The surgical repair of hernias has advanced significantly in the past 15 years through laparoscopic techniques and the use of newer types of mesh. These techniques can allow for many individuals to experience a more rapid recovery and resumption of the activities they previously enjoyed.
A hernia is a protrusion of abdominal contents through a hole in the abdominal wall, affecting approximately 5 million Americans, according to the National Center for Health Statistics.
Hernias can occur because of a congenital weakness, trauma or prior surgeries. These bulges can be seen in the midline of the abdomen, belly button, groin and upper inner thigh. Some hernias are present at birth, develop slowly or occur rather dramatically.
The most common location is in the groin, otherwise known as the inguinal area. More than 800,000 inguinal hernia repairs are done annually in the United States. This can have a significant effect on a patient’s ability to work. Lifting restrictions are necessary before surgery to ensure the hernia doesn’t worsen, and also are necessary after surgery to prevent reoccurrence.
Before the advent and widespread acceptance of the benefits of laparoscopic hernia repair, hernias were repaired by an open approach: incisions of 3 to 4 inches through the skin, fat and muscle overlying the area of bulge. The open technique of hernia repair would require four to six weeks of healing before the patient could resume normal lifting activities.
Laparoscopy now allows the surgeon to repair the hernia from the inside of the abdominal wall through three small incisions. The hernia hole is patched with mesh after pulling the hernia contents back into the abdominal cavity.
This laparoscopic and open mesh repair has a comparable recurrence rate of 2 to 3 percent at five years after surgery. I use the analogy of placing a patch on the outside of a bucket leaking water from a hole in its side. To keep this patch in place you would need to glue it, tack or fix it in place.
With open hernia surgery the patch is placed on the outside and sutured to the muscles surrounding the hernia hole. Sutures around muscles cause pain. If the patch is placed on the inside of the leaking bucket, the pressure of the water, trying to push the patch through the hole, will hold the patch in place.
The interesting principle of modern mesh is that the sutures holding it in place do not create the strength of the repair. It is the human body’s ability to scar the hernia mesh patches in place that creates the ultimate strength of the repair.
With laparoscopy, the mesh scarring at two weeks is roughly 80 percent of its ultimate scarred-in strength. With placement of the mesh on the inside of a hernia, a patient can return to work in as little as five days for light duty. By two weeks, the person can return to most normal reasonable activities. Severe lifting requirements still, in my opinion, should not take place until at least a month after the surgery. All hernia repair patients have to be thoughtful about how they lift for the rest of their lives.
Decreased postoperative pain, quicker return to work and less risk of chronic groin pain have all been seen in most studies comparing laparoscopic versus open hernia repairs.
In the past 15 years I have experienced the progression of repair techniques and modernization of ultralightweight mesh. In the more than 1,000 patients I have operated on, it is so nice to see most patients come back from surgery for a one week check, moving normally with minimal discomfort. Patients resume cycling, tennis, soccer, karate, lifting less than 50 pounds, running and other activities at two weeks.
Unfortunately not all hernias can be repaired laparoscopically. Some are too large or complex. These patients are often offered the open repair technique.
It is up to the surgeon to decide which technique is most appropriate for hernia repair, given the patient’s condition. In cases with patients who are not healthy enough to tolerate general anesthesia, laparoscopy may not be possible.
The progression of laparoscopic hernia repairs has come a long way since its initial acceptance in the early 1990s. This is not a technique that is particularly easy to learn and, in some studies, a learning curve of 200 cases is recognized as a milestone for a path to mastery. Fortunately, today’s graduating general surgeons receive training in this challenging procedure. For most patients this technique is available. Your surgeon will direct you to the best option.
Repairing inguinal hernias is easiest when fixed early. Smaller hernias with less scarring have the lowest recurrence rates after repair.
Dr. Daniel Sparks is a general surgeon with Providence Medical Group in Walla Walla.