Hernia Surgery in Beverly Hills | Dr. Daniel Golshani

Not all hernias are the same. They occur at different anatomical locations, through different tissue defects, and produce different symptom profiles. Understanding which type of hernia a patient has is the first step in determining the correct surgical approach.

Inguinal Hernia

The inguinal hernia is the most common hernia of all, accounting for approximately seventy-five percent of all abdominal hernias. It occurs in the groin, specifically through the inguinal canal, the passage through which the spermatic cord travels in men and the round ligament travels in women. In men, the inguinal canal represents an anatomical point of relative weakness in the lower abdominal wall, which is why inguinal hernias are significantly more common in men than in women.

Inguinal hernias are classified as direct or indirect. A direct inguinal hernia passes directly through the posterior wall of the inguinal canal through a zone of muscular weakness. An indirect inguinal hernia follows the path of the spermatic cord through the internal inguinal ring, which is the embryological pathway through which the testis descended into the scrotum before birth. Indirect inguinal hernias are the more common of the two and can extend into the scrotum in men when they are large.

The symptom that most commonly brings an inguinal hernia to clinical attention is a groin bulge that appears with exertion and may or may not produce discomfort. The pain, when present, is typically a dull ache or dragging sensation in the groin or lower abdomen that worsens with prolonged standing, lifting, or coughing and improves with lying down. Some patients have a large inguinal hernia that has been present for years and produces minimal discomfort. Others have a small hernia that produces significant pain disproportionate to its size.

Umbilical Hernia

An umbilical hernia occurs through the umbilical ring, the opening in the abdominal wall through which the umbilical cord passed before birth. In adults, umbilical hernias develop when the naturally weaker tissue at the navel is further weakened by increased intra-abdominal pressure from obesity, pregnancy, ascites, or chronic straining. The result is a soft bulge at or adjacent to the navel that is often reducible by gentle pressure and typically enlarges with coughing or straining.

Umbilical hernias are common and frequently asymptomatic. Many patients notice the bulge long before they notice any discomfort. When symptoms develop, they typically include a dull ache at the navel, particularly after prolonged activity.

Incisional Hernia

An incisional hernia develops at the site of a prior abdominal surgical incision. It is among the most common complications of abdominal surgery, occurring in five to fifteen percent of patients following laparotomy depending on the study cited, and at a higher rate in patients with obesity, diabetes, malnutrition, or wound infection following the original procedure.

The defect occurs when the abdominal wall closure from the prior surgery fails to maintain its integrity, producing an opening through which abdominal contents can protrude. Incisional hernias are frequently larger than primary hernias and can involve multiple defects along the scar line. They require specific repair strategies, including mesh reinforcement over an area of weakened tissue rather than simply closing a discrete defect.

Ventral Hernia

Ventral hernias are hernias of the anterior abdominal wall occurring in the midline above or below the navel, outside of the umbilical ring itself. Epigastric hernias occur above the navel through the linea alba, the fibrous midline of the abdomen. They are frequently small, multiple, and in some patients discovered incidentally. Hypogastric hernias occur below the navel and are less common.

Femoral Hernia

A femoral hernia occurs through the femoral canal, just below the inguinal ligament in the upper thigh. It is less common than inguinal hernia but significantly more likely to incarcerate or strangulate because the femoral ring is a particularly narrow and rigid opening. Femoral hernias are more common in women than in men, and their tendency toward complications makes timely repair important even when they are currently asymptomatic.

Hiatal Hernia

The hiatal hernia is a distinct category from abdominal wall hernias. Rather than a defect in the muscular abdominal wall, it represents the protrusion of the stomach or other abdominal organ through the diaphragmatic hiatus, the opening in the diaphragm through which the esophagus passes. Hiatal hernias produce symptoms related to gastroesophageal reflux, heartburn, and in some cases chest discomfort or difficulty swallowing, rather than the bulge and groin or abdominal pain that characterize abdominal wall hernias.

What Does a Hernia Actually Feel Like? Understanding the Pain

The symptom experience of a hernia varies significantly between patients and between hernia types, and understanding this variation is important both for recognizing a hernia when it presents and for understanding when the symptoms warrant urgent attention versus planned elective repair.

The asymptomatic hernia. Many hernias, particularly umbilical and small inguinal hernias, are discovered incidentally during a physical examination or imaging study performed for an unrelated reason. The patient may have noticed a bulge they did not consider significant enough to report. These hernias may remain asymptomatic for months or years. However, all hernias carry the risk of eventual complication, and the decision about timing of repair accounts for this risk.

The uncomfortable hernia. The most common symptomatic presentation is a dull, dragging, or aching discomfort at the hernia site that is present with activity and relieved by rest or lying down. The discomfort is produced by the mechanical traction on the hernia sac and its contents as the hernia enlarges with increased intra-abdominal pressure. Lifting, coughing, straining during defecation, and prolonged standing are the activities that most consistently reproduce it.

The painful hernia. When a hernia becomes acutely painful, particularly when the pain is constant rather than activity-related, and when the hernia bulge cannot be pushed back in by gentle pressure, a complication must be suspected. The most important complications are incarceration and strangulation.

Incarceration occurs when the contents of the hernia, most commonly a loop of small intestine or omentum, become trapped in the hernia defect and cannot be reduced back into the abdominal cavity. The hernia becomes firm, tender, and irreducible. If left unaddressed, the trapped tissue can progress to strangulation.

Strangulation occurs when the blood supply to the incarcerated hernia contents is compromised. The tissue begins to lose its viability. The pain becomes severe and constant. The patient develops systemic signs of illness including fever, nausea, and vomiting. Strangulation is a surgical emergency that requires immediate operative intervention, and the consequences of delayed treatment can include bowel resection, peritonitis, and in some cases life-threatening sepsis.

The recognition of strangulation signs, sudden increase in hernia pain, a firm, tender, irreducible bulge, fever, nausea, and vomiting, requires immediate emergency evaluation. This is not a situation for a scheduled appointment.

When Should a Hernia Be Repaired? The Right Time for Surgery

The decision about when to repair a hernia involves a careful assessment of the patient’s symptoms, the hernia’s characteristics, the risk of complication, and the patient’s overall health and surgical risk.

Emergent repair is required for incarcerated or strangulated hernias where the trapped contents are at risk of losing their blood supply. There is no waiting in this context. The surgery is performed urgently regardless of the patient’s other medical considerations.

Prompt repair is appropriate for hernias that are producing significant symptoms including pain that interferes with daily activity, limitation of physical function, or enlargement that suggests progressive risk of complication. Femoral hernias in particular, because of their narrow, rigid hernia ring and high risk of strangulation, are recommended for prompt repair even when currently reducible.

Elective repair is appropriate for hernias that are asymptomatic or minimally symptomatic and whose hernia type and size do not suggest high immediate risk of complication. In this category, the timing of surgery is planned based on the patient’s schedule, health status, and preference. Watchful waiting, the deferral of surgery while monitoring for symptom development, is a reasonable option for some patients with small, asymptomatic inguinal hernias, particularly elderly patients with significant comorbidities whose surgical risk may outweigh the hernia’s risk.

The general principle is that a hernia does not improve without surgery, and its risk profile does not decrease with time. A hernia that is asymptomatic today may be symptomatic next year. The defect that is small today may be larger in two years. The decision to repair is a question of timing and surgical risk, not of whether repair is eventually necessary.

The Surgical Approaches: Open, Laparoscopic, and Robotic

Hernia repair can be performed through three broad technical approaches, each with specific advantages, limitations, and appropriate indications.

Open Hernia Repair

Open repair involves a direct incision over the hernia site, through which the surgeon accesses the defect, reduces the hernia contents back into the abdominal cavity, and repairs the defect by closing the weakened tissue and reinforcing the repair with a mesh prosthesis. Open repair is appropriate for hernias where the defect location or size is not well-suited to minimally invasive access, for patients whose prior abdominal surgery has created adhesions that make laparoscopic access technically complex, and for hernias that require simultaneous repair of an associated skin excess or scar, such as incisional hernias following prior abdominal surgery where a concurrent tummy tuck component may be planned.

Smaller umbilical and ventral hernias can be repaired through a direct incision under local anesthesia with sedation rather than general anesthesia, which is a meaningful advantage for patients whose medical status makes general anesthesia a higher-risk undertaking.

Laparoscopic Hernia Repair

Laparoscopic repair uses several small incisions, each ranging from five to twelve millimeters in length, through which the surgeon introduces a camera and long instruments to repair the hernia from the inside out. The approach from the interior of the abdominal cavity allows the surgeon to place the mesh on the peritoneal surface of the defect, where the intra-abdominal pressure that caused the hernia in the first place now works to hold the mesh in place rather than to push through it.

Laparoscopic repair typically produces less postoperative pain, a shorter recovery, and faster return to activity than open repair for comparable hernias. It is particularly well-suited to bilateral inguinal hernias, where both sides can be repaired through the same small incisions in a single session, and to recurrent hernias where the previously operated tissue makes open re-exploration through scar tissue more complex.

Robotic-Assisted Hernia Repair

Robotic repair uses the same small incision approach as laparoscopic repair but replaces the long laparoscopic instruments with robotic arms controlled by the surgeon at a console, using a three-dimensional high-definition camera system that provides superior visualization and instrument control compared to standard laparoscopy. Robot-assisted repair has demonstrated shorter hospital stays and lower readmission rates than laparoscopic repair in matched patient populations. nih

The robotic platform is particularly valuable for complex hernia repairs, including large incisional hernias requiring component separation of the abdominal wall and diastasis recti repair. The combination of hernia repair and rectus muscle reapproximation through the robotic approach, sometimes called robotic TARUP or similar techniques, allows a simultaneous correction of both the hernia defect and the diastasis recti that frequently accompanies incisional hernias following prior abdominal surgery or pregnancy.

The Role of Mesh in Hernia Repair

Mesh is used in the majority of hernia repairs performed today, and understanding what it is and why it is used helps patients approach this component of their surgical plan with accurate information.

The principle behind mesh is straightforward. A hernia defect in the abdominal wall is a zone of weakened or absent tissue. Closing that defect with sutures alone, particularly in a patient whose tissue is already compromised, places significant tension on the closure and produces recurrence rates that are substantially higher than mesh-reinforced repairs. Mesh bridges the defect, distributes the mechanical forces of intra-abdominal pressure across a broader area, and provides a scaffold into which the patient’s own tissue grows over time, creating a reinforced abdominal wall that is stronger than the native tissue closure alone.

Modern surgical meshes are made from synthetic materials, most commonly polypropylene, or from biological materials derived from human or animal tissue. The choice of mesh type is based on the clinical context: synthetic mesh is the standard for most elective hernia repairs in patients without infection or contamination, while biological mesh is used in contaminated fields or in patients where the risk of infection makes a permanent synthetic implant less appropriate.

The FDA has reviewed surgical mesh for hernia repair and recognizes it as safe and effective for hernia surgery when used appropriately. Concerns about mesh-related complications, including mesh contraction, migration, and chronic pain, are taken seriously in the hernia surgery community, and mesh selection and placement technique are areas where surgeon experience and judgment have a direct impact on outcomes.

Anesthesia for Hernia Surgery: What to Expect

The anesthesia used for hernia repair depends on the approach, the scope of the repair, and the patient’s overall health status.

Local anesthesia with sedation is appropriate for small, straightforward hernia repairs, particularly open umbilical and small inguinal hernia repairs, performed through a direct incision. The surgeon infiltrates the surgical field with local anesthetic and the patient receives intravenous sedation to maintain comfort during the procedure. This approach avoids the physiological demands of general anesthesia and is appropriate for patients whose medical comorbidities make general anesthesia a higher-risk undertaking.

Regional anesthesia, including spinal or epidural anesthesia, can be used for inguinal hernia repairs, providing surgical anesthesia to the lower body without general anesthesia. It is particularly appropriate for inguinal hernia repair in patients who are not ideal general anesthesia candidates.

General anesthesia is required for laparoscopic and robotic hernia repairs, for complex open repairs involving the upper abdomen or simultaneous abdominal wall reconstruction, and for any repair that requires the surgical field to include zones not adequately reached by local or regional anesthesia. Under general anesthesia, the patient is completely unconscious, breathing is supported by a ventilator or supraglottic airway device, and surgical conditions are optimized.

Dr. Golshani discusses the most appropriate anesthesia approach for each patient’s specific hernia and medical situation during consultation. The choice is never arbitrary and is always made with both the surgical requirements of the repair and the patient’s safety as the primary considerations.

Hernia Surgery and Insurance Coverage

Hernia surgery is almost universally covered by health insurance as a medically necessary procedure. Unlike cosmetic surgery, which is elective by definition, hernia repair addresses a structural anatomical defect that carries documented risks of serious complication including incarceration, strangulation, and bowel obstruction.

Most insurance plans cover hernia repair with a referral and pre-authorization from the patient’s primary care physician or general surgeon. The documentation required typically includes a clinical examination confirming the hernia, the patient’s symptom history, and in some cases imaging to characterize the defect. Dr. Golshani’s team assists patients in navigating the pre-authorization process and in ensuring the documentation required for coverage is correctly prepared.

Patients are advised to confirm the specific coverage terms of their individual policy, including deductibles, co-pays, in-network versus out-of-network requirements, and the specific procedure codes that apply to their type of hernia repair.

When Hernia Surgery Is Combined With Other Procedures

Hernia repair, particularly incisional hernia repair following prior abdominal surgery, frequently connects to adjacent reconstructive and cosmetic concerns:

• Tummy Tuck and Advanced Abdominoplasty when incisional hernia repair is combined with abdominal skin excess correction and diastasis recti repair in a single coordinated surgical plan, particularly in post-pregnancy or post-bariatric patients where all three components are present simultaneously
• Diastasis Recti Repair as a component of hernia repair in patients where the widened linea alba has produced both a ventral hernia and a diastasis that require simultaneous correction
• Post-Weight Loss Body Sculpting where incisional hernia from prior bariatric surgery incisions is addressed alongside the skin excess correction of a comprehensive post-weight loss body contouring plan
• Mommy Makeover when umbilical hernia, diastasis recti, and abdominal skin excess are all addressed simultaneously as part of a comprehensive post-pregnancy abdominal reconstruction
• Plastic and Reconstructive Surgery as the broader surgical context within which Dr. Golshani’s hernia repair practice sits, reflecting the reconstructive foundation of his training