Hiatal hernia is a condition that occurs when part of the stomach pushes up into the chest cavity. It’s often caused by a weak spot in the diaphragm, the muscle that separates your chest from your abdomen. This weak spot can allow part of your stomach to “leak” up into your chest, making it look like you have a bulge in your upper abdomen.
Hiatal hernias usually don’t cause problems and are not serious. But sometimes, they can lead to complications such as acid reflux (GERD), which can cause heartburn or esophageal ulcers. Tummy tuck surgery is a procedure to remove excess skin and fat from around your waistline. You may choose this type of surgery if you have loose or sagging skin after losing weight or having children, or if you have stretch marks on your abdomen or thighs.
Read on for more information on Hiatal hernia and tummy tuck, spigelian and Hernia After Tummy Tuck
Hiatal Hernia And Tummy Tuck
A hiatal hernia is when part of the stomach extends up through the diaphragm and into the chest. It can cause severe acid reflux or GERD symptoms. Often, these symptoms can be treated with medications. If those don’t work, then your doctor may offer surgery as an option.
The cost of surgery for a hiatal hernia varies depending on the surgeon, your location, and the insurance coverage you have. The uninsured cost of the procedure is typically about $5,000 in the United States. However, additional costs may arise during the recovery process if you have complications.
What is the purpose of a hiatal hernia surgery?
Surgery can repair a hiatal hernia by pulling your stomach back into the abdomen and making the opening in the diaphragm smaller. The procedure may also involve surgically reconstructing the esophageal sphincter or removing hernial sacs.
However, not everyone who has a hiatal hernia needs surgery. Surgery is typically reserved for people with severe cases that haven’t responded well to other treatments.
If you have dangerous symptoms as a result of the hernia, then surgery may be your only option. These symptoms may include:
- bleeding
- scarring
- ulcers
- narrowing of the esophagus
This surgery has an estimated 90 percent success rate. Still, about 30 percent of people will have reflux symptoms return.
How can you prepare for a hiatal hernia surgery?
Your doctor will give you all the information you need about how to prepare for your surgery. Preparation generally includes:
- walking 2 to 3 miles per day
- doing several breathing exercises multiple times per day
- not smoking for 4 weeks before the surgery
- not taking clopidogrel (Plavix) for at least one week before surgery
- not taking nonsteroidal anti-inflammatories (NSAIDs) one week before surgery
Typically, a clear liquid diet is not needed for this surgery. However, you can’t eat or drink for at least 12 hours before the surgery.
How is a hiatal hernia surgery performed?
Hiatal surgeries can be done with open repairs, laparoscopic repairs, and endoluminal fundoplication. They are all done under general anesthesia and take 2 to 3 hours to complete.
Open repair
This surgery is more invasive than the laparoscopic repair. During this procedure, your surgeon will make one large surgical incision in the abdomen. Then, they’ll pull the stomach back into place and manually wrap it around the lower portion of the esophagus to create a tighter sphincter. Your doctor may need to insert a tube into your stomach to keep it in place. If so, the tube will need to be removed in 2 to 4 weeks.
Laparoscopic repair
In a laparoscopic repair, recovery is quicker and there’s less risk of infection because the procedure is less invasive. Your surgeon will make 3 to 5 tiny incisions in the abdomen. They’ll insert the surgical instruments through these incisions. Guided by the laparoscope, which transmits images of the internal organs to a monitor, your doctor will pull the stomach back into the abdominal cavity where it belongs. Then they will wrap the upper part of the stomach around the lower portion of the esophagus, which creates a tighter sphincter to keep reflux from occurring.
Endoluminal fundoplication
Endoluminal fundoplication is a newer procedure, and it’s the least invasive option. No incisions will be made. Instead, your surgeon will insert an endoscope, which has a lighted camera, through your mouth and down into the esophagus. Then they’ll place small clips at the point where the stomach meets the esophagus. These clips can help prevent stomach acid and food from backing up into the esophagus.
What is the recovery process like?
During your recovery, you’re given medication that you should only take with food. Many people experience tingling or burning pain near the site of the incision, but this feeling is temporary. It can be treated with NSAIDs, including over-the-counter options like ibuprofen (Motrin).
After surgery, you need to wash the incision area gently with soap and water daily. Avoid baths, pools, or hot tubs, and stick to the shower only. You’ll also have a restricted diet meant to prevent the stomach from extending. It involves eating 4 to 6 small meals per day instead of 3 large ones. You typically start on a liquid diet, and then gradually move to soft foods like mashed potatoes and scrambled eggs.
You’ll need to avoid:
- drinking through a straw
- foods that can cause gas, such as corn, beans, cabbage, and cauliflower
- carbonated drinks
- alcohol
- citrus
- tomato products
You doctor will likely give you breathing and coughing exercises to help strengthen the diaphragm. You should perform these daily, or according to your doctor’s instruction.
As soon as you’re able, you should walk regularly to prevent blood clots from forming in your legs.
Timing
Because this is a major surgery, a full recovery can take 10 to 12 weeks. That being said, you can resume normal activities sooner than 10 to 12 weeks.
For example, you can start driving again as soon as you’re off narcotic pain medication. As long as your job isn’t physically strenuous, you can resume work in about 6 to 8 weeks. For more physically demanding jobs that require a lot of hard labor, it may be closer to three months before you can return.
What is the outlook for hiatal hernia surgery?
Once the recovery period is over, your heartburn and nausea symptoms should subside. Your doctor may still recommend that you avoid foods and beverages that could trigger GERD symptoms, such as acidic foods, carbonated beverages, or alcohol.
Spigelian Hernia After Tummy Tuck
The umbilicus is formed by the umbilical ring of the linea alba. Intra-abdominally, the round ligament (ligamentum teres) and paraumbilical veins join into the umbilicus superiorly, and the median umbilical ligament (obliterated urachus) enters inferiorly. An umbilical hernia traverses the fibromuscular ring of the umbilicus This hernia is most commonly found in infants and children, is congenital in origin, and often resolves without treatment by the age of five. An acquired umbilical hernia may also be seen in an adult, and this hernia is more common in women with a history of multiple pregnancies and in patients with obesity or with increased abdominal pressure resulting from ascites and chronic bowel distention.
Umbilical hernia is more common in those who have only a single midline aponeurotic decussation compared with the normal decussation of fibers from all three lateral abdominal muscles. Strangulation is unusual in most patients; however, strangulation or rupture can occur in chronic ascitic conditions. Small asymptomatic umbilical hernias barely detectable on examination need not be repaired. Adults who have symptoms, a large hernia, incarceration, thinning of the overlying skin, or uncontrollable ascites should have hernia repair. Spontaneous rupture of umbilical hernias in patients with ascites can result in peri
Spigelian Hernias
Although spigelian hernias are uncommon (accounting for 0.1–2 % of all abdominal wall hernias), its diagnostic incidence has been rising because of improved imaging technology and incidental identification during laparoscopy. They occur in the anterolateral aspect of the lower abdomen, along the semilunar line formed by fibrous union of the rectus sheath with the aponeuroses of the transversus abdominis and oblique abdominal muscles The absence of posterior rectus fascia may contribute to an inherent weakness in this area. These hernias are often interparietal, with the hernia sac dissecting posteriorly to the external oblique aponeurosis. Patients usually present with a prolonged history of intermittent lower abdominal pain and intestinal obstruction associated with a slight swelling or vanishing anterolateral mass located midway between the umbilicus and the symphysis pubis. Most spigelian hernias are small (1–2 cm in diameter) and develop during 40–70 years of age, but the hernia has also been reported in younger patients. Spigelian hernias occur with almost equal frequency in males and females; they can be bilateral and associated with other ventral or inguinal hernias. Incarceration rates (often with omentum) have been reported to be as high as 20 % with these uncommon hernias
Spigelian hernia
9.2.4 Incisional Hernias
Incisional hernias are delayed complications of abdominal surgery and occur in 0.5–13.9 % of patients. These hernias tend to occur during the first four months after surgery, a critical period for the healing of transected muscular and fascial layers of the abdominal wall. Incisional hernias are caused by patient- and surgery-related factors. The former includes conditions that may increase intra-abdominal pressure (e.g., obesity, collagen vascular diseases, a history of surgically repaired aorta, nutritional factors, ascites). Conditions that impair healing, such as collagen vascular disease in patients receiving glucocorticoid therapy and smoking, can also increase postoperative hernia formation. Surgery-related factors include the type and location of the incision. It is more common for hernias to develop after a vertical midline incision than after a transverse incision but to also develop through small laparoscopic puncture sites
Eventration
Regardless of the cause, the loss of integrity of the abdominal wall reduces intra-abdominal pressure and causes serious disturbances, which is appropriately named “eventration disease” by Rives. The salient feature of this syndrome is respiratory dysfunction. A large incisional hernia produces paradoxical respiratory abdominal motion similar to the flail chest. Diaphragmatic function becomes inefficient. The diaphragm no longer contacts against the abdominal viscera and instead forces them into the hernia sac. Appraisal of respiratory function and blood gases is essential [9
9.3 Preoperative Evaluation of Abdominal Wall Defects
The correct diagnosis of abdominal wall hernias is usually based on careful inspection and palpation; however, there are several situations in which an accurate clinical diagnosis may be difficult or impossible, such as in obese patients, those with severe abdominal pain or distention, and those with excessive scarring. Five to ten percent of abdominal wall hernias are not detectable by physical examination alone [10
Although most abdominal wall hernias are asymptomatic, they may develop acute complications necessitating emergent surgery. In differential diagnosis it is important to keep in mind that the most challenging misdiagnosed conditions are diastasis recti and abdominal wall tumors [8
9.3.1 Clinical Evaluation
The evaluation of abdominal wall hernias requires diligent physical examination. The anterior abdominal wall is evaluated with the patient in standing and supine positions, and Valsalva maneuver is also useful to demonstrate the site and size of a hernia. Examination should focus on the umbilicus and any incisions that are present.
9.3.2 Radiological Evaluation
Imaging studies are not required in the normal workup of a hernia. The diagnosis of a hernia was made clinically, with plain radiographs or barium studies in the past. Increasingly, diagnosis is made by CT or ultrasonography.
However, cross-imaging studies may be useful in certain scenarios, as follows:
If an incarcerated or strangulated wall hernia is suspected, upright abdominal films may be obtained in clinical emergency patients to show small or large bowel obstruction; infrequently, the transition point is seen at the level of the complicated hernia.
Ultrasonography can be used in differentiating masses in the abdominal wall and allows dynamic evaluation (e.g., during Valsalva maneuver) to confirm herniation of intra-abdominal contents through a wall defect. Ultrasound may also have good specificity and a high positive predictive value for diagnosing postoperative incisional hernias
Multidetector-row CT (MDCT) is widely available and is fundamental in assessing patients with suspected abdominal wall hernia.
MDCT or ultrasonography may be necessary if a good examination cannot be obtained because of the patient’s body habitus, also mostly to diagnose spigelian hernia
Signs and Symptoms
- Characteristics of asymptomatic hernias:
An obvious swelling or fullness beneath the skin at the hernia site
A heavy feeling in the abdomen that is sometimes accompanied by constipation
Discomfort in the abdomen when lifting or bending over
Aching sensation (radiates into the area of the hernia)
No true pain or tenderness upon examination
Enlarges with increasing intra-abdominal pressure and/or standing
- Characteristics of incarcerated hernias:
Painful enlargement of a previous hernia or defect
Cannot be manipulated (either spontaneously or manually) through the fascial defect
Nausea, vomiting, and symptoms of bowel obstruction (possible)
- Characteristics of strangulated hernias:
Patients have symptoms of an incarcerated hernia.
Systemic toxicity secondary to ischemic bowel is possible.
Strangulation is probable if pain and tenderness of an incarcerated hernia persist after reduction.
Suspect an alternative diagnosis in patients who have a substantial amount of pain without evidence of incarceration or strangulation.
- Characteristics of various hernia types:
Umbilical hernia – central and mid-abdominal bulge.
Epigastric hernia – small lumps along the linea alba reflecting openings through which preperitoneal fat can protrude.
Spigelian hernia – local pain and signs of obstruction from incarceration; pain increases with contraction of the abdominal musculature.
9.4 Treatment of Abdominal Wall Defects
Abdominal wall hernias are either diagnosed on clinical examination or encountered intraoperatively during abdominoplasty. Skin and myofascial laxities, which are often found in overweight, postbariatric or multiparous women, are the primary indications for abdominoplasty procedure (Fig. 9.4). Abdominal wall hernias are frequently encountered problems associated with the occurrence of fascial laxity or diastasis. Both obesity and pregnancy cause increased intra-abdominal pressure, which are the main causes of rectus diastasis and anterior abdominal wall hernias [12
].
A 44-year-old woman with severe abdominal myofascial laxity and infraumbilical panniculus. In preoperative examination, there was no sign of hernia. Incidental umbilical hernia has been determined in abdominoplasty operation. Above, preoperative views of the patient. Below, postoperative second-year view shows that there is no sign of myofascial laxity
It is not uncommon to encounter various degrees of umbilical or paraumbilical incidental hernias during abdominoplasty operations, although symptomatic umbilical hernias can be diagnosed on preoperative physical examination. Also, postbariatric patients have increased risk of incisional hernias with a reported rate of ~20 %
Primary suture techniques, autologous techniques, and placement of prosthetic meshes and bioprosthetics have been described for repair of ventral abdominal hernias.
- Primary repairIncidental hernias during abdominoplasty operations are not rare in clinical practice, although the frequency of incidental hernia in the population and the rate of hernia in abdominoplasty patients are unknown. Usually a primary repair is enough, but first, the separation of the hernia sac from the abdominal wall ring is essential. After the sac is dissected, the peritoneum shall be examined. If intact, simple reduction of the sac is possible, but if the peritoneum is opened or injured, careful dissection and exploration of the intra-abdominal organs (omentum, intestines) is necessary. Following this exploration, the peritoneum should be closed separately. Finally the abdominal wall defect is closed by simple suture technique.However, if the fascial defect is larger than 2–3 cm, primary repair techniques are usually inadequate. Synthetic/organic mesh materials are commonly used to bridge the fascial defect with a tension-free closure in such conditions.
- Synthetic meshCumberland and Scales popularized the ideal characteristics of prosthetics [14, 1]. These properties include chemical inertness, resistance to mechanical stress, pliability, lack of physical modification by the body’s tissues, capability of being sterilized, no carcinogenic potential, no or limited inflammatory or foreign body reaction, and hypoallergenic nature. No prosthetics has been able to attain all these properties so far. In 1958, Usher et al. reported on the newly developed polypropylene mesh (Marlex) which was followed by similar plastic implantable prosthetic materials such as Mersilene and Gore-Tex . This was a notable advance for surgery and allowed tension-free repairs that, when used properly, substantially diminished recurrences after hernia repair procedures. Many abdominal hernias can be repaired using synthetic mesh which lowers the hernia recurrence rates; it is today the first choice in hernia repair These are associated with serious complications including surgical site infection, extrusion, foreign body reaction, bowel adhesion, fistula formation, and prolonged seroma drainage that occur in ~10–15 % of cases . Infection is one of the most significant causes of recurrent hernia, and the risk of infection is clearly elevated with the risk factors including high body mass index (BMI), smoking status, nutritional status, steroid treatment, and the presence of comorbidities (e.g., diabetes mellitus, chronic obstructive pulmonary disease (COPD)) in patients who have undergone synthetic mesh placement. Epigastric hernia after tummy tuck
A hernia is a generic term for a hole caused by a weak spot in your abdominal wall. An epigastric hernia is a type of hernia in the epigastric region of the abdominal wall. It’s above the belly button and just below the sternum of your rib cage.
This type of hernia is a somewhat common condition in both adults and children. About 2 to 3 percentTrusted Source of all abdominal hernias are epigastric hernias. It’s also seen in infants.
Most of the time, you’ll have no symptoms or only minor symptoms with an epigastric hernia. A lack of symptoms means that this condition tends to go unreported.
Symptoms of an epigastric hernia
An epigastric hernia usually causes a bump to occur in the area below your sternum, or breastbone, and above your belly button. This bump is caused by a mass of fat that has pushed through the hernia.
The raised area may be visible all the time or only when you cough, sneeze, or laugh. This bump, or mass, can grow and become larger in some cases. You can have more than one epigastric hernia at a time.
An epigastric hernia can also cause tenderness and pain in the epigastric region. However, it’s common for an epigastric hernia not to show any symptoms.
Causes of an epigastric hernia
An epigastric hernia can occur when the tissues in the abdominal wall don’t close completely during development. Research continues to look for the specific causes of this type of hernia. Not as much is known about epigastric hernias possibly because they aren’t reported many times due to a lack of symptoms.
However, one theoryTrusted Source has gained some credibility. It’s believed that the epigastric hernia may be caused when there is tension in the area where the abdominal wall in the epigastric region attaches to the diaphragm.
Treatment options for this condition
This type of hernia won’t go away on its own, and complications will eventually lead you to surgery. Surgery is the only way to repair an epigastric hernia. It’s the recommended treatment, even for infants, due to the risk of the hernia enlarging and causing additional complications and pain.
To complete the repair, you might only need sutures, or you may require an implanted mesh. The use of mesh or sutures is determined by the size of the hernia and other factors.
Emergency symptoms of an epigastric hernia
If your epigastric hernia hasn’t been treated, you should get medical treatment immediately if you have vomiting or fevers and an increase in abdominal pain. These may indicate a bowel blockage.
Surgery to repair an epigastric hernia can lead to certain serious complications. If you have any of the following symptoms after surgery, you should seek medical attention:
- high fever
- difficulty urinating
- discharge from the surgical site
- an increase in pain or swelling at the surgical site
- bleeding that won’t stop
- nausea
- vomiting
Complications and risks of an untreated epigastric hernia
The complications for an untreated epigastric hernia include the following:
- enlarged hernia, which eventual allows parts of the bowel to push through
- increase or onset of pain and tenderness
- bowel blockage
- loss of domain, in which the hernia becomes so large that’s nearly impossible to repair even with a mesh
The complications for the surgical repair of epigastric hernia includes any basic complications surrounding surgery and general anesthesia as well as those related to this specific surgical procedure. These complications may include:
- bleeding
- pain
- wound infection at the surgical site
- scarring left after healing
- blood clots
- development of a lump that isn’t a hernia
- a low chance of the hernia recurring
- mesh infection (in the event an artificial mesh is used to repair the hernia)
Outlook
Surgical repair of an epigastric hernia is a common procedure and has a very positive outlook. Most people are able to go home the same day as the surgery.
You might even be able to return to work or school within a day or two with some minor restrictions. Specifically, most surgeons don’t want you lifting any weight heavier than a gallon of milk for six to eight weeks.
Your doctor will tell you how quickly you should return to your normal activities. Usually, your restrictions will include no heavy lifting and no strenuous activities or sports for a brief period of time.