Abdominal Wall Hernia -
Laparoscopic Repair of Abdominal Wall Hernia
Abdominal wall hernia include epigastric, umbilical/para-umbilical, incisional and other rare hernias that involve the front of the abdomen wall. It may be an incidental finding or symptomatic. As any hernia, the usual way of repair involves using sutures or mesh, but with laparoscopic repair, we almost always repair with special mesh that fixed with clips and sutures to the abdominal wall.
Hernia usually present with gradually increasing swelling in the front of the abdomen, usually along the midline but could be to the sides, especially with incisional (previous wound) hernia. It may be reducible (disappear) on lying down or pushed back manually. It may be associated with mild ache or severe pain especially with lifting, sneezing or coughing. In severe cases, it becomes irreducible (stuck out and cannot be pushed back), causes bowel obstruction or strangulation (twist of hernial content to a limit that it cuts the blood supply to these structures, which could be bowel). These severe cases need urgent to emergent intervention with surgery and likely to be open surgery rather than key hole. You may have a combination of different types of abdominal hernia, but they still can be repaired together through the same surgery.
Clinically; symptoms and signs
Conservative: Do nothing, avoid heavy lifting, may use truss
over hernia site. Recommended for elderly frail patients unfit
for surgery. Risks of hernia persist.
Surgery: Laparoscopic / Open repair +/- Mesh
Laparoscopic hernia repair includes reducing the hernial content
(with/without the sac) back in to the abdomen then sealing the defect
from behind with mesh that is fixed to the abdominal wall with
clips and fascial sutures (4-6 sutures placed at the corners of the
mesh and tied on to the muscle). I don’t normally leave any drains
neither need for NG tube (tube through the nose to decompress the
stomach). I may insert a catheter in to the bladder especially in
repairing lower abdominal incisional hernia. This will be removed
soon after surgery. The operation may include division of adhesions
especially in incisional hernia. The wounds of this operation usually
include three left wounds and sometimes an extra right small
wound placed to help with mesh fixation (see the figure).
Infection, bleeding, visceral injuries (injuries to surrounding organs), removal of unhealthy bowel, seroma (collection of fluid in the cavity between the mesh and the skin where the hernia was, usually settles by itself, but may need aspiration), mesh out, adhesions, recurrence of the hernia or development of new hernia at site of the wounds, chronic pain (due to entrapment of nerve with the sutures or clips, this usually settles spontaneously), clot in the leg (DVT) that might migrate to the lung (PE) and cardiorespiratory complications. Also risk of conversion to open surgery, which is usually an incision over the hernia itself.
You will have general ache with backache and shoulder pain due to the inflation of the abdomen with gas that takes 48hr to be absorbed. It is advisable to have your pain killers regularly for the first 5 days then reduce them until stopping them.
There are no stitches to be removed, you will have glue over the wounds. You could have a shower but no bath until day 5 when you can rub the glue off in the bath.
Most patients can be discharged between day 2-3 days after surgery although those with conversion to open surgery need to stay for an extra 2-3 days to recover. Before discharge from hospital you need to meet 5 conditions:
• Feeling well and mobilising
• Tolerating soft food and drinking without being sick (vomiting)
• Normal observation (pulse, blood pressure and temperature)
• Passed urine
• Someone will stay with you overnight
You will have generalised ache and wound pain that usually lasts for 2-3 days, during which, you are advised to take your pain killers regularly and then taper them down when you need to. You can walk, but be careful with stairs, always protect your larger wounds when coughing, sneezing or straining. You should avoid driving the first 10 days, and after that, if you are able to control your vehicle and press emergency brake, then you can drive. Gradually increase activity back to normal over the the three weeks following surgery, but avoid heavy lifting or exercise for 6-8 weeks.
Ideally, you should avoid flights, especially long distance ones in the first four weeks after surgery and better to check with your flight insurer before booking.
We can give you a sick note for two weeks and if you need an extra week, your doctor (GP) can provide you with this.
I will review you in the clinic around 4-6 weeks following the surgery to assess your recovery and; if you have any problems, you could contact my secretary or the hospital ward to bring forward your appointment.