HERNIA REPAIR
Colorectal Surgeons Sydney have surgeons specialising in performing minimally invasive techniques for the following procedures:
GROIN HERNIA REPAIR
Groin hernias can be repaired as a day-stay procedure using an open or key-hole (laparoscopic) approach. Open repair can be performed under local anaesthetic with sedation, whereas key-hole (laparoscopic) repair requires a general anaesthetic.
Key-hole (laparoscopic) hernia repair
This involves removing the hernia and reinforcing the abdominal wall with the insertion of a custom-designed (Bard 3D®) polypropylene mesh that is secured with dissolvable (Securestrap®) staples. It is achieved with 3 small incisions less than a centimetre in size.
Key-hole (laparoscopic) hernia repair results in less pain than open surgery, allowing for earlier return to usual activities including work.
Why repair hernias?
Hernias will only ever get bigger with time. Elective repair is much easier and safer than emergency repair, and can be done with a key-hole (laparoscopic) approach. If a hernia is not operated on, there is a small chance of bowel getting caught in a hernia, and sometimes this can get stuck (incarcerated) or twisted blocking off the blood supply to the bowel (strangulation). This is a surgical emergency that can result in the need for major surgery including bowel resection.
Risks of hernia repair
There is a 1% risk of hernia recurrence with mesh repair. This risk is further reduced by the avoidance of any heavy lifting (greater than 10kg) in the first 4 weeks following your hernia repair.
There is up to a 5-10% risk of pain lasting more than a week following hernia repair and this is largely due to initial inflammation due to the presence of foreign material (mesh). A combination of simple anaelgesics such as paracetamol and a nonsteroidal such as ibuprofen can help reduce post-operative pain. If the pain lasts more than a week, notify your surgeon immediately, as chronic nerve-type (neuropathic) pain can be avoided by the administration of a nerve block to the groin and the commencement on special atypical pain killers such a nortryptyline (Pamelor®) 25-50mg daily and/or gabapentin (Pregabaline®) 25mg twice daily. These drugs both block neuropathic pain.
Bruising of the scrotal region is common after inguinal hernia surgery. Tight scrotal support (2 pairs of small underpants) in the first week after your surgery can reduce the risk of swelling and bruising to the scrotal region. Occasionally a large bruise or collection of blood (haematoma) develops. If this occurs, you should contact your surgeon immediately.
Testicular injury is a rare but serious complication of hernia repair. Hernia repair involves removing a hernial sac from the blood supply (testicular artery) and venous drainage (pampiniform plexus) of the testicle, as well as the spermatic cord (vas deferens). The risk of injury to these vital structures with risk of damage or even loss of testicle is less than 1:1000, except in cases of recurrent hernia surgery where the risk is considerably higher.
What to expect post operatively after key-hole groin hernia surgery
Key-hole (laparoscopic) groin hernia surgery can be performed as a day stay procedure. Following your hernia repair, you will recover for a hour until the effects of the sedatives have worn off. Usually you will be allowed to go home the same day or the very next day. You should not drive yourself home after your procedure and should have someone organised (a friend or relative) to accompany you.
Whilst return to light activities is possible within a few days of key-hole hernia surgery, no heavy lifting (>10kg) should occur for at least 4 weeks following your surgery to avoid a recurrence of your hernia. Simple over the counter analgesia is usually sufficient for pain in the first few days following your surgery.
Your outer (comfeel) dressings can be removed day 7 after your operation, and the inner dressings (steristrips) may be allowed to fall or peeled off day 7-14 after your operation. Your sutures are dissolvable so do not require removing.
You should follow up with your surgeon in 4-6 weeks to review your wound.
INCISIONAL HERNIA REPAIR
Incisional hernia repair can be performed as an open or key hole (laparascopic) procedure)
Open incisional hernia repair
Open incisional hernia repair is often required if suspected intra-abdominal adhesions prevent a key-hole (laparoscopic approach). The ideal open repair is a sublay in which the mesh is placed between the inner peritoneal lining on the inside and the posterior rectus sheath on the outside. This repair reduces the risk of mesh infection and fistula formation. Occasionally an open repair is combined with an abdominoplasty, where the excess skin and fat is also excised at the same time.
Key-hole (laparoscopic) incisional hernia repair
Key-hole (laparoscopic) hernia repair has the advantage of being minimally invasive thereby avoiding a large incision, resulting in less pain, and earlier return to normal activities. It involves the placement of a mesh inside the abdomen, with a smooth non-sticky surface on the visceral side, and a rough porous surface on the abdominal wall side (figure 1). This allows the mesh to be incorporated into the tissues of the abdominal wall, whilst preventing small bowel adherence to the mesh.
What to expect post operatively after key-hole incisional hernia surgery
Key-hole (laparoscopic) incisional hernia surgery can be performed as a day stay procedure, although usually requires admission overnight. Following your hernia repair, you will recover for a hour until the effects of the sedatives have worn off. If your surgery is being performed as a day-stay procedure, you will be allowed to leave several hours after your anaesthetic has worn off. You should not drive yourself home after your procedure and should have someone organised (a friend or relative) to accompany you.
Whilst return to light activities is possible within a few days of key-hole hernia surgery, no heavy lifting (>10kg) should occur for at least 6 weeks following your surgery to avoid a recurrence of your hernia. Simple over the counter analgesia may be sufficient for pain in the first few days following your surgery. However, you will be sent home with a script for stronger analgesia should you need this.
Your outer (Comfeel) dressings can be removed 7 days after your surgery, with the inner “steri-strip” dressings removed anytime from 7-14 days after your surgery.
You should follow up with your surgeon in 6 weeks to review your wound. Occasionally a sterile collection of fluid (seroma) will develop and will require a single needled drainage in the rooms.
STOMA HERNIA REPAIR
Common indications for a stoma hernia repair include:
- Increasing size of the para-stoma hernia;
- Skin breakdown or dermatitis around the stoma;
- Intermittent bowel obstruction; and
- Stoma appliance dysfunction and leakage.
Surgical technique
The ideal repair is one that is safe to perform, with limited morbidity, and associated with a low recurrence rate. A multitude of different techniques and approaches have been reported. There is a paucity of good quality evidence comparing each of these techniques. Laparoscopic para-stomal hernia repair has more recently increased in popularity, the main appeal the avoidance of a large abdominal incision, have added further confusion to this debate.
Sutured repair
Sutured repair without mesh was traditionally performed as a local direct repair or via a midline abdominal incision (laparotomy). More recently it is being performed key-hole (laparoscopically). A sutured repair alone without mesh is advised against as it is a tensioned repair that ultimately pulls through the weak tissues of the abdominal wall, and is therefore likely to be associated with a high recurrence.
Mesh repair
The high local failure rate of sutured fascial repairs for para-stoma hernias led Rosin and Bonardi in1977 to introduce the use of prosthetic mesh as a method of reinforcing the repair. The overall success rate for a repair with mesh is relatively high compared with repair without mesh. However, complications such as contamination of the mesh and fistula formation, while very rare, can be devastating. Nonetheless, mesh repair has become the standard practice for all para-stoma hernia repairs.
Direct fascial repair
This involves a skin and subcutaneous incision made either at or next to the stoma to allow dissection and direct sutured repair of the hernia defect, followed by reinforcement with mesh that is sutured on top of the fascia of the abdominal wall beneath the fat (onlay mesh repair).
Transabdominal repair
Access to the hernia is can be achieved by means of a midline abdominal incision (laparotomy) or via a key-hole (laparoscopic) approach. The mesh is placed inside the abdomen below the fascia (sublay technique). The evidence to support mesh repairs is mostly from small non-randomised series. Intra-abdominal mesh is becoming increasingly popular, with the increased use of the laparoscopic approach, as well as the increased production of improved meshes that are dual layered (composite) such as Composix® containing an inner non-porous ‘non-adherent’ layer of polytetraflouroethylene (PTFE) that prevents bowel adherence, and an outer porous layer of polyprophylene (Prolene®) that promotes adhesion (tissue incorporation) to the abdominal wall, thus strengthening it.
Biological absorbable mesh repair
The main biological substitute for prosthetic mesh on the market are those made from human collaged including AlloDerm® (non-crosslinked human acellular dermal matrix) and those made from porcine, which include Veritas® (non-crosslinked porcine pericardium), Periguard® (crosslinked porcine pericardium), Permacol®, and SurgiSIS® (crosslinked porcine dermal collagen). Crosslinked grafts have better tissue incorporation, neovascularisation and extracellular matrix deposition (similar to prosthetic mesh) than non-crosslinked meshed. But it remains controversial whether this translates into a better, stronger repair. The main theoretical appeal of biologic meshes is the avoidance of adhesions and infection or erosion into bowel seen more commonly with non-dissolvable synthetic meshes. However, their cost remains a prohibitive factor. These biological products are also not designed to last, with eventual disintegration. Whether these meshes are clinically useful depends on a balance between collagenase-mediated degradation and the rate of new tissue ingrowth. If the bio-prosthesis is absorbed before adequate collagen differentiation, the quality and strength of the newly formed tissue will be insufficient and the repair weak. This would presumably lead to a higher hernia recurrence rate.
Resiting
Resiting is a traditional approach that was popularised by a colorectal surgeon (Goligher). The problem with this approach is that the same approach is likely to achieve the same result, with the new stoma at the same high risk of hernia formation as the original stoma. High recurrence rates of 36% have led to resiting being an option of last choice.