Ventral and Incisional Hernia Repair
Hernias can occur in the abdominal wall with or without a previous surgical scar. Incisional hernias can occur anywhere there has been a previous abdominal incision, and can occur at any time following previous surgery. Ventral hernias can also occur in a variety of locations in the abdominal wall without previous surgical incision. Surgeons have learned that repairing such hernias without the use of some form of mesh device puts the patient at much higher risk of failure of the repair than if the repair had included the use of mesh. Furthermore, simply suturing mesh to the borders of the hernia defect has been shown to be inferior to placing mesh with considerable overlap of the mesh perimeter on the surrounding normal tissue. This can be done in a variety of methods depending on the patient’s circumstances. The approach to the repair of these hernias must be highly individualized and tailored to his or her unique situation.
Most of these patients require a preoperative CAT scan evaluation in addition to careful physical examination. Many patients have had numerous previous attempts at repair of the hernia, and each failed repair results in an increased risk of future failure. It is for this reason that many patients require advanced and radical solutions to achieve lasting reconstruction of their abdominal wall hernia.
Options for repair of ventral andd incisional hernias include:
- Laparoscopic mesh placement
- Requires intraperitoneal tissue separating mesh and fixation with transfascial sutures and tacking devices.
- Open preperitoneal mesh repair (modified Stoppa technique ) which may or may not require transfascial sutures or tacks.
- Open components separation reconstruction with underlay mesh placement (preperitoneal or intraperitoneal)
- Open components separation reconstruction with underlay and onlay mesh reinforcement (Sandwich technique).
- Tissue separating mesh (i.e. Proceed® Mesh orPhysioMesh® ) is used when the mesh must be placed into the abdominal cavity in contact with the intestine and other internal organs. These mesh products are constructed of a lightweight mesh foundation, and feature surface qualities which vastly reduce and inhibit the formation of scar adhesions to these internal tissues, while providing strong in-growth into the abdominal wall.
- Lightweight mesh (i.e. UltraPro or Prolene® Soft Mesh) without tissue separating features is useful in circumstances where the mesh can be placed between two layers of, or on top of the abdominal wall.
- Biologic Mesh (i.e. Flex HD ) is one of the newest tools available for hernia repair, and is usually recommended for procedures where there is risk of bacterial contamination or known existing infection. Use of non-biologic synthetic mesh in settings such as these can lead to infection involving the mesh, which often requires removal of the synthetic mesh. The use of biologic mesh in these cases greatly reduces both the risk of infection and the requirement of removal of the mesh.
Recovery from ventral and incisional hernias is dependent on numerous factors, all of which are patient-specific. Nevertheless, while some patients are able to have repair of these hernias as an outpatient, the majority of larger, or more complex abdominal wall reconstructive procedures require at least a few days in the hospital, and as expected, a few weeks to a month or more before returning to active life and work obligations.
Over the last several years, more and more publicity has emerged around professional athletes undergoing surgery for a "Sports Hernia". In fact, the condition is perhaps more accurately labeled as Athletic Pubalgia (pain in the pubic region), or any one of a number of other names. The condition is actually not a hernia at all, but is thought to involve a disruption of connective tissue in the pelvis, in or near the inguinal region, which is caused by an imbalance of muscular and tendinous forces focused in the groin. It occurs most commonly in athletic activities, which require certain motions of the hip, thigh, and abdominal muscles. Soccer and hockey players seem to be most at risk, but any activity that places stress in this area can produce symptoms of a sports hernia, especially when conditioning is somewhat out of balance.
Professional athletes are not the only ones at risk. In fact, it is likely that non-professional athletes and "weekend warriors" produce more injuries.
Diagnosis can be challenging, as diagnostic imaging studies such as MRI, CT scan, and ultrasound are often normal or inconclusive. Careful evaluation including analysis of the athletic mechanisms which produced the pain, and targeted physical examination, is usually the only way to accurately diagnose this condition.
Experts in the field argue about the appropriate treatment of this condition, and there is no clear-cut consensus as to which type of surgery is preferable.
Our approach is to avoid application of the "one surgery fits all" mentality, and devise a treatment plan that is suitable for the patient, his condition, and the urgency of returning to similar athletic activity. Clearly, professional athletes need to be "back in the game" as soon as possible, but it is important to allow adequate healing, whether surgery is involved or not, before allowing resumption of a full level of participation.
For some, surgery is not required. Quality physical therapy with a competent and knowledgeable therapist, combined with gradual strengthening exercises, can yield excellent results.
Surgical options for sports hernia include minimally invasive laparoscopic repair with lightweight mesh, and minimal incision "open" bilayer mesh repair with the Prolene Hernia System or UltraPro Hernia System. Release of the adductor muscle tendon in the groin is occasionally advised, but is employed very judiciously.
Professional athletes can usually be expected to return to the field of play in as little as two weeks, but 3-4 weeks is average. Others, depending on the level of conditioning and need for therapy after surgery, can require up to 6-8 weeks for adequate recovery.