Laparoscopic Hernia Surgery
What is a Hernia?
A hernia refers to tissue or an organ from one body cavity moving into another space where it should not normally be. In the majority of cases hernias are related to defects of the abdominal wall or diaphragm. The given medical “name” is based off of the location and nature of the hernia. A hernia is not something that is removed. Hernias are repaired. A punctured bicycle tire can be repaired in a number of ways. The tire puncture could be glued primarily, a patch placed over the opening or perhaps below the opening.
Regardless of technique, the problem area remains, it is not removed.
A hernia does not get better over time, nor will it go away by itself.
Why are Hernias a potential problem?
For some, hernias are a source of chronic pain and discomfort. For others, the hernia may be felt to be disfiguring or unsightly. It is not uncommon for patients to tell me that they feel uncomfortable wearing certain clothes for fear that the hernia makes them appear pregnant or misshapen.
Hernias, in general, enlarge over time becoming more symptomatic.
Symptoms generally correlate with the location of the hernia and what is protruding through the defect.
Although relatively rare, intestinal blockage remains one of the most common indications for emergency hernia surgery. When an organ, typically bowel, has been trapped for a period of time there can be potential for a reduction in blood flow and subsequent gangrene and perforation. The end result being overwhelming, life threatening infection.
The majority of hernias don’t lead to a life-threatening emergency. If you think you may have a hernia have your doctor evaluate.
How do I know if I have a Hernia?
The most obvious but not always the most common way patients identify a hernia is appreciating a “bump or lump” in the area of concern. The mass may be identified while taking a shower, exercising or getting dressed.
Pain or discomfort is the most common symptom first noted by patients who present to my office with concerns related to a hernia.
How are Hernias diagnosed?
The majority of hernias are easily identified by a trained Surgeon on physical examination. Inguinal hernias are much easier to diagnose in men than women because of anatomical differences between the male and female inguinal canal.
Occasionally, radiologic evaluation is required to make the diagnosis.
Inguinal hernias in females can generally be detected with dynamic U/S and in rare situations MRI may be required. CT imaging may be useful for pre-operative planning ventral hernias.
For most big Incisional hernias CT scan is mandatory for a complete evaluation and planning for surgery
Most inguinal hernias occur in men and a small percentage of women develop inguinal hernias. The reason for the much higher prevalence in men relates to major anatomical and embryologic differences. They are of 2 types, direct & indirect.
When women develop inguinal hernias it is almost always of the indirect variety.
The mechanism of formation is different but the end result is the same lining sliding alongside a uterine ligament that traverses the inguinal canal and anchors into the pubic bone.
Another factor that contributes to a higher prevalence in males is due to major differences in boney pelvis anatomy between sexes. The inguinal floor in males is generally broader and subjected to internal forces at higher pressures. This promotes gradual weakening of the floor and eventual eventration or bowing outward of the muscular floor. This type of hernia has been referred to as a direct inguinal hernia. This type of inguinal hernia is thought to develop as the result of “wear and tear”.
How are Hernias repaired?
Inguinal hernias can be repaired in an open or laparoscopic fashion both with and without mesh.
Mesh free repairs are referred to as primary repairs and several techniques have been described over the last century.
In the past 30 years the use of mesh has become increasingly used. At this time most surgeons will use mesh as it has been demonstrated to reduce the incidence of hernia recurrence.
In the last 20 years there has been increasing use of laparoscopic techniques to repair groin hernias. Laparoscopic techniques almost always require mesh for satisfactory repair.
What is the difference between OPEN & Laparoscopic technique?
The open repair requires a 4-6-inch oblique incision in the groin. The hernia(s) are identified and reduced (pushed back into place). Mesh is typically placed on top of the inguinal floor increasing its strength and durability and covering the potential openings through which tissue can slide. This is referred to as an “onlay” technique.
The laparoscopic techniques allow complete visualization of the inguinal region including the femoral space. Once the anatomy is delineated and the hernia(s) are reduced, mesh is placed under the abdominal wall defects. This is referred to as an “underlay”.
What are the advantages of laparoscopic technique?
When inguinal hernias are approached from within the abdominal cavity or just outside the abdominal cavity (preperitoneal) the entire inguinal floor can be visualized. The entire area of weakness can be reinforced or covered. The open technique only exposes a small area of the inguinal floor and thus wide coverage is difficult to obtain.
Laparoscopic and inguinal hernia repair enables repair of the left and right sides simultaneously through three small incisions.
Minimally invasive repair has also been demonstrated to be beneficial in those patients who are undergoing surgery for recurrent inguinal hernias.
The recovery is generally quicker and with less pain and swelling. Patients are generally able to return to work sooner and most patients can return to full activity within 3 to 4 weeks.
What is the recurrence rate for repaired Hernias?
When performed by highly trained and experienced surgeons the recurrence rate is identical between open and laparoscopic hernias and is 1-2%.
Following surgery, you
- Can take a shower only after 48 hours post-surgery on doctors advise.
- Can go home on the day of the procedure or next day
- Should avoid driving while taking pain killers as they induce drowsiness
- Can resume daily activities slowly while strenuous activities should be resumed only after consultation with your surgeon
- Use ice pack on the wound to reduce pain, prevent swelling and to lessen bloody discharge from the incision if present
- Recover in about 3 weeks
Risks and complications
Like most surgical procedures, hernia repair is associated with the following risks and complications:
- Reaction to anesthesia
- Bleeding at operation site
- Nerve damage and numbness of skin
- Damage to surrounding tissue
- Although the recurrence of hernias is seen in less than 5% of patients after surgery, you would need to follow preventive measures.
What is a Ventral Hernia
A hernia occurs when there is a hole in the muscles of the abdominal wall, allowing a loop of intestine or abdominal tissue to push through the muscle layer. A ventral hernia is a hernia that occurs at any location along the midline (vertical center) of the abdomen wall.
What are the common types of Ventral Hernia?
There are three types of ventral hernia:
- Epigastric (stomach area) hernia: Occurs anywhere from just below the breastbone to the navel (belly button). This type of hernia is seen in both men and women.
- Umbilical (belly button) hernia: Occurs in the area of the belly button.
- Incisional hernia: Develops at the site of a previous surgery. Up to one-third of patients who have had an abdominal surgery will develop an incisional hernia at the site of their scar. This type of hernia can occur anytime from months to years after an abdominal surgery.
What are the causes and risk factors for developing a ventral hernia?
There are many causes including:
- Weakness at the incision site of a previous abdominal surgery (which could result from an infection at the surgery site or failed surgical repair/mesh placement).
- Weakness in an area of the abdominal wall that was present at birth.
- Weakness in the abdominal wall caused by conditions that put strain on the wall. These include:
- Being overweight
- Frequent coughing episodes
- Severe vomiting
- History of lifting or pushing heavy objects
- Straining while having a bowel movement/urinating
- Injuries to the bowel area
- Lung diseases (chronic obstructive pulmonary disease and emphysema; struggling to breathe puts strain on the abdominal wall)
- Prostatism (enlargement of the prostate gland, which causes straining while urinating in older men)
- Older age (general loss of elasticity to abdominal wall)
What are the signs and symptoms of a ventral hernia?
Some patients don’t feel any discomfort in the early stages of ventral hernia formation. Often, the first sign is a visible bulge under the skin in the abdomen or an area that is tender to the touch. The bulge may flatten when lying down or pushing against it.
A ventral hernia causes an increasing level of pain when a person:
- Lifts heavy objects.
- Strains to have a bowel movement/urinate.
- Sits or stands for long periods of time.
Severe abdominal pain can occur if part of the intestine bulges through the abdominal wall and becomes trapped in the opening. If this happens, the trapped portion of the intestine becomes strangled, loses its blood supply and starts to die. This is a medical emergency that requires immediate care.
How is a ventral hernia diagnosed?
Your doctor will review your medical and surgical history. He or she will also perform a physical exam of the abdominal area where a ventral hernia may have occurred. Your doctor may then order imaging tests of the abdomen to look for signs of a ventral hernia. These tests may include an ultrasound, computed tomography (CT) scan or a magnetic resonance imaging (MRI) study.
How is a ventral hernia repaired?
Ventral hernias do not go away or get better on their own and require surgery to repair. In fact, without treatment, ventral hernias can get larger and worsen with time. Untreated hernias can become difficult to repair and can lead to serious complications, such as strangulation of a portion of the intestine.
The goal of ventral hernia surgery is to repair the hole/defect in the abdominal wall so that the intestine and other abdominal tissue cannot bulge through the wall again. The surgery often restores the tone and shape of the abdominal wall by repairing the hole and bringing the muscles back to their normal position.
There are 2 main types of hernia repair surgeries: open & laparoscopic :
- Open hernia repair: An open incision is made in the abdomen where the hernia has occurred, and the intestine or abdominal tissue is pushed back into place. A mesh material is placed to reinforce this repair and reduce hernia recurrences. The skin is usually closed with dissolvable stitches and glue.
- Laparoscopic surgery: Several small incisions are made away from where the hernia has occurred. A laparoscope (a thin lighted tube with a camera on the tip) is inserted through one of the openings to help guide the surgery. A surgical mesh material may be inserted to strengthen the weakened area in the abdominal wall. Advantages of this approach compared with open hernia repair include a lower risk of infection, because smaller-sized incisions are used.
Your surgeon will consider several factors to help determine the best surgical hernia repair method for you, including:
- Your age
- Existing health problems and medical history
- The size of the hernia
- The size and contour of the abdominal wall
- Amount of skin that can be used for the repair, and
- Presence of infection.
Importantly, your hernia repair is tailored to your specific situation based on the goals of the procedure and expected outcomes.
What are the advantages of laparoscopic repair?
Results may vary depending on the type of procedure and each patient’s overall condition. Common advantages may include:
- Less post-operative pain
- Shortened hospital stay
- Faster return to regular diet
- Quicker return to normal activity
- Less wound infections
What happens if the Ventral Hernia repair cannot be performed or completed by the Laparoscopic method?
In a small number of patients the laparoscopic method cannot be performed.
Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.
The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.
What should I expect after Ventral Hernia Surgery?
- Patients are encouraged to engage in light activity while at home after surgery. Follow your surgeon’s advice carefully.
- Post-operative discomfort is usually mild to moderate. Frequently, patients will require pain medication.
- Most patients are able to get back to their normal activities in a short period of time.
- Occasionally, patients develop a lump or some swelling in the area where their hernia had been. Frequently this is due to fluid collecting within the previous space of the hernia. Most often this will disappear on its own with time.
- Typically, patients schedule follow-up appointments within 2-3 weeks after their operation.
What Complications can Occur?
Although this operation is considered safe, complications may occur as they might occur with any operation, and you should consult your doctor about your specific case.
- Complications may include adverse reactions to general anesthesia, bleeding, or injury to the intestines or other abdominal organs.
- Other possible problems include pneumonia, blood clots or heart problems.
- If an infection occurs in the mesh, it may need to be removed or replaced.
- Also, any time a hernia is repaired it can come back. The long-term recurrence rate is not yet known.
- Your surgeon will help you decide if the risks of laparoscopic ventral hernia repair are less than the risks of leaving the condition untreated.
It is important to remember that before undergoing any type of surgery, whether laparoscopic or traditional, you should ask your surgeon about his/her training and experience.
When to call you doctor after any type of hernia surgery?
Be sure to call your surgeon if you develop any of the following:
- Persistent fever over 101 F (39 C)
- Increased abdominal swelling or pain
- Pain that is not relieved by your medications
- Persistent nausea or vomiting
- Persistent cough or shortness of breath
- Drainage from any incision