Operation

• Large umbilical hernia   > 2cm
• Large epigastric fracture  > 2cm
• Epigastric / umbilical hernia repair in patients at high risk of surgical wound infection.   
• Hernia repair in patients with morbid obesity.

Technique

Surgery is performed through small incisions. CO2 gas is injected into the abdominal cavity to create space to perform the hernia repair. Three small holes are created through which ports (trocarts) are inserted. A trocart (port) is a cylinder made of metal or hard plastic placed through the abdominal wall. Instruments necessary to perform the operation are inserted through the trocarts. At least two 5mm and one 10mm trocarts are inserted. In the first stage, the hernia sac is freed of its contents. The content consists in most cases of fatty tissue or bowel.

The fatty tissue attached to the abdominal wall is removed to obtain better adhesion of the mesh against the wall. The mesh usually has a diameter of 12 to 15 cm. It is rolled up like a cigarette leaf and inserted into the abdominal cavity through the 10 mm trocart. The mesh (prosthesis) is fixed to the abdominal wall with absorbable sutures (3-4 threads) and staplers. The trocarts are removed from the abdominal wall and the skin is closed with non-visible sutures (intra-dermo). The abdominal wall is closed with a separate stitch at the level of the 10 mm trocart. This suture can be the the most sensitive postoperatively.

What is a biphasic prosthesis/mesh?

A biphasic mesh has 2 sides. An upper side of polypropylene silk. Scar tissue will form through and around the openings in the mesh/prosthesis, causing it to be incorporated into the adjacent tissue. This forms a mechanical barrier against pressure and prevents hernia recurrences.
A smooth side on the bowel side that reduces the risk of the prosthesis adhering and growing into the bowel.

If the prosthesis infects and does not respond to antibiotic treatment, it may be necessary to remove the prosthesis / mesh.

A prosthesis is made of polypropylene with the following characteristics :

• Non absorbable
• Non carcinogenic
• Non allergenic
• Resistant to mechanical stress

Over time, scar tissue forms through and around the mesh of the prosthesis causing it to grow into the adjacent tissue, so to speak. Thus, it forms a mechanical barrier against pressure and against the formation of a new hernia.

If the prosthesis infects and does not respond to antibiotic treatment, it may need to be removed.

How long does the procedure take?

Depending on the size of the defect, the procedure takes 40 to 90 minutes.

What should one do to prevent a hernia recurrence after surgery?

For the first 6 weeks after surgery, do not play sports or engage in strenuous physical activities.

Avoid being overweight, as this increases intra-abdominal pressure and therefore the risk of a hernia recurrence.

Recurrence of an umbilical or epigastric hernia:

Incidence : < 4%

Risk factors promoting recurrence:

• BMI > 30kg/m2
• Diabetes
• Smoking 
• Wound infection
• Lung disease

Infection mesh / prosthesis

Rare : < 1%

Wound infection

Incidence : < 2 – 4 %, very rare

Seroma / fluid effusion

Incidence : < 6%

If a large hernia is removed or if part of the hernia sac remains in, the void left after treatment of the hernia may be filled with abdominal fluid (seroma) and blood.

Chronic pain

Incidence : +/-9% 

Bowel injury

< 1,5% when adhesions between bowels and the sac are loosened.

Hemorrhage:

Rare, mostly due to bleeding from small vessels on the abdominal wall. In most cases, the bleeding stops spontaneously.

To reduce the risk of complications, it is advisable to :

• Stop smoking for 6 weeks.
• Have a BMI of < 35 kg/m2 (body mass index (weight kg/height2 )

– Bientzle  Acute and chronic pain after laparoscopic incisional hernia repair pp 233 -237

– K Jensen Mesh versus suture elective repair of umbilical hernia:systematic review and meta-analysis; BJS Open 2020;4:369 – 379

– European and Americas Hernia Societies (EHS and AHS) Guidelines  for treatment of umbilical and epigastric hernias from the European  Hernia Society and Americas Hernia Society; BJS 2020; 107: 171 – 190

– Nienhuijs Simon Mesh or Patch  for hernia on epigastric and umbilical sites ( Morpheus trial)

Normal symptoms

In normal conditions, pain is well controlled with paracetamol (Dafalgan®), NSAIDs (anti-inflammatories) or morphine (Tradonal®…) and pain symptoms diminish over time.

• Nausea and vomiting  (24-48 hours) may occur. Adolescents and especially young women are more affected.
• Hardening and pain at the level of the scar. The wound may feel hard for several weeks.
• Abdominal bloating gradually decreases postoperatively for 2 weeks
• Pain is often aggravated by sudden movements of the abdominal wall laughing, coughing, sneezing,….)
• Shoulder pain  (24-48 hours) due to irritation from the CO 2-gas injected during the laparoscopic procedure.
• Urinary retention may occur in the first hours after the procedure. Temporary placement of a urinary catheter may be necessary.
• Swelling at the site of the hernia after surgery (seroma): Collection of wound fluid and blood that fills the void left after treatment of the hernia.
• On returning home, the joy of returning home, is often followed by an increase in fatigue and sometimes a drop in morale.

Abnormal symptoms

If certain symptoms seem abnormal to you contact your doctor

• If you have persistent fever
• If you have acute pain that increases over time
• If you have bloating with nausea and vomiting

If this is not possible, you can contact avec your surgeon.

If you are unable to contact your GP or your surgeon, go to the emergency department at St Elizabeth Hospital in Uccle.

Sport / Physical activity

• After a rest period of 4 to 6 weeks, sports and physical activities can be resumed.

Pregnancy

Pregnancy is always possible after open umbilicus/epigastric hernia repair with mesh or prosthesis.