Laparoscopic Hernia Repair | Specialist Surgery Singapore Pte Ltd

WHAT IS A HERNIA?

A hernia occurs when the inside layers of the abdominal muscle have weakened, resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon-like sac. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems that could require emergency surgery.
Both men and women can get a hernia.
You may be born with a hernia (congenital) or develop one over time.
A hernia does not get better over time, nor will it go away by itself.

HOW DO I KNOW IF I HAVE A HERNIA?

The common areas where hernias occur are in the groin (inguinal), belly button (umbilical), and the site of a previous operation (incisional).
It is usually easy to recognize a hernia. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, and strain during urination or bowel movements, or during prolonged standing or sitting.
The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day.
Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon.

WHAT CAUSES A HERNIA?
The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness present from birth. Anyone can develop a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting, persistent coughing, and difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate.

Laparoscopic inguinal hernia repair
Laparoscopic hernia repair is similar to other laparoscopic procedures. General anaesthesia is given, and a small incision is made in or just below the navel. The abdomen is inflated with air so that the surgeon can see the abdominal organs.

A thin, lighted scope called a laparoscope is inserted through the incision. The instruments to repair the hernia are inserted through other small incisions in the lower abdomen. Mesh is then placed over the defect to reinforce the abdominal wall.

There are many things to consider when deciding if you should have inguinal hernia repair surgery, such as whether your hernia is incarcerated or strangulated and whether you have other conditions that need to be addressed before hernia repair surgery is appropriate.

What to Expect After Surgery
Most people who have laparoscopic hernia repair surgery are able to go home the same day. Recovery time is about 1 to 2 weeks.

Studies have found that people have less pain after laparoscopic hernia repair than after open hernia surgery.¹

Why It Is Done
Surgical repair is recommended for inguinal hernias that are causing pain or other symptoms and for hernias that are incarcerated or strangulated. Surgery is always recommended for inguinal hernias in children.

Laparoscopic hernia repair is offered along with open surgery for hernia repair. It may be the preferred option for people who need to return quickly to work or other activities and for those who have hernias on both sides.²

Laparoscopic surgery repair may not be appropriate for people who:

Have an incarcerated hernia.
Cannot tolerate general anaesthesia.
Have bleeding disorders such as haemophilia or idiopathic thrombocytopenic purpura (ITP).
Are taking medicines to prevent blood clotting (blood thinners or anticoagulants, such as warfarin).
Have had many abdominal surgeries. Scar tissue may make the surgery harder to do through the laparoscope.
Have severe lung diseases such as emphysema. The carbon dioxide used to inflate the abdomen may interfere with their breathing.
Are pregnant.
Are extremely obese.

Laparoscopic hernia repair usually is not done on children. But a laparoscope may be used during open hernia repairs in children to explore the opposite groin for a hernia. This can be done by inserting the laparoscope into the side that is being operated on and looking at the opposite side. If a hernia is present, the surgeon can repair both sides during the same operation.

How Well It Works
Laparoscopic surgery has the following advantages over open hernia repair:

Some people may prefer laparoscopic hernia repair because it causes less pain and they are able to return to work more quickly than they would after open repair surgery.
Repair of a recurrent hernia often is easier using laparoscopic techniques than using open surgery.
It is possible to check for and repair a second hernia on the opposite side at the time of the operation.
Because smaller incisions are used, laparoscopy may be more appealing for cosmetic reasons.

What to Think About
Doctors and researchers of laparoscopic hernia repair say that laparoscopy has not yet been proved to offer long-term advantages over open surgery. They stress the need for more studies on laparoscopic safety and effectiveness in hernia repair.

Laparoscopic hernia repair is different from open surgery in the following ways:

A laparoscopic repair requires several small incisions instead of a single larger cut.
If hernias are on both sides, both hernias can be repaired at the same time without the need for a second large incision. Laparoscopic surgery allows the surgeon to examine both groin areas and all sites of hernias for defects. In addition, the patch or mesh can be placed over all possible areas of weakness, helping prevent a hernia from recurring in the same spot or developing in a different spot.
Most of the time, a person must receive general anaesthesia for laparoscopic repair. Open hernia repair can be done under general, spinal, or local anaesthesia.

Laparoscopic repair of a hernia is more expensive than open surgery because of the increased costs associated with slightly longer operating room time and the cost of laparoscopic technology.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED OR COMPLETED BY THE LAPAROSCOPIC METHOD?
In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

WHEN TO CALL YOUR DOCTOR
Be sure to call your physician or surgeon if you develop any of the following:

Persistent fever over 101 degrees F (39 C)
Bleeding
Increasing abdominal or groin swelling
Pain that is not relieved by your medications
Persistent nausea or vomiting
Inability to urinate
Chills
Persistent cough or shortness of breath
Purulent drainage (pus) from any incision
Redness surrounding any of your incisions that is worsening or getting bigger
You are unable to eat or drink liquids

Laparoscopic Incisional (Ventral) Hernia Repair

Laparoscopic hernia repair is a technique to fix tears or openings in the abdominal wall using small incisions, laparoscopes (small telescopes inserted into the abdomen) and a patch (screen or mesh) to reinforce the abdominal wall. It may offer a quicker return to work and normal activities with decreased pain for some patients.

What is an Incisional (Also called as Ventral) Hernia?

When an incisional hernia occurs, it usually arises in the abdominal wall where a previous surgical incision was made. In this area the abdominal muscles have weakened; this results in a bulge or a tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a balloon-like sac. This can allow a loop of intestines or other abdominal contents to push into the sac. If the abdominal contents get stuck within the sac, they can become trapped or “incarcerated.” This could lead to potentially serious problems that might require emergency surgery.
Other sites that ventral hernias can develop are the belly button (umbilicus) or any other area of the abdominal wall.
A hernia does not get better over time, nor will it go away by itself.

How Do I know if I have a Hernia?

A hernia is usually recognized as a bulge under your skin. Occasionally, it causes no discomfort at all, but you may feel pain when you lift heavy objects, cough, and strain during urination or bowel movements or with prolonged standing or sitting.
The discomfort may be sharp or a dull ache that gets worse towards the end of the day. Any continuous or severe discomfort, redness, nausea or vomiting associated with the bulge are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon is recommended.

What causes an Incisional Hernia?

An incision in your abdominal wall will always be an area of potential weakness. Hernias can develop at these sites due to heavy straining, aging, injury or following an infection at that site following surgery. They can occur immediately following surgery or may not become apparent for years later following the procedure.
Anyone can get a hernia at any age. They are more common as we get older. Certain activities may increase the likelihood of a hernia including persistent coughing, difficulty with bowel movements or urination, or frequent need for straining.

What are the advantages of Laparoscopic Repair?
Results may vary depending on the type of procedure and each patient’s overall condition. Common advantages may include:

Less post-operative pain
Shortened hospital stay
Faster return to regular diet
Quicker return to normal activity

Am I a candidate for the laparoscopic repair?
Only after a thorough examination can it be determined whether a laparoscopic incisional hernia repair is right for you. The procedure may not be best for some patients who have had extensive previous abdominal surgery, hernias found in unusual or difficult to approach locations, or underlying medical conditions.

What preparations are required?

Unlike inguinal hernia repair, incisional hernia repairs require overnight stay or longer in the ward, based on the case and will be discussed at the time of assessment in the clinic.
Preoperative preparation includes blood work, medical evaluation, chest x-ray and an ECG depending on your age and medical condition.
It is recommended that you shower the night before or morning of the operation.
Based on the case you may need bowel preparation for the surgery. You may be requested to drink clear liquids, only, for one or several days prior to the operation.
After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.(This also depends on the time of surgery and is adjusted accordingly)
Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.

How is the procedure performed?
There are few options available for a patient with an incisional hernia.

The use of an abdominal wall binder is occasionally prescribed but often ineffective.
Incisional hernias do not go away on their own and may enlarge with time.
Surgery is the preferred treatment and is done in one of two ways.
- The traditional approach is done through an incision in the abdominal wall. It may go through part or all of a previous incision, skin, an underlying fatty layer and into the abdomen. The surgeon may choose to sew your natural tissue back together, but frequently, it requires the placement of mesh (screen) in or on the abdominal wall for a sound closure. This technique is most often performed under a general anaesthetic.
- The second approach is a laparoscopic incisional hernia repair. In this approach, a laparoscope (a tiny telescope with a television camera attached) is inserted through a cannula (a small hollow tube).

The laparoscope and TV camera allow the surgeon to view the hernia from the inside. Other small incisions will be required for other small cannulas for placement of other instruments to remove any scar tissue and to insert a surgical mesh into the abdomen. This mesh, or screen, is fixed under the hernia defect to the strong tissues of the abdominal wall. It is held in place with special surgical tacks and in many instances, sutures. Usually, three or four 1/4 inch to 1/2 inch incisions are necessary. The sutures, which go through the entire thickness of the abdominal wall, are placed through smaller incisions around the circumference of the mesh. This operation is usually performed under general anaesthesia.

What should I expect on the day of surgery?

You usually arrive at the hospital the morning of the operation.
A qualified medical staff member will typically place a small needle or catheter into your vein to dispense medication during the surgery. Often pre-operative medications, such as antibiotics, may be given.
Your anaesthesia will last during and up to several hours following surgery.
Following the operation, you will be taken to the recovery room and remain there until you are fully awake.
Few patients may go home the same day of surgery, while others may need admission for a day or more post-operatively. The need to stay in the hospital will be determined according to the extent of the operative procedure and your general health.

What happens if the operation cannot be performed or completed by the laparoscopic method?
In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.

When to call your doctor?
Be sure to call your surgeon if you develop any of the following:

Persistent fever over 101 F (39 C)
Bleeding
Increased abdominal swelling or pain
Pain that is not relieved by your medications
Persistent nausea or vomiting
Chills
Persistent cough or shortness of breath
Drainage from any incision
Redness surrounding your incisions