Keyhole repair of midline/incisional hernias
For selected patients with small midline hernias a MAS approach may be possible. Here 3 ports are placed usually on the patients left side and mesh placed inside the abdomen over the hernial defect, securing with staples. Again these operations can be done as day cases and may lead to reduced postoperative pain and infection rates.
This technique is, however, really only effective in smaller hernias as the strength of the repair is based on the mesh only with no closure of the overlying defect. The complication rates of midline hernia repairs are higher than for groin hernias and this rises in conjunction with the size of the hernia. Most wounds are closed with dissolving sutures although metal clips maybe used for the larger cases.
The problems of bleeding/bruising, infection and recurrence apply as before but with the incisional hernias there is always the possibility of injury to the bowel, which is fortunately a rare but described problem. Recurrence of midline hernias is more common than for those found in the groin, reportedly up to 15% depending on the size/type of hernia. Another problem is that fluid may collect in the tissues underneath the skin so called seromas, which may be particularly problematic in large hernias. In order to reduce this when repairing large hernias a small plastic tube (a drain) maybe left in the space left behind after the repair is complete. This may stay for a few days until relatively dry and then be removed either on an in or outpatient basis.
Most incisional hernias will need repair although some patients may elect not to undergo surgery or may not be fit enough for such a procedure. In these cases the patient may elect to simply wear a ‘corset’ which acts as a truss (see groin hernias above) and will need to be ‘made to measure’.
The treatment of various types of hernia will vary depending upon the site and the nature of the problem although the principles of management are very similar. With improvements in technology and the establishment of specialist centres for hernia treatment patients should experience further improvements in outcomes.
