HERNIA REPAIR SURGERY

HERNIA REPAIR SURGERY2019-04-24T06:22:51+00:00
SURGERY FOR A HERNIA

There are two main ways surgery for hernias can be carried out:

  • open surgery – where one cut is made to allow the surgeon to push the lump back into the abdomen
  • keyhole (laparoscopic) surgery – this is a less invasive, but more difficult, technique where several smaller cuts are made, allowing the surgeon to use various special instruments to repair the hernia

Most people are able to go home the same day or the day after surgery and make a full recovery within a few weeks. The different approaches for each type of hernia are outlined below:

An inguinal hernia repair can be carried out as either open surgery or laparoscopic (or keyhole) surgery. The hospital will send you instructions about when you need to stop eating and drinking before the operation. The operation usually takes about 30 to 45 minutes to complete and you’ll usually be able to go home on the same day.

OPEN SURGERY

Open inguinal hernia repair is often carried out under local anaesthetic or a regional anaesthetic injected into the spine. This means you’ll be awake during the procedure, but the area being operated on will be numbed so you won’t experience any pain. In some cases, a general anaesthetic is used. This means you’ll be asleep during the procedure and won’t feel any pain.

Once the anaesthetic has taken effect, the surgeon makes a single cut (incision) over the hernia. This incision is usually about 6 to 8cm long. The surgeon then places the lump of fatty tissue or loop of bowel back into your abdomen (tummy). A mesh is placed in the abdominal wall, at the weak spot where the hernia came through, to strengthen it. When the repair is complete, your skin will be sealed with stitches. These usually dissolve on their own over the course of a few days after the operation. If the hernia has become strangulated and part of the bowel is damaged, the affected segment may need to be removed and the 2 ends of healthy bowel rejoined.

This is a bigger operation and you may need to stay in hospital for 4 to 5 days.

LAPAROSCOPIC (KEYHOLE) SURGERY

General anaesthetic is used for keyhole inguinal hernia repair, so you’ll be asleep during the operation. During keyhole surgery, the surgeon usually makes 3 small incisions in your abdomen instead of a single larger incision. A thin tube containing a light source and a camera (laparoscope) is inserted through one of these incisions so the surgeon can see inside your abdomen. Special surgical instruments are inserted through the other incisions so the surgeon can pull the hernia back into place.

There are 2 types of keyhole surgery.

Transabdominal preperitoneal (TAPP)
Instruments are inserted through the muscle wall of your abdomen and through the lining covering your organs (the peritoneum). A flap of the peritoneum is then peeled back over the hernia and a piece of mesh is stapled or glued to the weakened area in your abdomen wall to strengthen it.

Totally extraperitoneal (TEP)
This is the newest keyhole technique and involves repairing the hernia without entering the peritoneal cavity. Once the repair is complete, the incisions in your skin are sealed with stitches or surgical glue.

A femoral hernia repair can be carried out as either open surgery or keyhole surgery (also called laparoscopic surgery). The hospital will send instructions about when you need to stop eating and drinking before the operation. Femoral hernia repair is usually carried out under general anaesthetic, which means you’ll be asleep during the procedure and won’t feel any pain.

However, regional or local anaesthetic is sometimes used for open surgery. This means you’ll be awake during the procedure, but the area being operated on will be numbed, so you won’t experience any pain. The operation should take about 30 to 45 minutes to complete and you’ll usually be able to go home the same day. Some people stay in hospital overnight if they have other medical problems or if they live alone.

OPEN SURGERY

During open surgery to repair a femoral hernia, the surgeon makes a single cut (incision) in your lower tummy or over the hernia. This incision is usually about 3 to 4cm long. The femoral canal (a channel containing the main blood vessels and nerves leading to the thigh) is opened and the surgeon places the lump of fatty tissue or loop of bowel back into your tummy. The femoral canal is then closed, often with a mesh plug, to repair the weak spot that let the hernia through.

The incision in your skin is then sealed with stitches. These usually dissolve on their own over the course of a few days after the operation. If the hernia has become trapped (strangulated) and part of the bowel damaged, the affected segment may need to be removed and the ends of healthy bowel rejoined. This is a bigger operation and you may need to stay in hospital for a few days.

LAPAROSCOPIC (KEYHOLE) SURGERY

During keyhole surgery to repair a femoral hernia, several very small incisions are usually made instead of a single, larger incision. A thin tube containing a light and a camera (laparoscope) is inserted through 1 of the incisions, so the surgeon can see inside your tummy.

Special surgical instruments are inserted through the other incisions, so the surgeon can pull the hernia back into place. As with open surgery, a mesh patch is often used to strengthen the weak spot in the tummy where the hernia came through. Once the repair is complete, the incisions in your skin are sealed with stitches or surgical glue.

Umbilical hernia repair is a fairly quick and simple operation. It takes about 20 to 30 minutes and it’s usually possible to go home on the same day.

The hospital will send you instructions about when to stop eating and drinking before the operation. In most cases, the operation is carried out under general anaesthetic. This means you’re unconscious during the procedure and won’t feel any pain as it’s carried out.

THE PROCEDURE

During umbilical hernia repair, the surgeon makes a small cut of about 2 to 3cm at the base of the belly button and pushes the fatty lump or loop of bowel back into the tummy. The muscle layers at the weak spot in the abdominal wall where the hernia came through are stitched together to strengthen them. For large or adult umbilical hernias, a special mesh patch may be placed in the abdominal wall to strengthen the area instead.

The wound on the surface of the skin is closed with dissolvable stitches or special surgical glue. Sometimes, a pressure dressing is applied, which usually stays on for 4 to 5 days.

Keyhole surgery is usually used for a hiatus hernia – this involves making small cuts in your tummy (abdomen). It’s done under general anaesthetic, so you’ll be asleep during the operation.

After surgery it usually takes:

  • 2 to 3 days to go home
  • 3 to 6 weeks to go back to work
  • 6 weeks before you can eat what you want
  • a few months to recover from side effects like bloating, burping, farting and difficulty swallowing

There’s a small risk (about 1 in 100) that your side effects won’t go away and you’ll need more surgery.

EVIDENCE SUPPORTING OUR APPROACH TO HERNIA SURGERY

The Hernia Surge group are made of international hernia experts from every continent. These guidelines were published January 2018 with the aim of improving patient outcomes by reducing the risk of recurrence and the risk of chronic groin pain. The guidelines are extensive but these are some of what we think are the most important points:

  1. Factors associated with a higher risk of recurrence include poor surgical technique, low surgeon volume/experience and local anaesthetic approaches.
  2. It is recommended that all symptomatic hernias are repaired electively, as outcomes of emergency repair are poorer. Hernias in men which cause few or no symptoms can be safely managed without surgery but these patients eventually become symptomatic.
  3. A mesh repair is recommended over suture repairs. This is because the recurrence rate is lower with a mesh repair.
  4. Provided the surgeon has expertise in the technique, keyhole surgery for groin hernias has a faster recovery time, lower risk of chronic groin pain and is cost effective.
  5. In a keyhole operation, mesh fixation (with tacks) is only recommended for hernia with a large defect to reduce the risk of recurrence. Otherwise it is not necessary.
  6. Antibiotics at the time of surgery are not recommended for keyhole surgery, and only in high risk patients having open repairs.
  7. There is a learning curve in keyhole surgery and probably 100 repairs need to be carried out to be achieving the same outcomes as open surgery.

If you come to see us for a consultation, we will discuss these guidelines with you and explain the relevant sections for your particular case.

Read more at Hernia Surge here.

NICE issued guidance on the use of keyhole techniques in repair of groin hernias in 2004. At that time the techniques were relatively new and there was one study that seemed to present conflicting evidence. Most data suggested at that time that keyhole surgery resulted in a quicker return to normal activities, reduced numbness, reduced pain at 1 year, reduced complications and a similar risk of recurrent hernia (1.5-2.5%). Due to the resulting uncertainty, NICE recommended keyhole surgery for the repair of hernias on both sides simultaneously, as well as for recurrent hernias. NICE suggested that the choice of surgical approach for first time one-sided hernias can be left for discussion between surgeon and patient, taking available expertise and patient wishes into account.

 

  1. Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair. A large, registry based European study published in February 2019 directly compares these two approaches. Köckerling, Ferdinand, MD*; Bittner, Reinhard, MD†; Kofler, Michael‡; Mayer, Franz, MD; Adolf, Daniela, PhD; Kuthe, Andreas, MD; Weyhe, Dirk, MD. Annals of Surgery: February 2019 – Volume 269 – Issue 2 – p 351–357.

 

The above study was published in February 2019 and directly compares these two approaches, in over 55000 patients. The authors suggest that recovery times and pain scores are lower after keyhole surgery, supporting a role for the keyhole approach for all first-time groin hernias.

 

SPECIALIST UPPER GI SURGERY have expertise in both keyhole and open techniques to repair not only groin hernias, but other types of abdominal wall hernias. We can discuss this evidence and help you choose the most appropriate method of repair for your hernia.

One of the most important risks of groin hernia repair to consider is that of developing chronic groin discomfort after the surgery. At SPECIALIST UPPER GI SURGERY, we feel that one of the key technical factors that influences the risk of developing chronic discomfort relates to how the mesh used for the repair is fixed in place.

Meshes are fixed generally to avoid them moving out of position in the early post-operative period, thereby allowing a recurrent hernia to form. In the open technique, meshes are traditionally stitched in with permanent sutures. In keyhole repairs, meshes are usually held in place by tacks. These can be titanium or plastic and are permanent. Newer tacks are made of an absorbable material that disappears 6-12 months post-operatively.

However, all types of tack penetrate into the muscle and potentially can injure nerves.

At SPECIALIST UPPER GI SURGERY, we have switched to recommending the use of Pro-grip meshes, which have been available for over 5 years. These double sided meshes have a normal light weight mesh on one side, and what looks like “velcro-like” barbs on the other, again made of an absorbable material. There is a growing body of evidence (examples below) suggesting these meshes have low recurrence rates (0-1.5%) and are associated with less chronic pain that more traditional light weight meshes tacked in place.

  1. Surg Endosc. 2015 Sep;29(9):2690-6. doi: 10.1007/s00464-014-3991-y. Epub 2014 Dec 18. Progrip with no recurrence or chronic pain after 1 year. Use Carolinas Comfort Scale
  2. 2013 Jun;17(3):313-20. doi: 10.1007/s10029-013-1053-3. Epub 2013 Feb 15.. 220 patients with progrip, 1.4% recurrence, 1.2% severe pain, 3.6% mild pain at 2yrs.
RECOVERY FROM HERNIA REPAIR SURGERY

Obviously, recovery times depend on the type of hernia repair you are having done (see above).

In general, however, most people who have open hernia repair surgery are able to go home the same day. Recovery time is about 2 weeks. You most likely can return to light activity after 2 weeks. Strenuous exercise should wait until after 4 weeks of recovery.

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