What is the Abdominal Wall?

The abdominal wall forms the front cover of the abdomen. It is made up of muscle, fat and skin.  The muscles of the abdominal wall and their coverings have complex relationships to each other. 

In the middle, there is a set of bulky muscles called the rectus abdominis, sometimes called the six-pack. On each side of the abdomen there are three muscles, running from the six pack muscles to the spine at the back, and to the ribs and pelvis. These muscles and their relationships to each other give the sides of the abdominal wall strength.

The abdominal wall muscles have their own blood supply and nerves. Together they create a strong structure which supports the internal organs, keeping your insides, inside. They also help in providing abdominal pressure when needed, e.g. in breathing out, evacuating bowels and bladder.

What is an Abdominal Wall Hernia?

A hernia of the abdominal wall is a bulging of the abdominal contents through an area of weakness in the abdominal wall. Many hernias do not cause symptoms, but some may cause pain. If you have symptoms, and you would like your hernia repaired then we can consider this. However, you must be fit enough for surgery. 

What is a Complex Abdominal Wall Hernia?

These are usually large (greater than 10cms in size), or result from a previous failed hernia operation. 

They are notoriously difficult to fix, and surgeons skilled in this have formed their own specialty. If you are looking for a surgeon to fix your complex abdominal wall hernia, it is worth looking for someone experienced in this area. 

How can you repair a Complex Abdominal Wall Hernia?

The outcomes of a successful abdominal wall hernia operation should be to improve function, prevent further complications (e.g. Bowel obstruction or strangulation), and improve cosmesis. 

A good repair will improve symptoms, but nothing can restore your abdomen fully to its former function or appearance. 

a) Reeves-Stoppa repair

This is an operation around the rectus muscles, or six-pack. By dissecting behind the rectus muscles, the normal anatomy layers can be restored. The posterior muscle covering layer (fascia) is closed, to keep the mesh separate to the abdominal organs and bowel. A mesh is placed behind the muscles to support the repair as it heals. 

b) Component seperation

If a Reeves-Stoppa repair does not free up enough abdominal wall length, and the abdomen cannot be closed, then a component separation technique will be needed. This is where the lateral muscles are separated into two layers, to slip over each other. It is very good at releasing tension of the abdominal wall closure, but can result in post-operative fluid collections. For this reason, surgical drains are often left in the abdominal wall for some time. You may go home with them for a short time. 

The transversus abdominus release is the most common, and spares nerve damage in most cases. It is most commonly used in very large incisional hernias, and in parastomal hernia repair. 

Anterior component separation is less common, and risks damaging the nerves to the rectus muscles. It is a possibility where there has been a previous failed posterior release. 

What types of mesh are commonly used?

Broadly speaking there are three kinds of mesh, synthetic and biologic. Synthetic meshes are very strong, and give excellent long term repairs, but can cause problems if they become infected. Biologic meshes are normally constructed from human or animal tissue. They tend to degrade over time, and become replaced by your own scar tissue. They are much more tolerant of infection. 

Your surgeon will discuss the best mesh for you based on: 

• the kind of hernia you have 
• your risk of having problems with your surgical wound
• your views about the types of mesh being placed inside you

What are the benefits of this surgery?

The main benefits of having such complex surgery are to reduce hernia related complications, particularly those that challenge the function of the bowel. Repairing the integrity of the abdominal wall can often partially restore function. This is important if you suffer with back pain, or have an abdominal wall stoma. 

Am I fit for surgery?

This will be different for every single patient, and depend on your medical history, your weight, diet and regular physical activity. Normally you would have blood and heart tests prior to surgery. You may be asked to undergo a specialist exercise test to see how your body would cope with an operation. Some people may need specialist care on the Intensive Care Unit following surgery, to support their heart and lungs. 

It would be unlikely that you would be fit for surgery if you smoke, or if your BMI is over 35. The way these factors affect healing also mean that the risk of your hernia coming back would be unacceptably high. This is reinforced by national guidelines, which mandate that you stop smoking and lose weight prior to surgery. Help is available to do this. 

Will I be in any pain?

This is big surgery and it will be painful. Post-operative pain can be controlled using a combination of pain killers, anti-inflammatory drugs, and morphine. Before your operation your anaesthetist will discuss your analgesia plan. 

One form of pain relief that the anaesthetist may discuss with you is a spinal anaesthetic block. This is where the anaesthetist puts a fine tube into your back, and injects and anaesthetic which numbs the abdomen and relieves pain. It is usually very effective.

What complications could there be?

These type of operations have excellent results, if it is done with the right planning, and patient preparation. 

To reduce the chance of getting a DVT or chest infection after surgery, you will be given blood thinning injections, and encouraged to mobilise out of bed. This is really important for your recovery. 

Common complications are bruising, and the formation of small collections of fluid. These are more likely if you take blood thinners, and the more complex your surgery is. Your surgeon will try as far as possible to prevent bleeding during your operation. Small blood collections normally resolve over time. You may be left with surgical drains (a tube connected to an external reservoir) for a period of time following the operation to prevent collections forming. You will need to carry this around like a handbag, until your surgeon removes it. 

Precautions are taken to reduce the risk of wound infection, but they can occur. They typically cause symptoms of pain, redness, and heat. They can make you feel unwell, with fever and loss of appetite. They are treated with antibiotics, and sometimes fluid will need to be released from your wound. 

Ileus is where the bowel takes a while to “wake up” after your operation. Your abdomen can become bloated, and may result in vomiting. This can be helped by a tube placed in the stomach via your nose (a nasogastric tube). When your bowel function returns, the tube can be removed. 

A rare complication of this complex surgery is an injury to the bowel. Your surgeon will take great care to avoid this, but given the extensive nature of the surgery it is possible. Bowel injury is more common in people who have had multiple operations in the past, particularly with permanent mesh placement. If it happens during the surgery, then it can normally be repaired at the time. If missed, then it may form an abnormal connection to the abdominal wall, called a fistula. Waste products can be diverted from the bowel to the skin. Sometimes this requires another operation to fix, sometimes it will close spontaneously. 

A dangerous but rare complication is abdominal compartment syndrome. This is where returning your abdominal contents inside, increases the pressure inside your abdomen to such a level that you cannot supply blood to your abdominal organs. This would be unusual, as CT scanning would normally alert us to this possibility when planning your operation, and if you are deemed to be at risk we would normally have taken steps to avoid this. Sometimes emergency surgery is required to decompress the abdomen. 

Mesh infection is rare. It may require a long course of antibiotics to treat. The mesh may need to be removed if infection persists. 

With each operation on your abdominal wall, the strength weakens. This is unavoidable, and there is a risk of you having a further abdominal hernia developing. You can help to prevent this by maintaining a healthy weight, not smoking, and avoiding constipation.

The operation will leave permanent scars on your abdomen. They will become smoother and less noticeable over time. 

The operation may leave some loose or excess soft tissue or skin. There may also be some irregularities of shape and symmetry. Sometimes we will have to remove the belly button (umbilicus) as part of the operation. If you feel strongly about this please discuss with your surgeon.

There is a small risk of death after any major surgery like this. It is generally less than one in a hundred, but may be higher than this if you have serious pre-existing health condition, or suffer a major complication.  We do everything we can to reduce your risks. 

What will recovery be like after I leave hospital? 

It takes about two months to be able to mobilise comfortably and get back into your normal routine of taking walks and being active. It is important during this time that you do not lift anything heavier than 2-3kg, or a full kettle. 

You may need dressing changes, and this will be discussed with you before being discharged from hospital. 

You will be able to shower over your dressings. Pat them dry with a towel afterwards. If your wound has healed well, you will be able to take your dressings down a week after your operation. You will then be able to bathe and swim. 

You can return to driving when you are able to wear a seatbelt, and perform an emergency stop. You should not drive if you are taking medications that make you drowsy (e.g. codeine, tramadol, morphine). 

When can I return to work?

When you are able to return to work depends on the nature of the work you do, e.g. whether it is a physical job and whether it involves lifting. Please discuss this with your surgeon. Your ability to 

return to work may also be affected by your mood. Following such major surgery, it is usual to feel low in energy and mood, whilst your body heals. This will improve with time. 

When will I be able to return to normal activity?

After you have gone home it is helpful to do gentle exercises. You can build up your programme of doing gentle stretches and bending. Walk every day and plan to walk a little further distance each day. Initially walk on flat surfaces as they are more comfortable than uneven surfaces. Gradually build up to tackling curbs, cobblestone paths, rough ground or inclines. These surfaces cause abrupt small changes in direction and you can feel the discomfort in healing abdominal muscles. 

In general, if lifting an object causes pain do not do it. 

After two months you can resume moderate exercise like walking uphill or bicycling. However, continue to avoid sudden jerky movements while doing housework e.g. hovering.

We would advise you to avoid exercises like weight-lifting or sit-ups, as they put undue pressure on the abdominal wall, which though repaired, is still weak and prone to recurrent hernia developing. In general, the abdominal wall strength starts approaching original levels of strength after two years. 

Will I regain sensation in my abdomen?

In the initial few months you will notice a considerable area of numbness of the abdominal wall. This will slowly improve, and with time may recover completely. However, it is not unusual to be left with some numbness.