The definitive and curative solution for a hernia is a surgical repair of the defect. Hernia surgery comes in several forms, but all defects are patched with mesh, called a tension-free repair, or closed mechanically with sutures (with tension).
Treatment for a hernia will largely depend on the type of hernia and its symptoms. Asymptomatic hernias that are found incidentally may or may not be repaired, usually based on patient preference after consultation with a qualified surgeon. Conversely, we universally suggest that femoral hernias be repaired as soon as possible because of the higher risk of strangulation and associated complications.
Hernia Surgery Options
Hernia surgery can be performed either open, laparoscopically or robotically. While open surgery is still performed on certain patients, it has become less common due to the large, single incision increasing the likelihood for chronic pain due to nerve damage, while also extending the recovery period. More often, hernias are repaired using laparoscopic or robotic techniques. Bilateral hernias are almost always repaired using laparoscopy because both sides can be repaired during one procedure. Recurrent hernias are almost always repaired laparoscopically or robotically as well.
Suture-based repairs involve no mesh. During the procedure, the surgeon mechanically closes the defect using string. Depending on the technique used, recurrence rates can be high because any pressure put on the repair, even after it has healed, can begin to tear the tissue already weakened from the sutures. While there are methods such as the Shouldice technique that minimize recurrence, Drs. Tsuda and Ryan believe that mesh remains the best option for most patients.
The debate over chronic pain and complications due to hernia mesh has also given rise to many options for hernia patients. The most common and least expensive option involves a plastic mesh fitted to the size of the hernia. The mesh is placed over the defect, creating a tension-free repair. Because of the inflammatory response of having a foreign object in the body, scar tissue develops around the mesh and this permanent implant becomes a strong barrier. Mesh-based hernia repairs have a recurrence rate of under 2%.
Recent concerns about permanent mesh have given rise to some very innovative options including absorbable mesh. This is a biological or synthetic-based mesh that creates an inflammatory response much like a plastic mesh, but is eventually absorbed into the body leaving no chance for mesh migration or failure. Recent data on absorbable mesh has shown similar repair strength to a plastic mesh.
How Hernia Surgery is Performed
Using traditional laparoscopy or robotic surgery, three, four or five small incisions are made in the abdomen with the largest incision often hidden in the umbilicus or bellybutton. The hernia contents are reduced – meaning any abdominal contents protruding through the defect are pulled back into the abdomen and the fascia is prepared for the mesh. A specially selected mesh, both in size and composition, is placed over the hernia, with enough excess material for proper coverage. Today, most meshes are self-adhering. This avoids the need for permanent or absorbable tacks that were once used to affix the mesh. The laparoscopic incisions are then closed and the umbilical incision is sutured.
Depending on the size of the hernia and the location, surgery requires about 45 minutes of operative time under general anesthesia. Hernia surgery is almost always performed on an outpatient basis, allowing patients to go home on the same day. After surgery, patients will spend a couple hours in the recovery area, and once they are able to urinate and ambulate, will be discharged with postop instructions.
The Advantages of the Laparoscopic Approach
While it is imperative that patients take at least six weeks of rest with minimal pressure on their abdomen after surgery, one of the great benefits of laparoscopic or robotic surgery is that the mesh is placed from the inside the abdomen. This means that any pressure put on the defect actually presses the mesh onto the fascia. If mesh was placed from the outside of the defect, even a hard sneeze could dislodge it, causing a complication.
Risks and Considerations for Hernia Surgery
Choosing a surgeon that is highly experienced in hernia repair, as well as mesh selection, gives patients the highest likelihood of a good outcome. However, just like any major surgical procedure, hernia surgery has risks. These risks may include pain, blood loss, failure of the mesh, chronic pain, infection, and in very rare cases, death. Laparoscopic surgery and robotic surgery have reduced the likelihood of these complications significantly when compared to open surgery.
A Note on Chronic Pain
There has been a great deal of controversy over the existence and prevalence of chronic pain, especially after inguinal hernia surgery. There are many theories regarding chronic pain, which we will discuss on a separate page. Click here to learn more about chronic pain after inguinal hernia surgery.
Deciding whether to have hernia surgery will largely depend on a consultation with Dr. Tsuda or Dr. Ryan about the specifics of your hernia. While not all hernias need to be repaired urgently, they are progressive and get more difficult to repair as they get larger. Further, the degree of pain is not indicative of the size of the hernia. Small hernias may be very painful while larger defects may not be painful at all. So, while symptoms may be minimal, it could still be advisable to have a repair.
Since the greatest risk remains hernia strangulation, older patients with weaker abdominal muscles and patients with larger hernias are less likely to experience this complication.
Most importantly, if patients experience significant pain from what they suspect to be a hernia, – if the area becomes red and inflamed and the patients develops a fever, they should report to the emergency room or dial 9-1-1 as soon as possible as emergency hernia surgery will be necessary.
Hernia Surgery Aftercare
Recovery and Aftercare from hernia surgery is similar to other abdominal procedures with some procedure-specific instructions. Schedule a consultation to learn more about hernia surgery aftercare.