Complex Abdominal Wall Reconstruction
Abdominal incisional hernias are a common complication after previous abdominal surgery. A hernia is a separation of the abdominal wall fascia causing the abdominal contents to protrude through the opening, commonly referred to as a “bulge”. Abdominal hernias can negatively effect the function of the lungs, and intestines, as well can inhibit physical activity and abdominal and back muscle function.
The causes of incisional hernias from prior surgery are wound infections, poor nutrition and obesity. Abdominal hernias can be “patched” with a plastic mesh, however the failure rate of this repair is relatively high.
Abdominal wall reconstruction can help to close large and difficult abdominal hernias with your own bodies tissue and the possible use of a biologic rather than a plastic mesh. Dr. Trussler uses a limited access incision to make relaxing incisions in the abdominal wall (component separation) to advance your own tissue to close the hernia defect and often reinforces the repair with a biologic mesh under the fascial repair. This component separation combined with a biologic mesh underlay can decrease the hernia recurrence rate, as well as decrease the risk of infection and scar formation.
What Are My Options?
There multiple types of hernias which can occur in the abdomen. They include:
Congenital hernias at the belly button, or umbilical hernias.
Primary abdominal hernias which commonly occur at the belly button after pregnancy or form heavy lifting.
Incisional hernias which occur after a previous abdominal incision commonly found at the umbilicus, central abdomen or flank.
Treatment for small congenital or primary abdominal hernias may include a suture repair which closes the abdominal fascia to itself without the need for mesh or relaxing incisions. Repair of an incisional abdominal hernia usually involves the release of the scar tissue around the hernia to restore the protruding tissue back to its original location and repair of the weakened area of the abdominal wall with a component release, midline fascial repair with stitches, and reinforcement with a biologic mesh placed under the hernia repair.
Not every hernia repair needs the addition of mesh, but when reenforcement of the hernia repair is needed a biologic mesh is preferably utilized.
The advantages of a biologic mesh, usually bovine or porcine xenograft, over a plastic mesh:
- collagen scaffold which your body grows into
- less prone to infection
- does not promote scar formation
Complex abdominal wall reconstruction usually requires a general surgeon to release the scar tissue inside the abdomen and to remove any plastic mesh, and then a plastic surgeon to perform a component separation, implantation of the biologic mesh, and closure of the abdominal fascia. Small abdominal and/or simple abdominal hernias can be repaired without the need of two surgeons. A limited access component separation helps to maintain the blood supply to the abdominal skin. This technique encourages the removal of excess and/or scarred skin, decreases the risk of fluid collections under the skin, and improves skin healing.
Recurrent abdominal hernias are related to pre-existing medical problems which should be optimized prior to the surgery with the help of an internal medicine physician, cardiologist, and/or pulmonary specialist. Smoking cessation is a very important part of a successful outcome from abdominal incisional hernia. Dr. Trussler will discuss these considerations during your initial consultation for abdominal wall reconstruction.
The goal of this procedure is to repair and strengthen the abdominal wall. This should improve the function of the abdominal wall be eliminating the “bulge”, as well as improving the function of the lungs, bladder and colon.
Not every patient is a candidate for an abdominal wall reconstruction, though during the consultation process the right hernia repair for you will hopefully meet your expectations. An abdominal wall reconstruction does not negate the need to continue with a healthy lifestyle with a good diet and regular exercise. Dr. Trussler does encourage post-procedural abdominal wall strengthening with a physical therapist after hernia repairs.
Abdominal wall reconstruction takes approximately two to five hours under general anesthesia depending on what procedure is performed, the amount of scar tissue present, the size of the hernia, and the extent of excess skin. There are numerous types of abdominal wall repairs performed by Dr. Trussler and the choice does relate to the location, the size of the hernia, and the quality of the surrounding abdominal tissues.
Congenital hernias at the belly button, or umbilical hernias can typically be repaired through an incision under the umbilicus with internal stitches in the abdominal fascia to close the hernia. The belly button incision is then closed with stitches in the skin.
Primary abdominal hernias which commonly occur at the belly button after pregnancy or form heavy lifting and are usually closed through an incision under the belly button. These hernias are commonly repaired with fascial stitches at the time of an abdominoplasty if they are small, however larger hernias may require the placement of mesh to help reinforce the closure, and would be performed prior to any other abdominal procedure.
Incisional hernias which occur after a previous abdominal incision commonly found at the umbilicus, central abdomen or flank. These hernias typically will need a two surgeon approach with the general surgeon’s role to release any intra-abdominal scarring and reduce the hernia contents back into the abdomen, and the Dr. Trussler would release the top layer of abdominal muscle and fascia to facilitate the closure of the hernia with a biologic mesh used under the abdomen to strengthen the repair. Any scarred or excess skin can be removed safely with a limited access component release and then the abdominal skin is closed over 2 to 3 drains.
Dr. Trussler closes all incisions with deeper supporting stitches and then aligns the scars with stitches under the skin. Drains are usually placed in each of these procedures to help collect fluid that accumulates after these operations. A compression garment is placed at the conclusion of the operation to support the abdominal wall and avoid collections of fluid.
After Care & Recovery
After any type of abdominal hernia procedure, patients will likely experience mild soreness and swelling for a few days to a week. Dr. Trussler advises at least a one night stay in the aftercare unit to encourage early ambulation and make the first night after the surgery comfortable. Larger hernia repairs will usually stay in the hospital until bowel function has returned. This may be 3 to 5 days after the surgery.
- Dr. Trussler does make it easy to recover after an abdominal hernia repair by limiting the amount of care need on the incisions and surgical areas for the first week.
- In general,a compressive garment or abdominal binder is kept on the abdomen for at least 3 to 6 weeks for abdominal support. In larger abdominal hernias the abdominal musculature is very weak, and this external support allows for gradual strengthening of the abdominal muscles with the help of core physical therapy.
- After the first week, drains and stitches are removed, however the drains may be in place for up to 3 weeks.
Most patients will be able to return to caring for their children, work and light exercise within three weeks, although vigorous exercise and other strenuous activity should be avoided for about a month. Heavy lifting greater than 30 lbs is limited for at least 6 weeks. Dr. Trussler will provide you with specific instructions for your individual recovery.
The results of an abdominal hernia repair are visible immediately after surgery and will continue to improve as swelling subsides and scars fade. The body shape will evolve over a three month period. Scar treatment will be initiated at the 3 week visit and may be continued for 3 to 6 months after the operation, or until the scars soften and fade.
- Beale EW, Hoxworth RE, Livingston EH, Trussler AP. The role of biologic mesh in abdominal wall reconstruction: a systematic review of the current literature. Am J Surg. 2012 Oct; 204(4):510-517.
Whether you have a question or would like to setup an abdominal wall reconstruction consultation, Dr. Trussler and his staff are here to help. Please fill out our contact form, or call our office at 512-450-1077 to schedule an appointment. Start your journey to not only looking, but feeling better today!