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Inguinal

Another name for groin hernias.  It's the 2nd most common type of hernia.  It is 10x more common in men.  These hernias can be divided into direct or indirect.

Umbilical

The most common type of hernia.  Everyone has a small opening in the belly button left by the umbilical cord.  This opening can enlarge, resulting in a hernia.  The hernia must be repaired when it is enlarging or causing symptoms like pain or intestinal blockage.

Incisional

This type of hernia develops where a surgeon has previously cut through the abdominal wall.  These hernias come in all sizes and complexity.  Many can be difficult to repair, and require a robotic hernia specialist to achieve a durable repair.  The PATCH Institute is one of the only centers in the Bay Area with extensive experience in robotic repairs.

Hiatal

This type of hernia occurs when the stomach slips through the diaphragm hiatus into the chest.  Frequently patients have heartburn, chest pain or trouble swallowing.  There are 4 types of hiatal hernias.  Repairs are usually done through the abdomen and involve pulling the stomach into the abdomen, tightening the diaphragm hiatus and performing a fundoplication (wrap).

Additional Hernia Types

Paraesophageal

This is a type of hiatal hernia but is frequently used by general surgeons to refer to very large hiatal hernia where more than 1/3 of the stomach is in the chest.

Epigastric

A hernia that occurs in the linea alba in the upper midline of the abdomen.  These usually are small and feel like small lumps under the skin.

Diaphragmatic

The diaphragm is a muscle and can develop hernias. Hiatal & paraesophageal hernias are the most common.  Less common types include Morgagni or Bochdalek.

Spigelian

Occurs in either lower quadrant of the abdomen, above the groin, where the posterior connective tissue layer thins.

Parastomal

A hernia that forms around a stoma (colostomy, ileostomy or urostomy).  More than 50% of patients with stomas will eventually develop a parastomal hernia.  These should be fixed when the hernia affects the function of the stoma, or causes pain or blockage. 

Ventral

This is a term that applies to all hernias in the front of the abdomen.  Usually they refer to larger umbilical hernias.

The PATCH Institute offers all options

The general scientific knowledge of hernias has grown exponentially in the last few years. Advancements in technology have also greatly increased our surgery options. The surgeons at The PATCH Institute are experts in utilizing the latest knowledge, techniques and technology to repair your hernia with the smallest scars, quickest recovery and lowest complication rate. During the consultation, your general surgeon will determine the best surgery option for you.

OPEN SURGERY

This is the traditional approach with a larger incision at the hernia bulge. This type of surgery is still preferred when the hernia is either very small or very complex. For example, many inguinal and umbilical hernias are many times best performed open. Open surgery is sometimes better in complex hernia repair when there is mesh to be removed, when intestine needs to be resected or when there is a lot of skin/fat that needs to be removed.

LAPAROSCOPIC SURGERY

A form of minimally invasive surgery introduced in the 1980’s. Laparoscopic surgery uses small incisions away from the hernia bulge.  It frequently leads to less complications than open surgery. Today, it is used for hernia repairs that don’t require advanced robotic surgical systems.  It has several limitations:  the surgeon uses straight instruments that may limit the precision of surgery, it is difficult to place mesh outside the abdominal cavity, more surgeon fatigue due to poor ergonomics, and it requires sometimes painful fixation tacks and sutures.

ROBOTIC-ASSISTED SURGERY

A form of minimally invasive surgery through small incisions. It utilizes advanced robotic surgical systems such as the daVinci robot. The robot is not autonomous. It is simply a more advanced surgical tool and is FULLY controlled by the surgeon. The robotic platform offers the surgeon fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot doesn’t get tired and the surgeon sits during surgery, so there is less surgeon fatigue. For the patient, this translates into quicker recovery, less pain and less complications. This is the preferred approach for medium to large hernias and many inguinal hernias as it combines the best of open and laparoscopic surgeries. Also, the surgeon is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.

HYBRID SURGERY

Sometimes the best option is to combine multiple techniques. We call this a hybrid technique because we may perform part of the operation robotically and another part open.  Hybrid surgery is frequently performed for complex or unusual hernias, and ones that require skin or soft tissue removal.  

Experience Matters

Regardless of the option that is right for you, the surgeon's experience is probably what matters most.  Using the latest robotic technology does not guarantee great results.  Frequently surgeons will promise a laparoscopic or robotic approach but have a high conversion rate to open surgery.  At The PATCH Institute we are experts at minimally invasive hernia repair, and have an extremely low conversion rate.

What is mesh?

Mesh is a sheet of material designed to reinforce a hernia repair. It can be called a "screen" or "patch" also.

Material

Mesh can be divided into synthetic or biologic, and permanent or absorbable.  Biologic mesh can be made from human, pig, sheep or cow tissue.  The newest meshes are made with a combination of synthetic and biologic material.

Safety

Mesh is safe when implanted properly. It has been around for almost half a century and has been implanted in millions of people without problems.

Choice of mesh

There are many factors that determine which mesh your hernia surgeon will use. Most hernia repairs utilize permanent synthetic meshes that are made with either polyester or polypropylene.

Surgery without mesh?

You developed a hernia because of weakened tissue. Just sewing the weakened tissue with sutures is usually not enough to prevent a future hernia, so mesh is needed to reinforce the repair.

Dissolving mesh

Dissolving mesh can be derived from biologic or synthetic sources.  There is no benefit in using these meshes in most situation.  A hernia specialist at the PATCH Institute will be able to guide you with the choices.

What is the evidence regarding mesh and chronic pain?

The best available evidence shows that using mesh for hernia repairs does not lead to increased chronic pain. However, using mesh decreases recurrences significantly compared to not using mesh. Below are 2 good quality studies in the surgical literature:

van Veen RN, Wijsmuller AR, et al. Randomized clinical trial of mesh versus non-mesh primary inguinal hernia repair: Long-term chronic pain at 10 years. Surgery, Volume 142, Issue 5, 695 – 698.

In this study 300 patients were randomized to open repair with mesh and open repair without mesh. This is the gold standard method of performing a comparison study in surgery. After the surgery, the patients were followed for a median of over 10 years. The patients whose repair did not utilize mesh had a 17% recurrence rate (i.e. 17% failed over 10 years). Patients whose repair utilized mesh had a 1% recurrence rate. The authors also found “that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity.” In other words, patients who had mesh did not have more pain or discomfort than patients who didn’t have mesh repair. 

Scott N, Go PM, et al. Open Mesh versus non-Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3.

This study is from Cochrane. It is a non-profit, non-government organization formed to organize medical research findings to facilitate evidence-based choices about health interventions faced by health professionals, patients, and policy makers. Cochrane includes 53 review groups that are based at research institutions worldwide. 

This review by Cochrane examines the evidence from studies comparing different types of open surgery for people with groin hernia. They included only randomized studies comparing methods using synthetic mesh versus methods without mesh. There were 20 studies comparing mesh with non-mesh repair analyzed in this study.

Based on their analysis, there was strong evidence that fewer hernias recur after mesh repair than following non-mesh repair. There was a suggestion that people had less persisting pain after mesh repair, but results were only available for nine out of 20 trials. Open mesh methods were shorter to perform than Shouldice procedures (an open non-mesh repair) but took longer than other types of non-mesh repair. They found no clear differences between mesh and non-mesh methods for operative complications and persisting numbness. Overall, people spent less time in hospital and returned to their usual activities quicker after mesh repair.

The leading minimally-invasive general and hernia repair surgeon on the West Coast, serving patients in the greater SF Bay Area. 

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