Laparoscopy Surgery

PERSONALIZED PATIENT CARE

Laparoscopic Hernioplasty Treatment

A hernia is an abnormal protrusion, or bulging out, of part of an organ through the tissues that normally contain it. A hernia may develop in almost any part of the body; however, the muscles of the abdominal wall are most commonly affected. In this condition, a weak spot or opening in a body wall, often due to laxity of the muscles, allows part of the organ to protrude. Hernias by themselves usually are harmless, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated). If the hernia sac contents have their blood supply cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency. There are many different types of abdominal wall hernias. They are:

  • Inguinal hernia: Making up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women, these hernias are divided into 2 different types, direct and indirect. Both occur in the area of where the skin crease at the top of the thigh joins the torso (the inguinal crease), but they have slightly different origins. Both of these types of hernias can similarly appear as a bulge in the inguinal crease. Distinguishing between the direct and indirect hernia, however, is not that important because both are treated the same.
  • Femoral hernia: The femoral canal is the way that the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh. Although normally a tight space, sometimes it becomes large enough to allow abdominal contents (usually intestine) into the canal. A femoral hernia causes a bulge below the inguinal crease in roughly the middle of the thigh. Rare and usually occurring in women, femoral hernias are particularly at risk of becoming irreducible and strangulated.
  • Umbilical hernia: These common hernias (10-30%) are often noted at birth as a protrusion at the bellybutton (the umbilicus). This is caused when an opening in the abdominal wall, which normally closes before birth, doesn't close completely. If small (less than three quarters of an inch) this type of hernia usually closes gradually by age 2. Larger hernias and those that do not close by themselves usually require surgery at age 2-4 years. Even if the area is closed at birth, umbilical hernias can appear later in life because this spot remains a weaker place in the abdominal wall. Umbilical hernias most often appear later in elderly people and middle-aged women who have had children.
  • Incisional hernia: Abdominal surgery causes a flaw in the abdominal wall that must heal on its own. This flaw can create an area of weakness where a hernia may develop. This occurs after 2-10% of all abdominal surgeries, although some people are more at risk. After surgical repair, incisional hernias have a high rate of returning (20-45%).
  • Other rare hernias: There are also other hernias like Spigelian hernia, obturator hernia, epigastric hernias. All these are generally named after the region in which they appear.

Although one type of abdominal hernia can be present at birth (umbilical hernia), the others happen later in life. Some involve pathways formed during foetal development, existing openings in the abdominal cavity, or areas of abdominal wall weakness. The protrusion can be either reducible, which means it can be pushed back into the abdominal cavity and seem to disappear, or non-reducible, which means it cannot be pushed back into the abdominal cavity. A non reducible hernia is also called an incarcerated hernia. The American Medical Association says that when a non-reducible protrusion involves a portion of the intestine, it can become tightly trapped, lose its blood supply and die. This dangerous condition is called strangulation and often necessitates immediate surgical repair. Research concludes that any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia.

  • Persistent Coughing
  • Straining/Constipation
  • Sudden Physical Exertion
  • Obesity
  • Pregnancy

The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that one is unable to push back into the abdomen-possibly a strangulated hernia. A gap in the abdominal wall is not normally a problem in itself; it is the bulge of intestine that fills the gap that can potentially cause complications. Whether you feel severe pain or none whatsoever, it is important to have a hernia treated as quickly as possible. Every move you make puts more pressure on the internal tissues, forcing them further out of the gap. This enlarges both the gap and the bulge. If left untreated, a large part of the intestine can move inside the hernia.

In the case of an incarcerated hernia, the intestine gets trapped inside the hernia and is not able to come out. This causes a bowel obstruction, which results in severe groin pain, abdominal distension and vomiting. If it remains in the hernia too long, the blood supply can be cut off and the intestine can die, leading to a dangerous, sometimes fatal, strangulated hernia. Sometimes symptoms like nausea and vomiting may accompany pain. These are actually signs of bowel obstruction. Fortunately, with early treatment, the development of incarcerated and strangulated hernias is now quite rare.

All newly discovered hernias or symptoms that suggest that one might have a hernia, should prompt a visit to the doctor. Hernias, even those that ache, if they are not tender and easy to reduce (push back into the abdomen), are not surgical emergencies, but all have the potential to become serious. If one has an obvious hernia, the doctor will not require any other tests (if the person is healthy otherwise) but may diagnose by just examining the patient. This means that the doctor will ask the patient to cough or stand. This increases the intra-abdominal pressure and forces the hernia to bulge out.

Although non-operative treatments existed in the past, they proved to be ineffective, so surgery is currently the primary treatment for all hernias. The treatment of every hernia is individualized, and a discussion of the risks and benefits of surgical versus non-surgical management needs to take place. One will be surprised to know that herniorrhaphy is one of the top 10 surgeries performed in the United States alone.

For most people who develop a hernia, it is always advisable to see a doctor, even if there are no symptoms other than the protrusion. In order to reduce the risk of future strangulation, the doctor may recommend surgery which is called herniorrhaphy. There are two basic methods which are followed.

The more traditional method is an open hernia surgery. In this technique, surgery is done from the outside of the body. A cut is made through the skin over the hernia. This involves making a four- to six-inch incision and identifying the gap by looking through the layers of tissue. After this the protruding tissue is either removed or pushed back into the abdomen and the abdominal wall is repaired and strengthened. The abdominal wall can be strengthened by sewing surrounding muscle over it, or it can be strengthened with a special type of mesh.

Repair of simple and complex abdominal hernias by the laparoscopic technique is now the method of choice in many centers. Laparoscopic repair offers equivalent outcomes to open repair, with the additional benefits of greater patient satisfaction and reduced hospitalization. For some hernias, like incisional, the outcome appears to be superior using the minimally invasive technique. Laparoscopic hernia repair is similar to other laparoscopic procedures. This type of operation is done using a tiny telescope called a laparoscope. It is linked to a special camera. The device allows the doctor to see the hernia on a video screen. It requires smaller incisions (usually 1/5 to 1/2 of an inch). The laparoscopic approach to both inguinal and ventral hernias has resulted in a reduced hospital stay and faster recovery time.


A. Laparoscopic Inguinal Hernia Repair

Inguinal hernias are repaired with a 1cm incision for the camera and two 5mm ports. The preperitoneal repair, developed 40 years ago by Dr. Stoppa as an open operation and recently translated into a laparoscopic approach, is used to recreate the pelvic floor. The peritoneum is mobilized to the level of the umbilicus to create a large space behind the rectus abdominal muscle. A 6-by-6-inch piece of mesh is introduced into the concavity of the pelvis, which covers the origin of the defect from the inside, rather than the more traditional one that lay on top of the hernia. Currently, the two most popular laparoscopic techniques are :

  • TAPP (Trans abdominal preperitoneal)
  • Total

The most ardent critique of the TAPP procedure is that it is an intra-abdominal procedure with significant potential morbidity. On the other hand, the TEP procedure avoids intra-abdominal access. A major advantage of laparoscopic inguinal hernia repair is that bilateral hernias, which are not uncommon, can be repaired during the same operation. The laparoscopic procedure also allows the physician to see and repair small hernias not detected by a physical examination. Patients who cannot have laparoscopic inguinal hernia repair are those who have had bladder surgery, open prostate surgery, radiation for prostate cancer, or other prior invasion of the preperitoneal space.


B. Laparoscopic Ventral Hernia Repair

Incisional, Ventral, Epigastric, or Umbilical hernias are defects of the anterior abdominal wall. They may be congenital (umbilical hernia) or acquired (incisional). Incisional hernias form after surgery through the incision site or previous drain sites, or laparoscopic trocar insertion sites. About 95% of ventral hernias can be repaired laparoscopically. It is recommended that patients with hernias resulting from prior incisions, patients with umbilical hernias that have increased over time, patients who are substantially overweight, or patients with hernias larger than 4cm, have the hernia repaired laparoscopically with mesh. The only patients who cannot have a laparoscopic ventral repair are those who have experienced a loss of domain or those with severe adhesions that cannot be safely reduced laparoscopically.

The mesh has a smooth surface that faces the small bowel and prevents it from adhering to the mesh, while a rougher surface on the side facing the abdominal wall allows for rapid tissue ingrowth. Because the mesh is placed inside the abdomen, behind the defect, any strain tends to push it more tightly against the abdominal wall and distributes the pressure throughout the mesh. In comparison, traditional mesh repair uses an incision extending beyond the length of the hernia on either side to gain access to the hernia. Mesh is placed on the outside of the defect, and any strain would tend to push the mesh away, thus increasing the likelihood of a recurrence.

Since the first report of laparoscopic ventral hernia repair (LVHR) in 1992, the operation has grown in popularity with the belief that it may offer shorter hospital stays, improved patient outcomes, and fewer complications than traditional open procedures. A laparoscope (a tiny telescope with a television camera attached) is inserted through a small hollow tube. The laparoscope and TV camera allow the surgeon to view the hernia from the inside. Other small incisions will be made for placement of other instruments to remove any scar tissue, and to insert a surgical mesh into the abdomen.

The laparoscopic approach to both inguinal and ventral hernias has resulted in a reduced hospital stay and faster recovery time. Laparoscopic patients have no restriction on activity after surgery and most patients are back to work and pain free in 2 to 3 days after an inguinal hernia repair. Recovery time after a laparoscopic ventral hernia repair is usually only about two weeks, much shorter than the standard 6 week recovery from an open repair. The rate of recurrence is also much less with the laparoscopic approach (less than 10%) as compared to the 20-40% recurrence rate with the open procedure. So Laparoscopic herniorrhaphy has many advantages like :

  • Less postoperative pain
  • May shorten hospital stay
  • May result in a quicker return to bowel function
  • Quicker return to normal activity
  • Better cosmetic results

So, if we were to compare an open surgery with a laparoscopic surgery, we can display it in a nutshell as under:

LAPAROSCOPIC

  • Small Incisions (less than ½ an inch)
  • Hospital stay is 1 to 3 days
  • Patients usually return to work in 5 to 10 days
  • Lesser risk of Infection
  • Less painfull
  • Less chance of hernias

OPEN

  • Large Incision
  • Hospital stay of about 5 days
  • Return to work in about 4 weeks
  • Greater risk of infection
  • More painful
  • More chance of hernias

Once the patient is back at home, it is important to keep the incision clean and dry. The physician will give specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. Pain relievers for soreness can be taken as recommended by the physician.