservative measures such as weight reduction,
change of diet, change of lifestyle and drug-based treatment. If these prove unsuccessful, the hernia should
definitely be treated surgically as soon as possible.
In the less common paraoesophageal herniaWith this type of diaphragmatic hernia the proximal section of
the stomach near the oesophagus protrudes through the oesophageal hiatus into the chest cavity. the first
(proximal) portion of the stomach is displaced through the oesophageal hiatus and along the oesophagus into the
chest cavity (the entrance to the stomach, the cardia, remains within the abdominal cavityLatin term: cavitas
abdominalis. The region of the trunk situated between the diaphragm and pelvis containing the abdominal organs.
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The abdominal cavity is lined with the peritoneum., unlike in the case of the axial sliding hernia). In some cases
with this type of hiatal hernia parts of other organs, such as intestinal loops or parts of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity. are displaced into the
chest cavity. To begin with, patients have generally no complaints, as only later do symptoms such as a feeling of
fullness, or pressure occur in the chest, swallowing disorders or respiratory distress. Life-threatening complications
can occur because of strangulation of the displaced organs. Therefore the paraoesophageal hernia must always be
surgically treated as soon as possible.
In some cases mixed forms of sliding hernia and paraoesophageal hernia are seen. A rare, but severe form of
paraoesophageal hernia is the upside-down stomach, also known as a thoracic stomachSee Upside-down
stomach.. In such a case two-thirds or more of the stomach (or even the entire stomach) are displaced into the
chest cavity. This causes distortion of the stomach and displacement of the chest cavity organs, in particular of the
lungs and heart. Patients thus often suffer from cardiovascular complaints, respiratory distress or chest pain. Just
like other paraoesophageal hernias, an upside-down stomachAlso called thoracic stomach. A severe form of
paraoesophageal hernia where two-thirds or more of the stomach (or even the entire stomach) are displaced into
the chest cavity. must be operated on as quickly as possible to prevent dangerous complications.
1.4.8 Rare hernias
1.4.8.1 Internal herniaDisplacement of abdominal intestines into enlarged peritoneal pockets within the trunk,
possibly with incarceration. Often, this type of hernia cannot be detected with the naked eye.s
These types of hernias cannot as a rule be detected with the naked eye or be felt, because the hernial
sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is situated
within peritoneal pockets inside the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum..
1.4.8.2 Spieghel herniaA rare hernia which, in the region of the lateral abdominal wall, penetrates what is known as
Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the rectus
abdominis muscle).
This is a hernia which occurs in the region of the lateral abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity.. It penetrates what is
known as Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the
anterior rectus abdominis muscleLatin term: musculus rectus abdominis. The rectus muscle runs in two straight
lines from the chest to the pelvis. It is subdivided by several intermediate tendons.).
1.4.8.3 Morgagni’s hernia
A hernia protrudes through a small gap in the diaphragmDome-shaped muscle plate protruding into the chest
cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition between
the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle fibres contract when
breathing in and relax when breathing out., known as Morgagni’s gap Morgagni’s hernias occur close to the
breast bone.
1.4.8.4 Richter’s hernia
In the case of this hernia, which is also known as an intestinal wall hernia, the hernia contentsThe components of
the abdominal cavity, such as intestines or greater omentum, contained within the hernial sac. within the hernial
sac are composed of only a protruded part of the intestinal wall. Intestinal passage is unaffected since the entire
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intestines are not involved.
2 Examinations
Whether a herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes. is present or not and what is the nature of this is something
that the physician can determine in most cases during a physical examination. Only if the hernia is very small or in
the case of internal herniaDisplacement of abdominal intestines into enlarged peritoneal pockets within the trunk,
possibly with incarceration. Often, this type of hernia cannot be detected with the naked eye.s that can be neither
seen nor palpated is it advisable to resort to the use of imaging techniques (ultrasound, X-ray examinations,
computed tomographyAbbreviation: CT. Slice-wise imaging with computer control. The individual slices are
assembled by the computer, giving rise to a three-dimensional image where even the smallest of details are
visible. (CT), magnetic resonance imagingAbbreviation: MRI. Diagnostic procedure for generation of slice images
of the human body. As opposed to computed tomography, MRI uses magnetic fields rather than X-ray beams for
computer-assisted generation of the slice images. (MRI) for further clarification.
2.1 Medical patient history
Before examining the patient, the doctor takes the medical patient historyAn account of the patient’s medical
history given during a talk between doctor and patient, and sometimes relatives. It comprises, among other things,
the nature, onset and course of the current complaints as well as details of any previous or concomitant diseases.
during a consultation. For a reliable diagnosisDetection and designation of a disease. and to assure appropriate
treatment measures, the physician must obtain all important information on the patient and his/her history. This
includes, in particular, the nature, trigger and course of current complaints, any other diseases, medication taken,
drug intolerances, allergies, etc. Very useful in this context are documents produced by the patient on previous
examinations and treatment measures, for example copies of medical reports, X-ray and laboratory results.
2.2 Physical examination
Having taken the medical patient historyAn account of the patient’s medical history given during a talk between
doctor and patient, and sometimes relatives. It comprises, among other things, the nature, onset and course of the
current complaints as well as details of any previous or concomitant diseases., the physician conducts a thorough
physical examination. If there is a suspicion of abdominal wall herniaLatin term: hernia ventralis. Hernia of the
abdominal wall. , the respective area is examined for a protrusion, pressure pain and skin changes with the patient
mainly standing upright. The doctor palpates the hernia opening, inguinal canalLatin term: canalis inguinalis. A
canal measuring 4 to 5 cm long, running in the inguinal region through the abdominal wall. It originates at the
internal inguinal ring and leads into the external inguinal ring. The lymph vessels and, in the male, the spermatic
cord with the seminal duct and, in the female, the round ligament of the uterus pass through the inguinal canal. and
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents.
and checks whether it is possible to repositionReturn to its original site. the hernial sac. Depending on the location
of the hernia, he pushes the skin of the respective site inwards with a finger. In the case of an inguinal herniaThe
most common type of hernia with hernial orifice above the inguinal ligament in the region of the lateral or medial
inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal
hernia and medial inguinal hernia. in males, he pushes the skin of the scrotum downwards with a finger like a glove
into the inguinal canal; in females, he places a finger on the inguinal region, at the attachment of the labia majora.
The doctor may ask the patient to cough or press so that an unnoticeable hernial sac can project, making it easier
to feel. By listening with the stethoscopeInstrument for listening to body noises. he can then determine whether the
hernial sac contains intestinal loops and whether these are strangulated (intestinal noises!). To round off the
examination, the physician palpates and taps on the entire abdomenTummy, belly. to get an idea of the overall
condition of the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity. and ensure that any other hernias present are not overlooked.
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2.3 Ultrasound examination
The findings of the physical examination can be complemented or verified by means of ultrasound. For example,
using sonographySee ultrasound examination. the doctor can clearly diagnose a femoral herniaLatin term: hernia
femoralis. A hernia passing through the lacuna vasorum. which is scarcely palpable. Likewise, using this technique
he can distinguish between a scrotal herniaLatin term: hernia scrotalis. Lateral inguinal hernia whose hernial sac
stretches as far as the scrotum. (testicular hernia with displacement of intestinal structures into the scrotum) and a
hydroceleAccumulation of fluid in the region of the testicles or spermatic cord. (fluid accumulation in the scrotum).
Ultrasound examinationImaging technique where high-energy sound waves are reflected in different ways through
tissue, tumours, blood vessels or bones. causes the patient no pain at all and is very gentle since no X-ray beams
are used. The latest equipment produces precise images of the inside of the body, where even small changes in
organs can be detected.
2.4 X-ray examinations
X-ray examinations represent an imaging technique that can be used to visualize even the most minute structures
within the body. The tissues are visualized with X-ray beams, a process that suffers the drawback of a high
radiation dose. To improve visibility, contrast media containing iodine or barium are used for certain types of X-ray
examinations, such as for example in the case of gastrointestinal passageX-ray examination, with administration of
contrast medium, for visualizing the oesophagus, stomach and small intestine. described below.
2.5 Gastrointestinal passage examination
This entails X-ray examination of the upper digestive tract (oesophagusGullet., stomach and small intestine) with
use of a contrast medium that helps to identify any disease-induced changes in this area. For example, any
intestinal loops displaced into a hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It
may contain hernia contents. can be easily shown. Gastrointestinal passageX-ray examination, with administration
of contrast medium, for visualizing the oesophagus, stomach and small intestine. examination is thus used primarily
for diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia.s (hiatal herniaDiaphragmatic
hernia protruding through the oesophageal hiatus.) and internal herniaDisplacement of abdominal intestines into
enlarged peritoneal pockets within the trunk, possibly with incarceration. Often, this type of hernia cannot be
detected with the naked eye.s.
After the patient has swallowed the contrast medium, X-ray images are continuously taken to check the integrity
(regular structure) of the surfaces of the mucous membranes. The physician can view the images on a monitor
while they are being taken. The patient also ingests a gas-forming granulate or powder so that the organs of the
gastrointestinal tract become filled with gas, giving rise to expansion of wall structures and making it easier to
detect any irregularities. X-ray images of different body positions are taken until all important images needed for a
diagnosisDetection and designation of a disease. are available.
The contrast medium can give rise to short-term diarrhoea and flatulence. One major disadvantage of
gastrointestinal passage examination is the relatively high radiation dose, which is why this technique is only used if
no other alternative is available. To assure good examination results, it is important that the patient be fasting. That
means that on the day before the examination until the end of examination he/she must not take any nutrition, and
must also avoid coffee, milk, cigarettes. On the day prior to the examination, the patient should avoid any
flatulence-inducing foods (pulses, etc.). In a discussion with the doctor, the patient should also arrange to take any
medication only later on the day of the examination.
2.6 Computed tomography (CT)
Computed tomographyAbbreviation: CT. Slice-wise imaging with computer control. The individual slices are
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assembled by the computer, giving rise to a three-dimensional image where even the smallest of details are
visible. is a computer-controlled X-ray imaging technique where the body is imaged one slice after the other. The
patient is in a lying position inside the tubular computed tomography apparatus. As they take images of the various
tissues, the X-ray beams are weakened to different degrees, a finding recorded by special detectors, processed by
the computer and converted into an image. Even the most minute details can be easily detected on the CT images
– the latter are much more clearly visible than conventional X-ray images.
CT examination is used primarily for incisional herniaHernia occurring after an abdominal operation in the region of
the surgical scar.s, parastomal herniaA parastomal hernia is an incisional hernia in the vicinity of an artificial
intestinal outlet (endostoma).s and diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal
hernia.s. It is used to determine the extent of a defect in abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. or diaphragmDome-shaped
muscle plate protruding into the chest cavity, which is secured to the sternum, costal arches and lumbar spine. The
diaphragm forms a partition between the chest cavity and abdominal cavity. It is the most important respiratory
muscle; its muscle fibres contract when breathing in and relax when breathing out..
2.7 Magnetic resonance imaging (MRI)
With magnetic resonance imagingAbbreviation: MRI. Diagnostic procedure for generation of slice images of the
human body. As opposed to computed tomography, MRI uses magnetic fields rather than X-ray beams for
computer-assisted generation of the slice images. the body is also imaged slice by slice, but using a strong
magnetic field instead of the X-ray beams used in computed tomographyAbbreviation: CT. Slice-wise imaging with
computer control. The individual slices are assembled by the computer, giving rise to a three-dimensional image
where even the smallest of details are visible. . Therefore before such an examination, all metallic objects
(jewellery, spectacles, hearing aid, credit cards, etc.) must be removed. Patients wearing a pacemaker or metallic
implants in the body such as plates, screws and nails should definitely let the medical personnel know in advance.
2.8 Gastroscopy
During gastroscopy the doctor can clearly view the inside of the oesophagusGullet., stomach and duodenum (first
portion of the small intestine) and take tissue biopsies (samples) if necessary. The stomach should be completely
empty when performing this examination. The physician guides a thin, tubular instrument (endoscopeTubular or
hose-shaped instrument used to perform endoscopy.) through the patient’s mouth and into the stomach. Air is
pumped carefully into the stomach so that the stomach wall structures can expand and any disease-mediated
changes can be seen more easily. At the end of the endoscope is a mini-camera enabling the doctor to inspect
carefully the inside of the stomach and intestines. Using special working channels integrated into the endoscope,
he can introduce small instruments into the stomach and take tissue samples. Thanks to the use of modern
instruments with a soft tube and tiny camera as light source, this examination is scarcely unpleasant. But if the
patient is anxious about undergoing gastroscopy he/she can take a mild sedative or, if desired, an anaesthetic so
that as a rule the procedure is relaxed and painfree.
Gastroscopy is used primarily to investigate for the presence of hiatal herniaDiaphragmatic hernia protruding
through the oesophageal hiatus.s. It enables the doctor to distinguish between a sliding herniaAn organ, which is
lined only on one side with the peritoneum, juts into the hernial orifice. The respective organ thus forms part of the
hernial sac wall. with refluxBackflow of gastric juice into the oesophagus. of gastric acid into the oesophagus (reflux
diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric juice into the oesophagus with onset of
heartburn as well as swallowing disorders.) and a paraesophageal hernia where a portion of the stomach is pushed
up into the chest cavity. [For information on the various types of hiatal hernia, please see “What types of hernias
are there?”.] An exact diagnosisDetection and designation of a disease. is urgently needed here to decide on
optimal surgical treatment.
2.9 Measurement of the pH value of gastric juice
In rare cases neither with gastrointestinal passageX-ray examination, with administration of contrast medium, for
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visualizing the oesophagus, stomach and small intestine. nor coloscopyExamination of the intestinal mucosa by
means of a movable tube containing an optical system and small biopsy forceps for taking tissue samples. is it
possible to reliably diagnose hiatal herniaDiaphragmatic hernia protruding through the oesophageal hiatus. with
refluxBackflow of gastric juice into the oesophagus. of acidic stomach contents into the oesophagusGullet. (reflux
diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric juice into the oesophagus with onset of
heartburn as well as swallowing disorders.). In such cases, the pH value of the stomach juice must be measured
over a period of 24 hours (24-hour pH metry). This measurement is conducted via a probe that is inserted into the
oesophagus during coloscopy and left there for 24 hours. In this way, the quantity of gastric juice flowing back into
the oesophagus can be determined. Under normal conditions, only in isolated cases are acidity values below pH 4
measured. Any values below that reading persisting over a long period of time are deemed abnormal.
3 Surgical treatment
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. must always be operated on since the hernia opening will never close on its own.
Furthermore, surgery should be performed as soon as possible to prevent the dangers posed by strangulation of
portions of the intestines and/or omentum. There is no other treatment option. Even if under certain circumstances
the hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia
contents. is repositionReturn to its original site.ed in the abdominal cavityLatin term: cavitas abdominalis. The
region of the trunk situated between the diaphragm and pelvis containing the abdominal organs. The abdominal
cavity is lined with the peritoneum., it will be pushed forwards through the hernia opening once again the next time
there is a rise in abdominal pressure, for example when coughing, thus expanding the latter. The use of
conservative treatment methods, such as wearing a hernia trussBelt-like device used as a conservative treatment
method for abdominal wall hernias. This is supposed to keep the intestines in place within the abdominal cavity,
preventing them from protruding outwards through the hernial orifice. (a belt-like device intended to keep abdominal
structures in place within the abdominal cavity) have not only not proved very useful, but have even turned out to
be harmful. On using a hernia truss, the abdominal muscles can retract, making the abdominal wallThe anterior
tissue structures (skin, subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity.
more unstable and thus increasing the risk of further hernias. Moreover, under certain circumstances serious
injuries can be caused by the pressure exerted on the skin beneath the hernia truss.
Hernia operations are the most commonly conducted type of surgical procedures. Certain surgical techniques have
proved useful whereby the surgeon repositions the hernia contentsThe components of the abdominal cavity, such
as intestines or greater omentum, contained within the hernial sac. in the abdominal cavity, closes the hernia
opening and stabilizes the tissue. Which surgical method is the most appropriate will depend on the nature and
extent of the hernia as well as on the patient’s everyday demands and age. There are various methods to close
hernia openings – for example merely suturing methods where sutures are used to treat and stabilize the hernia, or
methods using a synthetic meshFor some surgical techniques used to treat hernias, an artificial mesh is implanted
for additional stabilization of the tissue in the region of the hernial orifice.. In principle, it is possible to perform the
operation in a conventional open surgery method or by means of an endoscopic (also called laparoscopic or
minimally invasive) technique.
3.1 Inguinal hernia
3.1.1 Shouldice operation
This is an open surgical technique where the herniaDerived from the Greek word “hérnos” (bud, sprout,
protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through
which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes. gap is closed using
tissue harvested from the patient himself. The surgeon removes a piece of skin, measuring around 5 to 8 cm and
running crosswise, from above the inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a fascia in
the lumbar region, which, inter alia, is fused with the aponeuroses of the oblique abdominal muscles and the
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transverse fascia. [Fig. 6], exposes the hernial sacEvagination of the peritoneum that protrudes through a hernial
orifice. It may contain hernia contents. via this approach [Fig. 7] and opens it to check the structures contained in it,
and if necessary treat it. Next, the abdominal contents are repositionReturn to its original site.ed in the abdominal
cavityLatin term: cavitas abdominalis. The region of the trunk situated between the diaphragm and pelvis
containing the abdominal organs. The abdominal cavity is lined with the peritoneum., the hernial sac is removed
and the peritoneumA smooth layer of connective tissue that lines the abdominal cavity and covers most of the
internal organs. sutured [Fig. 8]. To bestow better stability and strength on the posterior wall of the inguinal
canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the
abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels
and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass
through the inguinal canal., the inguinal ligament is sutured to the transverse fasciaLatin term: fascia transversalis.
Fascia running crosswise between the peritoneum and the inner surface of the abdominal wall. [Fig. 9]. This suture
is composed of several rows for greater safety [Fig. 10].
The Shouldice operationOpen surgical technique without mesh implant to treat inguinal hernias. is used primarily
for smaller hernia openings and is normally conducted under general anaesthetic, but can also be performed using
spinal anaesthesiaInjection of a locally active anaesthetic into the fluid-filled area surrounding the spinal cord; in
abdominal operations this is administered at the level of the lumbar spine to suppress pain and touch sensations in
lower innervated regions of the body. or local anaesthesiaLocally confined pain suppression that does not affect
consciousness..
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Fig. 6 and 7: Skin incision and exposure of hernial sac (Shouldice)
Fig. 8: Suture closure of abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well
as muscle layers) enclosing the abdominal cavity. (Shouldice)
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Fig. 9: Suturing of inguinal ligament to transverse fascia
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Abb. 10: Multirow suture (Shouldice)
3.1.2 Lichtenstein operation
This is an open surgical technique where the herniaDerived from the Greek word “hérnos” (bud, sprout,
protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through
which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes. gap is closed using a
synthetic meshFor some surgical techniques used to treat hernias, an artificial mesh is implanted for additional
stabilization of the tissue in the region of the hernial orifice.. The surgeon removes a piece of skin, measuring
around 5 to 8 cm and running crosswise, from above the inguinal ligamentLatin term: ligamentum inguinale.
Reinforcement of a fascia in the lumbar region, which, inter alia, is fused with the aponeuroses of the oblique
abdominal muscles and the transverse fascia. [Fig. 11], exposes the hernial sacEvagination of the peritoneum that
protrudes through a hernial orifice. It may contain hernia contents. via this approach [Fig. 12] and opens it to check
the structures contained in it, and if necessary treat it. Next, the abdominal contents are repositionReturn to its
original site.ed in the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between the
diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum., the
hernial sac is removed and the peritoneumA smooth layer of connective tissue that lines the abdominal cavity and
covers most of the internal organs. sutured [Fig. 13]. Then the surgeon covers the hernial orificeGap in the
abdominal wall or in the diaphragm through which the peritoneum, possibly together with parts of the intestines,
protrudes. with a synthetic mesh [Fig. 14], which is then sutured to the inguinal ligament [Fig. 15] and to the oblique
lateral abdominal muscle [Fig. 16].
The Lichtenstein operation is used for large hernia openings or in the event of multiple recurrenceRelapse or onset
once again of a disease.s of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal
ligament in the region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
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lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia.s (recurrent hernias).
This operation is normally conducted under general anaesthetic, but can also be performed using spinal
anaesthesiaInjection of a locally active anaesthetic into the fluid-filled area surrounding the spinal cord; in
abdominal operations this is administered at the level of the lumbar spine to suppress pain and touch sensations in
lower innervated regions of the body. or local anaesthesiaLocally confined pain suppression that does not affect
consciousness..
Fig. 11 and 12: Inguinal incision and opening of the hernial sac (Lichtenstein)
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Fig. 13: Suture of the peritoneum (Lichtenstein)
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Fig. 14: Covering of the hernial orifice with a synthetic mesh (Lichtenstein)
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Fig. 15: Suturing of mesh to inguinal ligament (Lichtenstein)
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Fig. 16: Suturing of mesh to oblique abdominal muscle (Lichtenstein)
3.1.3 TAPP
TAPPSee Transabdominal Preperitoneal (Repair). (Transabdominal Preperitoneal Repair) is an endoscopic or
minimally invasive surgical technique. With this technique, a small incision is made at the lower margin of the navel.
A special needle is introduced into this hole and the abdomenTummy, belly. is filled with gas in order to press back
the intestines and enable the surgeon to get a good view of internal structures. Next, a camera is introduced
through the same hole and via two further small incisions on the right and left of the navel surgical instruments are
introduced [Fig. 17]. After cutting through the peritoneumA smooth layer of connective tissue that lines the
abdominal cavity and covers most of the internal organs. [Fig. 18], the hernial sacEvagination of the peritoneum
that protrudes through a hernial orifice. It may contain hernia contents. is carefully removed from the herniaDerived
from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal
wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the
intestines, protrudes. orifice and then a sufficiently large synthetic meshFor some surgical techniques used to treat
hernias, an artificial mesh is implanted for additional stabilization of the tissue in the region of the hernial orifice. is
unfolded and placed over the hole ([Fig. 19]. In general, meshes measuring at least 15 x 10 cm are used. The
peritoneal opening is closed again with a suture [Fig. 20] to ensure that the mesh will not come directly into contact
with intestinal loops (danger of it becoming stuck to these (causing adhesions).
If a bilateral hernia is present, both hernias can be treated in a single procedure. TAPP is used in particular for
bilateral hernias as well as for recurrent hernias following previous open surgery. General anaesthesia is needed
for endoscopic or minimally invasive surgery of inguinal herniaThe most common type of hernia with hernial orifice
above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa
inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia.s.
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Fig. 17: Introduction of trocars (TAPP)
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Fig. 18: Incision of peritoneum (TAPP)
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Fig. 19: Fitting of synthetic mesh (TAPP)
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Fig. 20: Closing of peritoneum with suture (TAPP)
3.1.4 Total extraperitoneal repair (TEP)
With this procedure, the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between
the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum. is
not opened. Hence, the risk of injury to internal organs, such as the intestines, is virtually zero. Via a small skin
incision beneath the navel, a small balloon filled with air is inserted between the abdominal wallThe anterior tissue
structures (skin, subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. and
peritoneumA smooth layer of connective tissue that lines the abdominal cavity and covers most of the internal
organs. so as to separate these two layers from each other [Fig. 21]. The gap thus created is further enlarged by
introducing carbon dioxide (CO2) for expansion of wall structures and better visibility [Fig. 22]. Via two other small
skin incisions a working instrument and camera are introduced [Fig. 23 and Fig. 24]. The surgeon can now carefully
expose the hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia
contents. and repositionReturn to its original site. the hernia contentsThe components of the abdominal cavity,
such as intestines or greater omentum, contained within the hernial sac. in the abdominal cavity. A synthetic
meshFor some surgical techniques used to treat hernias, an artificial mesh is implanted for additional stabilization
of the tissue in the region of the hernial orifice. is introduced via the herniaDerived from the Greek word “hérnos”
(bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice)
through which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes. opening and, if
necessary, this is further secured by means of a suture, tacks or tissue glue. But even without any fixation, the
mesh rests firmly in place thanks to the naturally prevailing internal abdominal pressureThe pressure prevailing
inside the abdomen; this can be raised through coughing or pressing. [Fig. 25].
General anaesthesia is needed for endoscopic or minimally invasive surgery of inguinal herniaThe most common
type of hernia with hernial orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa
(Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and
medial inguinal hernia.s.
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Fig. 21: Insertion of balloon (TEPSee Total Extraperitoneal (Repair).)
Fig. 22: Inflation with carbon dioxide (TEP)
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Fig. 23 and 24: Introduction of trocars (TEP)
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Fig. 25: Fitting synthetic mesh (TEP)
3.2 Umbilical, incisional and epigastric hernias
3.2.1 Closure of the hernia opening by directly suturing it
In general, umbilical herniaHernia protruding in infants or young children through the, as yet, incompletely closed
umbilical ring (congenital hernia), and occurring in adults due to a weakness in the region of the navel (acquired
hernia).s have only a relatively small hernia opening of between 1 and 2 cm. On rare occasions, this is also the
case for epigastric herniaA hernia of the upper abdomen whose hernial orifice is situated in the region of the linea
alba. or incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar. following
small abdominal incisions (e.g. appendix removal). In such cases, the hernia opening can be closed by directly
applying a non-absorbable suture to it. The defect is closed using several sutures. A synthetic meshFor some
surgical techniques used to treat hernias, an artificial mesh is implanted for additional stabilization of the tissue in
the region of the hernial orifice. can be used for addition reinforcement.
This operation can be conducted under general anaesthesia, spinal anaesthesiaInjection of a locally active
anaesthetic into the fluid-filled area surrounding the spinal cord; in abdominal operations this is administered at the
level of the lumbar spine to suppress pain and touch sensations in lower innervated regions of the body. or local
anaesthesiaLocally confined pain suppression that does not affect consciousness..
3.2.2 IPOM (laparoscopic)
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The IPOMSee Intraperitoneal Onlay Mesh Technique. (Intraperitoneal Onlay MeshFor some surgical techniques
used to treat hernias, an artificial mesh is implanted for additional stabilization of the tissue in the region of the
hernial orifice.) technique is a special repair procedure where a mesh is introduced into the abdominal cavityLatin
term: cavitas abdominalis. The region of the trunk situated between the diaphragm and pelvis containing the
abdominal organs. The abdominal cavity is lined with the peritoneum. and placed from the inside over the
herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the
abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. opening.
To conduct this endoscopic IPOM technique, a small incision is first made in the scar-free abdominal wallThe
anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal
cavity. [Fig. 26]. Via this approach, gas is blown into the abdomenTummy, belly. to assure better visibility. Then an
instrument with a small camera is introduced. Using this optical facility, the surgeon has a clear view on a monitor
of the surgical field and the various procedural stepSee Total Extraperitoneal (Repair).s. Via two further small
incisions, two more working instruments are advanced into the abdominal cavity. Now the surgeon can, if
necessary, detach any adhesions and then expose the contents of the hernial sacEvagination of the peritoneum
that protrudes through a hernial orifice. It may contain hernia contents. [Fig. 27]. Once the hernia opening is fully
exposed, a decision must be taken as to whether a synthetic mesh can be placed directly over the defect –
something that is possible for defects measuring up to 8 cm – or whether the defect must be additionally
constricted with a suture so that the synthetic mesh is better supported [Fig. 28]. Then the synthetic mesh, which is
fitted with several sutures, is introduced and unfolded over the defect in the abdominal wall. Using a special
instrument, the exposed double threads are guided out via tiny skin punctures through the abdominal wall and
knotted via the small skin punctures to the abdominal wall fasciaA covering of connective tissue enclosing
individual muscles, muscle groups or organs.. This provides for secure fixation of the synthetic mesh to the
abdominal wall [Fig. 29]. In addition, the synthetic mesh is secured from the inside by means of special tacks with
titanium spirals or absorbable screws [Fig. 30]. For very big defects measuring more than 8 cm, first closing the
defect with a suture provides greater support to the mesh [Fig. 31].
The endoscopic IPOM technique can only be carried out under general anaesthesia.
Fig. 26: Abdominal wall incision (lap. IPOM)
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Fig. 27: Exposure of hernial sac (lap. IPOM)
Fig. 28: Defect constriction with suture (lap. IPOM)
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Fig. 29: Fixing synthetic mesh to abdominal wall (lap. IPOM)
Fig. 30: Additional fixation with tacks (lap. IPOM)
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Fig. 31: Additional defect constriction with suture (lap. IPOM)
3.2.3 Sublay-Mesh
The sublay meshFor some surgical techniques used to treat hernias, an artificial mesh is implanted for additional
stabilization of the tissue in the region of the hernial orifice. technique is an open surgical procedure for large
incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar.s. With this
technique a skin incision is made directly above the protruding hernial sacEvagination of the peritoneum that
protrudes through a hernial orifice. It may contain hernia contents. [Fig. 32] and the scar is cut out. Then the hernial
sac is opened, any adhesions in the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum. are removed and the hernial sac is repositionReturn to its original site.ed in the abdominal cavity. Next
the hernial sac is cut off at the edge of the hernia and removed [Fig. 33]. After that, the rectus sheathA covering,
composed of the tendinous plates of the anterior abdominal muscles, of the rectus abdominis muscle (Latin term:
musculus rectus abdominis) which runs down the midline of the body., the structure in which is situated the rectus
abdominis muscleLatin term: musculus rectus abdominis. The rectus muscle runs in two straight lines from the
chest to the pelvis. It is subdivided by several intermediate tendons., is opened on both sides and the posterior
layer is sutured at the midline. The synthetic mesh is then placed over the posterior layer of the rectus sheath,
behind the rectus abdominis muscle, and fixed with a few sutures or fibrin glue [Fig. 34]. If the defect remaining
between the two rectus abdominis muscles is still too big, a second mesh can be placed over the anterior layer of
the rectus sheath and fixed with sutures [Fig. 35].
The sublay mesh technique can only be carried out under general anaesthesia.
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Fig. 32: Skin incision above hernial sac (sublay-mesh)
Fig. 33: Removal of hernial sac (sublay-mesh)
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Fig. 34: Insertion and fixation of synthetic mesh (sublay-mesh)
Fig. 35: Fixation of second mesh (sublay-mesh)
3.2.4 IPOM (open)
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If there is an extremely large incisional herniaHernia occurring after an abdominal operation in the region of the
surgical scar. with complete lateral displacement of the rectus abdominis muscleLatin term: musculus rectus
abdominis. The rectus muscle runs in two straight lines from the chest to the pelvis. It is subdivided by several
intermediate tendons.s, using an open technique a large meshFor some surgical techniques used to treat hernias,
an artificial mesh is implanted for additional stabilization of the tissue in the region of the hernial orifice. can be
sutured from the inside to the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity. (IPOMSee Intraperitoneal Onlay Mesh Technique. =
Intraperitoneal Onlay Mesh techniqueAbbreviation: IPOM. Special endoscopic (= laparoscopic or minimally
invasive) surgical technique for treating abdominal wall hernias with mesh implant.). To that effect, the entire
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is
exposed [Fig. 36], and the intestinal loops detached from the abdominal wall, to which they had become affixed
due to adhesions strands from a previous operation. Then the hernial sac is removed completely as far as the
margin of the connective tissue sheath of the rectus abdominis muscles [Fig. 37]. After that, the synthetic mesh is
placed from the inside, with overlapping, over the defect. The synthetic mesh is fixed using U-sutures applied
through the supporting layers of the abdominal wall [Fig. 38]. The defect remaining between the two rectus
abdominis muscles can, if necessary, be further secured by means of a second synthetic mesh that is sutured to
the fasciaA covering of connective tissue enclosing individual muscles, muscle groups or organs. margin or the
fascia [Fig. 39]. This will depend on the condition of the individual patient.
This procedure can, of course, only be carried out under general anaesthesia.
Fig. 36: Exposure and opening of hernial sac (open IPOM)
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Fig. 37: Removal of hernial sac (open IPOM)
Fig. 38: Fixation of synthetic mesh (open IPOM)
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Fig. 39: Additional fixation with second synthetic mesh (open IPOM)
3.3 Hiatal hernia
3.3.1 Hiatal closure and fundoplication
In the presence of reflux diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric juice into the
oesophagus with onset of heartburn as well as swallowing disorders. and/or a diaphragmatic herniaHernia in the
region of the diaphragm. See also hiatal hernia., the gap in the diaphragmDome-shaped muscle plate protruding
into the chest cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a
partition between the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle
fibres contract when breathing in and relax when breathing out. must be closed with sutures and, in addition, a
barrier created against backflow of chyme (partially digested food from the stomach) into the oesophagusGullet..
To that effect, endoscopyLooking inside and inspection of hollow organs as well as performance of surgical
procedures under optical control, with the aid of an endoscope. is conducted to expose the defect in the diaphragm
and this is then closed by endoscopic sutures [Fig. 40]. Overall, 3 to 4 sutures are needed [Fig. 41]. If the
diaphragm gap is very large or there is a recurrent hernia, additional support by means of a light synthetic meshFor
some surgical techniques used to treat hernias, an artificial mesh is implanted for additional stabilization of the
tissue in the region of the hernial orifice., might be needed; this can be easily fixed at this location with fibrin glue
[Fig. 42]. Next the mobilised upper portion of the stomach (fundus of the stomach) is folded as a new valve by
either 360 º (Nissen fundoplicationA type of fundoplication where the fundus of the stomach is plicated by 360º
around the lower end of the oesophagus and secured with a suture.) [Fig. 43] or 270 º (Toupet fundoplicationA type
of fundoplication where the fundus of the stomach is plicated by 270º around the lower end of the oesophagus and
secured with a suture.) [Fig. 44] around the oesophagus and sutured before the oesophagus. In certain cases
where there is only a diaphragmatic hernia and no refluxBackflow of gastric juice into the oesophagus. disease
there will be no need to fold the upper portion of the stomach around the oesophagus. Then the fundus of the
stomach is only sutured to the undersurface of the diaphragm (fundophrenicopexyProcedure for treatment of reflux
disease or hiatal hernia where, following hiatoplasty, the fundus of the stomach is sutured to the undersurface of
the diaphragm.).
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Endoscopic suture closure of an oesophageal hiatusLatin term: hiatus oesophageus. Opening in the diaphragm
through which the oesophagus passes. and fundoplication or fundophrenicopexy can only be carried out under
general anaesthesia.
Fig. 40: Defect closure with sutures (hiatal closure)
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Fig. 41: Defect closure with additional sutures (hiatal closure)
Fig. 42: Insertion of synthetic mesh (hiatal closure)
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Fig. 43: Nissen operation (fundoplication)
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Fig. 44: Toupet operation (fundoplication)
3.4 Complications
All of the surgical techniques described here are very safe. Each procedure has its pros and cons and, depending
on the technique, different complications can occur, with their manifestation being more or less probable. Hence
the choice of a particular technique will depend mainly on the condition of the individual patient. Overall,
complications occur only rarely for all procedures but cannot be ruled out in principle. You should therefore be
informed about possible risks. If there are any signs of a complication once you have been discharged from
hospital, you should let your doctor know immediately.
The possible complications include:
·
Damage to nerves, intestines or urinary tract during the operation
·
Strangulation or injury to the spermatic cord (only in the case of an inguinal herniaThe most common type of
hernia with hernial orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin
term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial
inguinal hernia. operation in males)
·
ThrombosisComplete or partial occlusion of arteries or veins due to blood coagulation within the blood
vessel./embolismOcclusion of a blood vessel due to material that has entered the bloodstream, such as a blood
clot, tissue, fat droplet, parasites, tumour cells, air bubbles, etc., affecting the blood circulation in the proximal
(upstream) flow region. during or after the operation
·
Infection of the surgical wound
·
Chronic pain in the surgical area
·
Hernia recurrenceRelapse or onset once again of a disease. (recurrent hernia)
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While the probability of hernia recurrence is relatively low, this cannot be ruled out in principle. The sooner a
recurrence is noticed, the quicker can the necessary surgical treatment be initiated and the lower the risk of
complications. It is therefore important that you examine your body regularly and in the event of any body changes
suggestive of a recurrent hernia (in particular swelling) contact your doctor immediately. The same holds true, of
course, for any persistent complaints such as impaired sensations or pain at the operation site.
4 Before the operation
4.1 Medical consultation
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. must always be operated on to prevent strangulation of internal organs or to
ensure appropriate hernia treatment. There is no other form of cure. To provide you with the best treatment
possible, your doctor needs your cooperation. In an in-depth talk and after having reviewed all the examination
results you will jointly decide which surgical technique is best for you.
For the talk with your doctor we have drawn up a short checklist of possible questions to help you gain a better
understanding of your disease and how it can be treated. You can also make a note of your doctor’s answers as
well as notes of your own.
Questions addressed to the doctor about the disease:
·
At exactly what site have I the hernia?
·
Are organs affected which are now protruding through a gap in the abdominal wallThe anterior tissue
structures (skin, subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. (or
diaphragmDome-shaped muscle plate protruding into the chest cavity, which is secured to the sternum, costal
arches and lumbar spine. The diaphragm forms a partition between the chest cavity and abdominal cavity. It is the
most important respiratory muscle; its muscle fibres contract when breathing in and relax when breathing out.)?
·
If organs are affected: what implications has this for me?
·
Must further examinations be carried out for me and if yes, which?
Questions addressed to the doctor about the operation:
·
Why should I undergo surgery?
·
Which surgical technique is most suitable in my case and why?
·
What exactly is done during this operation?
·
If the operation performed under general anaesthesia, spinal anaesthesiaInjection of a locally active
anaesthetic into the fluid-filled area surrounding the spinal cord; in abdominal operations this is administered at the
level of the lumbar spine to suppress pain and touch sensations in lower innervated regions of the body. or local
anaesthesiaLocally confined pain suppression that does not affect consciousness.?
·
When will be operation be conducted and how long does it take?
·
What risks does the operation pose?
·
Around how big will my scar be?
·
How long am I likely to have to spend in hospital?
4.2 Preparing for the hospital stay
To enable you to make better preparations for your hospital stay, we have put together a few tips. Only pack what
is necessary and a few things you are particularly fond of. Books, magazines and games will help you cope with
long waiting times or dispel boredom.
Documents and medical results
You should as far as possible take with you any documents, identity cards and results needed or beneficial for your
hospital stay. These include:
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·
·
·
·
·
·
Copies of any documents issued by your doctor with regard to admission to hospital and medical insurance
Copies of examination results
Allergy documentation
Diabetic documentation
X-ray documentation
Blood group documentation
Medication and aids
If you are taking medication at home, take this with you in sufficient quantity – ideally in the original packaging with
package insert. Don’t forget your spectacles, any dental fixtures and other necessary items.
Fasting or not fasting?
For some examinations or treatment procedures you will not be allowed to have eaten or drunk anything over a
long period of time. This may also be true for short hospital stays, for example if you are to be examined once
again before the operation. Therefore: please don’t forget to ask for how long before your hospital stay are you
allowed to eat/drink!
Clothing
·
A pair of slippers and shoes with a good grip
·
Light clothing
·
Sports suit
·
Dressing gown
·
Nightdress or pyjamas
·
Enough underwear
·
Socks
Personal hygiene
·
Hand towels, washcloths, handkerchiefs
·
Shampoo, soap, deodorant
·
Toothbrush, toothpaste
·
Comb, hairbrush
·
Ladies hygiene items
What you should not take with you
If possible, you should not take any valuables with you to hospital, for example large amounts of cash or valuable
jewellery. The hospital will not be held liable in the event of theft or loss.
If you must remain in hospital for a long time
In such cases you should consider letting friends and relatives know.
·
·
Is it necessary to give someone a power of attorney to conduct administrative or bank transactions?
Have you someone to look after your home (pets, plants, mail, deliveries?)
5 After the operation
During the operation and afterwards you will be given a mild painkiller to avoid pain in the wound area. If
necessary, cold compresses can be applied to reduce swelling of the wound and alleviate pain. The intensity and
duration of wound pain after the operation varies from one patient to another. In general, pain resolves by the latest
once the wound is completely healed.
To prevent thrombosisComplete or partial occlusion of arteries or veins due to blood coagulation within the blood
vessel. during and after surgery, you will be given compression stockings as well as, if needed, a blood thinning
medication (heparin). To prevent constipation, you may be given a laxative. During the weeks after the operation
you should also pay attention to your diet to ensure you stools are soft, thus avoiding strong pressing during bowel
movements.
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As a rule, you can and should get up again a few hours after surgery and walk around slowly and for short
distances. This is important to avoid thrombosis or other complications such as pneumonia. As from when you will
be able to engage in physical exertion again will vary from one person to another. Overall, it is true that patients
become mobile once again more quickly after laparoscopic procedures and can resume work sooner again than
after open surgical procedures. There is no fixed rule here but you should always ensure that you should exert
yourself only to a degree that causes no pain (see also Back Home).
If absorbable sutures are used for surgery, there will be no need to remove these sutures. Otherwise, the stitches
are taken out around 10 days later – this is mainly done by the general practitioner or surgeon in independent
practice.
5.1 Medical consultation
Questions addressed to the doctor after the operation:
·
Has the operation progressed as expected?
·
Is there anything in particular that I must observe in the immediate future?
·
Is a further operation or treatment procedure necessary?
·
What problems or complications could possibly occur after discharge?
·
How great is the probability of a herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion).
Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the
peritoneum (hernial sac), possibly together with parts of the intestines, protrudes. recurring at the surgical site or at
another site?
·
Is follow-up needed, and if yes, what does this entail?
5.2 Back home
Your mobility and general physical condition will improve quickly during the hospital stay so in general you can be
discharged after a few days (on average after 2 to 4 days). Once home, you will soon be able to resume your
normal daily activities. You need have no reservations about engaging in physical activities so long as you feel no
pain. But you should avoid a number of things so as not to place undue stress on the surgical scar before the
tissue has regained its entire strength.
The following checklist can help you here.
·
If you have covered your wound with a water-repellent material, you can shower briefly again as from the
2nd day after your operation. But you should wait around 2 weeks before taking a full bath.
·
As from when you will be able to resume work will depend on the nature of your job. On average you can
do so 2–6 weeks after open surgery and somewhat sooner after a laparoscopic procedure.
·
You should wait for some time before carrying heavy loads. The first two weeks after surgery you should
not lift anything heavier than 10 kg, and weights over 30 kg only after around three months. Here, too, you should
definitely ensure that you feel no pain. Never under any circumstances lift anything by exerting pressure on your
back or abdomenTummy, belly.; instead, bend your knees and put the weight on your legs.
·
You should drive an automobile, motorbike or other motor vehicle or bicycle only when you are
completely painfree.
·
As from when you can engage in sport again will depend on your pain perception and type of sport. You
should wait for some time before engaging in any type of sport involving jerky movements, jumping or abrupt
braking and acceleration movements (e.g. ball games). You should wait around 12 weeks before engaging in
heavy athletics, in particular any exercises aimed at strengthening the abdominal muscles.
·
You need have no reservations about engaging in sexual relations so long as you feel no pain.
These tips are of a general nature, but the level of exertion tolerated will differ from one patient to another. You
doctor will therefore be happy to answer any particular questions you might have.
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6 Herniamed Quality Assurance Study/Registry
The quality of herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes. surgery can only be assured or improved if, first, the
surgeon records all important details about his hernia patients and their disease and, second, he is kept abreast of
the long-term outcome of his operations. For that reason experienced hernia surgeons set up the non-commercial
firm Herniamed, and within the framework of a voluntary quality assurance project, committed themselves to
recording the exact details of all hernia operations carried out in their hospital or practice and to conducting
scientific evaluation of the data collected.
6.1 Documentation and data protection
To put this project into practice, an online database was developed by specialists, into which for each patient
important data are entered in anonymized form (for example, risk factors, location and size of herniaDerived from
the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal wall or
diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the
intestines, protrudes., surgical technique used, complications during or immediately after surgery). Patients are
followed up at intervals of one year, five years and ten years and the follow-up data are also entered into the
database (see below).
Documentation and data entry are effected in anonymized manner in compliance with the legally binding
provisions of data protection so that in no case can conclusions be drawn from the data about the actual
patient.
6.2 Quality assurance
The opportunities and perspectives opened up in the field of herniaDerived from the Greek word “hérnos” (bud,
sprout, protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice)
through which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes. surgery by the
establishment of the Herniamed quality assurance study are enormous. First, the data recorded in anonymized
mannerserve as a basis for a national hernia register, which will make an important contribution to improving the
standard of healthcare for the German population (this has been confirmed by scientific studies conducted in
Scandinavia where alone through the introduction of a hernia register, the recurrenceRelapse or onset once again
of a disease. rate dropped considerably after inguinal herniaThe most common type of hernia with hernial orifice
above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa
inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. surgery).
Second, if within the framework of the quality assurance study there is any suspicion of specific problems related to
hernia operations – for example as regards the surgical method or materials used such as synthetic meshFor some
surgical techniques used to treat hernias, an artificial mesh is implanted for additional stabilization of the tissue in
the region of the hernial orifice. – measures can be taken across all hospitals and improvements made. The
insights provided by the study will in particular help compile and improve standardized guidelines, which serve as a
benchmark for conductance of hernia surgical procedures in Germany.
6.3 Follow up
The hospital /medical practice treating you is very interested in following up the well-being of their patients once the
initial treatment has been successfully completed. It is therefore very important that you let them know about all
problems occurring after surgical treatment of your herniaDerived from the Greek word “hérnos” (bud, sprout,
protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through
which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes.. These could be
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complications or complaints, manifesting during the first weeks or months after the operation, or a
recurrenceRelapse or onset once again of a disease. manifesting perhaps only years after the original operation.
Only if the hospital /medical practice that treated you knows in the long term whether your operation has proved a
success can it in the future offer treatment of an optimal quality.
If your hospital /medical practice is participating in the Herniamed quality assurance study, you will be followed up
at intervals of one year, five years and ten years. This means that both the general practitioner and patient will
receive a letter requesting them to provide information on the long-term results of the operation – in particular about
any complications or recurrence of disease. The letter includes a questionnaire where yes/no questions are used to
query all important details. You can quickly answer the questions by checking (ticking) the boxes and return the
questionnaire by post or fax to the practice / hospital. In that way the time you need to invest in follow up will be
kept to an absolute minimum.
Since people are living increasing longer, are often overweight or undergo more operations, the number of hernia
cases (including incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar.s)
will continue to rise in the coming years. As someone affected by this condition, we kindly ask you to please
help improve treatment for all hernia patients by taking part in the Herniamed Quality Assurance Study,
including follow up. To do so, your signed consent is needed in all cases. You will be given a form to that effect
by your hospital / practice. Already at this stage, we would like to cordially thank you for your cooperation!
Source URL: http://www.herniamed.de/?q=en/node/429
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