Laparoscopic Ventral and Incisional Hernia Repair
Laparoscopic view showing loop of colon with small bowel herniating through mesentery into the abdominal wall
Many a time, a patient may find a defect at the site of a previous abdominal surgical incision. They may also witness a small balloon-like sac protruding out of the incisional site due to slackening of the muscular wall of the abdomen or at the site of the previous operation. These are called ventral or incisional hernias. Sometimes, internal organs or a loop of the intestine may get trapped in this sac and cause severe pain and discomfort.
This trapping of the intestines is called incarceration and can represent an emergency. Surgical interventions are often necessary to repair the defect in the abdominal wall and remove the sac-like protrusion. This operation is often performed using a small-telescope like instrument called a laparoscope.
Indications for laparoscopic repair
It is not always possible to carry out a laparoscopic ventral hernia repair. It is only if the patient is considered medically fit to undergo general anesthesia that they will be considered eligible for a laparoscopic ventral hernia repair. In addition to this, surgery is feasible only if the surgeon is confident of placing the laparoscopic trocars in positions that are deemed ergonomically feasible for their surgery. In some cases, the hernia may be so large that the abdominal wall gets so distorted that it proves to be difficult to safely place laparoscopic trocars.
Multiple defects are shown which trapped loops of intestine and caused a small bowel obstruction
In such conditions, laparoscopic ventral hernia repair may not be feasible. The decision on whether a laparoscopic ventral hernia repair is feasible can be decided based on the physical examination, the number of previous incisions, as well as through ancillary studies such as a CT scan of the abdomen and pelvis. If the patient has a history of multiple operations and intrabdominal adhesions are suspected, the surgeon may require that you have a special bowel preparation to evacuate the colon before surgery. This helps in decreasing the amount of intestinal bacteria in the colon.
Symptoms that prompt ventral hernia repair
With a ventral hernia, the patient finds a bulge in the abdominal area, which is usually painless. However as the hernia may be tender and causes discomfort during physical strain like coughing and straining and during bowel movements, patients may consider having it repaired. One common finding is that the hernia bulge usually disappears when lying down and is more visible when standing. Other symptoms of hernia include vomiting, nausea and difficulty in having bowel movements. If there is continuous discomfort or nausea, it indicates that the hernia is strangulated and this is when the physician has to be contacted immediately.
The procedure
Picture of a two-sided mesh used for ventral hernia repair. Anchoring sutures used for transfascial placement are seen in each quadrant.
Special instruments, a videoscope, television monitors and small incisors are what are required for a laparoscopic ventral hernia repair. The surgeon first makes a small incision in the abdominal wall. It is up to the surgeon to choose the location where there is minimum risk of their running into organs and scar tissues that were involved in prior operations. A few other tiny incisions are made as required, depending on the amount of scar tissue that has to be removed, and how well they can see the hernia. Then a laparoscope is inserted through a small, hollow tube. It is through this laparoscope and TV camera that the surgeon can see the hernia in the body. Other instruments are then placed through a few more incisions to remove scar tissue in the body. With this, a surgical mesh is inserted into the abdomen, under the hernia defect, and attached to the surrounding stronger tissues found in the abdominal wall. This mesh is used to reinforce the weakened part of the abdominal wall, and thus prevent the hernia from recurring.
Advantages of laparoscopic ventral hernia repair
The greatest advantage of the laparoscopic ventral hernia repair when compared to the traditional surgical approach is that it offers quicker recovery with shorter hospital stays. In addition to this, there is a reduced risk of any infection and recurrence of the hernia. Patients usually return home within a day of the surgery, and have less pain with quicker return to normal activities.
Postoperative conditions
With laparoscopic ventral hernia repair, the chance of recurrence of hernia is about 10%, when compared to the 20 – 40% recurrence rate of the open procedure. Laparoscopic ventral hernia repair patients are generally encouraged to walk around as quickly as possible after the sugary. This is to avoid postoperative complications like pneumonia, pulmonary embolism and deep venous thrombosis. It is quite normal to experience some pain after the surgery wherein the patient is given IV narcotics as usual, and then put on oral analgesics the next day. After discharge, the patient has to visit the surgeon one to two weeks after discharge. No dietary restrictions have to be made after the operation while the amount of activity typically depends on a patient’s comfort level. However, it is not advised to engage in strenuous activities or heavy lifting for a few weeks, as the hernia mesh has to seal into place. When you experience fever, vomiting, chills, and difficulty in urinating and find some drainage from the incisions, call on the surgeon immediately. Otherwise, you can return to your normal activities within a short time of the surgery.
