Hernia Repair

What Is a Hernia?

A hernia (or "rupture") is a weakness or defect in the wall of the abdomen. This weakness may be present at birth. Or, it can be caused by the wear and tear of daily living. If left untreated, a hernia can get worse with time and physical stress.

When a Bulge Forms

A weak area in the abdominal wall allows the contents of the abdomen to push outward. This often causes a noticeable bulge under the skin. The bulge may get bigger when you stand and go away when you lie down. You may also feel pressure or discomfort when lifting, coughing, urinating, or doing other activities.

Type of Hernias

The type of hernia you have depends on its location. Most hernias form in the groin at or near the internal ring. This is the entrance to a canal between the abdomen and groin. Hernias can also occur in the abdomen, thigh, or genitals.

An incisional hernia occurs at the site of a previous surgical incision. An umbilical hernia occurs at the navel. An indirect inguinal hernia occurs in the groin at the internal ring. A direct inguinal hernia occurs in the groin near the internal ring. A femoral hernia occurs just below the groin. An epigastric hernia occurs in the upper abdomen at the midline.

Surgery: The Best Treatment

A hernia will not heal on its own. Surgery is needed to repair the defect in the abdominal wall. If not treated, a hernia can get larger. It can also lead to serious medical complications. The good news is that hernia surgery can be done quickly and safely. In most cases, you can go home the same day as your surgery.

How a Hernia Develops

Although a hernia bulge may appear suddenly, hernias often take years to develop. They grow larger as pressure inside the body presses the intestines or other tissues out through a weak area. With time, these tissues can bulge out beneath the skin.

Stages of Hernia Development

The wall weakens or tears: The abdominal lining bulges out through a weak area and begins to form a hernia sac. The sac may contain fat, intestine, or other tissues. At this point, the hernia may or may not cause a visible bulge.	The intestine pushes into the sac: As the intestine pushes further into the sac, it forms a visible bulge. The bulge may flatten when you lie down or push against it. This is called a reducible hernia and does not cause any immediate danger.
The intestine may become trapped: The sac containing the intestine may become trapped by muscle (incarcerated). If this happens, you won’t be able to flatten the bulge. You may also have pain. Prompt treatment may be needed.	The intestine may become strangulated: If the intestine is tightly trapped, it becomes strangulated. The strangulated area loses blood supply and may die. This can cause severe pain and block the intestine. Emergency surgery is needed.

Having Hernia Surgery: Traditional Repair

Surgery treats a hernia by repairing the weakness in the abdominal wall. An incision is made so the surgeon has a direct view of the hernia. The repair is then done through this incision (open surgery). To repair the defect, a mesh patch may be sewn (sutured) in place, to make a "traditional repair." Follow your doctor’s advice on how to get ready for the procedure. You can usually go home the same day as your surgery. In some cases, though, you may need to stay in the hospital overnight.

Getting Ready for Surgery

Your doctor will talk with you about preparing for surgery. Follow all the instructions you’re given and be sure to:

• Tell your doctor about any medications, supplements, or herbs you take. This includes both prescription and over-the-counter items.
• Stop taking aspirin, ibuprofen, and naproxen as directed.
• Arrange for an adult family member or friend to give you a ride home after surgery.
• Stop smoking. Smoking affects blood flow and can slow healing.
• Gently wash the surgical area the night before surgery.
• Don’t eat or drink after midnight, the night before your surgery.

The Day of Surgery

Arrive at the hospital or surgical center at your scheduled time. You’ll be asked to change into a patient gown. You’ll then be given an IV to provide fluids and medication. Shortly before surgery, an anesthesiologist will talk with you. He or she will explain the types of anesthesia used to prevent pain during surgery. You will have one or more of the following:

• Monitored sedation to make you relaxed and sleepy.
• Local anesthesia to numb the surgical site.
• Regional anesthesia to numb specific areas of your body.
• General anesthesia to let you sleep during surgery.

During the Surgery

To make a traditional repair, an incision is made over the hernia. A piece of mesh is inserted to cover the area of the abdominal wall defect without sewing together the surrounding muscles. The mesh is safe and generally well-accepted by the body’s natural tissues.

After Surgery

When the procedure is over, you’ll be taken to the recovery area to rest. Your blood pressure and heart rate will be monitored. You’ll also have a bandage over the surgical site. To help reduce discomfort, you’ll be given pain medications. You may also be given breathing exercises to keep your lungs clear. Later, you’ll be asked to get up and walk. This helps prevent blood clots in the legs. You can go home when your doctor says you’re ready.

Having Laparoscopic Hernia Repair

Once you know you have a hernia, you and your doctor can discuss laparoscopic surgery to repair it. Laparoscopic surgery is done with a laparoscope, a tiny "telescope" attached to a camera. It allows your surgeon a close-up view of your hernia using only small incisions. Because large incisions are not required, recovery from laparoscopic surgery is often faster and less painful than after open surgery. The surgery usually takes 1 - 2 hours. You can likely go home the same day.

Preparing for Surgery

• Schedule lab tests: You may have blood tests, an ECG (electrocardiogram), and a chest x-ray. These tests help ensure that your heart and lungs are healthy enough for surgery.
• Ask about medications: Before surgery, you may be told to stop taking some medications, such as aspirin, ibuprofen, or herbal remedies.
• Quit smoking: To avoid straining your hernia from "smoker’s cough" and to promote good blood flow for healing, ask your doctor for help quitting smoking.
• Avoid heavy lifting: Avoid putting strain on your hernia. Don’t do any heavy lifting before your surgery.
• Keep your stomach empty: Don’t eat or drink anything (not even water) after midnight the night before surgery. Your surgery may be canceled if you eat or drink before surgery. If you take any regular medications and have been told to continue them, take them with small sips of water.
• Arrange for help after surgery: Plan to have someone drive you home afterward. You’ll want to take it easy after surgery, too, so you may need extra help at home.

Just Before Surgery

• You’ll be asked to sign consent forms.
• Your doctor or anesthesiologist will talk with you about the anesthesia you’ll be given during surgery.

During the Procedure

• You’ll be given general or regional anesthesia. This keeps you free from pain during surgery.
• You will have 3 - 4 small incisions. The laparoscope and other instruments are inserted through these incisions. The laparoscope has a tiny video camera that sends clear images to a video monitor.
• Carbon dioxide gas is injected into your abdomen through an incision near your navel. The gas inflates your abdomen, allowing your surgeon to work.

At VSA the totally extra peritoneal repair (TEP) approach during surgery is generally used. This provides for the placement of a large preperitoneal mesh with rapid return of patients to normal activity after repair and excellent long-term results.

Placing the Patch

The surgeon repairs the hernia, then places strong mesh directly over the weak spot in your abdominal wall. The mesh acts just as a patch would on a tire wall. The mesh is secured with surgical staples, tacks, clips, or sutures. These stay in place permanently. Neither the mesh nor the staples are harmful to your body. Other reinforcement methods besides mesh may be used. After the mesh is applied, the gas is released from your abdomen.

Discharge Instructions for Hernia Surgery

Arrange to have an adult drive you home after surgery. If you had general anesthesia, it may take 24 hours or more to fully recover. During this time, don't drive, use machinery or power tools, drink alcohol, or make any major decisions.

CARE FOR THE INCISION: 24 hours after surgery you may remove the bandages and shower. NO TUB BATHS or swimming for one week. Gently pat the incision dry after showering. There may be staples or tape (steri-strips) across the incision, which are to be left in place. Re-apply a light gauze dressing if you wish. Use an ice pack over the incisional and/or groin area intermittently in periods of 15-20 minutes fot the first 24 hours after surgery.

DIET: For the first 24 hours after surgery, you may not have much of an appetite or feel able to tolerate heavy foods. We encourage you to keep up with your liquids. As your appetite increases, you will find yourself eating normally. There are no restrictions- just eat what your system can tolerate.

MEDICATION: You will be given a prescription for pain medication. Take this as directed for post-operative pain. If you are experiencing only mild discomfort, you may find over-the-counter medications, such as Tylenol (acetaminophen) or Advil/Nuprin (Ibuprofen), may be all you need for comfort. If constipation becomes a problem, an over-the-counter stool softener (Metamucil) or a mild laxative (Milk of Magnesia) may be taken.

WHAT TO LOOK FOR: You may notice a slight drainage (usually pink or reddish in color), bruising, or slight swelling around the incision. This is normal and not cause for concern. Likewise, it is normal to have a lump or hardness under or near the incision. You may also have bruising and some swelling of the genitalia, which is not uncommon. However, please call our office immediately if you develop any of the following: excessive drainage, redness or swelling at or around the incision, fever over 100.5°F, persistent nausea or vomiting, or difficulty with urination.

REDUCING SWELLING: Early on, it’s common for the area around your incision to be swollen, bruised, and sore. To reduce swelling, put an ice pack or bag of frozen peas in a thin towel. Place the towel on the swollen area 3 - 5 times a day for 15 - 20 minutes at a time. Immediately post-operative, it is recommended men wear briefs in place of boxer shorts to provide additional support. This also aids in reducing post-operativeswelling. If needed, an athletic supporter may be worn.

An ice pack helps reduce swelling.

FOLLOW UP: You will be seen in our office 7 to 10 days after your surgery and again in several weeks. Prior to surgery, you should have made an appointment for your first post-operative visit. If for some reason that appointment was not scheduled, please call our office at (703) 359-8640 as soon as your return home to schedule your appointment.

IF DIFFICULTIES ARISE: Please call us if any problems or questions arise. We can be reached any time, including evenings and weekends, by calling our office number (703) 359-8640.