Hernia Repair

The Condition

A hernia is a weakness or defect in the muscles and tissues of the abdominal wall. The contents of the abdomen (such as intestines) can push through a hernia, causing a bulge and discomfort. Ventral hernias involve the front of the abdomen, and commonly occur at the site of a previous surgical incision. Groin hernias include inguinal and femoral hernias and there is usually a genetic predisposition.  Hernias can be repaired primarily (by placing stitches and bringing together the tissue) and/or by the use of mesh.

Symptoms

• Bulge in the abdominal wall
• Abdominal pain
• Change in bowel habits
• Bowel obstruction

The procedure

A hernia repair can be both laparoscopically or open.  For the laparoscopic approach the surgeon will make about 3-4 small incisions in the abdomen. A port (nozzle) is inserted into one of the slits, and carbon dioxide gas inflates the abdomen. This process allows the surgeon to see inside of the abdomen more easily. A laparoscope is inserted through another port. The laparoscope looks like a telescope with a light and camera on the end so the surgeon can see inside the abdomen. Surgical instruments are placed in the other small openings and used to repair the ventral hernia. The surgeon first will have to free the bowel which may have become entrapped into the hernia. This process by itself can be difficult and time-consuming. After the intestines have been reduced from the hernia, the repair usually is done by placing a mesh over the hole (the hernia), and securing this mesh to the surrounding edge of the abdominal wall. If the hernia is large, then it may require a very large sheet of mesh, more than 12 inches across. After this has been accomplished, the carbon dioxide is released out of the abdomen through the slits, and then these sites are closed with sutures or staples, or covered with glue-like bandage and steri-strips.

Nonsurgical Treatment

The treatment of hernias is surgical. Hernias that cause no symptoms, however, may not need to be treated.

Risks

• Infection of the skin
• Postoperative ileus (the intestines slow down/stop working for several days)
• Infection of the mesh
• Accumulation of fluid between the mesh and the abdominal wall (ceroma)
• Bowel obstruction
• Hernia recurrence
• Injury to the intestine
• Nerve entrapment
• Injury to the spermatic cord and vessels (testicular necrosis)

Medical Negligence

The above mentioned risks and complications are known to happen with hernia repair and such complications do not necessarily constitute deviation from the medical standard of care.  The following examples however may be considered as medical negligence.

• Delayed diagnosis of perforation of the small intestine is the most problematic post-operative complication of laparoscopic hernia repair which most of the time leads to litigation. 
• Nerve entrapment has been described both with open as well as with laparoscopic hernia repairs.  Patients with nerve entrapment have chronic pain in the distribution of specific nerves. In patients with laparoscopic inguinal hernia repair the following nerves can be injured or clipped: femoral nerve, genitofemoral nerve, anterior femoral cutaneous nerve, lateral cutaneous nerve.  In open inguinal hernia repair the ilioinguinal and the iliohypogastric nerves are more prone to be injured or entrapped.  Chronic groin pain following inguinal hernia repair has resulted in lawsuits.
• Spermatic cord injury can be the result of non careful dissection by the surgeon or by a tightly placed mesh (strangulation).  If the spermatic artery is interrupted then it is likely that the testicle will undergo acute necrosis (testicular death) or atrophy.