eSurgery

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.