New minimally invasive method for postoperative hernia repair

It is created when some intra-abdominal viscera falls out of its normal anatomical position, through a gap in an earlier surgical incision. Postoperative hernia is quite common, especially after open operations, with a rate that can reach up to 30%.

Why does a postoperative hernia occur?
“Every surgical procedure causes disruption of the normal anatomy of the muscular abdominal wall due to the incision or incisions that are made. Of course, the site of an old incision over time becomes a vulnerable (weak) point in the abdominal wall and potentially a hernia site under certain conditions.

Specifically, the combination of the auspiciousness of these points with the sharp or frequent and repeated increase in intra-abdominal pressure, will lead to the “exit” of the intra-abdominal splanchnic outside the intra-abdominal region”, points out Mr. Charalambos Spyropoulos, Surgeon, Director of the Minimally Invasive Surgery Clinic Digestive System / Obesity and Diabetes – 3rd Surgical Clinic Master Surgeon in Hernia Surgery, co-director of the Metropolitan General’s Center of Excellence for surgical treatment of patients with abdominal wall hernia.

Factors favoring the occurrence of postoperative hernia are:
• The numerous previous surgeries
• Poor initial surgical suturing
• The perfusion (contamination) of the surgical wound
• Smoking
• Weight gain / obesity
• Pregnancy
• Immunosuppression
• Poor nutritional status.

What symptoms does a postoperative hernia cause?
The main symptom is swelling at the site of the old surgical incision, while pain, nausea and bloating may occur. As in any form of hernia, its most dangerous complication is the tightening, i.e. the blocking of its contents. Since very often the content in this form of hernia is the small intestine, this complication is very quickly accompanied by ileus and threatened intestinal ischemia and perforation.

Peculiarities of postoperative hernia

Size and intra-abdominal adhesions are the two characteristics that influence its treatment:

1. The size
A postoperative hernia can become particularly large, especially in neglected cases or after multiple, failed repair attempts. These hernias often have numerous gaps (swiss cheese hernias) with the presence of several parts of the intestine or other organs inside them, often without the possibility of complete reduction. Over time and as long as the hernia remains untreated, the muscle layers of the abdominal wall weaken and degenerate completely resulting in a significant loss of the structural support of the intra-abdominal viscera (loss of domain).

2. The presence of intra-abdominal adhesions
Any surgery performed, especially open, involves the future development of scar adhesions, that is, strings of fibrous tissue inside the abdomen and near the site of the surgical incision. These adhesions create “compartments” inside the abdomen making it difficult for the normal mobility of hollow organs such as the intestine, while very often they are zones of adhesion of the organs to each other and to the inside of the abdominal wall.

Coping
Treatment of a postoperative hernia is only surgical. However, due to older operations, surgical repair of postoperative hernia requires a combination of modern surgical technology and extensive experience from a specialized hernia surgeon.
The modern trend of surgical reconstruction focuses on performing the operation extraperitoneally, i.e. in the narrow space between the membrane that surrounds the abdominal viscera and the posterior surface of the abdominal wall (Extraperitoneal Reconstruction Technique – eTEP). The integration of robotic technology in hernia surgery allows the eTEP technique to be performed with a variety of dissection approaches (eTEP, eTEP-RS, eTEP-TAR) even in large-sized hernias, with the possibility of using even larger meshes and reconstructing virtually the entire abdomen wall.

“The robotic approach offers the possibility of surgical hernia repair outside the abdomen and within the abdominal wall, i.e. within the muscular compartments. Robotic arms can enter between the abdominal muscles and not within the abdomen, thus avoiding the “hostile” environment of numerous intra-abdominal adhesions.

At the same time, it becomes possible to place large-sized meshes also outside the abdomen, inside the affected abdominal walls, which has been shown to be associated with better recovery, reduction of recurrences and avoidance of post-operative infections.

Patients who are operated with eTEP techniques usually have a one-day hospitalization, minimal pain, they usually do not have drains and the return to their daily activities is immediate”, concludes Mr. Spyropoulos.

Written by:

Mr. Charalambos Spyropoulos, Surgeon, Director of the Clinic for Minimally Invasive Surgery of the Digestive System / Obesity and Diabetes – 3rd Master Surgeon in Hernia Surgery Clinic, co-director of the Metropolitan General Center of Excellence for surgical treatment of patients with abdominal wall hernia

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