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Laparoscopic incisional hernia repair

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14/09/2006

What is an incisional or ventral hernia?

  • Ventral hernias usually arise in the abdominal wall where a previous surgical incision was made. In this area the abdominal muscles have weakened (age, postoperative wound infection etc); this results in a bulge or a tear.  This can allow a loop of intestines or other abdominal contents to push through the defect.  If the abdominal contents get stuck within the sac, they can become trapped.  This can lead to serious problems requiring emergency surgery. 
  • They do not get better over time.

Symptoms?

  • Discomfort - may be sharp or a dull ache that gets worse towards the end of the day.  Any continuous or severe discomfort, redness, nausea or vomiting associated with the bulge are signs that the hernia may be entrapped or strangulated.
  • Anyone can get a hernia and at any age. They are more common as we get older. Certain activities may increase the likelihood of a hernia including persistent coughing, difficulty with bowel movements or urination, or frequent need for straining.


 

ADVANTAGES OF A LAPAROSCOPIC REPAIR?

Results will vary on the type of procedure and each patient’s overall condition.  Common advantages include:

  • Less post-operative pain
  • Shortened hospital stay
  • Faster return to normal diet
  • Quicker return to normal activity
  • No big scar
  • Improved longterm outcome 

Are you a suitable patient?

Only after a thorough examination can your surgeon determine whether a laparoscopic ventral hernia repair is right for you. The procedure may not be best for some patients who have had extensive previous abdominal surgery, hernias found in unusual or difficult to approach locations, or underlying medical conditions.

What will happen?

  • Most require an overnight stay
  • Preoperative investigation may include blood tests, chest x-ray and an ECG
  • Have a shower the morning of the operation.
  • Do not eaat for 6hrs pior to surgery.
  • Take all your medications that your surgeon has told you to take with a sip of water the morning of surgery.
  • Drugs such as aspirin, blood thinners, anti-inflammatory medications will need to be temporarily stopped for a week prior to surgery.

 

What happens?

The traditional approach is done through a latge incision in the abdominal wall.  It may go through part or all of a previous incision. The surgeon may choose to sew your natural tissue back together, but frequently, it requires the additional placement of a piece of nylon mesh placed either in or on the abdominal wall. This technique is performed under a general anesthetic.

The second approach is a laparoscopic repair. In this approach, a laparoscope (a tiny telescope with a television camera attached) is inserted through a cannula (a small hollow tube) into the abdomen a short distance away from the edge of the hernia. The laparoscope allows the surgeon to view the hernia from the inside.

Two additional 5mm incisions will be required for other cannulas which will allow for placement of instruments to divide adhesions, mobilise any bowel from the hernia, remove any scar tissue and to insert a surgical mesh into the abdomen.

The mesh is fixed under the hernia defect to the strong tissues of the abdominal wall.  It is held in place with several sutures passed from outside, through the entire thickness of the abdominal wall and mesh before been passed back out and tied (requires several small incissions).  The edge of the meash is then fixed with several special titanium surgical tacks. The operation usually takes about an hour.


An incisional hernia occurs at the site of a previous incision (A). Intestinal contents break through the abdominal wall and then lie under the skin.

In a laparoscopic repair, the surgeon uses laparoscopic instruments to pull the intestines and omentum from the hernia (B).

A mesh is inserted into the abdomen over the site of the hernia (C and D).
 
It is sutured into place and finally, tacked arround the edges (E).


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 include obesity, dense scar tissue, inability to visualize organs or bleeding problems during the operation.  This is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is based on patient safety.

What happens afterwards?

  • We would encourage you to engage in light activity. 
  • Post-operative discomfort is usually mild to moderate.
  • Analgesia will be prescribed for you to take home.
  • If you develop fever, chills, vomiting, are unable to urinate, or experience drainage from your incisions seek medical help. 
  • If you are getting no relief from your pain medication, notify your surgeon.
  • Most patients are able to get back to their normal activities within a short period of time.  These activities include showering, driving, walking up stairs, lifting, work and sexual intercourse.  Your body will let you know if you are doing too much.
  • 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. If not, your surgeon may aspirate this with a needle in outpatients.
  • You will be reviewed in 6-8 weeks.

COMPLICATIONS ?

  • Complications can develop as they might with any operation. Complications during the operation may include adverse reactions to general anesthesia, bleeding, or injury to the intestines or other abdominal organs.  If an infection occurs in the mesh, it may need to be removed or replaced.  Other possible problems include pneumonia, blood clots or heart problems. Also, any time a hernia is repaired it can come back.
  • The long-term recurrence rate is not yet known. The early results indicate that it is as good as the standard or traditional approach.  
  • It is important to remember that before undergoing any type of surgery, ask your surgeon about his/her training and experience.

 


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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
claire.TRENBERTH@spirehealthcare.com
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