How is an incisional hernia repaired?
Incisional hernias can be hard to repair as the tissue is stretched and thinned out. Surgery involves reducing the hernia back into the abdomen and repairing the defect with a patch (called mesh) made from a special plastic. With time the body grows into this mesh making it part of the abdominal wall.
There are two ways to do this repair:
- Open technique: This is done via an incision through the old scar to push the hernia back and close the defect with mesh. A drain tube attached to a bottle may be inserted for few days.
- Laparoscopic (keyhole) technique: This is done with three or more small 5-10 mm cuts to put a video camera into the abdomen and fill the abdomen with CO2 gas. The hernia is repaired with a mesh from the inside.
Which technique is better?
This depends on many factors like the size of the hernia, its location, previous operations, presence or absence of abdominal adhesions and many other factors.
Laparoscopic repair has the advantage of being minimally invasive and thus quicker recovery and less chance for wound infection and fluid collections. However, bowel adhesions on the inside can make the procedure difficult or not possible.
What are the complications of surgery
- Seroma formation : this is a temporary fluid collection at the site of the original hernia. It is very common and tends to settle with time. Occasionally this need to be aspirated with a syringe from time to time until it settles. Rarely this fluid gets infected causing mesh infection.
- Mesh infection: This is very rare but may necessitate removal of the mesh by another surgery.
- Recurrence of the hernia: 5-10%. This is more often in patients with medical conditions. The risk is reduced by not lifting weights for 6 weeks after surgery.
- Loss of skin. Repeated operations in the same site can lead to areas of skin not getting enough blood supply leading to death of that skin. Rarely this can be a big problem requiring weeks of dressings and even plastic surgery.
- Bleeding into the wound. This is rare and tends to happen in people who continue to take drugs that thins the blood.
- Nerve damage. This is rare but can cause chronic groin pain due to entrapment of the nerve in scar tissue.
- Injury to the intestine. This can occur because bowel may be stuck to scar tissue (adhesions) and get torn easily. This is usually identified and repaired at time of surgery, however, mesh will not be used due to risk of infection. Rarely bowel injury may be too small and not recognized leading leakage of bowel content from the wound afterward. This is a serious complication that require further surgery.
- Bowel obstruction: Often the mesh is placed inside the abdomen and despite using a special non-adherent mesh intestinal loops can still get adherent to it leading to bowel obstruction months or years later. The use of newer types of mesh has reduced this risk.
- Conversion from laparoscopic operation to open repair: This is not a real complication. The amount of adhesions cannot be predicted before operations sometimes it is just not safe to persist trying to complete the surgery laparoscopically. Conversion to open surgery is safer in this situation.
- Cardiovascular problems: heart attacks and strokes. Both are very rare.
- Respiratory problems: pneumonia and aspiration.
- Wound infection or urinary infection
- Clots in the legs that may travel to the lungs. This is a rare but serious complication.
- Wound pain and abnormal (keloid) scarring.
- Death from general anaesthetic. This is very rare (1 in 40,000).
- Chipped teeth and sore throat form the insertion of the breathing tube.
- Drug reactions.
Preparation for Surgery:
- Shower at home the morning of the operation
- Do not shave the surgery site! This will be done in the operating room. Shaving at home increase the chance of wound infection.
- You need to fast for 6 hours prior to surgery. The time to fast depend on the time of your operation and the hospital will notify about that time. Generally, for morning operations, you should fast from midnight the night before and for afternoon operations, you should have a breakfast at 6 AM then fast. You can still take your heart and blood pressure medications with a small sip of water.
- If you are diabetic let me and the anaesthetist know to advice you about changes to your medications.
- Do not smoke for 4 weeks before surgery. Smoking increases the complications.
- Do not drink alcohol for 24 hours prior to surgery.
- Let me and the anaesthetist know If you are on drugs that thin the blood. Some of these drugs need to be stopped or changed a week before surgery to reduce the risk of bleeding.
- Stop herbal medications for two weeks prior surgery. Medications like Garlic, fish oil, St John's Wort, Ginseng, Ginko can increase the risk of bleeding.
What to expect after surgery?
Patients with small hernias may go home same day, however, the majority of patients spend between 1 to 5 days in hospital.
Pain control: Local anaesthetic will be used in the wound. This will last for 6-12 hours.
The extent of postoperative pain and its medications depends on the extent and type of the surgery.
- Narcotic medications (e.g morphine and fentanyl) may be needed for the first day or two. Patients with large hernias may require a pain pump (PCA).
- Panadol taken regularly is can be very effective without causing constipation.
- NSAIDs class drugs like Nurofen, Mobic, Brufen or Indocid can be used. These need to be used with caution in the elderly, patients with kidney disease and patients with peptic (stomach) ulcer disease.
Following laparoscopic operation you will be able to resume eating shortly after surgery. However after open surgery eating will be commenced more slowly.
Passing Urine: If the hernia is very large or involve the lower part of the abdomen a urinary catheter may be inserted at time of surgery. This will be removed as you recover and start to mobilize.
After any operation some patients may have trouble passing urine. This is temporary and may require the insertion of a catheter.
Wound Care: The wound may be closed by internal dissolving sutures or non-dissolving nylon sutures or skin staples. These need to be removed 10 days after surgery by your GP. The wound will be covered by a water-proof dressing and it is ok to have a shower but pat the wounds dry with a towel afterward.
Very often you will have an abdominal elastic binder on top of the dressing. This is compress the site of hernia to reduce the chance of fluid collection. You need to wear the binder for 4 weeks.
Bruising at the site of the wound or some blood staining of the dressing is expected. However, more significant bleeding requires medical attention and review. If a drain was inserted at time of surgery, its often removed before you leave the hospital. Occasionally, you may go home with the drain until it dries up. Remove the water proof dressing after five days. Leave the paper tapes until they fall by themselves. This will give you a better scar. Continue wearing the binder for full 4 weeks. Some thickening like a ridge under the wound is expected. This will soften with time. It is normal to have a patch of numbness under the wound. This will improve with time as well. Discomfort and pricking type pain on either side of the wound is common. This may last few weeks until the healing tissue grows into the mesh making it part of the abdominal wall.
Activity: You should not drive for at least a week after surgery and only when you can respond in an emergency. Walking and light activities are encouraged from day one. Light exercise can be resumed when you feel comfortable. This varies between patients and you should listen to your body. Heavy lifting (more than 10 kg) should be avoided for 6 weeks after open surgery and 2 weeks after laparoscopic surgery. Swimming can be resumed two weeks after surgery. Sexual activity can be resumes after one week.
When to return to work?
This depends on the job, level of activities and method of surgery (open versus laparoscopic). Desk jobs (light activities) can be resumed within one week. Jobs with moderate activities (lifting less than 20 kg) can be resumes with two weeks (one week for key-hole surgery). Heavy jobs with frequent lifting of more than 20 kg) can be resumes after three to four weeks (two weeks for key-hole surgery).
I see most patients within 4-6 weeks after surgery. You should come and see me at any time if you have any one of the following:
- Fever >38 degrees or chills
- Large fluid collection at the site of the hernia
- Increasing pain or redness around the incision
- Foul smelling or creamy wound discharge
- Increasing pain, nausea or vomiting
- Feeling dizzy or light headed
- You are not able to tolerate liquids
- Persistent cough or shortness of breath
- Persistent pain in the shoulders
- If you are concerned about anything