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Complex Hernia

What is hernia and where it is located ?

Hernia is a lump or mass that is caused due to weakness or strain in the muscle tissue in the abdominal area. It occurs when an organ pushes in through an opening of a muscle or the adjoining tissue that holds it intact. For example a portion of the small intestine or large intestine may protrude out from the weakened portion of the abdominal wall which may cause pain and discomfort. Hernias usually form in the abdomen region, may also form in the belly area, upper thigh and groin portion. Hernia once formed does not dissolve on its own and has to be removed surgically, they may not be a life threatening but cause severe pain and discomfort and may turn out be complicated to remove as one ages. The most common types of hernia are :

  • Inguinal Hernia: Inguinal hernia is formed in the inguinal canal when the intestines protrude from the lower abdominal wall which has become weak. These types of hernia are quite common and comprise almost 70% of the hernias, and are most commonly found in men.
  • Hiatal Hernia: A hiatal hernia forms when a part of the stomach protrudes through the diaphragm into the chest. The diaphragm is a muscle sheet that helps us breathe by contracting and drawing oxygen into the lungs. It separates the organs in the abdomen from those in our chest.
  • Umbilical Hernia: Umbilical hernias form in babies under 6 months old usually. This happens when the intestines bulge out through the abdominal wall near the bellybutton. One may find a bulge in or near the child’s bellybutton, particularly when they are crying. This hernia disappears usually when the child is one or two years, if it does not then the surgery is performed.
  • Incisional Hernia: Incisional hernias can occur after any abdominal surgery. The intestines may push through the incision scar or the surrounding area of the, weakened tissue or muscles causing severe cramps.
 

What is complex hernia ?

A hernia is a relatively common condition that can affect the young and mostly elderly men and women over the age of 50. Hernia is estimated to affect approximately 5 percent of the population at any given point of time in their lives.

 

How does it occur ?

Abdominal wall hernia repair has made major advances in recent years owing to extensive research, leading to smoother recovery minimizing resurfacing of the hernia, dismantling post repair incision-point tension, and making treatment possible for hernias previously considered impossible to repair.

A hernia becomes complex when repeated surgical attempts to close the hole in the abdominal wall fail. When the surrounding tissue is particularly weak or stretched it may need o be augmented or replaced. This often occurs in the places of previous surgical scars, the umbilicus part or the groin region.

Treating complex hernia:

There is a potential risk that the piece of intestine poking through can get trapped, its blood supply restricted, and then start to die eventually. This is often termed as a strangulated hernia or strangulated bowel. It’s medical emergency that needs immediate treatment to avoid peritonitis, infection that spreads throughout the inside of the abdomen.

Most hernia repairs are straight and forward and can done using open surgery or with laparoscopic hernia repair procedures. In certain cases there can be complications such as:

Recurrent hernias:

They return after surgical repair. They have to be treated very carefully by specialized procedures.

Complicated incisional hernia:

scar tissue and weakness in the abdominal wall due to any previous abdominal surgery such as a caesarean section or an appendix removal poses a challenge and may lead to complex hernias. Repair or plastic surgery to remove and replace scar tissue may often be the answer.

 

What is the repair for complex hernia ?

Several techniques have emerged over the last three decades to address the growing challenges in mesh repair as well as primary closure techniques.

It is established fact that mesh based repairs have a recurrence rate of 5 to 30% as opposed to primary repair sutures only with recurrence rates over and above 50%. Additionally laparoscopic techniques have demonstrated that recovery is faster and hernias of many sizes are treatable. Despite the advancement in minimally invasive techniques adopted, large hernias and resurfacing hernias after repair remain a challenging situation for patients and precarious for surgeons to operate upon.

Laparoscopic surgery can be opted for complex hernias. Instead of a single long incision few requisite tiny incisions are made in the area around the hernia. A device called a laparoscope which is a mini scope is attached to a video camera, and is inserted into one of the incisions. The surgeon can ably see the hernia and the surrounding tissue and the affected organ on a video screen.

Instruments used to repair the hernia are then inserted through the other incisions and the surgery proceeds in much the same way as any open surgery.

Post operative complications:

Any procedures associated with surgery carry the risk of certain complications. Only a small percentage of people who undergo complex hernia repair surgery have postoperative complications, which include :

  • Bruising the scrotum and shrunken testicles can occur in men following an inguinal hernia repair
  • Bleeding
  • Inability to urinate
  • Infection
  • Resurfacing of the hernia
  • Respiratory problems usually resulting from general anaesthesia

The surgeon should be notified immediately if you cannot urinate, experience severe pain that is unrelieved by medication, develop fever of 101F or higher or have bleeding, discharge, and or severe swelling at the incision site.

Advantages of laparoscopic surgery :

Laparoscopic surgery techniques were developed at the end of the 1980s has since become the method of choice for many abdominal operations. Surgery with laparoscopy is minimally invasive and does not require a large incision. It less complex and recovery is faster.

Laparoscopic hernia repair for inguinal hernias:

Laparoscopy can be opted to treat inguinal hernia, but must be performed by a team who has specialisation in it to avoid post laparoscopy complications though very rare in nature. Care must be taken to avoid infections or re occurrence of hernia.

Femoral hernia:

Femoral hernia is relatively a rare type of hernia (only 3% of all hernias) but it is more common in women. A femoral hernia is named by its location, just below the ligament in the upper thigh.

This type of hernia is quite dangerous because it is likely to strangulate. This means that the piece of bowel that pushes out through the body wall becomes pinched and starts to die out. If this happens, it can lead to life threatening complications. Any lump in the groin should be addressed and assessed by a medical professional as soon as possible if the lump is irreducible or be broke (cannot be pushed back to the abdomen).

 
How is a laparoscopic hernia repair performed?

A laparoscope is a fibre optic instrument that is inserted in the abdominal wall or any other area where hernia is present. This device transmits images from within the body to a video monitor connected to instrument allowing the surgeons to see the affected region on the screen. The operation is usually done under general anaesthesia as a day procedure.

A central incision is made in the abdomen portion to place the laparoscope into the space between the skin and the body wall.

The instruments are then placed through two or three other ports at the side of the abdomen. These are lowered down to one side for groin hernias.

The surgeon uses images transmitted from the camera inside the laparoscope to push the fatty tissue and bowel that is sticking through the hole in the body wall.

Hernia repair mesh is then stitched in place using stitches that dissolve over the next few weeks.

The laparoscope and instruments are then pulled out and the port incisions are closed.

Recovering from laparoscopic hernia repair:
You will be wheeled to the recovery room after your. Even if you have this procedure done for a complex or resurfaced hernia, the recovery time will be relatively faster. You will normally need over the counter painkillers for a day or two and will be back to daily activities after about a week.

You will have discomfort at the site of the surgery and possibly in the shoulders or chest which will disappear gradually.

Open hernia repair surgery:

Many surgeons prefer to do open surgery hernia repair as it may be the best choice for the patient particularly if they have a huge complex hernia.

During a routine traditional open surgery for hernia repair:
The surgeon makes a single incision (generally 2 to 4 inches) in the abdominal wall. The protruding tissue or organ is moved back into place. The surgeon closes the abdominal wall and refurbishes it with synthetic mesh. The surgeon then closes the incision with several stitches.

After an open hernia repair patients can go home the same day, but need bed rest for at least a few days. Depending on the type of job you do you may be away from work two weeks or more.

Preventing hernia:

You can’t always prevent the muscle weakness that allows a hernia to occur. However, one can reduce the amount of strain one places on the body. This may help avoid hernias or keep the existing hernia from getting bad to worse. Prevention tips include :

  • Not smoking,
  • Not abusing alcohol intake
  • Exercising regularly
  • Maintaining Ideal body weight

Outlook:

It’s important to recognize the early signs of a hernia. An unattended hernia will not go away on its own and may create problems or discomfort. However with medical care or lifestyle changes, one can reduce the effects of hernia and avoid life threatening complications like strangulation or resurfacing of the hernia.

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