What does surgery involve?
Primary abdominal wall hernias include groin hernias (inguinal and femoral), hernias around the umbilicus, epigastric hernias (between the umbilicus and the lower part of the sternum) and rare hernias such as obturator, spigelian and lumbar hernias.
Large abdominal wall hernias, especially those arising after surgery, can be very complex and difficult to fix. Repair may be done laparoscopically or open or a combination of both (hybrid). It usually requires a large mesh (see below) and may require incision and mobilisation of the abdominal wall muscles on the side allowing to move centrally to bridge the hernial defect (component separation).
A mesh is a piece of synthetic (or less commonly biological) material which is used to support the weak tissues around a hernia. The hernial defect is usually closed (under minimal tension) and mesh is place either underneath (sublay) or on top (on-lay) of the closed defect. If the defect cannot be closed, the mesh may be used to bridge the gap (in-lay). The best type of repair is one where the mesh is in the sublay position.
Before repairing a very large abdominal wall hernia, the side muscles may need to be relaxed a few weeks before with an injection of Botulinum toxin A (Botox) which is done under ultrasound guidance.
Not all abdominal wall hernias can be or should be repaired. It depends on the patient’s medical condition and other factors such as the size of the defect, previous repairs, the amount of tissue within the hernial sac compared to what is left inside the patient’s abdomen. This should be assessed on a case by case basis.
What are the risks of surgery?
Surgical procedural risks can be divided into anaesthetic and surgical risks.
Anaesthetic risks are usually discussed with the patient by the anaesthetic team.
Surgical risks specific to major abdominal hernia repair include:
Infection – of the wound, the mesh or inside the abdomen.
Bleeding – inside the abdomen or within the wound (hematoma).
The risk of recurrence depends on patient factors and surgical factors. It increases with increased patient weight, size of hernial defect, smoking, increased intra-abdominal pressure by straining, lifting or coughing. Surgical factors include the position and size of the mesh, type of suture material used, post-operative complications such as bleeding or infection.
The risk of bowel injury is small but depends on the history of previous surgery and degree of post-surgical adhesions. These are usually recognized and repaired at the time of surgery and can increase the risk of infection.
Other risks of major surgery include:
- Deep venous thrombosis or DVT: formation of blood clots in the legs. This risk is reduced by wearing compression stockings (called TEDS), injection of blood thinning medications (Clexane) and mechanical calf-compression.
- Chest infection: This is prevented by adequate pain-relief, deep breathing, early mobilization and chest physiotherapy.
- In hospital:
Pain usually depends on the size of incision and degree of dissection.You will be prescribed regular pain-killers during your hospital stay.You are also likely to have a PCA (patient-controlled anaelgesia). This is a button you can press which delivers strong pain-killers directly into your blood stream.
- Upon discharge:
Take regular Panadol (as long as there are no medical reasons for you not to take it such as an allergic reaction or liver disease).Non-steroidal anti-inflammatory medication such as Neurofen and Voltaren can also help with pain and inflammation but should be taken on a full stomach. Take these for the first 3-5 days as required.Stronger pain killers such as opioid anaelgesics (Endone, Codeine) should be taken sparingly as they can cause constipation which results in more straining.
Bowel function may take a few days to return to normal following major abdominal wall surgery involving division of bowel adhesions. Post-surgical diet depends on the speed at which normal bowel function returns. If there has been minimal bowel involvement, you can start on a light diet soon after surgery. Otherwise, you may be started on clear fluids and build up to a normal diet prior to discharge from hospital.
You may have a urinary catheter put in at the time of surgery to monitor your urinary output and prevent retention which may be caused by pain or immobility.
This will be removed as early as possible depending on whether or not monitoring of urinary output is required and how mobile you are.
Early mobilization is vital in preventing complications such as chest infection and DVT. You will be encouraged to sit out of bed and go for a walk (under supervision at least initially). Physiotherapists play an essential role in this part of your recovery.
Dressings are usually in two layers – Steristrips with a padded-Opsite on top.
These are waterproof so you can shower but cannot swim or have a bath for 2 weeks or until after your follow up wound review.
The top dressing stays on for 5-7 days.
Once the top dressing comes off, leave the Steristrips on for a few more days until they start to peel off by themselves.
You may have a drain (or sometimes more than one drain) depending the type of hernia repair. This is removed when the output reaches a certain colour and volume.
You may go home with a drain which is usually monitored by the Hospital In The Home (HITH) nursing service. If this is not a free service through your private health fund, we will discuss alternative arrangements prior to your discharge.
You should avoid any heavy lifting or straining for at least 6 weeks after surgery to avoid hernia recurrence.
Patients will typically spend 3-5 days in hospital following a major hernia repair. However, duration of stay as well as speed of recovery depends on the specific surgery.
A wound review by your surgeon or local doctor is advisable 1-2 weeks after surgery.
The appointment is usually made for you by the ward clerk before leaving the hospital.