Incisional Hernia Repair
Incisional hernias occur on the front of the abdomen. They are caused by a weakness in the abdominal wall following a surgical incision from a previous operation. The scar from the first operation is a weak point in the abdominal wall and over time, the tissue can stretch, allowing a hernia to develop.
The problem for the surgeon is that (as with a recurrent hernia), the dissection is difficult because of the previous scarring. Incisional hernias can also be quite large, so plug type repairs are not usually possible.
The other big problem is that surgeons do not like to leave mesh in contact with the intestines, because the outer surface of the bowel can become stuck to the mesh. This is known to increase the possibility of post-operative adhesions – a serious complication.
Fortunately, a new type of mesh has been developed by Bard, the medical equipment company. The ‘Composix’ mesh has a smooth surface on one side, which does not stick to the intestine. One the other side is the strong polypropelene mesh which lets the surgeon suture the patch onto the abdominal wall securely.
The mesh can be placed by either open or laparoscopic surgery and is a major advance in the treatment of these difficult hernias.
Types of Mesh
Standard composite light weight mesh
Hernias these days are usually repaired by using some sort of mesh. The mesh is basically a piece of plastic ‘chicken wire’ which is sewn over the hernia defect to prevent the hernia sac bulging through it.
The initial types of mesh were referred to as a ‘Lichtenstein technique’ – not after the tiny European country but after the Lichtenstein clinic in the USA where the technique was first popularized.
The advantages of the mesh style techniques were that because less stitches were required on the inside, the tension of the hernia was less and this caused a lot less post operative pain – sometimes mesh repairs are referred to as ‘tension free’ hernia surgery
The standard hernia mesh can be made of several different surgical materials.
Over the last 20 years mesh technology has developed a lot and several different designs are now used. Mesh material these days is more lightweight, making it more comfortable for the patient, and some meshes dissolve with time which is thought to lessen the risk of post – operative infection.
All of these developments work well if used by capable surgeons. There is no specific technique or material which has, as yet, become universally accepted as the ‘best option’.
3 D Contoured mesh – designed to mimic the contours of the groin area rather than the standard flat mesh.
The Perfix plug – quite a neat design of mesh inserted into the hernia defect to prevent the hernia sac bulging through the gap.
Sutureless mesh “Progrip” – designed to stick in place without sutures and be completely tension free.
Biological mesh – made from lightweight material which dissolves over time.
What is a Hernia?
What is a hernia?
A hernia is caused by a weakness in the abdominal wall muscles. This weakness allows the contents of the abdomen to bulge through the gap and form a lump under the skin, which can be seen or felt by the patient. This is sometimes described as a ‘rupture’. The lump is usually more prominent when coughing or straining, as these activities raise the pressure in the abdomen and force the contents out through the weakness in the wall.
Although hernias can occur anywhere in the abdominal wall, some sites are more common than others.
How do people know they have a hernia?
Patients may notice a bulge in the groin area, which is the commonest place for a hernia to develop. Sometimes there may be no bulge only a pain which gets worse on physical exercise or straining. When examined there may be a ‘cough impulse’ – in other words the doctor can feel a bulge occurring when the patient coughs and the hernia pushes out through the muscle walls.
Who gets hernias?
Hernias are more common in men than women, though women can develop them as well. They can occur at any age although they do tend to be more common as the years roll by! Young people can get hernias as a result of weaknesses persistent from the time of birth, which do not become apparent until later life.
Are hernias dangerous?
Most simple groin hernias are not a particular risk to your health although it may be uncomfortable from time to time and will eventually get bigger. A hernia can become dangerous if a loop of intestine or gut bulges through it and becomes stuck in the hernia – this is called strangulation. This is a surgical emergency and needs to be repaired at once. The exception to this is a femoral hernia which is quite likely to strangulate and should be repaired promptly.
What causes hernias?
The weakness in the wall can be present at birth, although the hernia may not be noticeable until much later. Men are more likely to get certain types of hernias (inguinal hernias) because of the spermatic cord making a hole in the wall of the abdomen.
- Hernias are very common.
- They affect an estimated 2 – 3 % of the population at any one time.
- Over 110,000 hernia repairs are done every year in the UK.
- The reason for repairing a hernia is that over time they tend to get bigger. They do not get better on their own.
- There is a small risk that an untreated hernia might ‘strangulate’. Repairing the hernia eliminates this risk.
- To date, there are no methods of identifying a hernia that does not require an operation.
- Most doctors feel that hernias should be repaired by some sort of surgery.
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Types of Hernia
There are several types of abdominal hernia depending on where the muscle weakness occurs. The commonest types are described on this page.
Inguinal Hernias
These are the most common type of hernia. They usually are noticed as a lump in the groin, which may be painless or tender. The bulge may get larger after exercise or lifting heavy objects. Usually the lump is ‘reducible’ – which means it can be pushed back in or goes back in on lying down flat. A big inguinal hernia can extend into the scrotum. When a hernia occurs for the first time it is said to be a ‘primary’ hernia.
Inguinal hernias can occasionally become ‘strangulated’. This occurs when a piece of bowel from inside the abdomen bulges out into the hernia and becomes trapped. This can be very painful and is a surgical emergency. For this reason doctors advise patients to have hernias fixed before they strangulate.
Recurrent Hernia
Occasionally a hernia can recur after an operation to repair it (recurrent hernia). This occurs less commonly these days than in the days before mesh repairs became available. Recurrence rates after mesh hernia repair are very low – about 3 %.
Femoral Hernia
Femoral Hernias are more common in women than men. They are important because they are quite likely to strangulate and should be repaired promptly. The lump is usually felt in the top of the thigh, below the groin crease. It can sometimes be difficult to distinguish between an inguinal and a femoral hernia, which is why all lumps in the groin should be looked at by an experienced surgeon.
Epigastric Hernias
Epigastric Hernias are caused by weaknesses of the abdominal wall at the front. They are felt as a lump in the upper abdomen, above the belly button. They tend to occur more frequently in middle aged people and can affect either men or women. Umbilical Hernias occur around the umbilicus, or belly button. The bulge pokes out through the weakness in the abdomen left by the remnants of the umbilical cord.
Incisional Hernia
Incisional Hernias occur through scars caused by previous surgical incisions in the abdomen. The defects can often be quite large and sometimes difficult to repair. Complex incisional hernias are often repaired by laparoscopic techniques.
Open or Laparoscopic Hernia Repair
Hernias can be repaired by either ‘open’ surgery or laparoscopic ‘keyhole’ surgery.
There are pro’s and con’s to each approach.
Open surgery is most commonly used for first time hernias, because it is quick, quite easy to perform and does not need any specialized pieces of equipment. The results are much the same as for keyhole surgery for hernias that have not been operated on before. It can also be performed under local anaesthetic, whereas keyhole surgery requires the patient to be asleep.
In ‘keyhole’ hernia repair the principles are very similar to conventional open surgery but the repair mesh is placed through much smaller incisions using special instruments.
All laparoscopic surgery is performed under general anaesthetic. Once the patient is asleep, the first step of the operation is the insertion of a small plastic tube through the skin in the navel into the area behind the abdominal wall. This is followed by inflation of the abdomen with gas (usually carbon dioxide) to create a space in which to operate. The camera is placed through this ‘port’ enabling the surgeon to see inside the abdomen.
Two more small tubes are then inserted through the skin below the first in the midline to allow placement of the operating instruments. The groin is then dissected from within the abdominal cavity. Mesh is placed over the hernia defect from the inside and secured in place by a few metal staples. The gas is removed and the skin closed. The advantage of the minimally invasive approach is less pain post operatively (particularly for bilateral groin hernia repairs which may then be done as day cases) and a faster return to normal activities.
Repair of a groin hernia by Laparoscopic or Minimally invasive surgery involves placing the mesh repair from the inside of the body.
A photograph taken during laparoscopic hernia repair showing fixation of the mesh inside the abdomen.
The National Institute for Clinical Excellence (NICE) has recommended that all patients may be offered a minimally invasive groin hernia repair if performed by a suitably qualified surgeon.
Minimally invasive repair of recurrent groin hernias is especially effective as the approach enables the surgeon to avoid the scarring that would be encountered from the front, resulting in reduced complication rates.
Hernia Repair Procedure
Before the operation:
You will have a consultation with one of our consultant surgeons. He will take a full medical history and examine you. You will be able to discuss the best type of treatment for your hernia, and arrange a suitable time for the operation to be done.
The day of the operation:
You will be admitted to the ward about two hours before the operation. If you are having a general anaesthetic, you will need to be ‘nil by mouth’ (nothing to eat or drink) for 6 hours before surgery. If you are having a day case procedure, you will be discharged home 2 to 3 hours after the operation.
The day after the operation:
If you are staying in hospital overnight, you will be visited by the consultant surgeon in the morning to check you are fit to be discharged home. The nursing staff will provide you with some painkillers to take for the first few days.
The Recovery from Surgery
Recovery from surgery can be a little unsettling if you don’t know what to expect.
In the initial few days you may require some pain killing tablets and feel sore on walking around. By the end of the first week after surgery you should be back to most normal activities including driving a car.
Some mild discomfort and pins and needles sensations are common up to 6 to 8 weeks after surgery. Sometimes an area of numbness is felt around the scar or at the top of the leg. This is due to the small sensory nerves regrowing after surgery.
Initially the area over the scar will feel quite lumpy and raised as the healing process develops. The wound may take up to 8 weeks to flatten out again and feel normal. Some numbness over the skin may persist.
TEN POST-OPERATIVE INSTRUCTIONS FOR PATIENTS AFTER OPEN HERNIA SURGERY
- Take your painkillers regularly (4 to 6 hourly) for the first 2 days. The painkillers are very effective, but may make you constipated, so take plenty of water and fruit etc to keep your stools soft.
- After the first couple of days you will be able to tail off the use of the painkillers, using the drugs ‘as you need them’ rather than on a regular basis. Take it easy for the first 2 to 3 days. You can move around the house etc, but do not do any heavy lifting / carrying shopping / digging the garden etc.
- You will find that you are quite comfortable at rest in one position, but that changing position from sitting to standing to lying down etc, may be uncomfortable.
- After a week you should find you are fairly comfortable doing most of the normal day to day activities.
- Keep the wound dry for the first 7 to 10 days. Avoid showers / baths to prevent the wound getting wet.
- If the wound becomes RED, VERY TENDER, HOT AND OOZY, then it may be infected. The ‘danger time’ for wound infection is about 5 to 7 days after the operation. Should this happen, then you should contact your GP immediately to get some antibiotics. Oral antibiotics will sort out the problem in the vast majority of cases.
- The stitches are dissolvable and do not need removing. The dressing can be removed after about 7 days if you wish. Otherwise it can be left on until you see your surgeon in clinic, about 2 weeks after the operation.
- You may notice some bruising and swelling around the wound and even in the scrotum if the hernia was particularly large. This is normal. If the scrotum is very swollen, then wearing a pair of tight Y fronts is usually helpful.
- After 1 week you should be OK to drive a car, BUT ALWAYS INFORM YOUR INSURANCE COMPANY FIRST TO MAKE SURE THEY WILL COVER YOU IN THE EVENT OF AN ACCIDENT.
- Telephone our secretaries to arrange a suitable time for a follow up visit about 2 weeks after the operation.
The post-operative visit:
The surgeon who did your operation will see you in clinic to examine your wound and check that it has healed well. He will also be able to answer any questions you may have at this time.
Radiance Health provides Hernia Surgery and Treatment as well as information on the common types of hernia that we treat.
Clinical excellence:
We provide hernia surgery at several hospitals in Central and South East London andKent, includingBMIWeymouthStreetHospitaland thePrincess GraceHospitalnearHarley Street, BMI Blackheath, BMI Sloane andBMIChelsfieldParkHospitals.
Full range of options:
Our consultant surgeons offer the full range of options for hernia repair, using the latest open and Laparoscopic hernia surgery techniques.
Latest technology:
For all hernia surgery, we use the latest mesh products including the Perfix plug and Composix mesh developed in theUSA.
Patient focused – your choice:
You can choose to have your hernia operation under local or general anaesthesia, as a day case or as an overnight stay. A consultation with our surgeons will guide you as to the most appropriate surgery for your hernia.
- Initial consultations are normally available within seven to ten days.
- Both the hospital and the consultant surgeons are recognized by all the major healthcare insurance providers (BUPA, PPP, AVIVA etc). The extent to which these insurers will cover costs depends on the type of policy you have.
- For patients who are ‘self paying’ we offer a competitive package price deal which covers pre and post-operative consultations as well as all operative costs for a fixed price with no ‘hidden extras’.
Get treatment
Radiance Vein Clinic’s staff are some of the UK’s leading authorities on venous treatments. We provide the latest treatment options across London and Kent. For an initial consultation and advice, contact us now.