Treatment of Hernia by Laparoscopic Surgery:

Is it beneficial?

Dr Shahzad Alam Shah MBBS (PMC) FCPS (General Surgery)Assistant Professor Laparoscopic SurgeryFatima Jinnah Medical College, Visiting Surgeon Sir Ganga Ram Hospital LahoreConsultant, Minimal Access Surgery, Mid City Hospital, Jail Road, Lahore

What is Hernia? Hernia is a very common condition found in large number population throughout the world and almost everyone is aware of its name if not exactly what it is. A hernia is in fact a defect in the wall of tummy (abdomen). It commonly becomes prominent when the fat and intestines from the tummy force their way out of this defect in the muscle and fat. Coming out of the tummy contents through this defect causes a bulge (swelling) and sometimes pain in that particular area. If not treated at time there is a danger of the intestine to get damaged (strangulated or gangrenous). The problem increases with time and unfortunately the only treatment for this condition is surgery. This traditionally involved a cut over the hernia, reduction of the contents back to the tummy and some form of stitching of the defect to prevent the hernia from coming back. This is what is called the repair of the hernia by open method or incision.

With the advent of instrumentations and technology the repair of hernia through laparoscopy has rapidly gained popularity in the West. In this particular article I just want to discuss the benefits of this technique that I have employed in hundreds of my patients with excellent results and patient satisfaction. Earlier, most surgeons were even not of the opinion that Gallbladder should be removed by laparoscope but now all agree that Laparoscopic removal of gall bladder is the best way of treating gall stones and gall bladder disease.

Conventional Surgery or open hernia repair

This question is commonly being raised that if hernia repair surgery is being done for centuries with good results by conventional surgery then why to complicate the issues with this new technique? The main problem with a hernia operation is the average six weeks of rest after surgery and the chance of the hernia coming back (failed operation that is known in medical terms as a recurrent hernia). Detailed analysis at many centers has revealed that the recurrence rate after open hernia repair is considerable. The large number of operations being done for recurrent hernia confirms this. The techniques basically involve minimum stitching and a tensionless placement of a net (mesh) at the defect site with little disturbance to the body physiology. However all open surgical techniques involve cutting of the muscles overlying the hernia in order to be able to reach the defect. Which in effect weakens already weak muscle tissue? This like any other way of hernia repair means pain and rest after the operation.

Why laparoscopic treatment of hernia is more beneficial?The Principle of Laparoscopic Hernia Repair

The basic difference and the concept of laparoscopic repair of hernia can be explained by a simple example. Imagine a bathtub. When you put the rubber stopper at the outlet hole and fill the tub with the water, the water pressure pushes the stopper in place and keeps it fixed there. The more you fill the water, the firmer will be the stopper. Now, if we were to put the stopper from the outside. Then the water pressure in the tub is going to push the stopper out as the pressure increases. This is Pascal's law.

The same scenario can be imagined with placing a mesh on the hole where the hernia is. Is it going to be better fixed from outside or inside? Open surgery places it from outside and laparoscopic surgery places it from inside. Its will be more beneficial to fix it from inside. It is because hernia develops whenever there is increase in the pressure inside the abdomen, for example coughing, straining, constipation etc: Laparoscopically placed mesh placed from inside can better cope with all such conditions that can cause recurrence of the hernia.

1. Fat being pulled in from the hernia defect 2. The defect as it looks from the inside3. A mesh introduced like a rolled cigarette is being unrolled and4. The mesh being fixed into place.

The Technique

During laparoscopic surgery, we make a small ½ inch cut in the skin at the belly button. Then a cannula (thin tube) is introduced in between the muscle fibres without cutting any of the muscle. Through the cannula, the laparoscope (camera) is inserted into the patient's body. It is equipped with a tiny camera and light source that allows it to send images through a fibre-optic cord to a television monitor. The television monitor shows a high resolution magnified image. Watching the monitor, the surgeon can perform the procedure. While looking inside the patient, further two ½" diameter cannulas are put in. This way, the already weak muscles are not disturbed and the net is placed through the half inch holes that are away from the hernia. Thus there is minimal disturbance to the normal body physiology and as a result the pain is minimal and very little rest is required. Also the hernia that is going out from the tummy is pulled back in rather than pushed in from outside as is done in an 'open' operation. There are more and more reports now from different studies across the world showing the success of this technique in reducing post operative pain, rest and recurrence rates.

The greatest advantage of laparoscopic surgery for hernias is in patients of recurrent hernias where the anatomy has already been disturbed and also in patients of hernias on both sides, as they can be repaired through the same three holes avoiding any further pain or trauma.

The problem of the laparoscopic hernia repair is the cost of the operation, due to the expensive imported instruments that are needed. The increased cost should be compared with the gain associated by a quicker and more productive return to work by the majority of the patients. Laparoscopic hernia is an efficient technique that compares favorably to current open surgical techniques. Patients are relatively pain free following this procedure and can return to work and normal activities much quicker than following conventional hernia repairs.

Frequently asked questions

Q. Why laparoscopy is better for treatment of hernia?A. Because there is no large incision and cutting of muscles the patient experiences minimal pain after the operation and get back to its normal activity quite early. Secondly, as the mesh is placed in a secured way from inside the chances of the hernia coming back become extremely low.

Q. In how much time the patient get recovered from surgery?A. The patient starts drinking liquids soon after coming out of the anaesthesia which is about 2 hours after the operation. He can start eating soon thereafter and are allowed to get off the bed and walk to the toilet to pass urine within four hours after the surgery. They are usually fit to go home the same day or very next day. These patients can climb stairs and the majority can get back to routine activity in 5 days.

Q. What are the chances of the hernia coming back (recurrence)?A. If the operation has been performed properly the chances of hernia coming back are almost negligible. This has been proved by many studies carried out so far.

Q. In patients with other medical problems like diabetes and blood pressure, is it feasible?A. Yes it is. The absence of any major cuts to the body causes minimal disturbance to the physiology. Also the early mobility and return to normal diet makes it easy for the body to recover.

Q. Is there an increased risk of infection?A. No. In the absence of large incision the chances of wound infection are much less.

Q. Why do you approach the hernia from inside?A. The hernia is protrusion of the body contents through the weakness in the muscle. It is logical that something coming from inside is best dealt from inside. Also this way one does not cut and weaken the already weak muscles at the hernia site.

Q. Is it a safe operation? How safe is it to leave a mesh inside the body?A. This is an absolutely a safe operation and the mesh used is the same as the one used for open operations over last 30 years. Therefore, its safety and efficacy is beyond doubt as proved by the numerous trials in the USA and Europe.

Q. Is this an expensive operation? A. As compared to open surgery the operative cost of laparoscopic surgery is more. This is because the use of laparoscopic equipment and the imported ' one use only (disposable) ' instrument that is used to fix the mesh inside increases the cost of surgery. However, the increased cost should be compared with the gain associated by a quicker and more productive return to work by the patients and greatly reduced disruption of the routine life.

The author Dr. Shahzad Alam Shah MBBS; FCPS is nowadays working as Assistant Professor of Laparoscopic Surgery at Fatima Jinnah Medical College and Sir Ganga Ram Hospital Lahore.

He also is a practicing Consultant Laparoscopic Surgeon at Mid City Hospital, Jail Road Lahore.