Hernia Repair
Laparoscopic Inguinal Hernia Repair
Inguinal hernias can be repaired via the open or laparoscopic approach. The type of operation depends on hernia size and location, and if it is a repeat hernia. Your health, age, anesthesia risk, and the surgeon’s expertise are also important.
A laparoscopic repair of inguinal hernia results in less painand numbness, lower infection rate, and faster return to normal activity when compared with open surgery.A recurrence from a previous open hernia repair is best repaired laparoscopically because you avoid scar tissue from previous incisions. Laparoscopic repair of a bilateral (both sides) inguinal hernias also results in earlier return to work than open repairs.The risk of complications increases for both the open and laparoscopic procedure if the hernia extends into the scrotum.
Dr Papoulas has great expertise in both types of laparoscopic inguinal hernia repair including Totally Extra-Peritoneal (TEP) and Trans-Abdominal Pre-Peritoneal (TAPP) Repair.
Both procedures are performed through 3 tiny holes in the lower abdomen. The hernia sac is completely released from the adjacent structures of the inguinal canal and returned back into the peritoneal cavity. The hernia defect is repaired with mesh and sutured or stapled in place. The procedure lasts about 45-60min and the patient is normally discharged on the same day.
Image 1. Techniques of laparoscopic inguinal hernia repair including the trans-abdominal pre-peritoneal approach (top) and the totally extra-peritoneal approach (bottom).
Open Inguinal Hernia Repair
Open inguinal hernia repair is usually the treatment of choice for very large inguinoscrotal hernias, non reducible, incarcerated or strangulated hernias. It is also the recommended approach for the recurrent inguinal hernias previously repaired laparoscopically. Open inguinal hernia repair can be done under general, local or regional anaesthesia.
The repair is done via a small 5-8cm incision over the hernia site. The bulging tissue is pushed back into the abdomen. The hernia defect is closed using a tension free technique. A hernia mesh is attached using sutures sewn into the stronger tissue surrounding the hernia site. Mesh plugs can also be placed into the inguinal or femoral hernia space.
Most of the inguinal hernia repairs are done as day procedures. You may need to stay overnight if you had a repair of a large or incarcerated hernia, post-anesthesia issues such as severe nausea and vomiting, or you are unable to pass urine.
Image 2. Open Left Inguinal Hernia Repair with a mesh.
Ventral Hernia Repair
Ventral hernias (epigastric, paraumbilical/umbilical or incisional) do not go away or get better on their own and require surgery to repair. In fact, without treatment, ventral hernias can get larger and worsen with time. Untreated hernias can become difficult to repair and can lead to serious complications, such as strangulation of a portion of the intestine.
The goal of ventral hernia surgery is to repair the hole/defect in the abdominal wall so that the intestine and other abdominal tissue cannot bulge through the wall again. The surgery often restores the tone and shape of the abdominal wall by repairing the hole and bringing the muscles back to their normal position. Dr Papoulas offers both laparoscopic and open hernia repairs.
Laparoscopic Ventral Hernia Repair is normally done through three tiny incisions away from where the hernia has occurred. All adhesions around the hernia sac are released and the content of the hernia sac is pulled back into the abdominal cavity. A surgical mesh material is inserted to strengthen the weakened area in the abdominal wall. Advantages of this approach compared with open hernia repair include a lower risk of infection, less postoperative pain and earlier return to work.
Image 3. Laparoscopic ventral hernia repair using a mesh.
Open Ventral Hernia Repair is performed via an incision where the hernia has occurred. Depending on the size of the hernia neck, the surgeon will decide wether to repair the hernia primarily without mesh (normally for small defects less than 2cm) or with mesh. Increasing numbers of patients have large or complex abdominal wall defects such as giant abdominal wall hernias. These may result from from an incisional hernia due to multiple abdominal operations, surgical resection of the abdominal wall or necrotizing abdominal wall infections. Management of complex hernias are more difficult to repair and often have higher rates of recurrence and other complications.
To manage these complex hernias, component separation is one technique that can aid in the repair of these difficult hernias. It is particularly used when there is insufficient muscular wall that can be pulled back together during a conventional hernia repair. Component separation involves separating and advancing certain layers of the abdominal wall muscle, lengthening them so that the right and left sided muscles can be brought closer to the mid-line for sufficient closure. This technique restores the structural and functional integrity of the abdominal wall and aesthetic appearance.A combination of component separation and mesh repair is frequently used to repair giant abdominal wall hernias. Component separation is a complex procedure that is best done in the hands of experienced surgeons, and it is a technique we commonly use.
Image 4. Open ventral hernia repair. Apart form small epigastric and umbilical hernias that could be repaired primarily, most incisional hernia repairs are reinforced with mesh. Mesh repair decreases the risk of recurrence. As shown in the image, mesh materials can be placed in several locations under the skin.