Brandon H. Kilgore, MD, FACS Hernia surgery Brandon H. Kilgore, MD, FACS

Definition A defect or hole allowing contents of one cavity to pass into another cavity or potential space Most commonly, this hole occurs in the fibromuscular tissues comprising the abdominal wall This is an anatomic problem requiring surgery for definitive treatment.

Types of Hernias Inguinal Umbilical Incisional Traumatic: Lumbar Direct Indirect Femoral Umbilical Incisional Traumatic: Lumbar Repetitive strain: “Sports Hernia”

Causes of Hernia Relative ‘weakness’ of tissue Openings or previous openings in the abdominal wall (or canal where a structure perforates the wall) Groin: spermatic cord or femoral vessels Umbilicus: umbilical cord Any incision: scar is weak relative to native tissue Any activity that increases intra-abdominal pressure - thereby increasing abdominal wall tension - may contribute to development of hernia signs or symptoms Heavy lifting, coughing, straining, strenuous activity

Symptoms Bulge May be obscured in obese individuals Natural history: enlarge over time Pain Usually caused by stretching of the hernia ring Improved by ‘reduction’ of the hernia ‘contents’ Worse in evening, after upright, after straining Diagnosis: description of symptoms, physical exam (sometimes imaging)

Complications Incarceration Obstruction Strangulation Hernia contents get stuck – and cannot be reduced Requires EXPEDITED surgery Obstruction When bowel is extruded through a hernia and becomes so tight that food cannot pass through that segment Causes severe pain, nausea, vomiting Requires URGENT surgery Strangulation When hernia contents – especially bowel – become stuck so tightly that adequate blood flow cannot reach these contents Causes necrosis (death) of the strangulated contents Eventually results in perforation, peritonitis, sepsis, and death Requires EMERGENT surgery

Indications for Surgery / Timing Complications of hernia Potentially incapacitating or life-threatening Symptoms of hernia Lifestyle- and productivity-limiting Presence of hernia Potential for development of complications Greatest potential: new, small, femoral, recurrent, scrotal Otherwise difficult to predict who will experience complications (2.8% @ 3mo, 4.5% @ 2y; 0.0018 hernia-related adverse events / patient-year) Potential for development of symptoms Asymptomatic groin hernias may be followed, but a quarter to a third become symptomatic within 2-4 years. Impaired perception of health or ?decreased productivity

Principles of Inguinal Surgery Tension = Recurrence Suture repair = Tension Forces are concentrated at the suture line Mesh = minimal tension  standard of care Distributes tension over the surface area of the mesh Less pain than suture repair Prosthetic (woven plastic lattice) mesh: more durable Allows ingrowth of tissue (incorporates into the tissue) Less dependent upon tissue healing for success Few exceptions: contamination, small umbilical hernia

Types of Inguinal Hernia Surgery Open (anterior) Single incision directly overlying the abnormal anatomy Dissection is distant from bowel and vasculature Mesh is sutured anterior to the fascia Recurrence rates are thought to be lower (<5%) Improved durability may be preferable for manual laborers Pain may be greater up to 2 weeks Laparoscopic (posterior) Multiple incisions distant from anatomy Potential for incisional hernia in addition to recurrence Mesh is tacked posterior to fascia Potential for rare but serious complications Recurrence rates are thought to be higher (up to 10%) Pain may be less in first 2 weeks Possible earlier return to work for sedentary workers (~1 day)

Principles of Ventral Hernia Surgery Reconstruction of normal anatomy Reduce or excise hernia contents Excise hernia sac Excise scar Reapproximate native tissues under minimal tension May require component separation Mesh reinforcement Posterior prosthetic mesh Anterior biological mesh Meticulous wound closure Excise redundant tissue

Types of Surgery for Ventral Hernia Umbilical Suture repair if small Fascial closure over mesh ‘patch’ ?laparoscopic Incisional Laparoscopy Unable to reestablish native anatomy Hole remains, but excluded from abdomen Possible seroma formation Less pain & decreased length of recovery Open Combined suture closure and(?dual) mesh reinforcement Greater potential for wound complications Longer in-hospital and at-home recovery

Surgical Consultation Surgery will not be at the time of initial visit Initial visit will include history, examination, discussion of options, and explanation of risks. Request that patients bring the following: List of previous medical conditions and surgical interventions List of current medications and allergies If pt has had previous surgery for hernia, please bring operative reports.

Outpatient Surgery Logistics Preoperative prohibitions Eating or drinking after midnight Aspirin, plavix, coumadin, pradaxa, etc. Smoking Timing Admitting & pre-op prep: ~1.5 hours Surgery: 1-1.5 hours Recovery Room: 1-2 hours Outpatient Surgery Recovery: 2-6 hours Postoperative checklist Pain and nausea control Tolerate liquids Ambulatory Urinate Ride home

Surgical Risks Medical risks of anesthesia & surgical stress Heart attack, stroke, kidney failure, blood clot, pneumonia, abnormal heart rhythm Infection & wound complications Bleeding Mesh complications Recurrence Nerve injury(numbness & chronic pain) Urinary retention Risks of intra-abdominal surgery Bowel, bladder, vascular injury, etc.

Early Post-Operative Expectations No driving for 2-3 days or while on narcotics Swelling, bruising, and soreness are common Keep wound clean & dry for 2 days – no immersion for >1 week Generally plan to avoid travel for 1 week Diet is as tolerated but prudence is advised Expect increased rest requirements Ambulate multiple times a day Ensure adequate bowel function

Pain & Return to Work Varies widely between people and procedures Return to Work dependent upon: Type of procedure (open incisional v. umbilical) Patient comorbidities (age, obesity, debilitation, etc.) Availability of ‘light duty’ for 4-8 weeks Laparoscopy & Umbilical hernia Pain should be much improved after 1 week Return to work when stamina & pain allow (~1wk) Open Inguinal Hernia Pain may last 2 days to 2 weeks Return to work within 2 weeks given pain & stamina WC patients may experience greater time off work over those with commercial insurance (34 days vs. 13 days)

Rationale for activity restrictions Tensile strength The tendency of the wound to resist disruption Native, intact tissue > operated tissue / scar Increases with wound remodeling and collagen deposition Proportional to time Nears eventual strength at approximately 6 weeks Healing is slowed by tobacco use, diabetes, steroid administration, etc. Need tensile strength to increase prior to activities which would disrupt the repair: Heavy lifting & coughing > moderate lifting, bending, straining > jogging, walking