ROBOTIC REPAIR OF ABDOMINAL WALL HERNIAS
(Umbilical • Epigastric • Incisional • Ventral)
Explanation written by Barry N. Gardiner, M.D.

Some may prefer just this brief statement identifying the approach I recommend for repair of hernias in the abdominal wall (which include umbilical, epigastric, incisional and ventral hernias). In the vast majority of cases I’m able to use a robotic (da Vinci®) laparoscopic technique to accomplish these repairs. This approach has reduced the recurrence rate to less than 5% (from as much as 60% reported with open surgery techniques), and it frequently reduces the pain experienced with a traditional non-robotic laparoscopic surgical approach. Those interested in more detail than this brief statement are referred first to my write-up Robotic, Laparoscopic & Open Surgery: How Do They Differ In Abdominal Operations? (found under a separate tab on my web page), and then to the detailed write-up of Robotic Repair of Abdominal Wall Hernias below.

Overview of hernias:

For our purposes, a hernia can be defined simply as a hole (defect) that allows an organ or other tissue to protrude through it, either in the diaphragm (hiatal hernia), the groin (inguinal hernia), or the abdominal wall (umbilical, epigastric, incisional, ventral hernia).

Hiatal hernias are due to a hole in the diaphragm that allows the stomach to protrude up into the chest - so are therefore not abdominal wall hernias. Although I also usually recommend a robotic laparoscopic technique to repair this type of hernia, the technique is slightly different from the repair of abdominal wall hernias, so is not included here.

Inguinal hernias (which comprise nearly 75% of all hernias) also do not occur in the abdominal wall, but rather in the groin. Because in my opinion inguinal hernia repairs are more suitably approached with traditional laparoscopy than robotic laparoscopy, I’ve described them separately.

The remaining are abdominal wall hernias, and these are the hernias that are discussed here. They occur either through the navel (umbilical hernia), in the midline of the abdomen between the navel and breastbone (epigastric hernia), or through any previously made surgical incision in the abdominal wall that fails to heal completely (incisional hernia). Umbilical, epigastric and incisional hernias may also be referred to as ventral hernias because they occur through the front (i.e.,ventral) aspect of the abdominal wall. (fig. 1) Regardless of where they occur in the abdominal wall, I usually recommend the same robotic laparoscopic technique to repair them.

Why do they occur, and when?

Figure 1
Figure 1

An umbilical hernia (fig. 1) is a developmental defect and even though it may not have been evident to the patient, these hernias have usually been present since birth. The ring of muscle and other tissue that forms where blood vessels in the umbilical cord enter a fetus’s body is known as the umbilical ring. The umbilical cord is cut at birth and eventually falls off flush with the abdominal wall. This umbilical ring then closes with scar tissue. If this scar doesn’t form or is weak, activities of daily living will increase intra-abdominal pressure and start pushing tissue through this weak spot in the navel and ultimately a visible and palpable bulge will appear at the umbilicus. These hernias have the same natural history as all other hernias. They tend to enlarge progressively over time, especially in anyone with heightened stress on the abdominal wall such as occurs during pregnancy, with obesity, or in patients suffering from chronic lung disease. As a result, umbilical hernia defects can vary in size from less than an inch to large hernias involving a significant portion of the abdominal wall.

Figure 2
Figure 2

An epigastric hernia will always occur directly in the midline, between the breast bone and the navel (fig. 1). Why? The center of the abdominal wall is made up of two large rectus muscles. These muscles run right next to each other and attach to the ribs above and the pelvis below. Each is contained inside a fibrous tube called the rectus sheath. These two sheathes are held together by fibers from one tube that cross the midline and fuse to the sheath on the opposite side. In the upper abdomen these fibers run at angles to each other crossing in the midline and forming a strong band of fibrous tissue that runs from the breast bone above to the umbilicus below. Normally these interlacing fibers are tightly packed together leaving no spaces between them. But if any space does exist between adjacent fibers, there is room for structures inside the abdomen to protrude (herniate) through this defect. Thus the epigastric hernia occurs in this very specific area. These hernias are usually quite small but over time they do have the potential to increase substantially in size, especially in patients with heightened stress on the abdominal wall (such as occurs in pregnancy, with obesity, or in patients with chronic lung disease).

Figure 3
Figure 3

Incisional hernias, of course, occur at the site of a previous incision. Patients undergoing any traditional open (non-laparoscopic) abdominal surgery have as much as a 15% chance or more of eventually developing an incisional hernia at the site of that incision (fig. 1 & 2) – either because the sutures pull through the tissue, or the scar that forms is just not strong enough to withstand the forces inside the abdomen pushing against the abdominal wall. They can also occur following a previous laparoscopic operation, either at a drain site or through an instrument (trocar) insertion site. Incisional hernias are especially common in patients with heightened stress on the abdominal wall (such as occurs in pregnancy or with obesity or chronic lung disease), patients with diabetes, those on steroids, or in a patient whose original wound was complicated by an infection. Issues such as these tend to compromise wound healing and can promote herniation of intestine through the abdominal wall next to or in the area of the incision. (fig. 2 & 3) These hernias are not usually apparent in the early postoperative period, but can become evident several months to several years later. Incisional hernias can be quite small, but if they are allowed to go untreated, will usually enlarge over time and may come to involve most of the abdominal wall.

Going forward, the explanations, descriptions and illustrations represent all abdominal wall/ventral hernia repairs (umbilical, epigastric and incisional), and the surgical repair I recommend is essentially the same for all of them.

How are they diagnosed?

Photo 1
Photo 1

Most often, the patient notices the bulge in the abdominal wall and seeks a medical opinion. At the time of consultation, we are usually able to diagnose an abdominal wall hernia by simple physical examination given the presence of a visible and palpable bulge through the abdominal wall – as in the example shown of an incisional hernia. (photo 1) It is very uncommon to need to do any additional evaluation or imaging studies (such as a CT scan) to establish the diagnosis.

What are the symptoms?

The main symptom of an abdominal wall hernia is a soft bulge under the skin in the affected area (umbilicus, epigastric or next to a previous incision). Most of these hernias are either painless or produce an intermittent dull ache, especially after activity. The majority are also reducible (meaning the contents of the hernia can be pushed back in or will move back and forth into the abdomen spontaneously). As you might expect if the hernia is reducible, the bulge may get smaller or actually disappear when the person is lying down and relaxing.

Why repair them?

There is no acceptable nonsurgical treatment for an abdominal wall hernia, nor will it go away without treatment. It may develop slowly over a period of weeks or months or it may appear suddenly after any activity that increases pressure inside the abdomen (such as lifting or straining, exercising, or bouts of coughing). In general, these hernias get bigger with time. The larger the hernia, the more involved it is to repair, and the more likely it is for that repair to result in a recurrence.

Figure 4
Figure 4

In addition (and more problematic) the contents of the hernia, including in some cases part of the intestine, can become trapped (incarcerated) by the defect. When this occurs, the contents of the hernia can no longer be pushed back into the abdomen (i.e., cannot be reduced). This incarceration may be asymptomatic (i.e., may not produce symptoms). However, if it’s associated with the sudden onset of persistent pain and/or if it is accompanied by nausea or vomiting – it should be evaluated urgently. This symptomatic incarceration can lead to strangulation (death of the intestine trapped inside the hernia as a result of its blood supply being shut off). (fig. 4)

Note: Again, if these symptoms persist, treat them as an emergency because urgent surgical intervention may be required (i.e., call the doctor or go to the emergency department – no matter the time of day or night).

These are the reasons we usually recommend elective (i.e., non-urgent) surgical repair (even though the hernia may be causing few or no symptoms) . . . before the hernia has an opportunity to increase in size and/or become strangulated. Otherwise, what could be a straight-forward elective hernia repair can become instead an urgent and perhaps major operation with the potential for very significant complications.

Individuals who are a very high operative risk (those with severe heart or lung disease, for example) may be followed closely by a physician rather than pursue elective hernia repair, but even these patients will require surgery if symptoms become severe or if strangulation occurs.

What factors lead to a strong surgical repair of a ventral hernia?

There are two fundamentally different approaches to repairing any ventral hernia --- the traditional (open) approach and the laparoscopic approach. Open surgery has been used to repair these defects for over 100 years and the overwhelming majority of surgeons are still using this approach today despite recurrence rates that can approach 30% (or more depending on circumstances). There are very few surgical procedures of any kind with such a disappointing record of success, but prior to 1991 and the advent of laparoscopic surgery, there were really no viable options. The development of laparoscopic surgery offered an alternative to open abdominal surgery that would prove to significantly reduce the unacceptably high recurrence rate of all ventral hernias. How? It enabled the surgeon to repair the hernia defect from the inside of the abdomen, so that the forces which contributed to the development of the hernia in the first place could now contribute instead to a stronger repair. To understand why this is the case, we need to first review what factors/forces create a strong ventral hernia repair. This will demonstrate how the laparoscopic approach takes advantage of these forces while the open surgical approach usually does not.

Modern thinking suggests that to create the strongest ventral hernia repair possible the surgeon needs to accomplish all of the following four goals: (fig. 5)

Figure 5
Figure 5
  1. Suture the defect closed. For a variety of reasons this is not always achieved. However it is one of the four required components if the strongest repair is to be accomplished.
  2. Reinforce the repair with mesh. This material is usually made of a woven nylon. It looks much like window screen, and allows the body to grow into the spaces within the mesh. This ingrowth of tissue fuses the mesh to the abdominal wall adding strength/reinforcement to what would otherwise be an un-reinforced sutured repair. The fusion process begins immediately following the operation and continues for a number of months.
  3. Place the mesh inside the abdomen on the underside of the abdominal wall musculature (underlay repair). Placed in this location, it excludes the mesh from the abdominal cavity so the mesh is not exposed to the underlying intestine while allowing pressures inside the abdomen (including those caused by physical activity) to force the mesh against the underside of the abdominal wall, facilitating the body's ingrowth/fusion into the mesh.
  4. Achieve the broadest possible contact of mesh with the musculature of the abdominal wall. The strength of any mesh repair is determined by the amount of that mesh that is available for the abdominal wall to grow into. This overlap beyond the edges of the defect should be as large as possible, but needs to be at least two to three inches because the larger the surface area of fusion between the abdominal wall and the mesh, the stronger the hernia repair.

How does traditional open surgery compare to the laparoscopic approach in ventral hernia repair?

Understanding what factors make the strongest possible ventral hernia repair now allows us to compare the traditional open repair to the laparoscopic repair. This will make clear how the laparoscopic approach takes advantage of those factors, and the most commonly used open surgical approaches do not.

Open Ventral Hernia Repair:

In the traditional open repair of a ventral hernia, an incision is made over the hernia, the hernia defect located, and the intestine pushed back into the abdomen. At that point in the open operation, there are four options available for completing the repair. Unfortunately, all but the underlay technique still contribute to the high recurrence rate.

The surgeon can either:

  1. perform an un-reinforced closure of the defect by simply stitching the defect closed. However, this usually places the repair under significant tension. This tension can be reduced by making relaxing incisions, but to make these incisions the surgeon needs to expose an extensive area of the abdominal wall on both sides of the incision. This increases the scope of the surgery, causes additional post-operative pain, and increases the likelihood of wound complications. Even if relaxing incisions are made, if the surgeon relies on simple closure of the defect alone, the sutures tend to pull through the tissue over time, the edges of the defect then pull apart, and the hernia is likely to eventually recur. So while it is the easiest approach for the surgeon to use, it provides the weakest repair of the several options available, and should rarely be used. or
  2. fill the hole with a plug of nylon mesh or trim a piece of mesh to the size of the hole and sew the edges of the mesh directly to the edges of the defect. Both the plug approach and the edge to edge type of repair are technically straightforward for the surgeon, but lead to a very weak repair because each provides minimal contact between the edges of the defect and the mesh. As a result there can only be limited tissue ingrowth into the mesh. In addition the pressures coming from inside the abdomen that helped contribute to the hernia in the first place tend to push the mesh out of the repair. or
  3. perform an overlay repair by suturing the defect closed and then placing a piece of mesh on top of the sutured hole as added reinforcement. The mesh is then tack sutured to as much of the top surface of the abdominal wall as exposure through the incision will allow. However, an overlay repair is inherently weaker than an underlay repair because the advantages gained by placing the mesh on the underside of the abdominal wall are lost (see # C above). or
  4. Figure 6
    Figure 6
  5. perform an underlay repair. However, this approach requires substantial dissection of the tissue on both sides of the defect to gain sufficient access to the surgical site.  (fig. 6) Once this exposure is achieved, the mesh can then be positioned on the underside of the abdominal wall, sutured in place and the defect then closed over the top of the mesh. This approach achieves the strongest repair possible, but substantially increases the magnitude of the operation, increases the length of recovery, and is associated with a significant increase in pain and in the incidence of wound complications, including infection of the mesh. For these reasons, it is a less commonly used technique.

Laparoscopic Ventral Hernia Repair:

Figure 7
Figure 7

(Reminder: conventional laparoscopic technique is described fully in Dr. Gardiner's write-up Robotic, Laparoscopic & Open Surgery: How Do They Differ In Abdominal Operations?).
Repairing a ventral hernia with any open technique requires making an incision at the site of the bulge and dissecting through the skin, fat, fascia, and muscle layers to expose the hernia defect. (fig. 6) Instead, the laparoscopic approach avoids all of this dissection (and its potential complications) by accessing the abdominal cavity through three small punctures in the abdominal wall (for ports to introduce the camera and instruments through) -- some distance away from the hernia itself. (fig. 7) This allows the laparoscopic repair to be accomplished from inside the abdominal cavity. Operating from a projected video image of the operative site, the surgeon first returns all of the contents of the hernia

Figure 8
Figure 8
back into the abdominal cavity and then divides across any adhesions (scars) that may be present at or near the hernia. Because un-wristed laparoscopic instruments make suturing in this location very difficult, sewing the defect closed is not typically done, and the mesh is not sewn in place. Instead, the nylon mesh that overlaps the edges of the defect by two to three inches is secured to the underside of the abdominal wall with specially designed staples or tacks. (fig. 8) It is also necessary to provide additional fixation of the mesh to the abdominal wall using transfascial sutures. These sutures must be placed through and through both the abdominal wall and the mesh using a specially designed needle (fig. 8) They are then tied on the outside of the abdomen and the knots are pushed back through the puncture wounds in the skin so they come to lie on the top of the fascia. (photo 2) Depending on the size of the mesh, there are usually 6 to 8 of these transfascial sutures (in addition to the staples or tacks),
Photo 2
Photo 2
spaced evenly around the edge of the mesh. (fig. 8) With the fixation of the mesh thus accomplished in the underlay position, the forces on the inside of the abdomen push the mesh against the underside of the abdominal wall facilitating ingrowth of tissue into the mesh, thus strengthening the repair. However, since the transfascial sutures encompass a through and through portion of the abdominal wall, spasms of the abdominal muscles occur contributing to significant postoperative pain. Moreover, because the hernia defect is seldom sutured closed (i.e., the mesh simply bridges the hernia defect), A above is not typically accomplished with the traditional laparoscopic repair. However, since B, C, and D above are accomplished, repairing these defects laparoscopically has greatly reduced the incidence of recurrence---from up to 30% or more in the open repair to less than 5% with a laparoscopic repair. This is particularly true in overweight patients or those in whom wound healing is compromised by diabetes, steroids, or smoking. For this reason, absent extenuating circumstances, I now do practically no open ventral hernia repairs.

Robotic Laparoscopic Ventral Hernia Repair:

Figure 9
Figure 9

As noted above, the traditional laparoscopic technique is still associated with two significant drawbacks. Because the defect is typically left open, the strongest repair is still not achieved. In addition, the transfascial sutures are very painful (the pain can be well controlled with injectable medication, but this usually necessitates a longer hospital stay). As a result the majority of general surgeons are continuing to use the open approach to ventral hernia repair rather than adopt a laparoscopic technique. However, the reduction in recurrence rate associated with the laparoscopic repair was so compelling that I began to consider how the da Vinci® robot could be used to maintain the advantages of the laparoscopic approach to repair of ventral hernias while overcoming the two drawbacks. (Again, the reader is referred to the full description of the capabilities of the da Vince® robot in my write-up Robotic, Laparoscopic & Open Surgery: How Do They Differ In Abdominal Operations?). A colleague and I began developing this approach in October of 2005. It soon became apparent that the wristed instruments of the robot gave us the ability to sew in this otherwise difficult to reach location.

Figure 10
Figure 10
This meant it was now possible to suture the defect closed (fig. 9) – an almost impossible task with traditional un-wristed laparoscopic instruments. At the same time, when it proved to be necessary, we could rather easily reduce the tension this closure created on the sutures by making relaxing incisions inside the abdominal wall on each side of the repair. This was achieved without increasing the scope of the procedure or the incidence of wound complications because these incisions were accomplished from inside the abdomen through the small laparoscopic punctures used to gain access to the surgical site. In addition we were able to precisely position the mesh in place and sew it directly to the underside of the abdominal wall, eliminating the need for the painful transfascial sutures necessary in the traditional laparoscopic approach. (fig. 10) To evaluate whether this approach led to less post-operative pain, we studied a series of our patients from October of 2005 through August of 2006 and presented our findings at the 2007 meeting of SAGES (The Society of American Gastrointestinal and Endoscopic Surgeons). Although this study included a relatively small number of patients, in fact we did demonstrate a statistically significant reduction in post-operative pain with this robotic laparoscopic approach when compared to traditional laparoscopic repair.

Since presenting our findings in 2007, I have continued to evolve my robotic technique for the repair of ventral hernias. The major, unresolved issue associated with the robotic ventral hernia repair (or an open approach with an underlay mesh repair) was that at times part of the mesh, if not all of it, was exposed to the underlying structures inside the abdomen—primarily the intestine. To avoid this drawback and the resulting adhesions (i.e. scars) that can develop between the intestine and the mesh when placed in this location, I have recently been able to use the robot to develop an approach that involves placing the mesh inside the abdominal wall—immediately next to the underside of the muscles of the abdomen rather than on the underside of the entire abdominal wall itself. The mesh is still properly positioned against the muscles with sutures and then absorbable tacks are placed throughout the mesh to further facilitate ingrowth of tissue into all areas of the mesh. This is still an underlay technique, but has the advantage of completely excluding the mesh from any exposure to the underlying structures inside the abdomen (including intestine) while maintaining all of the other advantage to this robotic form of ventral hernia repair.

In summary then: with the drawbacks of the traditional laparoscopic approach addressed with the robotic laparoscopic technique, all four primary goals in establishing the strongest possible ventral hernia repair have been accomplished. Given these advantages, including reducing the higher recurrence rate associated with the open repair and reducing the post operative pain associated with the transfascial sutures needed in the laparoscopic approach, I now do virtually all ventral hernia repairs using this evolved robotic laparoscopic approach.

Postoperative Course

Even though the robotic laparoscopic surgical approach is significantly less painful than either an open operation or a conventional laparoscopic approach to ventral hernia repair, it is still significantly more painful than repairs done in locations that do not require suturing within the abdominal wall (for example, in the groin for inguinal hernia repair). For this reason, patients with ventral hernia repairs may be kept more comfortable by remaining in the hospital for 24 to 48 hours so that epidural pain control can be used for postoperative pain until they can be comfortably managed with oral prescription pain medicine. However, if the hernia is small and the patient is otherwise healthy and is getting adequate pain control with oral prescription pain medicines (usually Norco and Toradol), discharge on the same day of surgery is certainly not uncommon if the patient desires.

To further help with post-operative pain control in patients I anticipate might go home on the same day of surgery, at the end of the procedure I may insert two catheters (tiny plastic tubes) into the operative site. These catheters are then connected to a bulb that is filled with a long acting local anesthetic. I discharge the patient home with these in place and over the next four days the bulb automatically and continuously pushes the local anesthetic through the catheters into the operative site to help reduce postoperative pain. Even after the bulb is empty, the apparatus can remain in place until the catheters are painlessly slid out at the time of the first postoperative visit in the office. However, if the catheters or bulb are causing significant annoyance, they can certainly be removed earlier if you wish (especially after the bulb is empty). There is a clear plastic adhesive covering the catheters that keep them in place. If you simply peel away that covering, the catheters will painlessly peel away at the same time because they are not otherwise fixed to you at the surgical site. It is not necessary to cover the site where the catheters have been, although you may want to apply a band aid to protect your clothing if you notice any clear serous drainage from the site.

Patients are discharged home with a prescription for oral pain medicines because they are likely to experience some bloating or fullness in the abdomen, some cramping gas pain, or pain that is felt in the shoulder area (on either side). In addition there may well be some tenderness or soreness in the areas of the puncture wounds in the abdomen. All of these symptoms may last up to several days. Patients are therefore encouraged to take enough pain medicine to be up and around since activity is good for blood circulation, bowel function and respiratory function. Prescription pain medicine should be taken with food to minimize the nausea that sometimes results when taken on an empty stomach. Prescription pain medicine can also contribute to constipation, so measures should be taken to minimize that effect. Within days, most patients find that over-the-counter medicines such as Advil or Motrin provide enough relief from surgical discomfort that they are able to do most of their day to day activities, and within 10 to 14 days are usually back to their normal routines. At the first post-operative visit, those who perform physically demanding work or have significant work-out routines should ask specifically about resuming those more strenuous activities. Driving can be resumed when you are not under the influence of prescription pain medicine – and when you can sit in a chair and demonstrate to yourself that you can perform a slam on the brakes motion without being limited by pain.

Wound care is certainly minimal. In most patients I use a surgical adhesive to close the small punctures (usually three of them) where the laparoscopic instruments and camera were inserted to conduct the surgery. These punctures are typically on the side of the abdomen, away from the actual defect, and will have a crust over them until the glue wears off in a week or so. In addition, a band aid is usually placed on top of each puncture site, primarily to keep the crust that develops from catching on clothing. The band aids can be left in place, changed if they come loose, or removed altogether. They are not needed for protection of the puncture sites. It is perfectly ok for patients to shower the day after the operation, but it is best to avoid tub baths, hot tubs and swimming until after you’ve been seen at your first post-operative visit (i.e., avoid soaking the puncture sites).

I usually send patients home with an abdominal binder. Although it is not necessary to wear the binder if the patient is more comfortable leaving it off, many describe that it provides comfort by relieving some of the pressure against the repair. It also may reduce the amount of fluid (serum) patients tend to accumulate in the space left behind where the contents of the hernia were reduced. A patient may or may not be aware of this fluid, but the body compensates for the created empty space by filling in with a varying amount of this fluid, depending on the size of space left behind. It’s worth clarifying that the temporary bulge created by the fluid accumulation is just that - a fluid bulge (seroma) -- not a recurrence of the hernia. Development of this seroma is very common and usually resolves on its own. However, if it persists, it may need to be drawn off with a needle and syringe, perhaps on more than one occasion. This can be done in the office during a post-operative visit and does not cause any significant discomfort, so is nothing to dread.

There are no dietary restrictions as a result of this operation, so patients are able to start their usual dietary routine shortly after surgery, even prior to hospital discharge.

Patients should never hesitate to call if experiencing anything that seems to be out of the ordinary, such as worsening pain, nausea and/or vomiting. If you have concerns, call.

Frequently Asked Questions:

If I have a hernia in my abdomen, does the surgeon need to use a mesh to repair it?
Ans: The answer to this question is almost always – yes. If the hernia is very small and can be repaired with a simple one or two stitch repair, an approach without a mesh can be tried. But in general the incidence of recurrence is significantly higher if a mesh is not used.

I have read that there are different kinds of mesh products available for surgeons to use. How do you choose?
Ans: This is a very complicated subject. Each surgeon will have his or her own preferences about which mesh to use and the choice will depend on your particular circumstances. However, in general, there are two large categories of mesh products: synthetic – usually nylon or polyester, and biologic – usually made from human or pig tissue specially treated to remove all of the individual cells leaving behind just a fibrous matrix that, when implanted, becomes remodeled and incorporated by the body as its own. The majority of hernias are very suitable to a synthetic mesh. The biologic meshes are usually reserved for hernias that have been associated with or caused by a previous infection.

I have read about mesh for hernia repairs being recalled. Is this a concern?
Ans: To date there has only been one significant recall of a mesh used for ventral hernia repair. This mesh has a plastic spring built into the edge of the mesh that expands open after it has been placed in position and stretches the mesh flat against the underside of the abdominal wall. The design flaw in this product was that some of these rings broke in two because of the continual flexing back and forth of the abdominal wall. Over time some of these rings injured the underlying intestine. This assist design has in general not been helpful to surgeons with significant experience doing laparoscopic hernia repair and of no help at all to those who use the da Vinci® system to perform this operation. Note: mesh placed in the pelvis to repair or prevent protrusion or prolapse of the bladder or uterus is a different application and placed in a different location so should not be compared to mesh used to repair ventral hernias.

If I have had a previously placed mesh that has been recalled, does it need to be removed?
Ans: No. Removal of these recalled products requires a very significant operation and should not be considered until or unless it is causing symptoms.

What are the most common complications of a ventral hernia repair?
Ans: Infection and bleeding into the wound can certainly occur, but are uncommon in ventral hernias if they are repaired before they develop into large defects involving most of the abdominal wall.

I need to have my gallbladder removed. Does using the laparoscopic approach reduce the likelihood I will develop a hernia in one of the incisions?
Ans: Yes, but it doesn’t eliminate the possibility altogether. Anytime an incision is made in the abdominal wall, even for one of the small ports used for laparoscopy, incomplete healing can result in the development of an incisional hernia. However, in general, the smaller the incision in the wall of the abdomen, the less likely a hernia is to result.

I have a very large hernia that involves nearly my entire abdomen. Am I a candidate for a robotic laparoscopic repair?
Ans: Perhaps not. But that would need to be determined by your surgeon after he/she actually examines your abdomen. It would also depend on that surgeon’s experience with robotic laparoscopic techniques.

I’ve heard about something called single port surgery. What is this?
Ans: Conventional & robotic laparoscopy is typically done through three or more small ports or tubes, each inserted into the abdominal cavity through its own separate puncture. The telescope (attached to the camera) goes through one of these ports and the instruments that the surgeon uses are passed through the others. Positioning the instruments and telescope separately from each other facilitates the conduct of the operation because each instrument can be used independently without interfering with or bumping into the other. Single port surgery is a technique in which the telescope and as many as three additional instruments are inserted through the same (one) port at the same time. This eliminates the need for any assist ports whatsoever – hence the term Single Port Surgery (SPS). However, passing the telescope and multiple instruments through one port significantly constrains the surgeon’s movements. There are conflicts not only between instruments but between those instruments and the telescope. To reduce the impact of these constraints, an add on modification to the da Vinci® robot has been developed that bundles all of the instruments and the telescope together into one port. This modification, known as Single Site Surgery, allows abdominal laparoscopy to be done robotically through a single incision. This add on feature to the da Vinci® can eliminate the need for some if not all of the additional small punctures used for assist ports in conventional laparoscopy - and as designed, does reduce the collisions the instruments have with each other and with the telescope. But so far, the only advantage of using this technique that has been documented in the medical literature has been a slightly improved short term cosmetic result. The potential disadvantage of using it comes from the 2 ½ to 3 times larger incision needed to accommodate all instruments and the telescope together through one site rather than the smaller punctures used to conduct either conventional or robotic laparoscopic surgery. This larger incision seems to be associated with more postoperative pain in some patients. In addition some of the preliminary trials evaluating this technique have reported an incidence of hernia formation that is 5 to 7 times higher through this larger incision than that through the punctures used to conduct either conventional or robotic laparoscopic surgery. So, whether there will be an ongoing role for this approach and if so what that role will be has yet to be established in the medical literature. Note: the da Vinci® system is still utilized as described in my write-up for robotic laparoscopic procedures. The Single Site Surgery System is only added on/attached to the da Vinci® platform when a surgeon is conducting a surgery through a single port.

What is NOTES?
Ans:NOTES is an abbreviation for Natural Orifice Translumenal Endoscopic Surgery as distinguished from NOS, an abbreviation for Natural Orifice Surgery. These natural orifices (openings) include the mouth, the nose, the anus, the vagina, and the urethra.

Many patients are already familiar with procedures or operations that are done by gaining access through naturally occurring orifices (openings). For example, a colonoscopy is a NOS procedure. It is accomplished by inserting a tube through the anus up into the colon. However, the bowel wall is left intact so the scope stays on the inside of the bowel. No incision is made through the bowel wall to gain access to tissue or structures outside its lumen. If a specimen is obtained (such as a polyp) it is removed from within the bowel’s lumen. In this circumstance, since the bowel wall remains intact, there is no risk of bowel contents passing from inside the colon into the peritoneal cavity.

So how does NOTES differ from NOS? The "T" in NOTES stands for “trans” or “across”. So this approach involves making an internal incision across (through) the wall of the structure that is approached through the natural orifice. It is an attempt to avoid making any external incisions at all, either in the abdomen or the chest, and is being advocated primarily for cosmetic purposes. An example of a NOTES procedure would be removing the gallbladder through a naturally occurring orifice. The surgeon could gain access to the gallbladder through the mouth (but that would require cutting across the wall of the stomach), through the anus (but that would require cutting across the wall of the colon), or in a woman, through the vagina. However, to make an incision through the wall of the colon (or stomach, or vagina) simply to avoid the small external puncture-like incisions in the abdominal wall associated with laparoscopic surgery puts the patient at risk for complications that would otherwise be avoidable. The additional internal incisions made in the bowel, stomach or vagina not only have to be closed securely but those incisions must heal without incident or complication if one is to advocate for this approach. The thrust behind developing the NOTES technique is primarily cosmetic. This is certainly a desirable goal, but only if it does not subject the patient to unnecessary or increased risk of potentially major complications that the patient would otherwise not have been exposed to if the NOTES approach had not been used.

Whether or not this approach will ultimately find its way into mainstream surgical practice is far from settled, but there is significant work underway developing equipment to conduct this type of surgery. This development is in its infancy, and none of these approaches have yet been validated in the medical literature as being either safe or effective. So, while it is certainly an interesting concept, NOTES remains very much in its developmental stage. And since it has the potential of being associated with significant complications that are not associated with conventional laparoscopic techniques, most of us feel that for the foreseeable future, it should not be conducted outside the setting of an organized and approved clinical trial and should be associated with an extensive and fully informed consent.

Hopefully this has provided you with insights you’ll find helpful for your specific situation, but you should never hesitate to discuss additional or clarifying information with your surgeon.