Sometimes hernia surgery can be frustrating because it can fail and patient comes back with recurrence. The reasons of failure of the surgery could be due to technique, giant defects, previous failed operation, mesh not used, obesity, etc. In planning for the second surgery in these complex hernias it is important to correct these factors- if possible- before going ahead with another operation.
There will be many procedures to choose from. However it is believed that these complex hernias should be repaired with a mesh- an artificial flat knitted material – if the failure is to be kept low. There has been astounding progress in the field of production of mesh. They are nowadays designed to provide more comfort and flexibility to the patient while keeping the failure rate low.
The second issue is to place the mesh in the right place. It can be placed just beneath the skin or behind the muscle by conventional open technique. Or the mesh can be placed inside the abdomen by Laparoscopic method. It is believed that keeping the mesh deeper inside the body leads to less chances of failure. Hence many surgeons have shifted to putting the mesh inside the abdomen by Laparoscopic method.
Another important issue in hernia is obesity. It has been observed that hernia surgery fails more often in obese patients. It has been advocated that hernia surgery should be performed after weight reduction if failure is to be avoided. This could mean dieting, physical activity or even bariatric surgery- stomach stapling surgery for severe obesity. In a severely obese patient with hernia, bariatric surgery could produce significant weight loss. After a few months when this has been achieved hernia surgery can be done and this approach has been shown to be more successful.
However there are some situations when hernia defects are so big thatconventional or laparoscopic surgery is not possible, even dangerous. A new technique- Component Separation Technique- addresses these issues and is proving to be more successful.
In 1990,Ramirezintroduced the “components separation technique” to bridge the giant hernia defect without the use of prosthetic material. Although initially it was not popular, there is renewed interest in this technique recently to tackle complex hernias. The technique is based on enlargement of the abdominal wall surface by separation and advancement of the muscular layers. In this way, defects of up to 20 cm at the waistline can be bridged. No mesh may be needed in this procedure. This is in contrast to previous beliefs that mesh is vital for the success of hernia repair.
Another modification of this technique is the “sandwich technique”. After the gap is closed in component separation technique, two meshes- one from outside and one from inside- can be placed to strengthen the defect. This is a novel idea, which is getting further evaluation.
Hernia surgery is evolving and there is huge development in the science of mesh, technique and treatment strategy- all of which aim to decrease the failure rate and provide more comfort to the patient at the same time.
These developments are good news for those patients who have complex hernias. They now have something to cheer about. To view how this is done you can see the video of Hernias on our you tube page .