Laparoscopic Hernia Repair
Approximately 600,000 hernia repair operations are performed annually in the United States. Many are performed by the conventional “open” method. Some are performed laparoscopically. Laparoscopic hernia repair is a relatively new surgical technique to fix tears in the abdominal wall (muscle) using small incisions, a patch (mesh), and special cameras to view inside the body. It frequently offers a more rapid recovery for the patient, less postoperative pain, and a quicker return to work and normal activities.
What is a Hernia?
A hernia is a defect in the abdominal wall, in which the inside layers of the abdominal muscle have weakened resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small bubble or balloon-like sac. When a loop of intestine or abdominal tissue pushes into the sac, severe pain and other potentially serious complications can result.
Both men and women can get a hernia. Some hernias are present at birth (congenital), while others develop over time. A hernia does not get better over time; a hernia will not go away by itself. Hernias most commonly occur in the groin (‘inguinal hernias’), around the belly button (‘umbilical hernias’), and near the site of a previous surgical operation (‘incisional hernias’).
Frequently, hernias are easily felt and diagnosed. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements or during prolonged standing or sitting.
The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day. Severe, continuous pain, redness and tenderness are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon.
The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness in the abdominal wall present at birth. Anyone can get a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting, persistent coughing, difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate, and hernias to form.
There is no acceptable nonsurgical medical treatment for a hernia. The use of a truss (hernia belt) can help keep the hernia from bulging but eventually will fail. The truss also causes the formation of scar tissue around the hernia making the repair more difficult. If you suspect you have a hernia, consult with your physician or surgeon promptly. Delayed hernia repair can result in intestinal incarceration (intestine is trapped inside the hernia sac) or strangulation (intestine is trapped and develops gangrene). The latter is a surgical emergency.
The hernia will not go away without treatment; it will only get bigger. The bigger the defect the bigger the operation required to fix it.
Under certain circumstances the hernia may be watched and followed closely by a physician. These situations are unique to those individuals who are at high operative risks (i.e. those with severe heart or lung disease, or bleeding problems). Of course, even in the high risk person, if the symptoms become severe or if strangulation occurs, then an operation must be performed.
There are two main options for hernia repair:
- Open Repair: The traditional, open repair has been the gold standard for over 100 years. There are 5-10 different approaches that are performed routinely with local and intravenous sedation. Due to the larger size of the incision, open hernia repair is generally painful with a relatively long recovery period.
- Minimally Invasive (Laparoscopic) Repair: Minimally Invasive (Laparoscopic) Repair has been developed over the past decade. It is usually performed under general anesthesia but spinal anesthesia is also an option. Local anesthesia can be used under special circumstances.
- shorter operative time
- less pain
- shorter recover period
In laparoscopic hernia surgery, a telescope attached to a camera is inserted through a small incision that is made under the patient’s belly button. Two other small cuts are made (each no larger than the diameter of pencil eraser) in the lower abdomen. The hernia defect is reinforced with a ‘mesh’ (synthetic material made from the same material that stitches are made from) and secured in position with stitches/staples/titanium tacks or tissue glue, depending on the preference of your individual surgeon.
Incisional, Ventral, Epigastric, or Umbilical hernias are defects of the anterior abdominal wall. They may be congenital (umbilical hernia) or acquired (incisional). Incisional hernias form after surgery through the incision site or previous drain sites, or laparoscopic trocar insertion sites. Incisional hernias are reported to occur in approximately 4-10% of patients after open surgical procedures. Certain risk factors predispose patients to develop incisional hernias, such as obesity, diabetes, respiratory insufficiency ( lung disease), steroids, wound contamination, postoperative wound infection, smoking, inherited disorders such as Marfan’s syndrome and Ehlers-Danlos syndrome, as well as poor surgical technique. Approximately 90,000-100,000 incisional hernia repairs are performed annually in the United States.
These hernias present much the same way inguinal hernias do. That is, they present with a bulge near or at a previous incision. Some patients may experience discomfort, abdominal cramping or complete intestinal obstruction, or incarceration as a result of these hernias.
The principle of surgical repair entails the use of prosthetic mesh to repair large defects in order to minimize tension on the repair. A tension free repair has a lesser chance of hernia recurrence. Traditionally, the old scar is incised and removed, and the entire length of the incision inspected. Generally, there are multiple hernia defects other than the one(s) discovered by physical examination. The area requiring coverage is usually large and requires much surgical dissection. A prosthetic mesh is used to cover the defect(s), and the wound closed. This is a major surgical procedure and often complicated. Infection rates following repair may be as high a 7.0%. Recurrence can be up to 5%, or higher, depending on the patient’s preoperative risk factors. While the use of prosthetic mesh has decreased the number of recurrences, it has also been implicated in increased infection rates, adhesion or scar formation of the abdominal contents to the anterior abdominal wall leading to intestinal obstruction and fistula formation. However, overall, recovery is usually excellent and patients return to normal activity within a matter of weeks.
The laparoscopic repair of ventral hernias was designed to minimize operative trauma to the patient. As mentioned, these are often complicated repairs requiring large incisions and extensive tissue dissection. The principles governing a laparoscopic ventral hernia repair are based on those of open Stoppa ventral hernia repair. A large piece of prosthetic mesh is placed under the hernia defect with a wide margin of mesh outside the defect (see figure). The mesh is anchored in to place with eight full thickness sutures and secured to the anterior abdominal wall with a varying number of tacs, placed laparoscopically.
A patient is a candidate for laparoscopic incisional hernia repair if they are medically able to undergo general anesthesia. Also, the defect must “allow” the surgeon to place the laparoscopic trocars in such positions that repair are ergonomically possible. In some very large or giant hernias, the abdominal wall is distorted to such a degree that it is impossible to safely place laparoscopic trocars. Ancillary studies, such as CT scan of the abdomen and pelvis are helpful in making this decision. Patients are also given a bowel preparation to evacuate the colon and decrease the number of intestinal bacteria prior to surgery.
Patients are admitted the same day of their surgery. Following the procedure and recovery from anesthesia, they are taken to a hospital room where they spend the night. We encourage our patients to move as quickly as possible. It is extremely important to be active early in order to stave off some of the complication seen postoperatively, such as pneumonia, deep venous thrombosis and pulmonary embolism (clots in the legs that break off and go the lungs). Postoperative pain is variable, and can be considerable during the first 24 hours. As such, patients are given I.V. narcotics as needed, and are changed to oral analgesics the next day. Generally, most patients stay in the hospital 1 or 3 days following surgery. Patients are then seen, by the surgeon, one to two weeks after discharge. There is no dietary restriction. Activity level is restricted by the patient’s comfort level. However, it is generally not advisable to engage in any strenuous exercise or heavy lifting for several weeks, to allow the hernia repair to heal.
- Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.
- There is a slight risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle.
- Difficulty urinating after surgery is not unusual and may require a temporary tube into the urinary bladder.
- Any time a hernia is repaired it can come back. This long-term recurrence rate is not yet known. Your surgeon will help you decide if the risks of laparoscopic hernia repair are less than the risks of leaving the condition untreated.
Only after a thorough examination can your surgeon determine whether laparoscopic hernia repair is right for you. The procedure may not be best for some patients who have had previous abdominal surgery or have underlying medical conditions.
In a small number of patients the laparoscopic method is not feasible because of an inability to visualize or manipulate the organs involved. Factors that may increase the possibility of converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, 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. The decision to convert to an open procedure is strictly based on patient safety.
- Most hernia operations are performed on an outpatient basis, meaning the patient will go home on the same day that the operation is performed.
- You should refrain from eating or drinking after midnight on the night before your operation.
- You should shower the night before or the morning of the operation.
- If you have difficulties moving your bowels, an enema or similar preparation should be used after consulting with your surgeon.
- Some preoperative testing may be required depending on your medical condition and the type of anesthesia needed for your operation.
- If you take medication on a daily basis, discuss this with your surgeon as (s)he may want you to take some of your medications on the morning of surgery with a sip of water. If you take aspirin, blood thinners or arthritis
- You should discuss with your surgeon the proper timing of discontinuing some medications before your operation.
- Following the operation, you will be transferred to the recovery room where you will be monitored carefully until you are fully awake.
- Once you are awake and able to walk, you will be discharged.
- With any hernia operation, you can expect some soreness. This will be mostly during the first 24 to 48 hours.
- You are encouraged to be up and about the day after surgery.
- If you begin to have fever, chills, vomiting, are unable to urinate, or experience drainage from your incisions, you should call your surgeon immediately.
- With laparoscopic hernia repair, you will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, work and sexual intercourse.
- If you have prolonged soreness and are getting no relief from the prescribed pain medication, you should notify your surgeon. You should call and schedule a follow-up appointment within 2 weeks after you operation.
(Excerpted from Society of American Gastrointestinal Endoscopic Surgeons’ Task Force on Patient Information)