Hernia Treatment and Surgical Options

There are multiple ways to effectively treat hernias. At the Stony Brook Center for Abdominal Core Health, our surgeons provide all of them for our patients.

Some of our procedures use a mesh patch — made of synthetic or natural material — to close the gap in the abdominal connective tissue where the hernia formed (see our FAQs page).

Suturing the patient’s own tissue back together with permanent sutures (no mesh or patch) is another option. This is called the Shouldice hernia repair (see our FAQs page and patient testimonials).

Repairs can be traditional “open” surgery with an incision or laparoscopic (a small hole, made with thin instruments guided by a tiny camera).

When it comes to post-operative results, each surgical approach has its own advantages. You and your surgeon will decide together which option is best for you, depending on the hernia and your medical history.

Traditional Repair
Most traditional open repairs use an incision that exposes the entire hernia defect/weakness to allow repair. In the groin, this involves a small, 3-inch skin incision that lies underneath the patient’s waistband. For hernias on the front of the abdomen, a vertical incision in the middle of the belly is usually made. Usually, the surgeon will attempt to close the hernia defect with sutures before placing a mesh to help strengthen the closure.

These open repairs have been performed for many years and, therefore, have the most research into them.

Laparoscopic Repairs
During a laparoscopic repair, the hernia is fixed from the inside of the abdomen using a slender lighted camera that allows the surgeon to work through small incisions. The incisions are usually less than half an inch in length each and are placed apart from the hernia itself. Almost all laparoscopic repairs use mesh to cover the hernia defect and seal the hole. Research has shown that laparoscopic repairs have lower wound complications, decreased postoperative pain, and faster return to normal activities.

Robotic Repairs
Robotic-assisted surgery has the same benefits of small incision surgery and laparoscopic procedures, but with more flexible and precise instruments. During a robotic-assisted surgery, the surgeon is sitting at a console in the same room but away from the patient, manipulating surgical instruments. Robotic instruments can move like your own wrists do, giving the surgeon increased precision and articulation.

Abdominal Wall Reconstruction
For extremely large or complex hernias, sometimes a simple mesh closure is not enough. In these cases, it may be necessary to bring the layers of the abdomen back together, one by one, with a mesh placed for strength and support. This is called Abdominal Wall Reconstruction, and is usually used for abdominal hernias larger than 3-4 inches in diameter. A technique call a “component separation” may also be needed to get the layers back together. These techniques are very technically demanding and should only be performed by experienced surgeons.

Surgical Procedures We Perform

• Open (with/without mesh), laparoscopic and robotic repair of umbilical and small midline ventral hernias
• Open (mesh & non-mesh), laparoscopic (total extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP) and robotic (TAPP) repair of inguinal and femoral hernias
• Open and robotic (TAPP) repair of off-midline hernias (flank, iliac, subcostal, lumbar, Spigelian hernias)
• Open (retrorectus) and robotic (extended-view totally extraperitoneal repair (eTEP), transversus abdominis (TAR)) repair of large recurrent ventral and incisional hernias
• Open and robotic abdominal wall reconstruction with posterior/anterior component separation (eTEP, TAR, external oblique release) for very large hernias, including loss of abdominal domain
• Panniculectomy and abdominoplasty with hernia repairs
• Management of chronic groin pain, including mesh explantation and neurectomy
• Excision of chronically infected mesh
• Management of enterocutaneous and enteroatmospheric fistulas (two-stage approach)
• Reconstruction after resection of abdominal wall masses (including desmoids)
• Open and robotic repair of parastomal hernias (Sugarbaker and Pauli repairs)
• Management of parastomal hernias and prolapsed ileal conduit, with or without midline incisional hernias (open and robotic)
• Laparoscopic and robotic repair of hiatal and paraesophageal hernias, including recurrent cases

Surgical Approach

Surgeons at the Stony Brook Comprehensive Hernia Center are proficient in all aspects of hernia surgery and abdominal wall reconstruction. The decision of which approach is the optimal one is based on a detailed assessment of the patient’s history, prior surgeries, medical conditions and hernia morphology (size, location, content). In general, we prefer to use minimally invasive approaches (laparoscopy and robotics) for its benefits of faster recovery and fewer complications.

Laparoscopic Surgery

Is performed via small (mostly 5 millimeters) incisions using long instruments and a high-definition endoscope (camera). In our practice, two most commonly performed laparoscopic procedures are inguinal hernia repair and repair of diastasis recti via subcutaneous onlay laparoscopic approach (SCOLA).

Robotic Surgery

The Da Vinci® Xi™ (Intuitive Surgical, Inc.) is a state-of-the-art platform for robotic-assisted minimally invasive surgery. Robotic surgery has revolutionized the modern approach to abdominal wall reconstruction and hernia surgery. It enables unprecedented precision, high-definition 3D vision and advanced instruments with six degrees of freedom, which expands the surgeons’ ability to address your complex abdominal wall condition via small incisions. Robotic abdominal wall surgery was evolved during the last decade and many procedures that we now consider gold standards were developed in the 2010s. Our surgeons utilize the robotic approach for repair of inguinal and ventral hernias. Even very large incisional and recurrent hernias can often be repaired robotically. The minimally invasive approach significantly minimizes pain, wound morbidity and shortens recovery time.

Open Surgery

The open surgical approach is a traditional way of performing hernia repairs. Despite the advancement of minimally invasive techniques, the open approach is still frequently utilized. It is typically reserved for very large, complex and recurrent hernias. If we see a lot of redundant skin and soft tissue, it is advisable to remove them as it prevents wound complications. If there is a large scar that the patient would like to revise, the open surgical approach is used as well. We work with a team of plastic surgery specialists who can offer a formal abdominoplasty, which is performed simultaneously with the hernia repair. Sometimes the robotic approach cannot be completed due to extensive intra-abdominal scar tissues or other unforeseen circumstances. In these cases the open approach is necessary to complete the operation.

Sometimes your surgeon may choose a hybrid approach. Most of the steps of the repair will be performed laparoscopically or robotically, but a few other steps will require the open approach. Recovery after hybrid surgery remains faster than after an entirely open procedure.

Glossary

• TEP — Total extraperitoneal repair of inguinal hernias (without entering the abdominal cavity).
• TAPP — Transabdominal preperitoneal repair, which involves formation of a peritoneal flap to cover the mesh. TAPP is used for inguinal and ventral/umbilical hernias.
• IPUM — Intraperitoneal underlay mesh repair, during which a specially covered mesh is placed to cover the sutured hernia defect and carefully secured circumferentially to the abdominal wall.
• Rives-Stoppa or retrorectus repair — Space for mesh placement is created behind the rectus muscle and fascia (posterior rectus sheath).
• MILOS — Similar to retrorectus repair, but performed through a smaller-sized open incision.
• eTEP — Extended-view totally extraperitoneal repair; the space for retrorectus mesh is created without entering the abdominal cavity and the entire repair is performed while staying within the layers of abdominal wall.
• TAR — Transversus abdominis muscle release; advanced technique used for repairs of very large (usually 10+ centimeters wide) hernias. TAR is a type of component separation or myofascial release procedure, which is necessary to close very large hernia defects without undue tension. TAR can be performed with an open or robotic approach.