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SECTION J: HERNIA AND SPLEEN

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Chapter 72

Abdominal Wall Hernias

Robert J. Fitzgibbons, Jr., Thomas H. Quinn, and Devi Mukkai Krishnamurty

Key Points

1 Surgeons have traditionally been taught the anatomy of the abdominal wall from an outside to inside

perspective. However, with the increasing use of intra-abdominal or preperitoneal approaches to

abdominal wall reconstruction, a better understanding of the anatomy from the inside to the outside

perspective is important.

2 Major risk factors for the development of an abdominal wall hernias include chronic obstructive

pulmonary disease, smoking, high intra-abdominal pressure, collagen vascular disease, thoracic or

abdominal aortic aneurysm, peritoneal dialysis, matrix metalloproteinase (MMP) abnormalities, and

an increased type I: type III collagen ratio.

3 Inguinal hernias constitute approximately 75% of abdominal wall hernias, with femoral hernia

accounting for 5%. Femoral hernias are more common in women, but a woman with a groin hernia

is still five times more likely to have an inguinal hernia (usually indirect) than a femoral. Incisional,

umbilical, and epigastric hernias account for 15%, and miscellaneous hernias make up the other 5%.

4 The literature dealing with groin hernia in women is insufficient making management decisions

difficult.

5 Watchful waiting is an acceptable alternative to routine repair for male inguinal hernia patients with

minimal symptoms. This does not apply to females because of the higher risk of a hernia accident.

Patients in the watchful waiting group should be aware of the likelihood long-term crossover into

treatment group.

6 The performance of a “tension-free” inguinal hernia repair dramatically reduces the risk of recurrent

hernia to a rate generally reported to be less than 2%.

7 The frequency of at least some long-term groin pain after inguinal herniorrhaphy is approximately

10% at 1 year with moderate to severe pain in 1% to 2%.

8 Abdominal wall dynamics are better addressed with muscles re-approximated, contributing to

improved quality of life and patient satisfaction.

9 Abdominal wall reconstruction and component separation are useful tools in the armamentarium of

the hernia surgeon.

10 Historical recurrence rates of 30% to 40% following ventral hernia repair have been dramatically

reduced by modern tension-free repairs.

One of the most frequently performed operations by general surgeons worldwide is the repair of an

abdominal wall hernia. According to the National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK), in the years 2009–2010, abdominal wall hernias were responsible for 3.6 million

ambulatory care visits, 380,000 hospitalizations, and 1,322 deaths in the United States.1 In the past,

most training programs relegated the repair of abdominal hernias to the junior members of the surgical

team with little regard for results.2 However, in the modern era of heightened emphasis on

accountability to our patients, this is changing rapidly. Interest by the academic community in the

science behind hernia repair as well as an explosion in device development by industry has resulted in

significant changes in many surgeons’ practices. In this chapter, we have provided a detailed description

of the abdominal wall anatomy, an understanding of which is key in the success of a hernia repair. We

have then described the different treatment options with their available evidence and have included

some of the newer developments in the field of hernia surgery.

ANATOMY OF THE ABDOMINAL WALL AND GROIN

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