Laparoscopic inguinal hernia repair- Mark Fusco MD


Laparoscopic Inguinal Hernia repair
	NETS GUARD OUT 6 WEEKS WITH HERNIA Published on October 4, 2000, The Record (New Jersey) The Nets shooting guard situation did not get any better Tuesday when it was learned that reserve Lucious Harris has a hernia. Harris is expected to have surgery Thursday and could miss six to eight weeks. "This summer I worked out like I should and tried to come into camp ready because the opportunity was there," Harris said after the Nets tipped off training camp at the Champion Center. "It's real disappointing right now to be out."
	Nets Getting Harris Back Published on November 8, 2000, The New York Times EAST RUTHERFORD, N.J., Nov. 7 -- Lucious Harris, the Nets' backup shooting guard, will be on the bench in uniform Wednesday night against the Wizards in Washington. Although he will most likely not play until Saturday against Seattle, his early return from hernia surgery is a welcome sight ...
Background Having hernia surgery doesn't have to mean putting your life on hold. Lucious Harris underwent laparoscopic hernia surgery and was able to return to the vigorous activity of an NBA athlete in just four weeks. Patients with less vigorous levels of activity often return to full activity much earlier. Hernia surgery is a common procedure with approximately 600,000 hernias repaired annually in the US. Hernias have been described since the earliest medical writings (Ebers papyrus - 3000 BC). The earliest known instance of named person with a hernia occurred in Pharaoh Ramesses V (c1141 BC) diagnosed by examining his mummified remains. Effective treatment of this ancient problem is a new phenomenon. The development of modern surgical techniques including anesthesia, asepsis, and attention to the anatomy of the area has lead to the only effective treatment for hernias.
Options for Hernia repair
Open repair without prosthetic material (mesh) Open repair with prosthetic material Laparoscopic repair - Dr. Fusco's preferred method of repair since 1994
Advantage of Laparoscopic repair (From the published literature and Dr. Fusco's observations)
Quicker return to full activity and work Exact definition of the anatomy Ability to assess and treat contralateral hernias if found Ability to repair Bilateral hernia repair without additional incisions Lower short term recurrence rate Lower complication rate secondary to decrease rate of wound complications and infections

Anatomy - Internal view - Left inguinal hernia (hole which is labelled as “Deep inguinal ring”)

Prior to surgery Depending on your age and medical condition you will be required to undergo preoperative testing. This may include blood work, x-rays, and an electrocardiogram. The office will arrange this and give you instructions when you schedule your surgery. Patients will also be given a prescription for pain medication. It is recommended that you fill this prescription prior to the day of surgery. It is very important that you do not eat or drink anything after midnight the night prior to surgery. This includes coffee, water, mints, gum, candies. You may ingest only a small sip of water with your morning medications. Dr. Fusco's office staff will advise you when to arrive at the hospital or surgery center. Since the procedures scheduled prior to yours may be longer or shorter than anticipated, we ask that you remain available prior to your arrival time so that you can be contacted and informed of any changes in your surgery time. When patients bathe the night prior to surgery they should thoroughly cleanse the umbilicus (belly button).
Incisions An incision approximately 1/2 inch long is made just below the umbilicus . This is used to insert the laparoscope (camera). Two additional 1/4 inch incisions in the mid abdomen on the side of the hernia are used to insert the instruments used to repair the hernia.
Conduct of the operation Using the inserted instruments the pelvic floor is examined to confirm the presence of one or more hernias. An incision is made in the peritoneum which is the inner most layer of the abdominal wall. A flap is developed and the hernia sack is usually fully reduced. The cord contents are "posteriorized" to prevent tenting of the mesh. A large mesh is inserted and is positioned over the hernia defect. Tacks are used to fixate the mesh on three corners. Fixation of the forth corner is precluded by the presence of the femoral vessels in this area. The tacks used are made of a material that is inert to the body. The tacks remain in place forever, they are not detected by metal detectors and they do not prevent patients from undergoing MRI scans. The mesh is then completely covered by the previously developed peritoneal flap. The incisions are closed with absorbable sutures. Steri strips (butterfly stitches) are placed. These remain on the wounds until they peel off on their own, usually in two weeks. The wounds are covered with Band-Aids. These Band-Aids can be removed the day after surgery. Patients are allowed to bathe normally the day following surgery.
Recovery The surgery is done as an outpatient surgery or sometimes as an overnight stay. Patients can resume light daily activity immediately. The average patient will require 1-2 weeks recovery before resuming more vigorous activity. There is no forced limitation of activity, instead patients are asked to advance their activity as tolerated. This applies to the resumption of work, sports, and sexual activity. Patients will want to eat light foods the night after surgery. Then they can eat food as tolerated. Some patients will experience some difficulty in voiding (passing urine) the night after surgery. This usually resolves the morning after surgery. In some patients they are unable to void completely. This is called urinary retention. If patients are having difficulty with urinary retention prior to 5 pm, they are asked to contact the the office (723-1027). The office will arrange for the patient to have a urinary catheter placed to drain the bladder. If patients have urinary retention after 5pm (when the office is closed), they are asked to proceed to the Emergency Department for this procedure. If patients are unsure what to do, they are encouraged to contact Dr. Fusco at 723-1027. Patients are seen in the office 5 to 9 days after surgery for a postoperative check, but patients are encouraged to contact the office sooner than this if they have any questions or problems. Dr. Fusco requests you contact the office for any of the following:
Nausea or vomiting that persists for greater then 24 hours after surgery - nausea shortly after surgery is commonly due to general anesthesia and usually resolves within this time period. Temperature greater than 101.5 degrees - Temperature elevations less than this are very common after surgery and usually have little significance. Pain that is not relieved by the oral pain medication prescribed. Inability to pass urine. Any questions or concerns. Patients experiencing any difficulty breathing, chest pain, change in level of consciousness, or loss of vision or strength should promptly call 911 for transport to the nearest emergency department.
Results Once the hernia is repaired, hernia symptoms usually resolve. This is only true if the symptoms patients have before hernia repair are in fact due to the hernia. Although this determination can never be made with absolute certainty, part of the patients preoperative assessment is an estimation of how likely the patients symptoms are secondary to the hernia.
Risks of surgery (with approximate incidence)
Hernia recurrence (redevelopment of a hernia) 2-5% Bleeding (needing transfusion) - less than 1% Infection - 2% Conversion to open surgery - 1% Injury to other structures in the abdomen including small intestines, liver, and blood vessels - <1% Hernia development at incision sites - < 1% Chronic nerve injury leading to chronic pain in the groin, scrotum, or leg - 1% Hematoma - Collection of blood in the groin area. This can sometimes occurs when the remaining hernia sac fills up with a small amount of blood. This problem usually resolves without any treatment. Depending on the size of the collection resolution may take many weeks. Patients who have a hematoma usually have more tenderness than other patients. - 5% Ischemic Orchitis - Injury to the blood supply of the testicle leading to pain in swelling in the testicle. In some instances this is severe enough that it requires removal of the testicle. - <1%
Additional Information Review of laparoscopic hernia technique Review of randomized study comparing laparoscopic and open hernia repair Merck Medicus - great overview of inguinal hernia

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