A hernia is a weakness on the abdominal wall that can be congenital or acquired. A hernia presents like a mass on the abdominal wall, which can increase in volume on cough of during the physical effort. The hernia can be symptomatic by the presence of pain, local discomfort or burning sensation.
The acquired hernias related to the intense physical activity, pregnancy, obesity (from a chronic increase of the intraabdominal pressure), chronic coughing, or due to the chronic constipation. (that will also increase significantly the intraabdominal pressure).
The treatment can be performed by laparoscopy or robotic surgery, or by laparotomy in case of big hernias that will need a parietal reconstruction.
-The laparoscopic cure of an inguinal hernia can be carried out in extra peritoneal space only (TEP), or via by opening the peritoneal leaflet through the peritoneal cavity or trans-abdominoperineal approach (TAPP).
-The laparoscopic approach is not indicated for patients with a medical condition (e.g. chronic obstructive pulmonary disease, stage Gold 4). For these patients, this intervention can be performed under spinal anesthesia or even under local anesthesia. Laparoscopic approach can also performed in emergency conditions for incarcerated or strangled inguinal hernias. This intervention should be supplemented by exploratory laparoscopy to rule out the presence of intestinal ischemia / necrosis. An indication may also be obsolete for patients with a history of orthopedics, prostate surgery or on anticoagulants. If the intervention is hemorrhagic, an aspirating drain can be left in place at the level of the inguinal canal.
– The patient can present a sensation of mass, pain during physical exertion or sporting activity during a prolonged orthostatic position. This mass can increase in volume during cough of physical effort. Inguinal hernia can be interstitial hernia (in the canal) / as a point of hernia (exceeding the superficial opening) / a funicular hernia (along the cord) / an inguino-scrotal hernia (unfolding the scrotum).
– In case of doubt at palpation, a control abdominal ultrasound is requested.
Postoperative attitude:
– After a laparoscopic hernia treatment, the postoperative attitude remains the same regardless of whether it is the treatment of a unilateral or bilateral inguinal hernia.
• Day0 – the evening of the operation the patient could have a TBB diet if there are no symptoms such as nausea or vomiting following the anesthesiologist, otherwise he can drink water for his comfort and the discharge can be authorized in the evening.
• Day1- The patient is mobilized during the morning, and the discharge is authorized.
Complications:
• Acute urine retention – in case of extensive bladder dissection, direct hernia with a bladder horn as content or significant hemostasis on the bladder wall
• Bleeding – clinically manifested by the appearance of a mass of fluid consistency in the scrotal area and a blue coloration of the integuments opposite the inguinal region concerned
• Acute testicular edema and pain during movement – probably related to improper positioning of the mesh.
-A hernia is a weakness in the abdominal wall. This weakness can be congenital or may develop with age or following conditions that increase intra-abdominal / physical pressure (physical exertion) or pathologies (chronic cough).
-The frequent place where it occurs is at the umbilical or epigastric level. There are also less frequent places like Spiegel’s hernia (on the lateral edge of the rectus femoris), dorsal or lumbar hernias (found in the posterior abdominal wall at the level of the lumbar region- upper lumbar triangle or Grynfelt hernia and the inferior lumbar triangle or Petit hernia).
-The laparoscopic approach is indicated for small parietal hernias or eventrations. The intervention consists of release of the hernia content, closure of the parietal defect and placement of non-absorbable prosthesis fixation to the posterior abdominal wall by absorbable screws (tacks) or biologic glue.
-A laparoscopic retro muscular approach is also possible for selected patients (eTEP).
Postoperative attitude:
-An abdominal belt is recommended postoperatively, because can reduce the pain during mobilization and therefore promotes early mobilization of the patient.
-In the evening or at Day 1 the patient will return home otherwise the patient will stay for an extra day for pain control.
Complications:
-Wound infection- manifested by local tenderness and signs of inflammation; antibiotics might be indicated
-Seroma/hematoma- due to hernia sac dissection; if the collection is small, a conservative treatment can be followed, otherwise a percutaneous or surgical drainage are possible.
– Rectus diastasis is an acquired condition in which the rectus muscles are separated by an abnormal distance along their length, but with no fascial defect. The classical performed by laparotomy is very invasive for the patient it comes with all complications of this type of surgery.
– The classical diastasis treatment performed by laparotomy is very invasive for the patient it comes with all complications of this type of surgery. Due to the minimally invasive technique the complications related to this approach are less important than in open surgery.
– Rectus abdominis separation is more predominant in the supra-umbilical region and can be linked to the patient’s age as well as and body mass index. Increased intraabdominal pressure causes tissue expansion of the abdominal wall, particularly at the linea alba. Certain conditions (such as genetic predisposition or chronic obstructive pulmonary disease) increase the risk of developing rectus diastasis. Most women develop rectus diastasis after pregnancy, particularly those involving multiple gestations or sequential large infants.
– The aponeurosis it’s approximate using resorbable sutures. By the same skin incision is possible to perform one suture on the cranial side and one on the caudal side. Using the same technique, the entire length of the aponeurosis it’s approximate.
– Due to the intraabdominal position of the mesh, a special mesh with a non-adherent side must be placed. The size of the mesh corresponds to the length of the diastasis approximation. The fixation of the mesh to the posterior side of the abdominal wall is performed with absorbable tacks.
-An eventration or incisional hernia is a postoperative hernia due to a healing issue of the abdominal wall. Is a more common situation after a laparotomy (which is surgery to open the abdomen for access) comparative with a laparoscopic or robotic surgery (that is performed by small incisions).
-An eventration is different from a hernia by its origin, in fact, it follows previous surgical incision on the abdominal wall. The healing of musculo-aponeurotic tissues at the level of the scar can present an issue and the scar can distend until it breaks. Thus, only the skin and the peritoneum retain the viscera. When the abdominal content is exteriorised completely, this pathology calls evisceration.
-An eventration can occur on all abdominal scars (midline, lateral or on old laparoscopy holes). In this orifice can pass from the digestive tract (small intestine or colon) but also the omentum (intra-abdominal fat apron) or any element contained in the abdomen.
–Smaller eventrations are treated by laparoscopy in the same manner as the midline hernias.
–Large eventrations, larger than 5 cm or several eventrations on the midline extending over (swiss cheese eventration) > 10 cm are a good indication for treatment by laparotomy with abdominal wall reconstruction and placement of the non-resorbable mesh at the retro-muscular level if the location is at the median or intermuscular level if the localization is lateral.
-Usually during surgery, an aspirating drain is positioned in a retromuscular position, if the dissection was difficult or haemorrhagic due to the scarring aponeurotic changes. Another aspirating redon can be also placed subcutaneously in order to decrease the occurence and quantity of seromas.
-An abdominal belt placement immediately postoperatively is important, especially for large parietal defects, because it can reduce wall pain during mobilization and therefore promotes early mobilization of the patient.
Postoperative attitude:
– Day1- The patient is authorized to have a normal diet. The early mobilization is encouraged and the patient is assisted by the medical team.
– Day2- The drain is removed if the quantity is <30cc and the appearance is clear, otherwise will be kept for the next days. If the patient is in good general status, the, discharge may be authorized. The patient can leave the hospital with the drains in place, which will removed in consultation.
Complications:
– Hematoma / Seroma- the most common complication for this type of surgery. The presence of aspirating redons significantly reduces this complication. If the seroma or hematoma is limited, conservative treatment is possible.
I am an Digestive Surgeon specialized in advanced laparoscopic and robotic surgery with activity in the field of parietal, bariatric, colorectal and hepatobiliary surgery with an active interest for the academic aspect and for the research in the field of digestive surgery.
Val des Seigneurs 53, 1150 Woluwe-Saint-Pierre
