Laparoscopic and Open Incisional Hernia Repair

Incisional hernias do not get better without treatment. Hernias cause discomfort as they get bigger. The larger they are, the more difficult they are to repair.
The feared complication of incisional hernia is when a piece of bowel becomes trapped, loses its blood supply and dies. This is a surgical emergency and can be life threatening. Symptoms of this include sudden, extreme pain in the hernia, inability to push the hernia back in, vomiting or redness over the hernia. Should this occur, you should immediately go to the Emergency Department.

Incisional hernias can be extremely difficult to repair because the tissue we are working with is stretched and has little strength.
Surgery involves reducing the contents of the hernia back into the abdominal cavity and placing a nylon material called MESH in the defect. This replaces the tissue that has been lost. The mesh becomes incorporated into the body and adds extra strength.

Incisional hernias can be repaired in two ways.

• Open Technique: – an incision is made though the previous scar – the hernia is reduced and a ‘mesh’ is placed across the hole.
• Laparoscopic or Keyhole Technique: – smaller incisions are made and the hernia is repaired from inside the abdominal cavity.

Laparoscopic surgery tends to have a lower rate of wound infections, serum leaks and mesh infection than open surgery. Laparoscopic surgery probably has a higher risk of bowel injury.
Both techniques have their pros and cons and are acceptable. Your surgeon will decide the best technique for you.

There are no treatment alternatives other than surgical repair of incisional hernias. Some people wear a support garment called a TRUSS. This is an elastic band that can attempt to keep the hernia in place. These do nothing to help repair incisional hernias.

No surgeon can ever return to abdomen to looking the way it did when you were born. Your abdominal wall will always be weaker and scarred. You will never have a so called “wash-board” abdomen.
The initial appearance is different for the two techniques:

Open surgery

Your old incision will be opened and the skin lifted up so the mesh can be placed over the defect. The wound is then closed with staples or invisible stitches. The wound may bulge for some weeks as fluid collects under it. Over time, this will smooth out.

Laparoscopic surgery

The best way to describe the appearance after this approach is that you will look like an “upholstered cushion”. There is a special instrument used to put stitches into these hernias. The result is many tiny puncture wounds in the abdominal wall.
A volume of fluid will collect, where the hernia once was. It may seem for a while that the hernia has come back. There may also be a lot of bruising. Over time, this fluid collection will disappear and smooth out. The contour of the “upholstery” will also smooth out over time.

There are different risks depending on whether the operation is done open or laparoscopically.
Risks Specific to Open Incisional Hernia Repair

• Seroma  It is common for a build-up of clear fluid to occur beneath the edges of the wound after surgery. Very often a drain will be left in to minimize this. It is common however, for there to be a leak of fluid from the wound often for several days after surgery.
• Injury to the bowel may occur in open operation. This is because the bowel may be caught up in scar tissue (adhesions) and easily torn. This is usually repaired at the time of the operation, but it may prohibit the use of mesh. Rarely, bowel contents may leak out of the wound after surgery and require another operation.
• Mesh infection The mesh used to repair the hernia may become infected. This is rare. If infection occurs, the mesh needs to be removed at another operation.
• Wound infection occurs in 1-4% of patients having this surgery.
• Recurrence of the hernia The mesh pulling away from the edge of the repair is relatively common. It is likely that approx. 5-10% of incisional hernias come back. This risk can be minimized by not lifting heavy weights for at least six weeks after surgery. The risk is increased in patient who have a poor immune system, diabetes, obesity or multiple previous surgeries.
• Loss of skin When you have had multiple incisions, there is a risk that the blood supply to the skin may be very poor. Another incision may result in the death of the skin over the wound. This is a big problem if it occurs and may require weeks of dressings and further plastic surgery. It is uncommon.
• Numbness of the skin After any surgery, there will be numbness of the skin around the wound that is permanent. This is something that your body gets used to.
• Bowel obstruction Because the mesh is often placed fully in the abdominal cavity, there is the risk of a piece of bowel sticking to the mesh – leading to a blockage of the bowel. This is uncommon.

Risks Specific to Laparoscopic Incisional Hernia Repair

• Injury to the bowel may occur. This because the bowel may be caught up in scar tissue (adhesions) and easily torn. It is more common in laparoscopic surgery that a tiny hole in the bowel may be made and not noticed. This will result in a leak of bowel fluid into the abdominal cavity and require a open operation to repair. This is a serious, possibly lifethreatening, but uncommon complication.
• Conversion to open operation This is not really considered a complication. Sometimes it is just not possible to safely repair hernias with key-hole surgery. This is usually due to bowel stuck in the hernia that is not safely removable. If this is the case, the surgeon will make a bigger cut and fix it with the open technique.
• Recurrence of the hernia The mesh pulling away from the edge of the repair is relatively common. It is likely that approx. 5-10% of incisional hernias come back. This risk can be minimized by not lifting heavy weights for at least six weeks after surgery.
• Injury to any other organ in the abdomen may occur with laparoscopic surgery: aorta, liver, stomach. This is rare.
• Mesh infection The mesh used to repair the hernia may become infected. This is rare. If infection occurs, the mesh needs to be removed at another operation.
• Wound infection The risk of wound infection in lower in laparoscopic surgery – in the order of 1%.
• Bowel obstruction Because the mesh is placed fully in the abdominal cavity, there is the risk of a piece of bowel sticking to the mesh – leading to a blockage of the bowel. This is very uncommon.
• Gas embolism In keyhole surgery, gas is used to inflate your abdomen. A bubble of carbon dioxide may get into a blood vessel and causes life threatening heart problems. This is very, very rare.
• Re-operation if the surgeon has to re-operate for any reason, this may be done with keyhole surgery or an open operation.

General Risks

• Death: approx. 1/10,000 risk for all patients having this type of operation.
• Bleeding: usually occurs in the first 24 hours and may require further surgery. This bleeding may be from the abdominal wall or from the gallbladder bed.
• Other blood vessel problems: heart attack, stroke. This is very rare.
• Infections: Wound, pneumonia, urine, intra-abdominal, IV line related.
• Clots in the legs that may travel to the lungs and be fatal.
• Wound pain, abnormal (keloid) scarring or hernia of the wound.
• You may require a blood transfusion (this is rare).

Pain Relief

Every effort will be made to minimize the discomfort. Your surgeon and nurses will be monitoring your level of pain control frequently. One of the advantages of the keyhole technique is less pain. Open hernia repair is done via a major incision and hence, is usually more painful. It is very common to have pain in the right shoulder after keyhole surgery. This is due to the effect of the gas pumped into your abdominal cavity during the surgery. The pain typically disappears one day after surgery. On the first day after surgery, there may be a moderate amount of discomfort at the site of the operation. You will have a few choices for pain relief.

There are two major types of pain relievers after keyhole surgery:

Panadol

• You will be amazed the power of regular Panadol. It will cut down the need for the very strong pain pills.
• It does not cause constipation.
• Do not take more than 8 tablets a day.

NSAIDs (Indocid, Brufen, Mobic)

• Also excellent pain relievers. They do not cause constipation.
• Must be used very cautiously in the elderly and those with kidney problems.
• They may cause stomach ulcers.  If you experience any pain in the upper abdomen you must stop this medication immediately and seek advice.

Morphine, Fentanyl (narcotics)

• It is uncommon to need an injection of these powerful painkillers after the first day of surgery.

Drain tubes

Sometimes you will wake up after surgery with a soft plastic drain tube in your abdomen. Your surgeon will advise when this needs to be removed.

Eating

If the surgery is laparoscopic, you will resume eating shortly after surgery. If you have an open operation, eating will commence more slowly. It is very common to feel slightly nauseated for 12 hours following surgery.

Urinating/Bowel Movements

If your hernia is very large, you will have a catheter placed in your bladder under anaesthesia.
After any surgery, a patient may have trouble passing urine. This is uncommon and temporary. Occasionally a catheter needs to be inserted to help you pass urine.
There may be some disturbance to your bowels in the week after surgery. Discuss this with your doctor if this occurs.
Activity

It is very important to begin light activity shortly after surgery. This is to prevent pneumonia, clots in the legs and loss of general condition. You can expect to have to wear stockings on your legs whilst in hospital to prevent clots and have an injection of heparin twice a day under the skin for the same reason. Increase your activity as you feel able.
Your Incision

• You can expect to have a waterproof dressing over your incisions for the first five days. You will be able to shower with this dressing. If there is serum leaking from the wound you will have a bag placed over the wound.
• If you go home in the first few days after the surgery, you can peel the dressing off 5 days after the surgery. The wounds should be healed by this time. You may get the wounds wet after 5 days. It is common for the wounds to be bruised.
• There will usually not be any stitches or staples to remove. This skin will be closed with dissolving stitches.
• Your incision may be slightly red along the cut. This is normal. You may gently wash dried material around your incision and let water run over it. Pat dry with a towel. Do not rub soap or moisturizer into your incision for at least 4 weeks or until it is fully healed. After this you may rub vitamin E cream along the wound.
• It is normal to feel a ridge along the incision. This will go away. It is normal to have a patch of numbness under the wound.
• Over the next few months your incision will fade and become less prominent.

Length of Stay in Hospital

Length of stay is variable depending on the size of the hernia. Small laparoscopic hernias can go home the following day. Patients with larger open hernia repairs may need a week in hospital.

Other Important Information

You can expect to see your surgeon every week day. On weekends or in times when your surgeon is operating elsewhere, you will see one of the practice partners. All are very experienced in this type of surgery and commonly assist each other in the operating theatre.
We will make every effort to keep you informed of your progress. We are always honest and open with you and your family. Feel free to ask questions.

WHAT CAN I EAT AFTER I HAVE HERNIA SURGERY?

It is best to eat a low fat health diet after any surgery. If there is a lot of dissection of the bowel involved, then you will be started off on clear fluids.

How you may feel

It is quite common to feel very tired and to want to have daytime naps for the first two weeks after surgery. Listen to your body and rest when you need to.

This is transient and can be expected to resolve in 2-4 weeks.

Activity

• Do not drive until you have stopped taking narcotic pain medication and feel you could respond in an emergency.
• You may climb stairs.
• Don’t lift more that 10 kg at least 6 weeks after hernia surgery. (This is about the weight of a briefcase or a bag of groceries) This applies to lifting children, but they may sit on your lap. Your hernia repair will never be as strong as your abdominal wall used to be and repeated heavy lifting will lead to a recurrence of the hernia.
• You may start some light exercise when you feel comfortable.
• You may swim after 2 weeks
• Heavy exercise may be started after 6 weeks – but use common sense and go slowly at first.
• You may resume sexual activity when you feel ready unless your doctor has told you otherwise.

Costs to be incurred from this surgery

• There will not be any out of pocket expenses for your surgery.
• Your health fund will be billed directly.
• Outpatient consultations are not covered by the health funds and you will receive an account for this.
• You will get some of the money for outpatient consultations back from Medicare.
• Your anaesthetist may also charge an out of pocket fee. You should ask them ahead of time about this cost. Ask who will be performing your anaesthetic and you can make enquiries with them as to any out of pocket expenses.
• You will also have to pay any hospital excesses that your policy dictates.