Treatment of abdominal wall hernias

Modern treatment for abdominal wall hernias is increasingly centered on minimally invasive surgery combined with careful patient selection and preoperative optimization. Recently, general surgeon Kelly J. Janke, DO, Managing Physician of the Surgical Group at Penn Medicine Lancaster General Health, joined the Penn Medicine Physician Interviews podcast to discuss her approach to treating abdominal wall hernias.

Minimally invasive surgery for abdominal wall hernias

Dr. Janke recommends minimally invasive approaches, especially robotic surgeries, as the first option for most of her patients with abdominal wall hernias.

“There can be a variety of complexity levels based on the type of hernia we’re treating,” she says.

Patients with very small, straightforward hernias are good candidates for open repair, since a very small incision is needed to place sutures. For hernias larger than about 2 centimeters, however, mesh is typically indicated. In those cases, Dr. Janke notes, most patients benefit from minimally invasive approaches.

“It is possible to do some very complex hernias, with very large pieces of mesh, through three to six 8-millimeter incisions rather than a laparotomy incision,” she says.

Those much smaller incisions are particularly valuable in patients with obesity, who are at increased risk of wound morbidity.

However, patients with a history of multiple complicated intra-abdominal surgeries may be better candidates for open surgery, Dr. Janke observes.

“Multiple factors go into the decision about which approach to take, including the size of the hernia as well as their surgical history, including prior operative reports to indicate what sort of condition the intra-abdominal cavity is in,” she adds.

Patient selection and optimization

In the past, surgeons paid less attention to patient selection and preoperative preparation, Dr. Janke says, but optimizing patients for surgery can improve outcomes. Patient selection factors that should be considered include:

• History of smoking
• Compromised immune status, including steroid use or other immunosuppressive medications
• COPD or other pulmonary risk factors
• Obesity

Research about the effects of smoking in the context of abdominal wall surgery is mixed, Dr. Janke says, but she recommends patients with complex abdominal wall hernias quit before surgery to reduce the risk of pulmonary and wound healing complications.

Obesity is also an important consideration, as it can increase the risk of recurrent hernias, which can be more complex. Still, some patients with obesity may be candidates for surgical repair. “Typically, for someone who has a very complex hernia, we would like their BMI to be under 36. That's a hard sell for some patients,” Dr. Janke says.

It’s important to follow patients who are unable to lose weight to consider whether the risk-benefit ratio changes as their hernia progresses. “In a patient with a less involved hernia repair or a smaller hernia, if they can’t function on a day-to-day basis because of pain, and they can’t exercise to lose weight because of pain, then we might be more apt to offer a minimally invasive repair with a nuanced discussion about the risks,” she says.

Because of such nuances, Dr. Janke advocates for a shared decision-making approach, discussing risks and modifiable risk factors as well as the preferred type of mesh and surgical method.

Expert care for hernias at Penn Medicine Lancaster General Health

Surgical treatment of abdominal hernias continues to advance, with the development of new mesh materials that better incorporate into the abdominal wall and reduce the risks of recurrence or other complications, Dr. Janke says. “We’ll continue to look at mesh materials to decide what’s best for each patient,” she adds.

At Penn Medicine Lancaster General Health, the general surgery team includes experienced surgeons who specialize in areas such as minimally invasive hernia repair, open hernia repair, and hiatal and paraoesophageal hernias, as well as bariatric surgery, colorectal surgery, and more. The team is happy to consult with patients to determine when and how to approach each unique hernia repair.

Board-certified general surgeon Kelly J. Janke, DO, sees patients at the Lancaster General Health Physicians Surgical Group in Lancaster, PA. For a provider-to-provider consultation with Dr. Janke, call 877-937-7366, or refer a patient online.