People are normally referring to the abdomen or groin when talking about hernias. As lead London hernia specialist Mr Arjun Shankar explains in his authoritative article, there are many types of these abdominal hernias including hiatal, umbilical, or incisional.

So what are Midline Hernias?

Midline Hernias are hernias that occur in the midline of the abdomen and are the second most common form. Repairs used to involve stitching and sutures, but these have now been replaced by mesh repairs and this has led to significant reductions in recurrence rates. The technological advances for midline hernia meshes allow them to be safely placed within the abdomen directly onto the bowel. This provides the most mechanically strong repair for what are often complex areas of weakness. Latest Expert Advice on Surgery for Hernias.

Midline hernias vary from small ones found within and adjacent to the umbilicus and complex hernias that may arise as a result of poor healing of a wound after surgery -  incisional hernias. All of these hernias are repaired using mesh, with the small ones done as day cases and sometimes under local anaesthesia.

Team of hernia experts
A hernia commonly occurs when a wound in the abdominal wall fails to heal. The subsequent protuberance of the underlying intestine through the defect may be very large indeed. Such cases need careful evaluation and often require the care of a team of surgeons including general abdominal surgeons and plastic surgeons. The operations may take hours to perform and the patient may have to stay in hospital for days with a requirement for intensive care support.

The story may not end even after the hernia has been repaired.  The plastic surgeon may still need to perform a cosmetic reconfiguration of the overlying tissues akin to a ‘tummy tuck’. This partnership of reconstructive and aesthetic surgery usually results in a strong and cosmetically pleasing outcome.

Key hole repair of midline hernias
A Minimal Access Surgery (MAS) approach may be possible for selected patients with small midline hernias. Three ports are put in place and mesh secured with staples inside the abdomen over the hernial defect. These operations can be carried out as day cases and are likely to lead to reduced postoperative pain and infection rates.

This technique is, however, really only effective in smaller hernias because with no closure of the overlying defect the strength of the repair entirely depends on the mesh. The complication rates for midline hernia repairs exceed those for groin hernias and rise in proportion with the size of the hernia. Most wounds are closed with dissolving sutures although the larger cases may require metal clips.

Recurrence of midline hernias is more common than for those found in the groin. Another problem is that fluid may collect in the tissues underneath the skin  – seromas – which may be particularly problematic in large hernias. In order to reduce this when repairing large hernias a small plastic tube (a drain) may be left in the space left behind after the repair is complete. This may stay for a few days until relatively dry at which time it can be removed.

The treatment of various types of hernia will vary depending upon the site and the nature of the problem although the principles of management are very similar. With improvements in technology and the establishment of specialist centres for hernia treatment patients should experience further improvements in outcomes.

Click the link to read more or Arjun Shankar’s Hernia article

If the groin hernia recurs then any subsequent re-repair is far more complex. Once a repair has been performed the anatomy of the groin is permanently changed with dense scarring around the groin structures. This is why it is so important to reduce recurrence rates to the lowest level possible. The scarring found makes identification of the anatomy far more difficult and hence complication rates are far higher. Nerves are more commonly damaged and the risk of injuring the blood supply to the testicle is not insignificant (up to 5% in some series).

This article is important for any patient who finds that they have done themselves an injury as it will inform the choice of treatment.

The National Institute for Clinical Excellence (NICE) now states that all patients may be offered a MAS groin hernia repair if performed by a suitably qualified surgeon. MAS repair of recurrent groin hernias is especially effective as by approaching the hernia from the back the surgeon avoids the scarring that would be encountered from the front and hence may reduce the complication rate. See Arjun Shankar’s Latest Expert Advice for the Treatment of Hernias for more information.

Over the last 100 years hernia surgery has developed into a speciality in its own right paralleled with huge leaps in technology and expertise.

Diagnosing Hernias

Most hernias are apparent on examination by an experienced clinician although in some circumstances it may be necessary to get a radiological assessment. The radiological techniques used range from simple ultrasound through to MRI and CT. Imaging of this type may be necessary when planning complex abdominal wall reconstructions, when the diagnosis of a hernia is in doubt or in the setting of a recurrent groin hernia (see below).

Suspicion of a hernia merits immediate referral to a suitably qualified doctor

The areas described include the following:

• Groin hernias
• Repairing groin hernias
• Weight lifting
• Potential complications
• Recurrent groin hernia repair
• Midline hernias
• Laparoscopic surgery for hernias