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

2. 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.

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

4. 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

5. 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)

6. 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

7. 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 3mo, 2y; 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

8. 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

9. 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)

10. 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

11. 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

12. 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.

13. 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: hours
Recovery Room: 1-2 hours
Outpatient Surgery Recovery: 2-6 hours
Postoperative checklist
Pain and nausea control
Tolerate liquids
Ambulatory
Urinate
Ride home

14. 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.

15. 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

16. 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)

17. 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