A hernia being a structural defect in the abdominal wall doesn’t heal on its own. If not treated on time, it can get bigger, leading to either discomforting the patient, pain or intestinal obstruction. In rare cases this can lead to a life-threatening complication. A hernia repair surgery, if done timely, it can reduce pain, and prevent complications, resulting in improved quality of life (QOL).
There are three types of surgery for hernia, with each including a different procedure, different recovery time along with advantages and disadvantages.
Open Hernia Repair Surgery (OHRS)
The most common hernia repair surgery is suitable for people of any age or patients who are not fit to undergo laparoscopic or the advanced extraperitoneal repair. Surgeons often recommend open hernia repair to patients who have a large hernia or a dense scar tissue from previous pelvic or abdominal surgery.
The surgery involves giving a wide cut through the skin and muscle layer of the groin to have an access to the hernia. The cut can be a minimum of 10 centimetres and in some patients the cut can go up to 20 centimetres (this occurs if the hernia is either very large, obstructed, or the patient is morbidly obese). A heavy mesh is placed over the groin muscles and then stitched to the muscles. The surgery usually takes 30 to 45 minutes, but it can go up to 2 hours (depending on the size and complexity of the hernia).
An open hernia surgery, is recommended for patients who are unfit for an operation as it can be done under local anesthetic and on patients who have had a prior lower abdominal open surgery. Most surgeons are proficient in performing an open hernia repair surgery.
Recovery is usually prolonged because of a bigger incision and more dissection. The patient might feel movement restriction and discomfort for a couple of weeks after the surgery. The requirement of Post-Operative Analgesia is also higher. Most patients, however, return to normal activities within 3 – 6 weeks.
- As open hernia surgery involves a larger incision and a splitting of the muscles, there will be a possibility of nerve damage, leading to either numbness, or chronic nerve pain in the groin.
- A recurrence rate is also high in comparison to other types of hernia repair surgeries. Due to the fact that this is not a very anatomical repair, it involves stitching the mesh to the muscles. This leads to weakness of the muscles in the future.
Laparoscopic Hernia Repair Surgery (LHRS)
Laparoscopic Hernia Repair Surgery (also referred as keyhole surgery) is inclusive of two types;
- Trans-abdominal Pre-peritoneal (TAPP)
- Total Extra Peritoneal (TEP)
Trans-abdominal Pre-peritoneal (TAPP)
TAPP is usually recommended to patients who are medically fit to undergo general anaesthesia (GA). This procedure can be used on patients who have had an open operation in the lower abdomen similar to hysterectomy, robotic prostatectomy ect era.
TAPP is a keyhole procedure that is less invasive and preserves the structure of the muscle tissues. The surgeon will make an incision of 1 – 2 centimetres next to the belly button. The surgeon will then insert a camera, and fill the abdomen with gas to create space to perform the operation. The surgeon will then make two small cuts below the above incision, which then allows the surgeon to be able to insert the additional surgical instruments to have the ability to perform the dissection. The membrane lining the abdominal cavity (peritoneum) is then cut and the hernia sac (which is a part of the peritoneum) is then reduced. The surgeon will then place a lightweight synthetic mesh over the abdominal wall defect to reinforce the abdominal wall and the divided peritoneum is then sutured back to close the opening.
This operation can also be performed robotically.
On an average, two out of three patients feel little to no pain after the procedure, and it takes 1 – 2 weeks to recover, after this period of time, the patient has the access to resume normal activities. The infection rate is low post-procedure, and there is a less of a possibility to the recurrence of hernia.
The largest disadvantage of TAPP is the increased risk of injury to the adjacent abdominal organs, mainly the intestine. Also, the possibility of post-operative adhesions (bowel to either the exposed part of the mesh or stitched part of the peritoneum) is high in TAPP. This operation can be performed robotically, but the disadvantages still remain the same.
Total Extra Peritoneal (TEP)
TEP is the highly advanced, least invasive and the most durable hernia repair surgery. TEP hernia repair similar to TAPP hernia repair is suitable for any patient fit for general anesthesia. This technique of hernia repair is highly recommended to any suitable patient with primary or recurrent, unilateral and bilateral hernia repair.
The difference between TEP and TAPP is that during TEP, the surgeon stays outside of the peritoneum, potentially avoiding the risk of bowel injury or adhesions. Total extraperitoneal hernia repair surgery does not involve muscle dissection and is the most anatomical repair. The surgeon makes an incision of 1 – 2 centimetres below the navel and places a balloon in the space between the peritoneum and the anterior abdominal wall. Gas (CO2) is then filled to separate the layers. The surgeon will then make two small cuts below the above incision, which then allows the surgeon to be able to insert the additional surgical instruments to have the ability to perform the dissection. The membrane lining the abdominal cavity (peritoneum) is then cut and the hernia sac (which is a part of the peritoneum) is then reduced. The surgeon will then place a lightweight synthetic mesh over the abdominal wall defect, to reinforce the abdominal wall and held in place with absorbable tackers (surgical screw). This repair does not involve any stitching inside, making it the most anatomical and tension-free repair.
As total extraperitoneal hernia surgery is the least invasive, the patient feels less pain after the procedure. The infection, as well as the recurrence rate is the lowest in extraperitoneal surgery, and patient can have the access to return to normal activities after a one or two weeks. The requirement of an analgesia post-operative (pain killers) is minimal.
In conclusion, not all hernias need immediate surgical correction. One should not delay an appointment with the surgeon to seek professional advice as surgery done at a correct time has a better outcome. Secondly, hernia repair surgery is a dynamic operation involving a moving part of the body with the mesh staying in place, as opposed to an operation involving a removal of an organ similar to an appendix or a gallbladder. This makes it more complex and that is why it’s important that this operation is performed by a surgeon dedicated to hernia repair surgery. Any redone hernia surgery, makes it more difficult and generally results in a poor outcome.
Most medical insurance policies cover hernia surgery. If you are not insured, I advise you to obtain a quote by calling my office (+61 3 92107277).