A hernia (soft tissue fracture) is a bump-like protrusion of the abdominal wall.

A hernia often occurs in places where the abdominal wall is interrupted in its continuity, where there are weak points and / or where organs / structures run through the abdominal wall. Acute (due to heavy lifting or carrying) or chronic pressure increase (pregnancy, tumors in the abdomen or increased fat content in the abdomen) favor the development of a hernia.

Hernias can vary in size and occur in different places. Most hernias develop in places where there are natural interruptions in the continuity of the abdominal wall: namely, where structures break through / leave the abdominal wall and thus create weak points in the abdominal wall: the most common are inguinal hernias due to the spermatic cord and cervical ligament, umbilical hernia due to the umbilical cord, and incisional hernias after operations/injuries , Diaphragmatic hernia through the esophagus. When there is a gap in the abdominal wall, the peritoneum bulges first through the gap. The speed at which a hernia develops is initially slower and subsequently faster from a certain size. Thus, the dynamics are directly proportional to the size of the hernia and thus to the wall tension at the edges and also to the internal abdominal pressure in analogy to Laplace's law. Due to the overpressure in the abdomen, intestines can also follow if the hernia is large enough. Depending on the size of the fracture or the size of the organ, entrapment can occur. If there is a suspicion of a trapped hernia (incarceration), competent medical help should be sought immediately (= medical emergency), as otherwise, in the worst case, there may be a loss of organs through constriction of the blood supply or intestinal obstruction.

Hernias can be congenital or acquired. Smaller fractures usually cause greater discomfort, as this is more likely to lead to entrapment. Larger breaks, on the other hand, cause other problems. Surgical reconstruction of the abdominal wall can be very difficult, especially in the case of very large fractures, in which the majority of the organs are no longer in the abdominal cavity but in the fracture (loss of domain).

Much rarer than external hernias are so-called internal hernias and are always an urgent indication for surgery.

Not every fracture has to be treated surgically. A hernia should always be treated if symptoms arise or if the break can no longer be pushed back. A fracture that has existed for years without symptoms does not require mandatory treatment.

The causes of the development are manifold: disruption at the cellular level, namely in collagen synthesis, is discussed. When hernias occur more frequently, both type I collagen, but above all type III collagen, are less synthesized and less detected in the tissue. A familial accumulation of hernias can also be explained in this way. A certain role could also be played by a disproportion between the (tear) strength of the supporting and holding apparatus, including the muscular membranes (= fasciae), and the contractile element, the muscles, in favor of the muscles. Furthermore, increased pressure in the abdominal cavity is beneficial for the development of the hernia. This should also be a focus of the therapeutic approach. The pressure in the abdominal cavity is in most cases caused by tensing the abdominal muscles (e.g. when lifting, carrying, exercising, coughing, sneezing, pressing as in the case of constipation) and thus reducing the size of the abdominal cavity while maintaining the same volume of the intestines or primarily by obesity (obesity ) or large tumors in the abdomen. Pregnancy or a (difficult) natural birth and the associated high pressure conditions in the abdominal cavity, which are transferred to the abdominal wall, can also promote the development of hernias.

If you are overweight, weight reduction brings decisive advantages both for and after the operation by reducing the pressure in the abdominal cavity and should therefore be sought. The hernia therapy can be open or laparoscopic with or without the implantation of a plastic mesh (prosthesis) can be made.

The open techniques are:
Primary hernial port closure with or without doubling the load-bearing layer (fascia): Bassini, Shouldice, Mayo OP. These techniques are only used in exceptional cases. Modern techniques make use of the so-called tension-free closure in combination with a large-area plastic mesh reinforcement. Depending on the location, a distinction is made between a mesh implantation in sublay or onlay technique; here the hernia is closed and reinforced with a mesh: Lichtenstein, closure of an abdominal wall hernia using sub- or onlay technique.

The laparoscopic techniques are:
TAPP (transabdominal preperitoneal mesh) and TEP (total extraperitoneal mesh) for inguinal hernias, IPOM (intraperitoneal onlay mesh) for brook wall hernias. The IPOM plus is a combination of closure of the hernia with a non-absorbable suture and a laparoscopic mesh implantation.

Modern techniques for large hernias and hernias on the lateral abdominal wall:
Large defects in the abdominal wall pose quite a challenge for the surgeon. On the one hand, when the intestines are shifted back from the hernial sac into the abdomen, there is a corresponding increase in pressure in the abdomen. This can lead to major problems and, on the other hand, a large defect in the abdominal wall can rarely be closed without tension. The tension-free closure of the abdominal wall is essential for a complication-free course and for a lasting result. There are now a number of possibilities for conditioning available to solve this problem. The first possibility is a preoperative stretching of the abdominal wall through continuous CO_² insufflation—a very laborious process. The technique of injecting Botox ultrasonically into all layers of the lateral abdominal wall around 3 weeks before the planned hernia operation is newer and better. This leads to tissue gain through relaxation and stretching of the shrunken fascia and thus a tension-free closure of medium-sized fractures can be carried out. In the case of larger fractures, a so-called "lateral release" or a component separation according to Ramirez can be carried out. With this technique, even large breaks can be closed successfully and sustainably. A different technique is used for lateral abdominal wall fractures, especially fractures outside the rectus sheath: a TAR (transversus abdominis release). This technique allows the entire abdominal wall to be sustainably reconstructed with a large plastic mesh in the case of very large and complex fractures that extend far outwards. Other techniques such as eMilos and eTEP are used for simultaneous diastasis recti and hernia.

The decision as to which procedure is to be used is made individually, whereby the size of the fracture, the location, any previous operations and the patient's wishes all influence the decision-making process.