Ascension Via Christi Hernia Center

Now more than ever, there are more options for the hernia surgeon in regard to technique (open surgery, laparoscopic surgery, robotic surgery) and products (mesh) than ever before.

When it comes to hernia surgery, however, one size very much does not fit all. So, how does your surgeon choose what to do and how do to it? Every surgeon is different, but here are some of our guiding principles:

Evidenced-based approach

We endeavor to make each and every decision that is made regarding the care of a patient, including planning and performing operations, based on best practices described by the medical literature. We are not making this up as we go along, but are guided by the principles of gathering, documenting, and using evidence to support taking the correct action at the correct time.

Minimally invasive surgery

Minimally invasive surgery is surgery through small incisions. Generally, patient’s recover faster and have less pain, but not always. The true benefit of minimally invasive surgery is decreased wound complications and infection. If a minimally invasive operation is considered, the expectation is that it has to be as good as or better than the traditional open procedure in regard to risk of complication and hernia recurrence rate. Our advanced minimally invasive capability sets us apart from our peers in the region.

Keep the mesh out of the abdominal cavity, when possible

As is described in Mesh, the development and placement of mesh to reinforce hernia repairs have revolutionized hernia surgery. Mesh placement in the abdominal cavity is not without risk, however. These risks can be decreased by placing the mesh in the layers of the abdominal wall, not in the abdominal cavity itself. Sometimes the only option for repair is to place mesh in the abdominal cavity, but every effort is made to implant the mesh within the layers of the abdominal wall and reduce the risk of mesh related complications. This priority is unique in this region and helps to set us apart from our contemporaries.

Maximize optimization before surgery

Healthier patients tolerate surgery and complications better. This is why we spend so much time talking about the process of optimization (see Optimization) and making each patient as healthy as they can be prior to their operation. Each patient has their own maximum potential, however. Once this point is reached, specific operations may be better choices than others.

Go into each operation with multiple plans of attack

The anatomy one may find during the actual operation may be much different that what was expected based on preoperative X-rays and examination of previous operative reports. Knowing how to repair a hernia in several different ways means that the surgeon can go into the operating room and can adjust the operative strategy based on what is found during the operation. The versatility in knowing when and how to switch from plan A to plan B, or even to plan C or D, comes with experience and being comfortable with multiple techniques.

Optimization is the process of trying to make the patient as healthy as possible before their operation.

This reduces complications and increases the durability of the hernia repair. Also, if a complication occurs the patient is more suited to tolerate whatever problem may need to be addressed.

Preoperative optimization is now considered every bit as important as surgical technique in the treatment of complex hernias. Often by the time a patient is referred to a hernia specialist they have had one or more failed attempts at repair. In evaluating many of these patients it is clear that some of the risk factors that would predict a higher risk of complication or hernia recurrence were not fully addressed prior to their original operations.

The key to having a good surgical outcome and a happy patient is getting the patient to be as healthy as they can be before and after the operation. This is essential in the care of all patients especially those with hernias.

Obesity

Target: BMI < 40 for complex laparoscopic or robotic repairs and all open repairs
BMI < 40-45 for noncomplex laparoscopic and robotic repairs

Rationale: There is no doubt that obesity (BMI > 30) is associated with an increased risk of medical and surgical complications in hernia repair. Chief among these are complications in wound healing that can result in a wound infection. These can range in severity from the inconvenience of a small wound infection to a severe problem that will require multiple operations and hospitalizations to correct (1, 2, 3, 4).

Although not shown in every study, much of the evidence available today supports the belief that obesity also contributes to an increased chance that the hernia will come back after repair (5, 6). This is referred to as hernia recurrence. Another repair, which will no doubt be costly and more complex, would be necessary to fix the recurrent hernia.

Complications that are associated with obesity also add to the cost of care for the patient and hospital. We know that reducing a patients weight prior to surgery, along with optimizing other risk factors, significantly decreases the charges for inpatient care, outpatient care, and total hospital charges (7). Another study has demonstrated that patient’s that hit their weight-loss targets incurred lower overall costs (8).

So achieving the goal BMI is better in all respects for the patient. It makes the operation safer, lowers the risk of complication, and costs less for everybody.

Generally speaking, minimally invasive repairs (laparoscopic or robotic surgery) usually are associated with lower risk of wound infection (9). Some patients question the need for weight reduction if a minimally invasive operation is recommended for them. There are three things that need to be kept in mind. First, a minimally invasive repair occasionally needs to be converted to open operation, so we must always plan for this possibility. Secondly, minimally invasive operations are usually longer and require more anesthesia than open operations. The more obese a patient is, the more difficulty they will have in tolerating and recovering from anesthesia. Finally, obesity is associated with other complications irrespective of the operative approach such as blood clots, pneumonia, and heart attacks (10).

Losing weight is not easy and we recognize that. We want to be your partners and will arrange for a nutritionist to work with you if needed and have regular discussions by phone or in person regarding progress. This process can and does work when both the patient and healthcare team are committed (11).

If medical weight loss therapy is not working, we can arrange a referral to discuss weight-loss surgery with a surgeon who specializes in this type of surgery.

Tobacco, Smokeless Tobacco, and Electronic Cigarettes

Target: Complete cessation and abstinence from cigarettes, smokeless tobacco, and electronic cigarette use 30 days prior to scheduled open operation or complex hernias. Recommended for all other operations.

Rationale: Cigarette smoking stands in the way of successful wound healing and significantly increases the risk of a wound infection. Smoking actually decreases the amount of blood and oxygen supplied to the tissues in your body (12, 13, 14). If a wound cannot get oxygen, it cannot heal.

There is a dose dependent relationship between smoking and wound complications and infections and death (15). Said another way, the more a person smokes, the greater the likelihood that they will have a problem healing their surgical wound, to say nothing of the greater chance of dying (15).

Open hernia repairs are especially sensitive to the risks of smoking because of the maneuvers that are required during a hernia operation. Smoking greatly increases risk of a complication from these operations (16, 17, 18).

Cessation of tobacco at least 30 days prior to surgery has been shown to be the minimal time required to decrease this risk (14, 19). During this interval of time nicotine replacement has been used as a bridge to completely quitting and does not appear associated with the same risk of smoking (19).

We will work with you to help you to stop smoking. Often this is the most difficult part of the optimization process and we recognize this fact but the importance of doing so cannot be overstated.

Diabetes

Target: Preoperative Hemoglobin A1C less than 7.0%.

Rationale: The high blood sugars associated with diabetes have long been associated with poor wound healing and a high risk of wound infections. These infections greatly increase the risk of the hernia repair failing and of mesh infection. These complications often require reoperation which will undoubtedly be more complex than the previous operation (20). This additional therapy is not only painful but costly.

In fact, patients with blood sugars greater than 180 (which corresponds to an A1C of greater than 8%) have constantly demonstrated significantly increased risk of infection, need for reoperation, and death (21, 22, 23, 24). The risk of the surgical wound coming apart, referred to as dehiscence, increases with a single episode of glucose greater than 200 after an operation (22).

The goal of preoperative optimization is to correct these glucose levels to a point where the possibility of these painful and costly complications is significantly decreased. Currently, the medical literature suggests that it is best to target a hemoglobin A1C of 6.5-7.5% (23, 24). This level of preoperative sugar control is associated with a decrease in overall infectious complications (23).

The strategy employed by our center first focuses on education and counseling. Working with a nutritionist and your primary care physician we will develop a strategy for control of your diabetes. If necessary, we occasionally refer patients an endocrinologist in order to assist with disease that is especially difficult to control.

Infectious disease

Target: Decrease the degree of infection or wound contamination present at the time of surgery.

Rationale: Much of what has been described in the optimization section so far (weight loss, diabetic control, and tobacco use) focus on decreasing the risk of wound infections. Surgeons will work diligently to limit any contamination of a wound that may lead to wound infection, whether it’s before, during, or after the operation.

Wound infection can occur after nearly any surgical procedure. This complication is especially relevant for the hernia surgeon because wound infections can lead to a chronic mesh infection, one of the most respected complications in hernia surgery (25). While some hernias in particular circumstances may not require mesh placement (mesh and mesh infections are discussed in greater detail in the Mesh section), nearly all complex hernias will require placement of mesh for long-term reinforcement of the hernia repair. Mesh is necessary to provide the best opportunity for a durable and long-lasting repair.

MRSA (methicillin-resistant Staphylococcus aureus) is a bacteria that is resistant to certain types of antibiotics and is especially problematic in hernia surgery. One study has noted that over half of the mesh infections during the study were infected with MRSA (26). Most concerning was that on average, the patient’s with mesh infections required an average of 2.1 additional operations (26).

Previous MRSA infection, regardless of where in the body it is, significantly increases the risk of wound infection within the first 30 days of the hernia operation (27). Previous MRSA infection also means that the hernia operation that needs to be performed will likely be a much more complex procedure (28).

In order to combat this problem, we have implemented a screening program for potential surgical patients (29, 30). Additionally, if a patient has had a previous MRSA infection, lives or works in close proximity to a person known to have MRSA, has been hospitalized in the last 6 months or lives in an institution or care home, or is currently on antibiotics, then they are referred to an infectious disease specialist to assure that the MRSA has been eliminated (31). All fluid collections and open wounds are cultured and treated. This is all in an attempt to decrease the risk of wound infection and to aid in preoperative planning.

Nutrition

Target: Identify patients who are malnourished or undernourished and restore their nutritional status prior to operation.

Rationale: At a given time, approximately 30% of hospitalized patients are undernourished (32). In response to the insult of surgery, the body’s metabolism increases and calls on its nutritional reserves to support recovery (37). If these reserves are depleted, recovery can be compromised. Many studies have confirmed that optimizing a patient’s nutritional status prior to surgery results in a lower rate of surgical complication, length of stay, and need for hospital readmission (33, 34, 35, 36).

Fortunately not all patients require nutritional support prior to an operation. Our goal is to identify those who are at risk and would benefit from nutritional optimization. While several nutritional risk screening tools exist, the nutritional risk screening has been validated in surgical patients and is most commonly used in the elective setting (32).

An immunonutrient is a chemical made by the body that can aid it in the recovery after surgery. Immunonutrition involves providing these substances before and after the operation in the form of specially designed nutritional supplements. This practice can decrease the rate of wound complications, hospital length of stay, and the costs of hospitalization (38, 39, 40, 41). Our practice is to attempt to provide these supplements for at least five days before an operation. Insurance most often will not reimburse for this treatment and patients are often asked to pay for this on their own with a cost between $50 and $150.

Organ system optimization

Target: Identify any preexisting medical problems and optimize each organ system.

Rationale: Every person has a unique medical history and sometimes a prior medical problem, such as a heart attack, can have a significant impact on that person’s ability to tolerate an operation. While risk can never be eliminated completely, much can be done to reduce and manage it. We may ask you to see one or several other doctors prior to your surgery if a previous medical problem is of concern.

As a hernia center, we have these specialists and the resources they require available and ready. Some of the most common reasons for preoperative evaluation in our clinic have been: heart disease, COPD, immune system problems, and patient’s who require anticoagulation.

During these specialty consultations, several things can be accomplished. First, the specialist can usually provide an accurate assessment of the risk of a particular problem affecting the successful outcome of an operation. In the past, these assessments have changed the approach to the planned operation. Secondly, if the problem can be improved or optimized prior to surgery this process can be initiated and directed by the specialist. Third, any additional problems can be identified and treated. Finally, any problems that may occur during or after the operation can be anticipated and a plan of action developed well before the operation.

In this way, we work through every previous diagnosis of a patient’s medical history. Every major organ system is considered and, if possible, optimized.

A patient’s risk profile is like a fingerprint and is unique to that individual.

Certainly, all surgery carries inherent risk of bleeding, infection, and damage to other structures. For a generally healthy patient with no other medical issues or problems, the risks for all of these is usually 3% or less (117). In the case of hernia surgery risks of hernia recurrence and complications from mesh placement are also considered and discussed (see Mesh section). These risks are dependent on a variety of factors including previous operations, history of smoking or infection, poorly controlled diabetes, previously placed mesh, and other medical problems.

There are several tools that we use to assess an individual patient’s risk for surgery. One is a Risk Calculator from the American College of Surgeons. This is a tool is derived from collecting years of data from patients who have had similar operations and provides a unique score and risk profile. This tool is used at the initial visit to assess and develop a strategy to make the patient as healthy as possible prior to surgery. For more information on how these tools are used, see the Optimization section.

Risk is unavoidable in surgery. However, much can be done to mitigate and manage it with careful and thoughtful planning and preparation. We will not offer a patient an operation if the perceived or calculated risks are greater than the potential benefit the operation would provide.

Groin Hernia

There are many ways to repair a groin hernia. Each surgeon has their own preferences. In our practice, we perform all of the types of repairs listed below. Each patient is different, generally a groin hernia operation can be an outpatient procedure with an expected return to activity 10-14 days after the operation.

• Open repair without mesh: A 1-2 inch incision is made over the hernia and the hernia is sewn shut using the body’s tissues without re-enforcing mesh. If a patient has a high risk of wound infection and is not a candidate for a minimally invasive operation, this type of operation may be the best option.
• Open repair with mesh: This is how most hernias are repaired in the United States today. A 1-2 inch incision is made and the hernia is sewn shut and then re-enforced with mesh.
• Minimally invasive: This is surgery performed through small incisions. It usually leads to faster recovery, less pain, lower infection risk, and quicker return to activity, though not always. These operations use several small incisions with a total length of less than one inch. There are two general categories of minimally invasive groin hernia surgery:
  • Laparoscopic surgery uses a camera and hand held instruments to perform the hernia repair. There are two different ways to perform laparoscopic repairs but both involve approaching the hernia from the inside of the abdominal wall and using a piece of mesh to cover the hole. This is how 83% of our hernia repairs are performed.
  • Robotic-assisted surgery follows the same principles as laparoscopic surgery but uses the daVinci robot system to move the instruments. This allows for the surgeon to see and move with extreme precision. Robotic-assistance allows for patients that may not otherwise be candidates for minimally invasive surgery to have their hernias repaired while still getting the benefits of the minimally invasive operation. In our practice this operation is considered for patients who have had prostate surgery, gynecologic surgery, or types of pelvic surgery or radiation.

Abdominal Wall Hernia

There are several techniques to fixing an abdominal wall hernia. Each one has its own particular advantages and disadvantages. Many patients are often discharged home the same day and return to normal activity in 10-14 days. More complex repairs may require longer hospital stays and rehabilitation.

Our goal is choose the right technique based on the patient’s unique set of variables.

One important factor to consider in each of these repairs is the use of mesh. Re-enforcing hernia repairs with mesh dramatically reduces the chance that a hernia will recur after repair (see Mesh). However, mesh is also associated with complications. Hernia surgeons have found that placing the mesh within the layers of the abdominal wall, rather than in the abdominal cavity itself significantly reduces the chance for mesh related complication.

Most minimally invasive repairs place mesh inside the abdominal cavity. We utilize new cutting-edge robotic-assisted technology that allows us to achieve the goal of placing mesh in layers of the abdominal wall through small incisions. This method allows the patient to gain the benefit of minimally invasive surgery while still achieving mesh re-enforcement with decreased risk of mesh-related complications and wound complications, such as infection.

• Open hernia repair: An open repair is traditional open surgery with its attendant risks and benefits. This can often be the best option for the patient, especially in patients with very small or very large hernias or who have skin problems over their hernia. Mesh may not be necessary in hernias less than 1/2 inch, women who plan to become pregnant, or in patients with complicated hernias or infected wounds. When mesh is necessary, we attempt to place it within the layers of the abdominal wall and not in the abdominal cavity, thus keeping the mesh away from the intestines and hopefully limiting future mesh complications.
• Minimally invasive hernia surgery is performed through small incisions. These techniques can lead to faster recovery, less pain, lower infection risk, and a quicker return to activity.
  • Laparoscopic hernia repair uses a camera and hand-held instruments to perform repair. The traditional teaching of this operation involved not sewing the hernia defect closed and instead used the mesh to “bridge the gap” between the sides of the hernia. This type of repair, also known as an “interposition”, is associated with less desirable cosmetic results as well as an increased likelihood of hernia recurrence. As a result the practice of bridging repairs has largely been abandoned. Most surgeons attempt to close the hernia before placing mesh.
  • Robotic-assisted hernia repair allows for the hernia to be sewn closed more than 96% of the time (115). There are several ways to perform a robotic-assisted hernia operation:
    • IPOM: Stands for intraperitioneal onlay mesh (IPOM). Most surgeons place the mesh in the abdominal cavity after sewing the hole closed. The mesh sits next to the abdominal contents and complications can result from interaction between the mesh and the intestines (see Mesh). Sometimes these complications will not become apparent until years later when the patient has another abdominal operation. Sometimes placement of mesh in the abdomen is the only reasonable option, but we try to avoid it when possible.
    • TAPP: Stands for trans-abdominal preperitoneal repair (TAPP). The layer of abdominal wall next to the intestines is called the peritoneum. Working outside this layer the hernia can be repaired and mesh can be placed. This keeps the mesh out of the abdominal cavity by using the peritoneum as the barrier and limits the complications that mesh in the abdominal cavity can cause.
    • eTEP: Stands for enhanced-view totally extraperitoneal hernia repair. It is generally employed for larger or more complicated hernias. The mesh can be placed directly behind the abdominal muscle. Not only is the mesh kept out of the abdominal cavity but the abdominal cavity is usually not entered to the extent that occurs with other operations. This can limit the potential for injury to the intestines during the hernia repair. It allows for large mesh to be placed in what surgeons believe to be the most optimum mesh position, behind the abdominal muscles while still gaining the benefits of minimally invasive surgery (see Mesh). When compared to open surgery, eTEP patients are discharged from the hospital 1-2 days sooner than similar operations performed in the open fashion (116).

Abdominal Wall Reconstruction

Sometimes a hernia becomes so large that the edges cannot be sewn back together without a special set of techniques referred to as release maneuvers. Abdominal wall reconstruction is the term used for the operation where these release maneuvers are employed to fix a hernia.

Because the abdominal wall is made of a series of overlapping strength layers, sometimes one of these layers can be divided and moved over to cover a large hernia, leaving the remaining layers to provide strength for the abdominal wall. Think of a sliding glass patio door with one layer sliding over the other to close the door.

There are several different types release maneuvers that can be performed and knowing when and how to employ these specialized techniques is something in which hernia surgeons specialize. These include open and minimally invasive operations and each maneuver has its own unique benefits, risks, advantages and disadvantages.

Our center is one of the only in the region to offer minimally invasive release maneuvers. These operations are complex and time consuming. Sometimes, a minimally invasive release maneuver is not the best choice for a particular patient. However, the benefits of minimally invasive release maneuvers are less blood loss, less pain, and shorter hospital stays. Above all though, operative experience is key.

A brief description of the different types of release maneuvers:

• Open Anterior Release: This is performed though a traditional open incision. This release maneuver involves dividing a layer of tissue referred to as the external abdominal oblique aponeurosis, or EAO. It is well-studied and useful in that it can help get large hernias closed. It does have some limitations. It requires dividing tissue away from the abdominal wall and this process can result in reducing the blood supply to the abdominal wall, leading to problems with wound healing. Most hernia surgeons avoid this problem by performing a “perforator sparing” version of this release. It is an effective operation and large hernias can be repaired but potential wound complications need to be considered. As traditionally described, the operation involves dividing two planes of tissue on each side of the abdomen. Most surgeons only divide one and as a result do not obtain the full release that the operation can provide.
• Endoscopic Anterior Release: This variation on the anterior release was conceived because of the wound healing issues noted above. It involves placing a balloon under the layer of tissue to be divided and then performing the release maneuver through small incisions, usually with the laparoscope. This maneuver is effective in limiting the wound complications traditionally associated with the open operation. The quality of the release in regard to how much the tissues can be moved is not as good as the open operation, however. Thus it is more difficult to close large hernias.
• Posterior Component Separation: This operation avoids the traditional wound problems associated with anterior release because it divides a different layer of tissue. Division of the transverses abdominus muscle allows for a large space to be created with no physiologic consequence. This is referred to as the TAR release. The first results of this technique were published in 2012, so it is a relative new comer to hernia surgery. This is an excellent tool for large hernia closure but it is an operation that requires skill, experience, and patience. Division of the wrong anatomic plane can lead to profound and costly consequences.
• Robotic-assisted trans-abdominal posterior component separation: This operation involves the same operative maneuvers as the poster component separation described above, except that it is performed through six 1/4 inch incisions. Also technically demanding, this operation has proved to be the operation of choice for large hernias. Benefits to this approach include less blood loss, less pain, and more rapid discharge from the hospital. Most patients are discharged on postoperative day #1 or #2, compared with day #4 or #5 in patients who require and an open operation with a release maneuver.
• Robotic-assisted eTEP/TAR: One of the benefits of the eTEP described above is that it can be transitioned into a posterior component separation. Still using 6 small incisions, or sometimes 4, the entire release can be performed with the goal of never entering the abdominal cavity. This affords the advantage decreasing the risk of injuring the intestine.

Hiatal Hernia

Hiatal hernias can be repaired using open or minimally invasive techniques. When the repair is elective and not an emergency the repair is usually performed in a minimally-invasive fashion with robotic-assistance. The same benefits that accompany other minimally-invasive hernia surgeries apply to hiatal hernia surgery as well. Generally, there is a less blood loss, less pain, and less time spent in the hospital.

Parastomal Hernia

Parastomal hernias occur around an ostomy where the intestine or another organ has been purposefully allowed to drain through the abdominal wall into a collecting bag. About 50% of patients with ostomies will develop a hernia (114).

Having success with these difficult repairs is difficult for many reasons. The best way to deal with a hernia around an ostomy is to move the ostomy or reconnect the bowel. These options are not applicable in some patients, however. Preoperative planning and optimization are even more important in these circumstances.

Usually these hernias are initially repaired using minimally invasive techniques and often with robotic-assistance. Recurrent hernias often require open approaches with abdominal wall reconstructions.

Fistula

A fistula is an abnormal communication between two organs or spaces in the body. This can be a debilitating and life altering problem.

Certain diseases, trauma or injury, or complicated abdominal surgery can lead to formation of a fistula. Also, fistulas formation is a rare complication from placement of mesh, usually in the setting of mesh infection or hernia surgery that has been complicated by bowel injury.

Operations to fix fistulas are complicated and complex but with planning and preparation can be affected successfully.

Mesh Removal

Mesh has revolutionized the treatment of hernias. Sometimes a patient can have a complication that leads to a compromise the mesh or can come to involve it. The best example of this is a wound infection leading to a mesh infection. In this circumstance the mesh sometimes needs to be removed.

Rarely, the mesh can be the source of the complication itself. Installing a foreign substance, like mesh, into the body causes the body to react. This response calms over time and the mesh grows into the tissues surrounding it. This is what it is designed to do. Sometimes the body’s reaction persists and this can lead to pain, loss of flexibility, and decreased quality of life. Though this is extremely rare and sometimes the best treatment is to remove the mesh.

Mesh removal is a consequential decision and can lead to other issues. Mesh removal can be an extremely complex operation. It is not to be taken lightly and hernia surgeons are well equipped to deal with these issues. Operations are not always required but if they are, preoperative planning and management of expectations are the keys to success.

Mesh and its use in hernia repair is and should be a frequent topic of conversation between the surgeon and the patient.

In fact, it is also a topic of debate between hernia surgeons. There are many common misunderstandings and misconceptions that are perpetuated by medical dogma, popular media, and concern regarding litigation. Little information exists that allows the non-surgeon to help understand the evidence regarding mesh and its use in particular patients and situations. The paragraphs below are designed to assist the lay public in understanding why between 70-82% of hernia repairs performed in the United States each year use some type of mesh (42).

Is mesh necessary to prevent the hernia from coming back?

A common complication that can occur with any type of hernia repair is recurrence. This means that the repair has failed and the hernia has come back requiring another more complex and costly operation to fix it (42). The likelihood of a successful hernia repair decreases with the number of repairs that have been performed previously (43, 44).

As surgeons we want to do everything that is reasonable and safe to try to achieve durable and long-lasting repair, one that does not come back, or recur. Mesh is an important tool used to help achieve this goal.

Generally speaking, there are two ways to fix a hernia:

• Primary Repair: Abdominal wall tissue layers are sewn back together with stitches. This is also referred to as a “tissue-based repair”. No additional re-enforcement of mesh is provided where the hole is sewn closed.
• Mesh Repair: This repair involves using mesh in one of two ways:
  • Bridging Mesh: If the hole cannot be sewn shut, then mesh is used to “bridge the gap” between abdominal wall tissues. This is also known as an “interposition" and this technique is generally associated with recurrence rates higher than other techniques using mesh.
  • Re-enforcing Mesh: The hole is sewn shut and mesh is used to provide additional re-enforcement to this closure. The mesh serves as a durable re-enforcing layer above or below the patient’s abdominal wall tissue that has been repaired. Medical literature now clearly indicates that this technique is the most desirable in achieving the lowest possible recurrence rates (45, 46, 47).

Several studies have been performed that compared the results of tissue-based repairs, just sewing the hole closed, versus the use of mesh. One well known type of tissue-based primary repair, known as the “Mayo” repair, was found to have a 5-year recurrence rate of 54% (51). In another study, this repair had a 37% risk of recurrence in an 10 year followup (111). Further, if the hernia was greater than 12 cm the recurrence rate was 78% (48).

In two landmark studies published in 2000 and 2004, respectively, mesh placement clearly reduced the number of recurrent hernias. For example, at 3 years the hernia recurrence rate after initial repair was 43% for non-mesh repairs and 24% for repairs where mesh was used (49). At ten years, this same group of patients had a recurrence rate after initial repair of 63% for tissue-based repairs compared to 32% when mesh was used (50). So, the risk of the hernias recurring was halved if mesh was used in the hernia repair.

Keep in mind, these studies are now 14 years old and significant improvements have been made in regard to the general understanding and techniques of hernia repair. For instance, the studies noted above used mesh as an interposition repair to bridge a gap (49). It was not used to reenforce a layer of tissue closed above or below it, something surgeons now know is absolutely essential to achieve the best long-term results (45). Patients that have a bridged repair have hernias that come back nine times more quickly and nine times more often (45). We now know that sewing the layers of the abdominal wall closed and then reenforcing this repair with mesh greatly reduces the risk of hernia recurrence (42, 45, 46, 47). This technique has been noted to decrease hernia recurrence rates to 8-14.6% at 5 years (45, 46, 113).

So, the importance of sewing the layers of the abdominal wall back together, what surgeons refer to as “fascial reapproximation”, is of paramount importance. In our practice the only time we bridge a hernia repair when the hernia cannot be or should not be closed at that moment.

In our practice mesh is used in most circumstances. One circumstance when mesh usually is not employed is the case of a hernia that is less than half an inch. However, exceptions to this are common based on a patient’s individual risk factors. Another circumstance where mesh may not be used is in the case of a complex hernia and an infected abdominal wall where a later and more complex operation will be required.

As will be explained below, there are several important decisions that factor into whether or not mesh is used, what type of mesh is used, and where it is placed in the abdominal wall. However, there is little doubt among hernia surgeons that mesh has revolutionized both simple and complex hernia repair, that it is necessary to achieve the lowest possible rate of hernia recurrence, and that it is here to stay (46).

What are the risks of mesh placement?

Based on the medical literature, the risk of a mesh-related complication between three and five years after it is placed is 4.5-5.6% (52, 53, 54, 113).

Excluding hernia recurrence, mesh complications occur in two major ways. The first of these involves mesh becoming infected and the second involves mesh interacting with other structures in the body, like the intestines.

Mesh Infection

To quote a recent review article from the Journal of Plastic and Reconstructive Surgery, “…the concern for performing a hernia repair with synthetic mesh stems from the fear that placement of a synthetic mesh in a contaminated field will result in a chronic mesh infection” (25).

While mesh infection may not be the most feared complication in hernia surgery, it certainly is something that surgeons are extremely concerned about and have studied extensively.

Because wound infections can and do lead to mesh infections, a great deal of time is spent prior to surgery making the patient as healthy as possible before an operation, a process referred to as optimization. To review information presented in the Optimization Section, obesity, smoking, diabetes, and prior infections all significantly increase the risk of wound infection.

Studies of hernia specific risks for developing a wound infection suggest that if patients have had a previous mesh infection or even if they simply have a recurrent hernia, they are at increased risk for developing a wound infection, which can lead to a mesh infection (44, 55, 56).

In 2010, a group of hernia surgeons came up with a classification system to try to predict the likelihood of a patient developing a wound infection based on some of these patient characteristics. This group, referred to as the Ventral Hernia Working Group, developed a system with 4 classes that noted increasing levels of risk for wound infection (47). For instance, the lowest risk class for development of a wound infection is a class 1, a healthy patient with no risk factors (47). Risk of infection increases through the four classes to its highest level, class 4, where a patient has a known active mesh infection (47).

This classification system has been studied to determine its predictive value. A group of 299 patients studied confirmed that risk for infection after a hernia repair increased as expected from class 1 ( 14%) to class 4 (49%) (57). One conclusion from this paper recommended streamlining the system from four classes of risk to three and this is the system that most surgeons use today.

So, if your surgeon tells you that your hernia is a “class 3” then you know that you have about a 38% risk of developing a wound infection after your surgery (57). This classification system matters because it will likely lead to other decisions being made in regard to the type of mesh used in your repair and where the mesh is placed in your abdominal wall. Sometimes, another operation will be necessary; and is referred to as a staged-repair. These decisions are discussed below.

Mesh infection is usually manifested by pain and a non-healing or draining wound and may not become manifest for a year or more after surgery (54, 58, 59). Once a mesh infection is diagnosed, management can be complicated. For many years, removing the mesh and starting over at a later time was thought to be the correct course of action (60).

In one study involving 619,751 hernia repairs mesh removal, a complex procedure referred to as explanation, was performed 438 times (58). This equates to about 1 mesh removal per 1000 patients, but this is felt to be a low number and other studies have suggested rates of 5-7% (52, 54).

However, salvaging the mesh is possible in some cases and it may be possible to treat the infection and the infected mesh with antibiotics and drainage (60, 61, 62, 68). Sometimes the mesh and infected tissue needs to be partially cut away in a procedure referred to as a debridement (60, 62).

These are not easy decisions and there is no textbook answer to management of infected mesh. Some important factors to be considered include the health of the patient, the severity of the infection, how the mesh was placed, where the mesh was placed, and what type of mesh was used. For instance, a wide-pore polypropylene mesh can usually be cleared of bacteria, but an infected mesh made with a material called PTFE nearly always needs to be removed (62).

In this practice, we have used multiple strategies to manage mesh and wound infections. Without a doubt, though, the best strategy is prevention of wound infection.

Intra-Abdominal Adhesions and Fistulas

The medical word for scar tissue is adhesion. Anytime a person has an operation in their abdomen they form adhesions and this process in the human is complex and not well understood (63). This is true for all types of abdominal surgery, not just hernia surgery.

Generally speaking, the presence of adhesions make the next abdominal surgery, whether it is to repair a hernia or to remove the gallbladder, more complicated (64). This is because things in the abdomen that are not supposed to be stuck together become that way as a result of the first surgery. This effect is additive and the more surgeries a person has had in their abdomen the more complex and disorganized it will be. The typical recurrent hernia patient in our practice has had, on average, between 5 and 8 abdominal operations.

The problem with this increased complexity is that separating the tissues that are stuck together, called adhesiolysis, increases the risk of damaging the same structures that are stuck together. When a surgeon damages a piece of intestine, say, puts a hole in it, this is called an enterotomy. This is a bad problem that can lead to death if not recognized and treated aggressively. Also, this is why surgeons have developed techniques for repairing hernias using minimally invasive techniques and never entering the abdominal cavity, thus avoiding or decreasing the risk of bowel injury.

As stated earlier, hernia repairs are often performed in patients who have had previous abdominal surgery and have adhesions in their abdominal cavity. The risk of a bowel injury during these cases is about 2-4%, but if a bowel injury does occur then the patient is at greater risk for wound infection, mesh infection, need for reoperation, and death (65, 66).

Another well-known and feared complication that is associated with increased complexity from dividing scar tissue around the intestines is called a fistula. This is an abnormal communication between two organs or spaces in the body that results from injury to the bowel during the operation. In this circumstance, the intestines drain out of the skin like an unintentional colostomy (67). This is a rare complication and it can be treated but requires patience and fortitude on behalf of the patient and surgeon (67).

A common practice is to place the mesh in the abdominal cavity. This is referred to as the “underlay” position and is discussed in the section below. In this type of procedure the mesh is placed directly over the intestines. Where-ever it is placed in the body mesh creates inflammation and this process is referred to as a foreign body reaction (63, 68, 69). This process leads to adhesion formation (63, 68, 69). So, when the mesh is placed directly over the intestines scar tissue can form between the mesh and bowel. This becomes an issue when patients have a hernia recurrence or need an another operation to have a hysterectomy or a gallbladder operation, etc.

One study showed that 23.3% of hernia repairs required surgery for a variety of problems not related to the hernia repair (gallbladder, gynecologic, colon cancer) in the 7 years following their hernia surgery (70). Many surgeons today perform laparoscopic hernia repairs where mesh is placed in the underlay position. In a review of 733 laparoscopic hernia repairs, 17% of patients required an abdominal operation during the first 2.2 years after their surgery (66). Again, many of these operations had nothing to do with their hernia repair (66).

The presence of mesh in the abdominal cavity significantly increases the risk of a complication, like a bowel injury, during the second operation (66, 70). In a study of 335 patients, the presence of mesh in the abdominal cavity was associated with increased overall complications at the time of the subsequent surgery including need for bowel resections and surgical site infections (71). Also, this study revealed a 5% rate of fistula formation (71).

The type of mesh used in these cases is different among the different studies. Many meshes are designed to reduce the formation of adhesions by coating the back of the mesh with a chemical or substance designed to decrease adhesion formation. This type of mesh is referred to as a “barrier-coated mesh” and there are several types produced by different manufacturers.

The idea and the science behind these meshes are sound, however, there is a lack of a reproducible animal model in which to study them (63). It is felt that any barrier should be effective for 5-7 days after the operation (68). There are many animal studies that review how effective an anti-adhesion barrier can be in an experimental setting, however, there is precious little data that exists in regard to how well they perform in the clinical setting, in a real group of patients (73). To be sure adhesions do still form to these products when they are used (72).

There are certainly times when putting mesh in the abdominal cavity is unavoidable. However, for the reasons noted above, whenever possible attempts are made to place the mesh somewhere else in the abdominal wall and outside the abdominal cavity.

Mesh fracture and chronic fibrosis will be discussed in the sections below.

What are the different types of mesh?

Three types of mesh are commonly used to repair hernias. Each has its own profile of performance and indications for use:

Synthetic Mesh

This type of mesh is derived from petroleum products (49). They are plastic polymers that differ from each other based on how different atoms are arranged on a carbon skeleton (49). They are permanent in the sense that they are designed to be functional for the rest of the patient’s life. The three materials of note are polypropylene, polyester, and a material called PTFE (73).

Of these, polypropylene, which was first used for hernia repair in 1958, is the most widely used as it is relatively inexpensive (73). Also, polypropylene mesh appears to have higher rates of salvage and less need for complete mesh removal when exposed to bacteria (62, 74).

Many hernia surgeons feel as though we are in the midst of a paradigm shift because this mesh appears to clear infection well. In situations where there is a high risk of infection (see discussion above) conventional wisdom has long held that installing a synthetic mesh was dangerous because it could not clear the infection and a complex operation with mesh removal would be required. However, new studies suggest favorable outcomes when this mesh is placed in situations where infection is statistically likely (55, 61, 75, 76).

Polypropylene is manufactured with different weights. This mesh is also designed to have holes that we refer to as pores. Think of a heavy weight mesh with small pores as a tightly woven blanket. It’s heavy and if held up to the light one cannot see through it. Conversely, light weight mesh with large pores is like a crocheted blanket and one can easily see through it. A midweight mesh is mix of the two and, as you would expect, in the middle in terms of weight and porosity.

The more lightweight a polypropylene mesh is, the less the body reacts to it (73, 69). Thus, it shrinks less and is more compliant that a heavier weight mesh (70). Because of the large pore size, this lightweight mesh also grows into tissues better that other mesh with smaller pores (69). Also, larger pores may give midweight and lightweight mesh an edge in dealing with bacteria as discussed above.

Considering these facts, lightweight polypropylene mesh would seem to be the right choice for most hernia repairs (77). For some types of hernias, like inguinal hernias of the groin repaired in particular ways, this is true (78). However, one problem that has been encountered with lightweight polypropylene mesh is referred to as mesh fracture (79, 80). Essentially, the mesh simply breaks and the hernia recurs through the broken material (79, 80). In a series of 36 patients followed over a 36 month period, 19% had recurrent hernias due to mesh fracture (80). Most likely, this fracture is the result of the layers of tissue sewn together above and/or below the mesh have separated, leaving mesh as the only strength layer, something it was not designed to do (80).

If you ask ten different hernia surgeons, you are likely to get 10 different opinions as to the best type of synthetic mesh to use in a particular situation. At this time, we believe that the evidence supports the use of a midweight large pore polypropylene mesh for most standard hernia repairs in a patient with low or intermediate risk of infection.

Biologic Mesh

In patients with high risk of wound and mesh infection there has been concern about placing a synthetic mesh. Every hernia surgeon has an unpleasant tale to tell regarding mesh infection and the operation to remove it and reconstruct the abdominal wall. This problem is what biologic mesh was designed to address.

Biologic mesh is tissue that is derived from cows (bovine), pigs (porcine), and humans (81). Essentially, these tissues are harvested and processed in a proprietary fashion with each company having their unique process (81). The goal of this processing is to remove everything that the patient’s body could reject (cells, viruses, bacteria) and to provide a scaffolding on which the body can add its own cells (81).

Benefits that have been noted when using biologic mesh include increased growth of blood vessels, increased incorporation into the bodies tissues, decreased adhesion formation to the intestines, and the ability to heal if exposed in a wound infection (82, 83, 84, 85, 86). Though little evidence for the use of biologic mesh existed at the time, the Ventral Hernia Working Group (discussed above) recommended the use of biologic mesh in patients with a high risk of wound infection with the goal of decreasing the risk of mesh infection (47, 57).

However, some of the initial studies using biologic mesh called into question its utility as it was noted to have higher wound complications and rates of recurrent hernias (81, 82) of the hernia repair (83). One important aspect of this study was that in 19% of the hernias in this study, the mesh was used to bridge a gap, not as a layer of reenforcement (83). Thus, these hernias were much more likely to recur. One important point that is often missed, however, is that these patients were all at high risk for wound and mesh infection but no mesh removals were required (83).

We now know that biologic mesh has a hernia recurrence rate comparable to synthetic mesh when used to reenforce a repair (84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94). In a review of 1229 hernia repairs, biologic mesh was found to have less infectious complications and similar recurrence rates compared to synthetic mesh (84). This was also found to be the case in other large reviews of 761, 359, and 126 patients, respectively (85, 86, 887). In complex cases were complete reconstruction of the abdomen is required, similar findings were noted (88, 89, 90, 91, 92, 93, 94).

One of the benefits of biologic mesh is that infected wounds can be managed with little worry of mesh infection and need for mesh removal (86, 87, 91, 92, 93, 94, 95, 96). In some cases, a device called a wound vacuum has been attached directly to the biologic mesh and the wound has healed (91, 94, 95).

So, if biologic mesh has a rate of hernia recurrence and wound complication that are comparable to synthetic mesh in hernias at high risk for infection, why is it not used all of the time? Well, it is extremely expensive and not all biologic meshes are created equal (97). Some of these products are extensively studied and others are not. Each mesh has its own chemical arrangement and they do not all behave equally.

Again, if you ask those same 10 hernia surgeons we referenced above about when and how to use biologic mesh, you are likely to get 10 different answers.

Our policy is to strongly consider biologic mesh in two distinct circumstances. The first is if a patient is at high risk of developing a wound or mesh infection. Our expectation here is a definitive repair that will be long-lasting. The second situation is in the form of a temporary fix. For example, if a patients has a severe infection or is too ill to tolerate a definitive reconstruction, then a bridging biologic mesh can be placed to buy time until a definitive reconstruction can be performed. This is done with the expectation that the hernia will likely come back, but the patient will be better able to tolerate the operation later on down the road.

Long-Acting Resorbable Mesh

This type of mesh is designed to offer the same benefit of biologic mesh at a lower cost (98). Essentially, these synthetic products that are designed to offer temporary reenforcement of the abdominal wall and then to melt away after a period of time (98). It is felt that these products should decrease the risk of mesh infection and need for mesh removal (98). They are also known as biodegradable mesh, bioabsorbable mesh, or biosynethetic mesh (98).

Currently, there are three of these products available for use in humans and though the technology behind these products has been available for many years, they are a relative new-comer to hernia surgery. Currently, few published studies are available regarding the use of this type of mesh in complex hernia repair. One study, referred to as the COBRA study followed complex repairs for 24 months and was noted to have a recurrence rate of about 14% (99). It is tempting to compare these results to those studies regarding biologic mesh noted above but that is a dubious endeavor. First, more is known about the importance of avoiding a bridging repair (discussed above) and the hernias in the bioabsorbable study were smaller. (98, 99). Though it is a good beginning, the COBRA study presents more questions than answers as to which type of mesh, biologic or bioabsorbable is best to use in wounds at high risk of infection (86).

Another more recent study examining bioabsorbable meshes displayed an 18 month recurrence rate in complex patients to be 9% (100). However, the predicted absorption time for the mesh that was studied was 18 months (100). It is possible that more hernia recurrences will be discovered after the mesh has completely dissolved. Other recent work compared polypropylene mesh to biosynthetic mesh in 75 patients and found that the bioabsorbable mesh had higher rates of wound complications and hospital readmissions (101).

Bioabsorbable mesh may figure prominently in the field of complex hernia repair in the future. It may also may not. We just do not have enough study and data regarding the long-term use of these products to know if they behave better, worse, or the same as the other products for which good data already exists (79). As a result, we use these products are employed in our practice sparingly and only under specific circumstances.

What does mesh position mean and why is this important?

Basic Anatomy

If one were to pass an imaginary needle from the skin to the inside of the abdominal cavity, where the intestines live, that needle would pass through 7 distinct layers of tissue as it travels further away from the skin. This is an oversimplification of the relevant surgical anatomy as additional more subtle planes of tissue exist but for the purposes of keeping it simple, this number works.

The strength layers of the abdominal wall are referred to as the fascia. When a patient has a hernia, he or she has a hole in the fascia. There are generally two layers of fascia in the abdominal wall they lay in front and behind the abdominal muscles, respectively. These muscles are referred to as the rectus muscles. These are the “six-pack” muscles. Between the layer of fascia behind the muscle and in front of the intestines is a tissue-paper thin layer of tissue referred to as the peritoneum. The peritoneum is a big sac that your intestines live in.

What is important to understand is that these layers create several different places where mesh can be installed during a hernia repair with a different set of benefits and risks for each individual layer of placement. Different choices are made in consideration for the patient’s unique anatomy, risks, medical history, and sometimes lifestyle and activity level.

Onlay

With this procedure, mesh is placed above the layer of fascia in front of the rectus muscles. In this procedure, the skin and tissue over this layer of fascia are dissected apart, this is referred to as “making a skin flap”. The hernia is closed with stitches and the mesh is placed in the pocket of tissue between the tissue and the fascia (102). Some benefits of this technique include the fact that mesh is placed outside of the abdominal cavity and that patients appear to have less pain (102). This technique is also valuable for atypical hernias where other techniques may be more difficult (102).

However, one must remember that there are blood vessels that supply the skin that pass through the space that is separated and these are nearly always compromised to some degree by this operation (103). This is an extremely important concern in patient who have had previous abdominal operations or aortic surgery (102). Patients who smoke and have this operation are at especially high risk for wound complications and need for further surgery (102). In comparing this technique to the retromuscular technique describe below, the onlay technique demonstrated higher infection and recurrence rates (104).

This mesh position also places the mesh as close as is possible to the skin and thus, a wound infection does not have far to travel to involve the mesh.

In a recent cumulative review of 13 studies that placed the mesh in this area, 472 patient outcomes were reported (105). The overall infection rate was approximately 14% and hernia recurrence rates were 12.9% nearly two years after repair (105).

Interposition or Bridging

As described in other sections, this technique involves not closing the hernia and bridging it with mesh. Despite evidence that signifies the importance of sewing the defect closed and using mesh to reenforce this closure, many surgeons routinely perform bridging repairs in the form of laparoscopic hernia repair. Only recently have surgical atlases begun to describe techniques for closing the fascia during laparoscopic repairs (103).

This technique is described in more detail in the Hernia Education section. What is important to understand is that mesh is delivered into the abdominal cavity and secured to the inside of the abdomen with small absorbable rivets, referred to as tacs.

A cumulative review of 20 studies involving 821 patients, the overall infection rate was 12% and hernia recurrence rates were the highest of the evaluated mesh positions at 21.6% at 36 months after repair (105).

Retromuscular or Retrorectus

This technique involves closing both the front and back layers of fascia individually and placing a mesh in the space behind rectus muscle (102, 103). For many dedicated hernia surgeons, this repair has become the standard of care (102).

There are several benefits to this repair. First the mesh is kept out of the abdominal cavity and next to abdominal muscles that have a rich blood supply, this affords the mesh an opportunity to become incorporated quickly and thoroughly (102, 103, 106). Also, wide mesh overlap of the defect is possible (102, 103). With the maneuvers required to place the mesh in this position, the shape of the rectus muscles change and move closer to the midline, thus enhancing the ability to close a larger hernia (102, 103, 107). This operation also serves as a platform for other more complex reconstructions (102, 103,). Finally, the mesh is kept out of the abdominal cavity and serves to reenforce two layers of repaired fascia (102, 103).

Referring back to the cumulative review noted in the sections above, retromuscular repair was noted to have an average infection rate of 10.4% and a hernia recurrence rate of 5.8% at 18 months (105). The conclusion of another recent analysis involving 51 independent studies and more than 6200 patients concluded that placing the mesh in the “underlay” position is associated with a lower recurrence rate and other reviews and studies have confirmed these findings as well (52, 53, 104, 108, 111, 112).

Underlay

Mesh is said to be placed in the underlay position when it is placed in the abdominal cavity (inside the peritoneal lining) or outside the abdominal cavity but behind the layer of fascia behind the muscles (extreperitoneal or preperitoneal) (105). Preperitoneal mesh placement affords the advantage of a layer of tissue, the peritoneum, between the mesh and the intestines. While this may be some confusing anatomy, it is an important distinction if one is to consider the ramifications of mesh placement inside the abdominal cavity discussed above.

In the cumulative study that is referenced in the sections above the underlay position was noted to have a high infection rate, 17.7% and a low recurrence rate of 10.9% at 24 months (100). However, many of these procedures were performed with open surgery (37.8%) and so newer and minimally invasive techniques, such as the robotic or laparoscopic TAPP procedure (see General Questions and Hernia Education Section) (105).

Putting it all together

To paraphrase the conclusions from the review noted above, now more than ever there are more options available to the hernia surgeon in regard to technique and mesh types (105). There is also an astounding amount of data that involves different and complex problems and inherent bias on the part of the researchers and the readers (105).

Thus, it is important for each hernia surgeon to do several things. First, they need to understand their own limits of technique and abilities. The need to know their own results. This is accomplished by following patients over the longest possible period of time after their operation and why this center participates in data collection and analysis programs like the Americas Hernia Society Quality Collaborative.

Secondly, the surgeon needs to be up to date on the medical literature and available data as there is always somebody, somewhere who is taking a new look at an old problem. Such is the case with surgeons now using minimally invasive robotic techniques to perform complex operations that used to only be accomplished with large open incisions.

So, considering mesh position several priorities have evolved as to how we treat hernias.

When possible, we try to keep mesh out of the abdominal cavity and to place it in the retrorectus or preperitoneal position. We believe the data available strongly suggest the benefits of this position in regard to lower recurrence rates and overall lower complication rates.

Also, if we can achieve the goals of a good and durable repair in a minimally invasive fashion, then that is how the operation is performed. With the advanced techniques of eTEP and TAPP used on the daVinci robot system, this is often possible. These techniques are reviewed in the General Questions and Hernia Educations section.

Hospital Stay

Most groin and ventral hernias can be discharged home the day of surgery. More complex repairs can have hospital stays of one to seven days. Each patient and every operation is different.

Early hospital discharge is a benefit of minimally invasive surgery and we have found that even the most complex robotic-assisted abdominal wall reconstructions are discharged 2-3 days earlier than patients who require traditional open operations.

Are there restrictions after a hernia repair?

Because the spectrum of hernia-related disease is so broad, this is not a simple answer. Also, we realize that activity restrictions impact home and work life.

In general, most repairs require several days before patients start feeling well enough to do much of anything. For a straight forward repair we generally tell patients to plan on 10 days of no vigorous physical activity or lifting more than 5-15 pounds. Stairs are OK and so is driving once the patient has stopped taking their narcotic pain medication. Our goal for these patients is to be walking three times daily for 20-30 minutes per session by the time the return to clinic for their postoperative visit, usually between 10-12 days after their operation. After this postoperative visit, they can advance to their normal activity levels at their own pace.

For more complex repairs, as in the case of abdominal wall reconstructions, we generally recommend a gradual increase in activity over 4-6 weeks followed by 6-8 weeks of physical therapy to strengthen the abdominal core muscles. Again, this is variable and driven more than anything by how the patient is progressing.

How will my pain be treated?

Hernia operations are notorious for being painful and controlling this pain is one of the most common concerns discussed in preoperative planning sessions.

We have a five part strategy to address the pain and discomfort associated with hernia repair:

1. Minimally-invasive surgery. In addition to lower infection rates, shorter hospital stays and less blood loss, most patients who have minimally-invasive hernia repairs have less overall pain. In our experience this is especially true in regard to robotic-assisted operations.
2. TAP blocks. After a patient is asleep in the operating room the anesthesiologist uses an ultrasound machine to guide injection of local anesthetic into the nerves of the abdominal wall. This is referred to as a TAP block and can provide effective pain relief for 8-24 hours.
3. Nonnarcotic alternatives. Significant pain control can be achieved with medications that are not narcotic. Our goal is to maximize the use of these nonnarcotic alternatives and minimize the use of narcotics.
4. Encourage activity. In our experience, patients who have persistent pain are those who are not active enough after surgery. We have found encouraging walking and stretching in the days after surgery to be of significant benefit in regard to pain control.
5. Enhanced-recovery pathways. An enhanced-recovery pathway is recipe for a group of medicines to be given to the patient with the goal of decreasing pain and encouraging return of normal body function. ERP’s have been show to be beneficial in many types of surgery patients, including those who have hernia repairs.

Narcotics are prescribed sparingly and much less often than they were several years ago. We have specific policies that are guided by national guidelines that dictate how many narcotic pills are prescribed for a given procedure.

This five part strategy is often successful and patients often take less than 5 pills. Some do not even fill their prescription.

What should I worry about after hernia surgery?

The bottom line if you have a question, give us a call. We take a great deal of pride in being available for our patients and referring physicians.

Things that we want to know about include but are not limited to: signs of bleeding or swelling around the wound, wound drainage, redness around the wound, fever greater then 101.5, nausea, more than 2-3 episodes of vomiting or diarrhea, inability to urinate, abdominal bloating, constipation for more than two days, or pain that is new, different, or poorly controlled.