OUTPATIENT SURGERY PROCEDURES:

Also called “Day Surgery” or “Ambulatory Surgery” these procedures require general anesthesia or IV sedation (more than just local anesthesia), but do not require an overnight hospital stay.  Minimally invasive surgery procedures are applied to a growing variety of procedures, and they are ideal for the outpatient setting. 

 

Preoperative Covid-19 testing will be required.

Hernias

General Comments About Hernias:

The primary source of a hernia is a tear in the strength layer of the abdominal wall, called fascia. Fascia gives structural support to the muscles.  When the fascia is torn, the muscles retreat to where there is fascial support.  This is why you can’t exercise (strengthen muscle) to improve a hernia.  Damaged or torn fascia requires surgical intervention.  In fact, hernias can get worse with exercise as you increase your internal, intra-abdominal pressure and push more tissue out.  With time, the hernia can get larger and entrap internal fat or even parts of your intestine.  If intestine is trapped in the hernia sac, it is called incarceration and requires immediate evaluation at the emergency room.  The reason for this is that incarcerated bowel can result in a cut-off blood supply leading to intestinal strangulation, which means the tissue is ischemic or non-viable.  Both incarceration and strangulation are indications for emergency surgery.  I recommend elective hernia repair for this reason, whenever possible.

Inguinal Hernias

The inguinal hernia repair procedure is one that has had notable technological advances in recent years due to the ability to perform a minimally invasive repair by use of laparoscopy.  I still perform open inguinal hernia repair in select cases but laparoscopic repair is associated with less postoperative pain and faster recovery, so most patients who are good candidates for laparoscopy choose this approach.  Ultimately, we discuss the options and choose the best procedure for you together. 

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  • Location: in the groin regions, above the crease that is between the lower abdomen and upper thigh, left or right of pubic bone. 

  • Characteristics: A bulge that can come and go, but when large enough it may be always present.  It may become more prominent as the day progresses or become noticeable with coughing or straining.

  • Pain: Can be painful.  Severe pain would indicate possible incarceration and warrant going to the ER immediately.

  • Size: Early inguinal hernias may not be visible as a bulge.  Large inguinal hernias that are easily seen can contain bowel. 

  • Why do they form?: The inguinal region is an area of anatomic weakness of the fascia.  In males, testicular descent into the scrotum occurs during the final stages of fetal development and the path to the scrotum may not fully close (yes, infants can be born with hernias). Even if this tract closes, this area is still weaker than other areas of the abdominal wall. 

  • Women also get inguinal hernias as the layers of muscle and fascia become a single layer to insert into the pubic bone and this layer can be weaker than the rest of the abdominal wall. ​

 
  • ​Do I need to have to have my hernia repaired?:  Yes, even small hernias can get incarcerated, and over time hernias will continue to increase in size.

  • What are the risks of surgery for inguinal hernia repair?: 

Infection- There is small risk of infection with any procedure.  Preoperative IV antibiotics, given just before surgery are routinely administered to minimize any risk for infection.

Bleeding- There are blood vessels that are observed and in the area of dissection, however working around them is standard during surgery and expected blood loss is minimal – less than a vial of blood that one would give for lab draws. 

Hernia recurrence- Studies have shown that inguinal hernia recurrence is comparable regardless of whether they are done as a laparoscopic procedure or open procedure.  Individuals with other medical conditions are at increased risk for hernia recurrence, however the greatest incidence of recurrence is associated with obesity.

Chronic pain- there is a 1 % chance of chronic pain after inguinal hernia surgery regardless of whether an open or laparoscopic procedure is done.  This incidence is due to the inguinal region having several nerves that supply sensation to the area- these are the ilio-hypogastric, ilioinguinal, and genitofemoral nerves.  99% of patients do just fine.  For the 1% of patients where chronic pain develops there are measures we can take to manage and treat the pain- these include topical anesthetic ointments, scar tissue steroid injections, and rarely- neurectomy (resection of nerve segments). 

Mesh complications- First of all, what we refer to as “mesh” is the woven synthetic material that is used to reinforce the abdominal wall where there is absence or weakness of fascia.  There are advertisements on TV these days by law firms looking for potential litigation cases to bring against the makers of hernia repair mesh.  This is a complex subject which I will reduce to a relatively simple answer.  Mesh has been used for hernia repair for many decades.  Overall, the advent and use of hernia mesh has been tremendously beneficial in lowering hernia recurrence rates.  The vast majority of hernia surgeons use mesh for hernia repair.  There are various kinds of mesh used in the past, some which may have had good logic for their use at the time but have not had good outcomes, such as heavy-weight meshes that were associated with increased pain or light-weight meshes that could tear with time and result in hernia recurrence.  In my 20+ years of practice, I have used a medium weight polypropylene mesh and have had reliable, good results.  Allergic reactions to mesh are reported at 1 out of 100,000-200,000.  There are many additional types of meshes with various benefits and weaknesses, but these are beyond the scope of our discussion here.

Laparoscopic Inguinal Hernia Repair with

Mesh Procedure

The laparoscopic approach to inguinal hernia repair gained traction in the early 2000’s and is now a widely accepted, and often preferred approach to inguinal hernia repair due to their association with less pain and faster recovery. 

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What to expect the day of procedure:

  •  Pre-procedural prep: In anticipation of general anesthesia, nothing to eat after midnight prior to surgery.  Clear liquids up to 2 hours prior to surgery.

  • Surgery will take 1-1 ½ hours depending on features of the hernia and whether the hernia is only on one side or bilateral.

  • You will be asked to present to the surgery center 1 hour prior to procedure or hospital 2 hours prior to procedure.

  • The preop nurse will place an IV and start mediations. 

  • Then the anesthesiologist and OR nurse will bring you into the operating room.

  • The anesthesiologist will provide general anesthesia, which means you will be completely asleep for the surgery and you will there will be a temporary breathing tube in your airway.

  • Sterile skin prep is applied to the surgical area once you are asleep.

  • Three small incisions are made, one at the umbilicus and two on either side of the lower abdomen and tubes called “trochars” are placed via which carbon dioxide is introduced to create an internal “tent” and then the camera and instruments are placed. ​

 
  • The inner lining of the abdominal cavity, called the peritoneum is opened, and mesh reinforcement is placed to cover the hernia fascial defect, then the peritoneum is replaced.

  • The three small incisions are then closed with sutures that are dissolvable and Steri-strips (reinforced tapes) and band-aids are applied as dressings.

  • You will be transported to the recovery room and this is where you are carefully observed as you wake up fully, which is usually about a 1 hour process.

 

Post-procedural care and what to expect for recovery:

  • Diet-A light dinner is recommended after surgery then you can eat a regular diet the following day.

  • Activity- It is better that you do not stay in bed other than for sleep as getting up and walking around at home helps with blood circulation in your legs and taking deep breaths prevents pneumonia. 

  • Lifting restrictions- Avoid lifting greater than 20 lbs for one month.

  • Shower and removed the band-aids in 48 hours and allow the Steri-strips to fall off on their own.  The Steri-strips can be removed if they are still on the skin after 7 days.

  • Pain control- Stronger, narcotic pain medications are required for 2-4 days and then a combination of Tylenol and Ibuprofen/Advil/Motrin can be used for less severe pain.

  • Schedule a telemedicine or in-office post- procedural visit for 10-14 days weeks.

  • Return to work- Most people are feeling only minor discomfort by one week after surgery and are no longer taking narcotics, so if you have a sit-down job returning to work at that point may be possible, but it is reasonable to take 2 weeks off and return to work earlier if you are feeling well.  Lifting restrictions are no greater than 20 lbs for one month from surgery date, and my office will write a note for work to that effect if you have a physically demanding job.