Laparoscopic Management of Incisional Hernia
January 27th, 2018
Incisional hernia can be termed as heterogeneous problem that keeps can be repaired using laparoscopic method. The open method can also be used to repair the incisional hernia. Studies have shown that there are very many patients out there who require an abdominal incision every year in order to repair the defects. Some studies have also shown that about 20% of patients who have undergone abdominal surgery may subsequently form an incisional hernia. Patients should be made aware of the risks of developing large hernia that keeps on growing. A massive grown hernia can be difficult to perform a surgical repair on.
Sometimes those that develop hernia will have to undergo certain emergency procedures that specifically involve the resection of the bowel and also on those with increased risk of morbidity and mortality. There are some risk factors that are associated with hernia, in which obesity is the most common risk factor for incisional hernia development. More often than not you will find people confusing obesity as being a contra-indication to the surgery, which is clearly not the case.
Laparoscopic management of incisional hernia can be safely performed on patients with a body mass index that is greater than 40kg/m2. This laparoscopic procedure is also good for patients who have co-morbidities that are affecting up to two systems.
How laparoscopic management of incisional hernia is performed
Laparoscopic approach to incisional hernia has gained rapid popularity over the years since it was first described in 1993. This surgical technique is minimally invasive unlike its counterpart, open surgery. Laparoscopic approach involves making three or more incisions away from the hernia. Placemen of the ports away from the hernia helps in the allowing the adhesiolysis and the removal or reduction of the contents of the hernia sac, better visualisation of the hernia defect as well as the placement of the mesh which is done intraperitoneally to overlap the defect completely. The mesh is a placed in such a way that is secured to the abdominal wall by making sutures. The surgeon may also use the metal tacs which have two rings in order to form a double crown or he may choose to combine both the sutures and metal tacs to secure the mesh.
Before, laparoscopic approach to incisional hernia was associated with a various major complications such as bowel injury during the dissection itself, erosion into the bowel or mesh adherence which prompted the need to convert to open surgery. Over the recent years there has been a growing clinical experience among practitioners which is leading to the reduction of the complications and the improvement of the procedure.
Advantages of laparoscopic management of incisional hernia
There have been various reports that have since confirmed the advantages of laparoscopic approach to the management of incisional hernia. According to the random reports, it was first established that patients who underwent the procedure experienced less postoperative pain. This is different from those who underwent the open surgery approach to the management of incisional due to the large incision that is often made. Laparoscopic approach only involves the making of small incisions through which the necessary instruments are passed for the operation to be performed. Patients also were linked to faster return to their normal activities after having the procedure conducted on them. The reports also show that patients often experience mire satisfaction with the improvement of the cosmesis.
Laparoscopic surgery can be conducted as a day case which has really helped in reducing the length of hospital stay by unlike with the open surgery. After the surgery is performed there are usually reduced rates of re-admission to the hospital. If the laparoscopic procedure is performed by a very experienced surgeon, the management for small incisions can be done and completed laparoscopically in about 95% of all the cases of hernia and reduce the reoccurrence rates to as low as 3%. If the surgery is done by a less experienced practitioner the reoccurrence rates can be a bit higher ranging between 3-15%. According to the studies, laparoscopic surgery has been described as a good approach, actually better than open surgery in lowering the rates of the recurrence of hernia in the short to medium term.
The best thing about laparoscopic approach over the open surgery is that the laparoscopy used in the procedure allows the practitioner to clearly identify all defects on the abdominal wall which was caused by the previous incision. This is quite good compared to the fact that the clinical examination will not provide the appropriate number of defects associated with a single incisional hernia. Laparoscopic management helps identify an average of 2.7 defects which is higher compared to 1.2 defects that are identified through the clinical examination. This helps lower the reoccurrence rates because all the defects can be addressed during the operation. The open surgery greatly misses out on this because the significant defect may not be addressed during the operation which present a higher rate of recurrence in future.
When performing the surgery, the abdomen has to be filled with carbon dioxide in order to perform the repair and then deflate it after the placing the mesh. This helps make sure that there is tension in the operated sites and ensure greater success. The risk of mesh infection is greatly reduced because it does not come into contact with the human skin and it is placed away from the new incisions where the infected sites have not been reopened.
Risks and complications of the laparoscopic management of incisional hernia
Laparoscopic approach does not go without being associated with some risks. The formation of seroma is actually the most common complication that is associated with this procedure. This seroma forms around the site of the hernia, however, it can be reduced by the use of special compression binders. These compression binders or bandages should be worn by the patient for 10 days after the operation. This will help the seroma to get eliminated naturally, but if they don’t, the patient should seek some treatment that will help resolve the complication.
There can be severe postoperative pain immediately after the surgery. This pain is associated with the use of metal tacs or sutures or the combination of both in order to secure the mesh. This pain can be controlled by offering the patient with opiate analgesia in the recovery room. The patient should continue using oral analgesics in order to reduce the length of stay in the hospital. With the use of the oral analgesics, the pain will not hinder the patient’s return to normal activities. This development and advancement of this procedure has greatly reduced major complications such as bowel vessel injury.
Laparoscopic surgery to repair incisional hernia can take a longer time if it is being performed by a less experienced practitioner. This has greatly contributed to the perception by people that laparoscopic approach takes longer operative times. However, if is performed by an experienced practitioner, the operating time can greatly be reduced.
There have been some increased costs of the equipment used in the operation as well as the increased cost of the specialised mesh. However, laparoscopic approach is quite inexpensive in terms of the stay at the hospital. This procedure reduces the hospital bed charges due to faster recovery and the patient is discharged the same day of the surgery of after a day or two. There are lower readmission rates which help reduce the cost of hospital bed occupancy. The lower reoccurrence rates associated with the surgery reduces the need for another surgery, which means saved costs.
Laparoscopic management for incisional hernia continues to gain popularity among very many individuals and practitioners across the world. Ever since it was first defined, laparoscopic surgery has gone through various major improvements or advancements which have led to an advanced procedure that is safe and efficient. The numerous advantages associated with the procedure including faster recovery and quick return to normal activities for the patients has made it become most preferred procedure for incisional hernia over the open surgery. With the improved clinical experience it is projected there will be an increase in the number of highly experienced practitioners who will be able to perform the surgery safely and efficiently. This will help improve the quality of this procedure in the coming future.
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