eSurgery

An inguinal hernia repair with a mesh using the open technique has been the gold standard operation. Hundreds of thousands of these operations have been done worldwide. The technique is simple and the recurrence rate with a mesh is low. In addition, this can be done under local anaesthesia.
The reason for using a mesh is that it will provide an anatomical repair and provide a scaffold for the body’s scar tissue to grow through the mesh(this gives long term strength to the repair and reduces the rate of recurrence)
The repair is done without any tension – the mesh is secured with staples/sutures to the muscles in a way which does not pull on the muscle(If the mesh is sutured too tightly onto the muscles under tension, there may be pain on coughing/straining)
Length of the incision – A cut is made over the inguinal canal – the length of the cut depends on the thickness of the body fat. In a lean person, it is about 3-4cm in the author’s hands. (Just slightly longer than a keyhole. This is nearly the same length as the sum of the length of 3 incisions needed in a laparoscopic repair)
Occassionally a mesh plug may be used to as well to patch the “hole” in the abdominal wall where the hernia is popping out from.

Advantages of having surgery – Planned elective surgery is much safer than leaving a hernia until it strangulates!

Risks of not having surgery:
1. Hernia may get bigger – as it gets bigger, there is more likelyhood that the intestine will come out in the hernia as well.
2. Risks of contents of the hernia becoming trapped and blocked or gangrenous(if there is bowel in it, the bowel wall may die and burst causing life-threatening peritonitis). Treatment of the latter would mean a more extensive bowel resection and a weaker repair especially if a mesh is contraindicated in the presence of infection

What anaesthetic options are available? Local anaesthesia & sedation vs General anaesthesia vs Spinal(rarely used by the author) This should be discussed with your surgeon and anaesthetist before your operation.
Benefits of local anaesthesia and sedation: 1. For patients with serious heart or lung problems, there is a significantly lower anaesthetic risk having a repair under LA and sedation. 2. Patient is awake throughout the procedure – some patients are afraid of being put under a general anaesthesia. 3. Quicker recovery as the patient is given a lower dose of the anaesthetic drugs when compared to a general anaesthesia(although this benefit is minimal in someone who is fit and well – ie a matter of minutes)
Benefits of general anaesthesia – some patients prefer to be asleep for the procedure(Local anaethesia will also be injected during the operation)

Risks of any inguinal hernia repair – both from open or laparoscopic method
1. Urinary retention – usually a temporary problem and more common in elderly men who have enlarged prostate. May need a temporary urinary catheter. There risks is low if local anaesthesia has been effectively injected
2. Wound problems -
(i)Wound infection (1%) : may need antibotics
(ii)Bleeding into wound/ bruising around wound( 3%)
(iii)Scar/keloid – the scar may thicken and be prominent
3. Testicular problems – swelling of the testicles/scrotum, testicular pain. Injury or damage to the vas(sperm tube) – especially in a recurrent hernia repair. Damage to the blood vessels to the testicles – this may cause testicular ischaemia and testicular pain.(the risks are increased in a recurrent hernia repair). Change in position of the testicle – the testicle on that site of surgery may sit slightly higher in the scrotum after the operation.
3. Damage to bowel/bladder and blood vessels(rare – more so in a laparoscopic repair where one can get serious life threatening vessel injury). Development of adhesions in the bowel that is pushed back in.
4. Recurrence of hernia(<1-3%) : Higher in laparoscopic inguinal hernia repair
5. Unexpected findings – eg bowel cancer in the hernia – this may mean having a bigger operation than planned
6. Ongoing pain and discomfort – sometimes this is due to a nerve in the groin being cut or trapped in a stitch/staple or caught in scar tissue.

General risks of any operation
There are risks with any operation which may also happen with a hernia repair.
1. Deep venous thrombosis(Blood clots in the deep veins of the leg) with risk of pulmonary embolism(clot may break off and go to the lung – this can be life-threatening). The risks are less if local anaesthesia is used instead of general anaesthesia and if the operating time is shorter.
2. Lung collapse. Chest infection. Heart attack, stroke and death.
Also in general, smokers and obese patients have increased risk of developing complications.

Risks specific to laparoscopic surgery include:
(i) Injury to organs near the hernia site such as the intestine and bladder
(ii) Massive haemorrhage from injury to major blood vessels
(iii)Gas embolism – from the carbon dioxide gas used to insufflate; this can be life threatening
(iv)Swelling of scrotum due to seroma – may need decompression postop
(v)New hernia – at any of the laparoscopic port sites(usually 3 keyhole sized cuts are made)
(vi)Adhesions causing bowel obstruction
(vii) Subcutaneous emphysema – gas tracking in soft tissue causing swelling under skin from chest to scrotum
(viii)Injury to nerves from pigtail metal staples used to tack mesh down – causing postop pain
Studies have also shown a HIGHER RISK OF HERNIA RECURRENCE from a laparoscopic repair compared with an open mesh repair(N Engl J Med 2004; 350:1819-1827).
The is also a potentially higher risk of blood clots developing from the combination of the laparoscopic technique and general anaesthesia.

POSTOP RECOVERY
You are encouraged to move you legs and flex and extend your ankles as soon as you can once in the recovery ward. Once fully alert, you can eat and drink.
Pain-killers – It is recommended that Parecetamol be taken regularly for the first few days together with a non-steroidal anti-inflammatory medications(eg Brufen) (Provided there are no contraindications to the latter eg peptic ulcer disease, severe asthma). In addition, stronger analgesics like Codeine can be used in the first few days depending on the degree of pain.
Bowel motions – It is important to drink plenty of fluids and take lots of fibre(fruits and vegetables) after the operation to avoid constipation.
Dressings – Dissolving sutures is usually used on the wound. Sometimes adhesive strips are placed across the wound for additional closure strength. A waterproof dressing is usually placed over the top of the wound. This should be left in place for 5-10 days. The adhesive strips can be removed another week later.
RECOVERY – You are encourged to walk and do light activities as soon as you get home. Take care when you get out of bed(avoid straining). It is advisable not to do any heavy lifting for 4-6 weeks.
BACK TO WORK – this varies from person to person. For office work – about 1-2 weeks. For manual work – it slightly longer. (The author has had self-employed patients return to work lifting 10kg boxes from the 3rd day without any problems with the repair)
DRIVING – it is best to not drive for at least a week(the risk is of pain in the wound when braking)

Hernias occur most commonly here. Locations of the hernia include:
1. In the groin area – either a inguinal or femoral hernia
2. Around the umbilicus – a paraumbilical hernia, this can be to the left of right of the belly button or above and below the belly button(True umbilical hernias occur in children but rarely in adults)
3. In the epigastric area – in the midline between the belly button and the lower part of the sternal bone(called the xiphoid process)
4. In any area where there has been a previous incision – this is called an incisional hernia. Common locations are at sites where laparoscopic ports have being previously inserted especially in the midline; scars from laparotomy(especially a midline scar) and also from incisions for hysterectomy or Caesarean sections.

Symptoms caused by the hernia
1. Lump – usually this contains fat(either omental fat from the peritoneal cavity or extraperitoneal fat). Rarely, this can contain bowel (the danger here is of the bowel becoming stuck leading to either bowel obstruction or strangulation of the blood supply causing the bowel to die/necrose)
2. Pain or discomfort – this is often associated with the lump
3. If the hernia has developed a complication such as bowel obstruction – then one can get a severe cramping abdominal pain, nausea and vomiting, abdominal distension. If the bowel within it has perforated, the one can get a fever and become septic. (These are both surgical emergencies and one should be take to the hospital urgently for resuscitation and surgery)

Treatment of the hernia around the belly button area (On the ventral abdominal wall)

Surgical options include:
1. Direct repair without mesh – this involves using suturing the defect with nondissolvable sutures eg 1 Nylon. This alone has a higher risk of recurrence. In the past, a Mayo repair is used – this involves overlapping two layers of tissue and suturing the defect together under tension. Again this has a higher risk of recurrence.
2. Mesh hernioplasty – there are many variations to these. My preference is to use a sublay Ventralex mesh. This mesh is a dual surface mesh with PTFE(smooth) on one side(the side facing the bowel) and polypropelene on the outside. This is placed in a sublay position – that is under the hole of the hernia defect within the peritoneal cavity. The PTFE surface is in contact with the bowel – because this is smooth there is much reduced risk of developing adhesions of the bowel(adhesions can cause small bowel obstruction). The outside surface is the usual polypropelene mesh – the most commonly used mesh. This mesh allows fibrous tissue to grow it. This mesh is secured by suturing its two polypropelene straps to the edges of the hernia defects without any tension. The overlying skin is then closed in layers with dissolvable sutures.

Postoperative Care
1. This surgery is usually carried out as a day case.
2. It is important to take regular analgesics as soon as one wakes up from the surgery before feeling any pain(ie before the local anaesthesia wears off)
3. Leave the plastic waterproof dressing on for 1-2 weeks(there is also often a piece of gauze rolled into a ball under that – this is to push the belly button back in and avoid fluid filling the space of the hernia) . Leave the tape dressings on for a further 1-2 weeks.
4. Surgical review is at 2 weeks and 2 months.

When to return to driving ?
This varies from person to person – the answer is : only when one is comfortable especially to apply the brakes! Please discuss this with your doctor

When to return to work?
Because this mesh is placed in a sublay position(ie the mesh to patch the hole from the hernia is placed on the inside of the hernia defect), there is no strict restrictions to be completely off work.

Generally, I find that most of my private patients particularly those who are self-employed return to work within days. For example, the next day for office work. I have had one patient, a fruiterer, return to his work within 3 days – lifting dozens of boxes of fruits.

It really depends on how comfortable ones feel from the cut on the skin and the stitches holding the mesh! I try my best in the surgery to minimize the pain by:
1. Using as little tension as possible in suturing
2. Minimizing tissue damage and dissection
3. Keeping the skin scar short and vertical (this can make the operation technically more challenging; but I can operate with both hands and have a surgical assistant to retract)
4. Ensuring a good local anaesthetic block from right before I make the skin incision(preemptive analgesia).

I do not encourage prolonged time off work. I often have Workcover patients tell me that their colleagues have had 6 weeks off from a hernia repair! I would really encourage my patients to get back to light duties within the week and slowly increase their hours. Of course one has too be sensible in the type of work one returns too – I certainly do not recommend getting into and driving a 16 tonne truck until one is fully comfortable. I would also not recommend lifting 200kg boilers(in fact, there must surely be a Worksafe rule on the limit one can lift – more so as not to develop hernias elsewhere!)

What if I have lots of sick leave?
Again that is not a reason for not returning to light duties sooner especially with the sublay mesh technique!

Risks of surgery
Risks of anaesthesia
Scar
Pain – rarely complex regional pain syndrome(those at highest risks are Workcover patients who have delay in returning to work)
Bleeding, bruising
Recurrence – especially from a sutured repair
Adhesions – rarely bowel obstruction(rare with the sublay dual surface mesh)
Risk from the mesh – the PTFE and polypropelene material are generally inert. Of course with any foreign material placed within the body, new discoveries may be made in future of potential new side-effects.
Future laparoscopic surgery may be more difficult – especially if port has to be place around the belly button area! There might also be increased risks of bleeding and of damaging other organs.