A M E R I C A N COL L E G E O F S U R G E O N S• D IVIS I O N O F E D U C A T I O N Adult Umbilical Repair

Bene ts and Risks of Your Operation Patient Education An operation is the only way This educational information is to repair a hernia. You can return to your to help you be better informed normal activities and in most cases will about your operation and not have further discomfort. empower you with the skills and Risks of not having an operation—Your knowledge needed to actively Umbilical Hernia Location hernia may cause pain and increase in participate in your care. size. If your intestine becomes squeezed The Condition in the hernia pouch, you will have sudden Keeping You pain, , and require an immediate An umbilical hernia occurs when a tissue operation. Informed bulges out through an opening in the muscles on the abdomen near the navel Possible risks include return of the Information that will help you or belly button (umbilicus). About 10% of hernia; infection; injury to the bladder, further understand your operation abdominal are umbilical hernias.1 blood vessels, intestines, or nerves; and and your role in healing. continued pain at the hernia site. Common Symptoms Education is provided on: ● Visible bulge on the abdomen, Overview ...... 1 especially when coughing or straining Expectations Condition, Symptoms, Tests ...... 2 ● Pain or pressure at the hernia site Before your operation—Evaluation Treatment Options…...... 3 may include blood tests, urinalysis, and Risks and ultrasound. Your surgeon and Possible Complications ...... 4 Treatment Options provider will discuss your health history, Preparation Surgical Procedure home medications, and pain control and Expectations ...... 5 options. Open hernia repair—An incision is made Your Recovery near the site. Your surgeon will repair the The day of your operation—You will and Discharge ...... 6 hernia with mesh or by suturing (sewing) not eat or drink for six hours before the Pain Control...... 7 the muscle layer closed. operation. Most often, you will take your Glossary/References ...... 8 normal medication with a sip of water. You Laparoscopic hernia repair—The hernia will need someone to drive you home. is repaired with mesh or sutures inserted through instruments placed into small Your recovery—For a simple repair, you incisions in the abdomen. may go home the same day. You will need to stay longer for complex repairs.4 Nonsurgical Procedure Call your surgeon if you have severe pain, Watchful waiting is generally not stomach cramping, chills or a high fever recommended for adults with an umbilical (over 101°F or 38.3°C), odor or increased hernia. You may be able to wait to repair drainage from your incision, or no bowel umbilical hernias that are very small, movements for three days. reducible (can be pushed back in) and not uncomfortable.2 There is a risk of the intestines being squeezed in the hernia

(strangulation). If this happens, you will need an immediate operation.3

This rst page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation

99728A_HERN.indd 1 9/17/13 11:27 AM The Condition, Symptoms, Umbilical Hernia Repair Surgical and and Diagnostic Tests Nonsurgical Treatment

Intestines Keeping You Informed Umbilical Hernia Bulge Who Gets an Umbilical Hernia? Ten percent of all hernias in adults are umbilical.2 Umbilical hernias can Abdominal Muscle suddenly bulge out. They occur more often (Abdominal Lining) Open Repair in adults over 60 years Hernia Location when the muscles Internal View start to weaken.5 Some risk Surgical Treatment factors are: The Condition Symptoms The type of operation depends on • Older age—muscles hernia size and location, and if it is a An umbilical hernia occurs when part of The most common symptoms are: become weaker repeat hernia (recurrence). Your health, the intestine or fatty tissue bulges through ● Bulge in the abdominal area that often age, and the surgeon’s expertise are • Overweight and the muscle near the belly button (navel, increases with coughing or straining also important. An operation is the —increased umbilicus). Most (9 of 10) umbilical hernias only treatment for a hernia repair. weight places in adults are acquired. This means that ● Pain or pressure at the hernia site pressure on increased pressure near the umbilicus Your hernia can be repaired either as ● Increasing sharp and abdominal muscle causes the umbilical hernia to bulge out. an vomiting can mean that the hernia is The repair can be done by using sutures • Chronic straining A reducible hernia can be pushed back strangulated. This is a surgical emergency only or adding a piece of mesh. • Family history into the opening or decrease in size when and immediate treatment is needed. Open Hernia Repair • The surgeon makes an incision near the in the space between 4 be pushed back, it is irreducible or hernia site, and the bulging tissue is gently the tissues lining Common Diagnostic Tests incarcerated. A hernia is strangulated if pushed back into the abdomen. Sutures the abdomen and the intestine is trapped in the hernia pouch History and Physical Exam or mesh are used to close the muscle. abdominal organs; and the blood supply to the intestine is Checks for the presence of bulge may be due to ● This is a surgical emergency. alcoholism Additional Tests (see Glossary) Herniorrhaphy is the surgical repair of a hernia. • Pregnancy, Other tests may include: particularly multiple Hernioplasty is surgical repair of a hernia with pregnancies mesh inserted to reinforce the weak area. ● Ultrasound ● Computerized tomography (CT) scan ● Pregnancy ● Blood tests Considerations ● Urinalysis The repair of umbilical ● Electrocardiogram (ECG) – for patients hernias during over 45 or if high risk of heart problems pregnancy is considered only if the hernia becomes incarcerated or strangulated.2

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99728A_HERN.indd 2 9/17/13 11:28 AM Umbilical Hernia Repair Surgical and Umbilical Hernia Repair Nonsurgical Treatment

Mesh Repair Sutured Muscle Repair

Open Repair Laparoscopic Repair

Internal View ● Your surgeon may inject a local anesthetic Keeping You Surgical Treatment around the hernia repair site to help The type of operation depends on control pain. Informed hernia size and location, and if it is a ● With complex or large hernias, small Open versus repeat hernia (recurrence). Your health, drains may be placed going from inside to age, and the surgeon’s expertise are the outside of the abdomen. Laparoscopic Repair also important. An operation is the only treatment for a hernia repair. Laparoscopic Hernia Repair on the best technique to repair an The surgeon will make several small umbilical hernia, and more study Your hernia can be repaired either as is needed. The type of repair may punctures or incisions in the abdomen. Ports an open or laparoscopic approach. also depend on the size of the or trocars (hollow tubes) are inserted into The repair can be done by using sutures hernia. the openings. Surgical tools and a lighted strangulated. This is a surgical emergency only or adding a piece of mesh. camera are placed into the ports. The • When comparing open mesh Open Hernia Repair repair with laparoscopic mesh The surgeon makes an incision near the gas to make it easier for the surgeon to in the length of hospital stay 4 hernia site, and the bulging tissue is gently see the hernia. Mesh may be sutured or or recurrence rate. There Common Diagnostic Tests is a slightly lower wound pushed back into the abdomen. Sutures hernia site. The port openings are closed complication rate, including or mesh are used to close the muscle. seromas, hematomas, and with sutures, surgical clips, or glue. infection, with laparoscopic ● For a suture-only repair: The hernia sac is repair. 6, 8 Both types of removed. Then the tissue along the muscle operations have similar edge is sewn together. The umbilicus Nonsurgical Treatment long- term results. procedure is often used for small defects.6 Watchful waiting is not usually recommended • Open repairs can be done except for very small umbilical hernias.7 A with local anesthesia instead of general anesthesia and are ● For an open mesh repair: The hernia surgical repair is recommended for adults sac is removed. Mesh is placed beneath frequently done as outpatient who have symptoms, incarceration, thinning procedures. the hernia site. The mesh is attached of the skin, or uncontrollable ascites. using sutures sewn into the stronger • Strangulated hernias may tissue surrounding the hernia. The mesh Because abdominal muscles weaken with have to be repaired as an extends 3 to 4 cm beyond the edges of age, the hernia can increase in size, and there open approach. is a risk of incarceration and strangulation.2 • The use of mesh provides a to the muscle. Mesh is often used for Abdominal binders that apply pressure and stronger repair and decreases large hernia repairs and reduces the risk push back the bulge will not repair the hernia. the rate of recurrence.9 that the hernia will come back again. • Suture repair will result in ● For all open repairs, the skin site is closed a small incision around the using sutures, staples, or surgical glue. hernia site. Laparoscopic repairs usually have 3 to 4 smaller scars ● An open repair may be done with at the site of the entry ports. local anesthesia and sedation given through an IV. www.facs.org/patienteducation 3

99728A_HERN.indd 3 9/17/13 11:28 AM Umbilical Hernia Repair Risks of this Procedure

RISKS WHAT CAN HAPPEN KEEPING YOU INFORMED

Immediate There may be a feeling of tightness in the abdomen postoperative suture vs. mesh vs. laparoscopic repair of umbilical because the muscle has been pulled together.6 Your pain pain hernias by postoperative day 3.6 The laparoscopic approach avoids a long incision and dissection. medications and by resting and avoiding straining or lifting.

Long-term pain Long-term pain has not been reported by patients at Relaxation and deep breathing exercises may be performed follow-up visits extending between 1 and 24 months to reduce postoperative pain. A pillow can be used as a after the repair.6 splint and held against the abdomen for support when walking, laughing, or coughing.

Recurrence The use of mesh appears to reduce the rate of Mesh is commonly used with large hernias to decrease the (hernia comes umbilical hernia recurrence in most patients.6,8,9 recurrence rate.10 Laparoscopic repair is recommended back) for large or recurrent hernias because the surgeon avoids healing and increase recurrence rates.11 making an incision and avoids previous scar tissue.6

Seroma Seromas can form around the former hernia site. Most 50 of 1,000 patients having suture repair and 60 of 1,000 of patients having mesh (laparoscopic and needle may be required.2 open) repairs.9

Infection Wound infection is similar regardless of the type of An antibiotic may be given just before the operation. repair done. 9 Smoking and having other diseases can increase infection rates.2

Hematoma Hematomas (collections of blood) are rare. There is and rest. Most will resolve on their own with time. and mesh repair.9

Hernia at the Hernia at the site where the laparoscopic instruments This risk is reduced with the use of smaller ports and port site were inserted occurs in less than 4 of 1,000 adults.12 instruments.13

Heart/ There are no reports of heart or breathing Other health problems can increase the risk for heart and breathing breathing anesthesia-related complications. Your anesthesia hernia operation. provider will suggest the best option for you.

Elderly risks The length of hospital stay may increase in elderly If general anesthesia is a concern, an open surgery with patients. Complications related to general anesthesia local anesthesia may be recommended. may be higher because of other diseases/health problems.

Death No surgical deaths are reported directly related Stopping smoking and being at the ideal body weight to umbilical hernia repair except for strangulated before surgery reduces the risks of complications. Your hernias. surgical team is prepared for all emergency situations.

The data have been averaged per 1,000 cases

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99728A_HERN.indd 4 9/17/13 11:28 AM Umbilical Hernia Repair Expectations: Umbilical Hernia Repair Preparation for Your Operation

What You Can Expect The Day of Your Questions Home Medication Operation to Ask Bring a list of all of the medications, vitamins, and ● You should not eat or drink for at least any over-the-counter medicines that you are taking. 6 hours before the operation. About my Your medications may have to be adjusted before Operation: medications and by resting and avoiding straining or lifting. ● You should bathe or shower and clean your abdomen, especially around the • What are the side recovery and response to anesthesia. Most often, you Relaxation and deep breathing exercises may be performed umbilical area, with a mild antibacterial will take your morning medication with a sip of water. soap. of anesthesia? • What technique Anesthesia ● You should brush your teeth and rinse will be used to Let your anesthesia provider know if you have your mouth with mouthwash. Mesh is commonly used with large hernias to decrease the repair the hernia? allergies, neurologic disease (epilepsy, stroke), heart ● Do not shave the surgical site; the (Laparoscopic or disease, stomach problems, lung disease (asthma, surgical team will clip the hair near the open? Mesh or emphysema), endocrine disease (diabetes, thyroid incision site. with sutures?) conditions), or loose teeth; use alcohol or drugs; take any herbs or vitamins; or if you have a history of What to Bring • What are the risks and vomiting with anesthesia. of this procedure ● for me? If you smoke, you should let your surgical team know, ● Advance Directives (see glossary) • Will you be and you should plan to quit. Quitting before your performing the surgery can decrease your rate of respiratory and ● List of medicines entire operation wound complications. Quitting also increases your ● yourself? chances of staying smoke free for life. Resources to help you quit may be found at www.facs.org/ ● Slip-on shoes that don’t require that you • What level of pain patienteducation or www.lungusa.org/stop-smoking. bend over should I expect, and how will it Length of Stay ● Leave jewelry and valuables at home be managed? If you have local anesthesia, you will usually go After Your Operation • How long will it home the same day. You may stay overnight if you You will be moved to a recovery room be before I can have a repair of a large or incarcerated hernia. A where your heart rate, breathing rate, return to my normal breathing anesthesia-related complications. Your anesthesia laparoscopic repair may result in a longer anesthesia oxygen saturation, blood pressure, and activities (work, time. Complications such as severe nausea and urine output will be closely watched. Be driving, lifting)? vomiting or an inability to pass urine may also result sure that all visitors wash their hands. in a longer stay. Preventing Pneumonia Safety Checks and Blood Clots Movement and deep breathing after your with your name and hospital/clinic number will be operation can help prevent postoperative placed on your wrist. These should be checked by all health team members before they perform any your lungs, and pneumonia. Every hour, procedures or give you medication. Your surgeon will take 5 to 10 deep breaths and hold each The data have been averaged per 1,000 cases mark and initial the operation site. breath for 3 to 5 seconds. Fluids and Anesthesia When you have an operation, you are at An intravenous line (IV) will be started risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater For general anesthesia, you will be asleep and the risk. This risk is decreased by getting up pain free during the operation. A tube may be and walking 5 to 6 times per day, wearing placed down your throat to help you breathe special support stockings or compression during the operation. For spinal anesthesia, a boots on your legs, and for high-risk small needle with medication will be placed in patients, taking a medication that thins your back alongside your spinal column. You will your blood. be awake during the operation but pain free. www.facs.org/patienteducation 5

99728A_HERN.indd 5 9/17/13 11:28 AM Umbilical Hernia Repair Your Recovery and Discharge

Keeping You Your Recovery When to Contact Informed and Discharge Your Surgeon Thinking Clearly Contact your surgeon if you have: High-Fiber Foods If general anesthesia is given or if you are ● taking narcotics for pain, it may cause you to Handwashing Steri-strips ● bran cereals and whole-grain Wound Care trouble remembering and feel tired. You ● apricots, and dates), raspberries, should not drive, drink alcohol, or make any ● Always wash your hands before and after ● blackberries, strawberries, big decisions for at least 2 days. touching near your incision site. sweet corn, broccoli, baked ● Nutrition ● Do not soak in a bathtub until your potatoes with skin, plums, pears, stitches, Steri-strips, or staples are apples, greens, and nuts. ● When you wake up from the anesthesia, removed. You may take a shower after the ● you will be able to drink small amounts second postoperative day unless you are of liquid. If you do not feel sick, you can told not to. begin eating regular foods. ● ● Follow your surgeon’s instructions on ● Continue to drink about 8 to 10 glasses of when to change your bandages. water each day. ● A small amount of drainage from the ● incision is normal. If the dressing is soaked Pain Control while having a bowel movement. with blood, call your surgeon. Activity ● If you have Steri-strips in place, they will scale from 0 to 10 is used to measure pain. At a “0,” you do not feel any pain. A “10” is ● Slowly increase your activity. Be sure the worst pain you have ever felt. Following to get up and walk every hour or so to ● If you have a glue-like covering over the a laparoscopic procedure, pain is sometimes prevent blood clot formation. felt in the shoulder. This is due to the gas ● You may go home the same day for a ● Avoid wearing tight or rough clothing. It inserted into your abdomen during the simple repair. If you have other health may rub against your incisions and make it procedure. Moving and walking help to conditions or complications, such as harder for them to heal. decrease the gas and the shoulder pain. nausea, vomiting, bleeding, or infection Extreme pain puts extra stress on your body after surgery, you may stay longer. ● Protect the new skin, especially from the sun. The sun can burn and cause darker at a time when your body needs to focus ● Do not lift items heavier than 10 pounds scarring. on healing. Do not wait until your pain has or participate in strenuous activity for at reached a “10” or is unbearable before telling least 4 weeks or longer if advised by ● Your scar will heal in about 4 to 6 weeks your provider. It is much easier to control pain your surgeon. and will become softer and continue to before it becomes severe. fade over the next year. Work and Return to School Common Medicines to Control Pain Bowel Movements ● After recovery, you can usually return to Narcotics or opioids work within 2 to 3 days. Avoid straining with bowel movements by sleepiness; lowered blood pressure, heart You will not be able to lift anything over ● rate, and breathing rate; skin rash and 10 pounds, climb, or do strenuous activity Do not lift anything (like Metamucil and Fibercon). Be sure you are for 4 to 6 weeks following surgical repair over 10 pounds. drinking 8 to 10 glasses of water each day. urinating. Some examples of narcotics include of an umbilical hernia. A gallon of milk Pain morphine, oxycodone (Percocet/Percodan), weighs 9 pounds. ● Lifting limitation may last for 6 months for and hydromorphone (Dilaudid). Medications complex or recurrent repairs.2 can be given to control many of the side person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia.

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99728A_HERN.indd 6 9/17/13 11:28 AM Umbilical Hernia Repair Umbilical Hernia Repair

Non-Narcotic Pain Medication When to Contact Your Surgeon Contact your surgeon if you have: (NSAIDs). They are used to treat mild pain and ● Pain that will not go away ● Pain that gets worse of NSAIDs are stomach upset, bleeding ● A fever of more than 101°F (38.3°C) Always wash your hands before and after ● Repeated vomiting short-term use. Let your doctor know if you have heart, kidney, or liver problems. ● Swelling, redness, bleeding, or foul- Examples of NSAIDs include ibuprofen, smelling drainage from your wound site Motrin, Aleve, and Toradol (given as a shot). removed. You may take a shower after the ● Strong or continuous abdominal pain or Pain Control without Medicine second postoperative day unless you are swelling of your abdomen Distraction helps you focus on other activities ● No bowel movement by 3 days after instead of your pain. Listening to music, the operation playing games, or other engaging activities can help you cope with mild pain and anxiety. Pain Control Splinting your stomach by placing incision is normal. If the dressing is soaked a pillow over your abdomen with Splinting Your Stomach

If you have Steri-strips in place, they will scale from 0 to 10 is used to measure pain. movement can help reduce the pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following Guided imagery helps you direct and a laparoscopic procedure, pain is sometimes control your emotions. Close your eyes felt in the shoulder. This is due to the gas and gently inhale and exhale. Picture inserted into your abdomen during the yourself in the center of somewhere Avoid wearing tight or rough clothing. It beautiful. Feel the beauty surrounding may rub against your incisions and make it procedure. Moving and walking help to decrease the gas and the shoulder pain. you and your emotions coming back to your control. You should feel calmer. Protect the new skin, especially from the Extreme pain puts extra stress on your body sun. The sun can burn and cause darker at a time when your body needs to focus on healing. Do not wait until your pain has OTHER INSTRUCTIONS: reached a “10” or is unbearable before telling Your scar will heal in about 4 to 6 weeks your provider. It is much easier to control pain Guided imagery and will become softer and continue to before it becomes severe. Common Medicines to Control Pain Narcotics or opioids are used for severe Avoid straining with bowel movements by FOLLOW-UP APPOINTMENTS sleepiness; lowered blood pressure, heart rate, and breathing rate; skin rash and WHO: (like Metamucil and Fibercon). Be sure you are drinking 8 to 10 glasses of water each day. urinating. Some examples of narcotics include morphine, oxycodone (Percocet/Percodan), DATE: and hydromorphone (Dilaudid). Medications can be given to control many of the side after your operation is for pain control, and PHONE: your doctor will advise how much you should have sore throat pain from the tube placed www.facs.org/patienteducation 7

99728A_HERN.indd 7 9/17/13 11:28 AM Umbilical Hernia Repair More Information

For more information, please go to the American College of Surgeons Patient Education website at http://www.facs.org/patienteducation. For a complete review of hernia repair, consult Selected Readings in , “Hernia” 2012 Vol. 37 No. 8 at www.facs.org/SRGS. GLOSSARY REFERENCES Abdominal X ray: Checks for any Electrocardiogram (ECG): Measures The information provided in this report is chosen from recent the rate and regularity of heartbeats, articles based on relevant clinical research or trends. The research the size of the heart chambers and below does not represent all that is available for your surgery. Ask Abdominal ultrasound: Sound any damage to the heart. your doctor if he or she recommends that you read any additional waves are used to determine the research. location of deep structures in the General anesthesia: A treatment body. A hand roller is placed on top with certain medicines that puts you 1. Klinge U, Prescher A, Klosterhalfen B et al. Entstehung un d of clear gel and rolled across the into a deep sleep so you do not feel Pathosphysiolgie der BauchwanddefekteD. er Chirurg. 1997;68:293. pain during surgery. abdomen. 2. Muschaweck U in Umbilical and epigastric hernia repair, Ascites: Hematoma: A collection of blood that Surgical Clinics of North Americ2a0.0 3;1207-1221. has leaked into the tissues of the skin between the tissues lining the 3. Malangoni MA, Rosen MD. Hernias. In: CM Townsend, R D or in an organ, resulting from cutting abdomen and abdominal organs; Beauchamp, et al.T extbook of Surge. rPyhiladelphia, PA. Saunders , in surgery or the blood’s inability to may be due to alcoholism or liver 2008. disease. form a clot. 4. Incarceration: The protrusion or Advance Directives: Documents Abdominal Wall.C urrent Surgical Diagnosis and Treatm.e Endts. L.W. constriction of an organ through signed by a competent person Way and Gerald M. Doherty. 11th ed. New York: McGraw-Hill, 200 4. the wall of the cavity that normally giving direction to health care 783-796. providers about treatment choices. contains it. 5. “Strangulated Hernia” retrieved fromht tp://medicaldb.blogspo t. Local anesthesia: The loss of Blood tests: Tests usually include a com/2011/01strangulated-hernia.ht. ml sensation only in the area of the body chloride, carbon dioxide, blood where an anesthetic drug is applied or 6. Lau H, Patil NG. Umbilical Hernia in AdultSs,u rgical Endoscopy. urea nitrogen and creatinine) and injected. 2003;17:2016-2220. complete blood count (red blood Seroma: A collection of serous 7. cell and white blood cell count). Mulhollan M et al. Lippincott Williams & Wilkins, 2011. Pp. 1131. Computerized tomography (CT) Strangulation: Part of the intestine or 8. Solomon TA, Wignesvaran P, Chaudry MA, Tutton MGSu. rgical scan: A diagnostic test using X ray fat is squeezed in the hernia sac, and Endoscopy 2. 010;24:3109-3112. and a computer to create a detailed, three-dimensional picture of your 9. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpeña R. abdomen. A CT scan normally takes Urinalysis: A visual and chemical Randomized clinical trial comparing suture and mesh repair of about 15 minutes or less. examination of the urine, most umbilical hernia in adultsB. ritish Journal of Surge.ry often used to screen for urinary tract 2001;88:1321-1323. infections and kidney disease. 10. Hidalgo M, Higuero F, Alvarez-Caperochipi J, Machuca J, Laporte E, Figueroa J et al. Hernias de la pared abdominal. Estud io multicentrico epidemiologico (1993-1994)Ci. rugia Española. 1996; DISCLAIMER 59:309-405. 11. Martin DF, Williams RF, Mulrooney T, Voeller GR. Ventrelex mesh in umbilical/epigastric hernia repairs; clinical outcomes an d surgeon who is familiar with your situation. It is important to remember that each complications.H ernia .2008;379-383. 12. Wright BE, Becerman J, Cohen M, Cumming JK, Rodriquez JL. Is upon the patient’s individual condition. laparoscopic umbilical hernia repair with mesh a reasonab le alternative to conventional repairT? he American Journal of Surg.e ry organization that is dedicated to the ethical and competent practice of surgery; it 2002;184:505-509. was founded to raise the standards of surgical practice and to improve the quality 13. Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia aft er of care for the surgical patient. The ACS has endeavored to present information for laparoscopic surgery: A qualitative systematic reviewH.e rnia. 2011; 15:113-121. warranty on the timeliness, accuracy, or usefulness of this content. Reviewed by: We are grateful to Ethicon Endo-Surgery for the educational grant Nancy Strand, MPH, RN to the American College of Surgeons Foundation in support of the Mark Malangoni, MD, FACS Division of Surgical Patient Education Program Hernia Brochures. Brian Heniford, MD, FACS Reviewed April 2013

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