New Techniques in Hernia Repair
~ By Dr. Gregory J. Lareau
Surgical repair of hernias has advanced quite a bit over the past 25 years. Previously, all hernia operations were “open,” that is, performed through larger incisions and using heavier permanent sutures (stitches). Patients usually spent a couple of days in the hospital. Reinforcing mesh, a polypropylene “patch,” that looks and feels like heavy screen material, became the standard technique by 1985. Since 2000, laparoscopic repair of hernias has become much more common and accepted by the medical community and patients. Younger surgeons have been trained in this method and more experienced surgeons currently using laparoscopic techniques for gallbladder and appendix operations have often switched to this less invasive form of hernia repair. Today, most laparoscopic hernia operations are done on an outpatient basis and can go home the same day as the surgery.
A hernia is a defect, tear or weakness of the abdominal wall, the muscle layers. In the past, patients used to call this a “rupture.” Through this hernia defect, intestines or internal fat can protrude resulting in a visible and palpable bulge. This hernia bulge can cause a chronic dull ache or a more severe sharp burning pain. Hernias often cause more pain towards the end of the day after someone has been on his or her feet working or engaging in heavier physical activities. Patients often hold and push on their hernias when coughing, sneezing or straining in order to prevent pain. Some patients “reduce” their own hernia by pushing the hernia back into the abdominal cavity to decrease local discomfort.
The two main risks of hernias are incarceration and strangulation. Incarceration means that something is “stuck” in the hernia – fat or intestine – that cannot be pushed back inside and this occurrence can cause increased pain. Strangulation, which occurs when the blood flow to the incarcerated hernia contents becomes blocked or kinked, causing the hernia contents to die, is a much more dangerous occurrence. This is a surgical emergency and must be repaired immediately. Physicians always hope to repair hernias prior to strangulation. In general, any hernia that is symptomatic or incarcerated should be surgically repaired.
There are several types of hernias: inguinal (groin), umbilical, epigastric, and incisional. Laparoscopic technique is especially useful for most inguinal and some incisional hernias.
Inguinal hernias can be due to congenital weakness or acquired over time due to wear-and-tear injury from heavy manual labor, straining due to constipation or prostate issues, and coughing secondary to smoking. Men are more prone to inguinal hernias since they have a natural opening in the groin muscles to allow blood vessels, nerves and the sperm duct to pass down into the scrotum.
Umbilical hernias can develop during pregnancy or due to increased abdominal pressure from weight gain, coughing, or straining.
Epigastric hernias develop in the midline of the upper abdomen, between the umbilicus and lower portion of the breast bone.
Umbilical and epigastric hernias are usually repaired in the “open” fashion. They require only a small- to medium-size incision and they repair with or without mesh.
Incisional hernias develop when a prior surgical wound did not heal completely and a gap remains in the muscles of the abdominal wall. Through this defect, intestines and internal fat can protrude. Incisional hernias can be difficult to repair since they are associated with internal scarring or adhesions between loops of bowel. Both “open” and laparoscopic techniques can be used to repair this type of hernia. The technique chosen will often depend on the size of the hernia and how many prior abdominal surgeries the patient has had.
Laparoscopic repair of inguinal hernias has become relatively common. Patients can have a hernia on one side only or both (bilateral). Laparoscopic repair with mesh patch is performed as an outpatient procedure. General anesthesia is required since the abdomen and its muscles must be relaxed in order to inflate this area with carbon dioxide gas. The patient voids just before surgery so that a bladder catheter is not necessary. A dose of intravenous antibiotic is given since mesh will be implanted. The surgery usually takes no more than an hour. Three small incisions are made then later closed with absorbable sutures. Waterproof dressings are applied. The patient spends one and a half to two hours in the recovery room and then returns home. Pain medications are prescribed. Ice to the groin for the first 48 hours helps. In men, the scrotum may swell or bruise but this resolves in three to four days. In older men with prostate problems, there can be difficulty voiding after the surgery, however, it is rare that the patient has to return to the hospital for a urinary catheter.
Compared with traditional open repairs, laparoscopic hernia patients in general experience half as much pain and can return to work and other non-strenuous activities twice as quickly. Patients can walk and climb stairs immediately and they may drive in two to three days, as long as they are not taking pain medications. Patients who do not perform manual labor can be back to work in five to seven days. Patients are seen for a post-operative exam two weeks following the surgery.
If you are experiencing symptoms consistent with a hernia, you should contact your primary care physician for a medical evaluation.
South Shore Surgical Specialists
The Vein Center
780 Main Street, #2A
South Weymouth, MA 02190
www.sssurgical.com • www.ssveins.com
Monday – Thursday: 9 a.m. to 5 p.m.
Friday: 8:30 a.m. to 4 p.m.