Explanation written by Barry N. Gardiner, M.D.
Some may prefer just this brief statement identifying the approach I recommend for incisional hernia repair. In the vast majority of cases I’m able to use a robotic (daVinci™) laparoscopic technique to accomplish the repair. This approach reduces the recurrence rate to less than 5-7% (from up to 30% reported with most “open surgery” techniques), and it 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 Dr. Gardiner’s write-up “Robotic, Laparoscopic & Open Surgery: How Do They Differ?”, and then to the detailed write up of Incisional Hernia below.
Overview of hernias:
Why do they occur, and when?
How are they diagnosed?Most often, the patient notices the bulge and seeks a medical opinion. At the time of consultation, we are usually able to diagnose an incisional hernia by simple physical examination given the presence of a visible and palpable bulge through the abdominal wall in the vicinity of a previous incision. (photo 1)
What are the symptoms?The main symptom of an incisional hernia is a soft bulge under the skin, usually underneath or adjacent to the 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 by lying down and relaxing.
Why repair them?There is no acceptable nonsurgical treatment for an incisional 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.
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
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?Going forward the term “incisional hernia” may be used (and illustrated) interchangeably with “ventral hernia” because the surgical repair I use for all ventral hernias (epigastric, incisional and umbilical) is essentially the same.
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 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. Laparoscopic surgery offered an alternative to open surgery that would prove to significantly reduce the unacceptably high recurrence rate of all ventral hernias (not just incisional 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)
A. 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.
B. 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.
C. Place the mesh inside the abdomen on the underside of the abdominal wall (underlay repair). Placed in this location, pressures inside the abdomen (including those caused by physical activity) force the mesh against the underside of the abdominal wall, facilitating the body's ingrowth/fusion into the mesh.
D. Achieve the broadest possible contact of mesh with 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 a minimum of 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?
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 Repair:In the traditional "open" repair, the previous incision is opened, the hernia 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:
- 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 will 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
- 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
- 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
- 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 not a commonly used technique.
Laparoscopic Repair:(Reminder: conventional laparoscopic technique is described fully Robotic, Laparoscopic & Open Surgery: How Do They Differ?”). Repairing an incisional hernia with any open technique requires making an incision at the site of the previous incision and dissecting through the skin, fat, fascia, and muscle layers to expose the hernia defect. (fig. 6) Instead, the laparoscopic approach avoids this dissection (and its potential complications) by accessing the abdominal cavity through three small punctures in the abdominal wall. (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 back into the abdominal cavity and then divides across the adhesions (scars) from the prior operation. Because un-wristed laparoscopic instruments make suturing in this
Robotic laparoscopic surgical approach:
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 necessitates a longer hospital stay). As a result the majority of general surgeons are continuing to use the "open" approach rather than adopt a laparoscopic technique.Robotic, Laparoscopic & Open Surgery: How Do They Differ?"). 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. This means it is now possible to suture the defect closed - an almost impossible task with traditional "un-wristed" laparoscopic instruments. (fig. 9) At the same time, if 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 approach.
In summary: 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 robotic technique.
Even though the robotic laparoscopic surgical approach is significantly less painful than either an open operation or a conventional laparoscopic approach for this operation, it is still significantly more painful than repairs done in locations that do not require suturing in the underside of the abdominal wall (for example, in the groin for inguinal hernia repairs). For this reason patients with ventral hernia repairs frequently are more comfortable remaining in the hospital for pain control with IV pain medicine until they can be comfortably managed with oral prescription pain medicine (usually within 24 hours). Occasionally, if the hernia is small and the patient is otherwise healthy and is getting adequate pain control with oral prescription pain medicine - usually Norco or Vicodin - discharge on the day of surgery is certainly reasonable if the patient desires.
Most patients will have just three small punctures (where the laparoscopic instruments were inserted), closed with a surgical adhesive glue that wears off in a week or so. These "puncture incisions" 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. 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 your first post-operative visit (i.e., avoid "soaking" the puncture sites).
I usually send patients home with an abdominal binder. Relieving some of the pressure against the repair seems to make them more comfortable and it also may reduce the amount of fluid these patients tend to accumulate in the space left behind when the contents of the hernia are removed. It is not necessary to wear the binder if the patient is more comfortable leaving it off.
In most patients I insert two catheters into the operative site at the end of surgery. These catheters are very small plastic tubes connected to a bulb that is filled with a long acting local anesthetic. I discharge the patient home with these catheters in place. The bulb automatically and continuously pushes the local anesthetic into the operative site over the next four days to help reduce postoperative pain. These catheters are painlessly "slid out" in the office at the first postoperative visit.
Patients are discharged home with prescription oral pain medicine since there will probably be significant enough discomfort for up to 3 to 4 days following the repair that it will be needed. Patients are encouraged to take enough pain medicine to be "up and around" since activity is good for circulation, bowel function, and respiratory function. Within days, most find that over-the-counter medicines such as Advil or Motrin provide adequate enough relief from discomfort to be able to do most of their day to day activities, and within 10 to 14 days are usually back to their "normal" routines. Those who perform physically demanding work, or have significant work-out routines should ask specifically about resuming that activity. 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.
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, 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: The only significant mesh recall has been the Composix mesh manufactured by Bard and it has since been recalled under direction of the FDA. 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 daVinci system to perform this operation.
➤ If I have had one of these Composix meshes installed, 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.
➤ I've heard that after surgery, "fluid" can accumulate under the skin where the hernia was. What is this?
Ans: The body doesn't "like" empty spaces. When contents of the hernia are "reduced" back inside the abdomen, fluid accumulates in the space that this leaves behind. This is a very common occurrence and usually resolves on its own. However, if this fluid accumulation persists, it may need to be drawn off with a needle and syringe, and may have to be done on more than one occasion. This can be done in the office during a post-operative visit. It does not cause any significant discomfort, so is nothing to "dread".
➤ 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 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 laparoscopic or a robotic repair?
Ans: Probably 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 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 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 port at the same time. This eliminates the need for any "assist" ports whatsoever - hence the term "Single Port Surgery" (SPS). However, using multiple instruments passed through one port along with the telescope significantly constrains the surgeon's movements. There are conflicts not only between instruments but between those instruments and the telescope. And since up to three instruments and the telescope are all bundled together and passed through the same port, the incision in the abdomen through which that port is inserted must be substantially larger than any of the individual ports used to conduct conventional or robotic laparoscopic surgery. The development of this technique is still in its infancy and many of the instruments that will enable its adoption (including a robot configured for SPS) are still under development or in restricted use. Despite this, an internet search for SPS will already produce a number of reports describing its use; although none have yet to establish a clear advantage of this technique over conventional or robotic laparoscopy. An additional concern is that the larger incision this technique requires may well place the patient at greater risk of developing an incisional hernia. So, whether there will be a role for this approach, and if so what that role will be, has yet to be established in the medical literature.
➤ 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 within the bowel's lumen (cavity). 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 comes from within the bowel's lumen. In this circumstance, since the bowel wall remains intact, there is no risk of bowel contents passing from the lumen of 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, at this stage in its development NOTES remains experimental. And since it has the potential of being associated with significant complications that are not associated with conventional laparoscopic techniques, most of us feel it should not be conducted outside the setting of an organized and approved clinical trial and it must be associated with an extensive and fully informed consent.