Ascension Via Christi Hernia Center

Groin Hernia

There are many ways to repair a groin hernia. Each surgeon has their own preferences. In our practice, we perform all of the types of repairs listed below. Each patient is different, generally a groin hernia operation can be an outpatient procedure with an expected return to activity 10-14 days after the operation.

• Open repair without mesh: A 1-2 inch incision is made over the hernia and the hernia is sewn shut using the body’s tissues without re-enforcing mesh. If a patient has a high risk of wound infection and is not a candidate for a minimally invasive operation, this type of operation may be the best option.
• Open repair with mesh: This is how most hernias are repaired in the United States today. A 1-2 inch incision is made and the hernia is sewn shut and then re-enforced with mesh.
• Minimally invasive: This is surgery performed through small incisions. It usually leads to faster recovery, less pain, lower infection risk, and quicker return to activity, though not always. These operations use several small incisions with a total length of less than one inch. There are two general categories of minimally invasive groin hernia surgery:
  • Laparoscopic surgery uses a camera and hand held instruments to perform the hernia repair. There are two different ways to perform laparoscopic repairs but both involve approaching the hernia from the inside of the abdominal wall and using a piece of mesh to cover the hole. This is how 83% of our hernia repairs are performed.
  • Robotic-assisted surgery follows the same principles as laparoscopic surgery but uses the daVinci robot system to move the instruments. This allows for the surgeon to see and move with extreme precision. Robotic-assistance allows for patients that may not otherwise be candidates for minimally invasive surgery to have their hernias repaired while still getting the benefits of the minimally invasive operation. In our practice this operation is considered for patients who have had prostate surgery, gynecologic surgery, or types of pelvic surgery or radiation.

Abdominal Wall Hernia

There are several techniques to fixing an abdominal wall hernia. Each one has its own particular advantages and disadvantages. Many patients are often discharged home the same day and return to normal activity in 10-14 days. More complex repairs may require longer hospital stays and rehabilitation.

Our goal is choose the right technique based on the patient’s unique set of variables.

One important factor to consider in each of these repairs is the use of mesh. Re-enforcing hernia repairs with mesh dramatically reduces the chance that a hernia will recur after repair (see Mesh). However, mesh is also associated with complications. Hernia surgeons have found that placing the mesh within the layers of the abdominal wall, rather than in the abdominal cavity itself significantly reduces the chance for mesh related complication.

Most minimally invasive repairs place mesh inside the abdominal cavity. We utilize new cutting-edge robotic-assisted technology that allows us to achieve the goal of placing mesh in layers of the abdominal wall through small incisions. This method allows the patient to gain the benefit of minimally invasive surgery while still achieving mesh re-enforcement with decreased risk of mesh-related complications and wound complications, such as infection.

• Open hernia repair: An open repair is traditional open surgery with its attendant risks and benefits. This can often be the best option for the patient, especially in patients with very small or very large hernias or who have skin problems over their hernia. Mesh may not be necessary in hernias less than 1/2 inch, women who plan to become pregnant, or in patients with complicated hernias or infected wounds. When mesh is necessary, we attempt to place it within the layers of the abdominal wall and not in the abdominal cavity, thus keeping the mesh away from the intestines and hopefully limiting future mesh complications.
• Minimally invasive hernia surgery is performed through small incisions. These techniques can lead to faster recovery, less pain, lower infection risk, and a quicker return to activity.
  • Laparoscopic hernia repair uses a camera and hand-held instruments to perform repair. The traditional teaching of this operation involved not sewing the hernia defect closed and instead used the mesh to “bridge the gap” between the sides of the hernia. This type of repair, also known as an “interposition”, is associated with less desirable cosmetic results as well as an increased likelihood of hernia recurrence. As a result the practice of bridging repairs has largely been abandoned. Most surgeons attempt to close the hernia before placing mesh.
  • Robotic-assisted hernia repair allows for the hernia to be sewn closed more than 96% of the time (115). There are several ways to perform a robotic-assisted hernia operation:
    • IPOM: Stands for intraperitioneal onlay mesh (IPOM). Most surgeons place the mesh in the abdominal cavity after sewing the hole closed. The mesh sits next to the abdominal contents and complications can result from interaction between the mesh and the intestines (see Mesh). Sometimes these complications will not become apparent until years later when the patient has another abdominal operation. Sometimes placement of mesh in the abdomen is the only reasonable option, but we try to avoid it when possible.
    • TAPP: Stands for trans-abdominal preperitoneal repair (TAPP). The layer of abdominal wall next to the intestines is called the peritoneum. Working outside this layer the hernia can be repaired and mesh can be placed. This keeps the mesh out of the abdominal cavity by using the peritoneum as the barrier and limits the complications that mesh in the abdominal cavity can cause.
    • eTEP: Stands for enhanced-view totally extraperitoneal hernia repair. It is generally employed for larger or more complicated hernias. The mesh can be placed directly behind the abdominal muscle. Not only is the mesh kept out of the abdominal cavity but the abdominal cavity is usually not entered to the extent that occurs with other operations. This can limit the potential for injury to the intestines during the hernia repair. It allows for large mesh to be placed in what surgeons believe to be the most optimum mesh position, behind the abdominal muscles while still gaining the benefits of minimally invasive surgery (see Mesh). When compared to open surgery, eTEP patients are discharged from the hospital 1-2 days sooner than similar operations performed in the open fashion (116).

Abdominal Wall Reconstruction

Sometimes a hernia becomes so large that the edges cannot be sewn back together without a special set of techniques referred to as release maneuvers. Abdominal wall reconstruction is the term used for the operation where these release maneuvers are employed to fix a hernia.

Because the abdominal wall is made of a series of overlapping strength layers, sometimes one of these layers can be divided and moved over to cover a large hernia, leaving the remaining layers to provide strength for the abdominal wall. Think of a sliding glass patio door with one layer sliding over the other to close the door.

There are several different types release maneuvers that can be performed and knowing when and how to employ these specialized techniques is something in which hernia surgeons specialize. These include open and minimally invasive operations and each maneuver has its own unique benefits, risks, advantages and disadvantages.

Our center is one of the only in the region to offer minimally invasive release maneuvers. These operations are complex and time consuming. Sometimes, a minimally invasive release maneuver is not the best choice for a particular patient. However, the benefits of minimally invasive release maneuvers are less blood loss, less pain, and shorter hospital stays. Above all though, operative experience is key.

A brief description of the different types of release maneuvers:

• Open Anterior Release: This is performed though a traditional open incision. This release maneuver involves dividing a layer of tissue referred to as the external abdominal oblique aponeurosis, or EAO. It is well-studied and useful in that it can help get large hernias closed. It does have some limitations. It requires dividing tissue away from the abdominal wall and this process can result in reducing the blood supply to the abdominal wall, leading to problems with wound healing. Most hernia surgeons avoid this problem by performing a “perforator sparing” version of this release. It is an effective operation and large hernias can be repaired but potential wound complications need to be considered. As traditionally described, the operation involves dividing two planes of tissue on each side of the abdomen. Most surgeons only divide one and as a result do not obtain the full release that the operation can provide.
• Endoscopic Anterior Release: This variation on the anterior release was conceived because of the wound healing issues noted above. It involves placing a balloon under the layer of tissue to be divided and then performing the release maneuver through small incisions, usually with the laparoscope. This maneuver is effective in limiting the wound complications traditionally associated with the open operation. The quality of the release in regard to how much the tissues can be moved is not as good as the open operation, however. Thus it is more difficult to close large hernias.
• Posterior Component Separation: This operation avoids the traditional wound problems associated with anterior release because it divides a different layer of tissue. Division of the transverses abdominus muscle allows for a large space to be created with no physiologic consequence. This is referred to as the TAR release. The first results of this technique were published in 2012, so it is a relative new comer to hernia surgery. This is an excellent tool for large hernia closure but it is an operation that requires skill, experience, and patience. Division of the wrong anatomic plane can lead to profound and costly consequences.
• Robotic-assisted trans-abdominal posterior component separation: This operation involves the same operative maneuvers as the poster component separation described above, except that it is performed through six 1/4 inch incisions. Also technically demanding, this operation has proved to be the operation of choice for large hernias. Benefits to this approach include less blood loss, less pain, and more rapid discharge from the hospital. Most patients are discharged on postoperative day #1 or #2, compared with day #4 or #5 in patients who require and an open operation with a release maneuver.
• Robotic-assisted eTEP/TAR: One of the benefits of the eTEP described above is that it can be transitioned into a posterior component separation. Still using 6 small incisions, or sometimes 4, the entire release can be performed with the goal of never entering the abdominal cavity. This affords the advantage decreasing the risk of injuring the intestine.

Hiatal Hernia

Hiatal hernias can be repaired using open or minimally invasive techniques. When the repair is elective and not an emergency the repair is usually performed in a minimally-invasive fashion with robotic-assistance. The same benefits that accompany other minimally-invasive hernia surgeries apply to hiatal hernia surgery as well. Generally, there is a less blood loss, less pain, and less time spent in the hospital.

Parastomal Hernia

Parastomal hernias occur around an ostomy where the intestine or another organ has been purposefully allowed to drain through the abdominal wall into a collecting bag. About 50% of patients with ostomies will develop a hernia (114).

Having success with these difficult repairs is difficult for many reasons. The best way to deal with a hernia around an ostomy is to move the ostomy or reconnect the bowel. These options are not applicable in some patients, however. Preoperative planning and optimization are even more important in these circumstances.

Usually these hernias are initially repaired using minimally invasive techniques and often with robotic-assistance. Recurrent hernias often require open approaches with abdominal wall reconstructions.

Fistula

A fistula is an abnormal communication between two organs or spaces in the body. This can be a debilitating and life altering problem.

Certain diseases, trauma or injury, or complicated abdominal surgery can lead to formation of a fistula. Also, fistulas formation is a rare complication from placement of mesh, usually in the setting of mesh infection or hernia surgery that has been complicated by bowel injury.

Operations to fix fistulas are complicated and complex but with planning and preparation can be affected successfully.

Mesh Removal

Mesh has revolutionized the treatment of hernias. Sometimes a patient can have a complication that leads to a compromise the mesh or can come to involve it. The best example of this is a wound infection leading to a mesh infection. In this circumstance the mesh sometimes needs to be removed.

Rarely, the mesh can be the source of the complication itself. Installing a foreign substance, like mesh, into the body causes the body to react. This response calms over time and the mesh grows into the tissues surrounding it. This is what it is designed to do. Sometimes the body’s reaction persists and this can lead to pain, loss of flexibility, and decreased quality of life. Though this is extremely rare and sometimes the best treatment is to remove the mesh.

Mesh removal is a consequential decision and can lead to other issues. Mesh removal can be an extremely complex operation. It is not to be taken lightly and hernia surgeons are well equipped to deal with these issues. Operations are not always required but if they are, preoperative planning and management of expectations are the keys to success.