Laparoscopic Umbilical Hernia Surgery in Ahmedabad

Adult Umbilical Hernia Repair

The Condition

An umbilical hernia occurs when a tissue bulges out through an opening in the muscles in the abdomen near the navel or belly button (umbilicus). About 10% of abdominal hernias are umbilical hernias

common symptoms?

visible bluge on the he abdomen, especially with coughing or straining

Pain or pressure at the hernia site

Treatment Options

Surgical procedure

open hernia repair An incision is made near the site, and the hernia is repaired with mesh or by suturing (sewing) the muscle closed

laparoscopic hernia repair The hernia is repaired by mesh or sutures inserted through instruments placed into small incisions in the abdomen

Non-surgical procedure

Watchful waiting is generally not recommended for adults with an umbilical hernia. You may be able to wait to repair umbilical hernias that are very small, reducible (can be pushed back in) and not uncomfortable. There is a risk of the intestines being squeezed in the hernia pouch and blood supply being cut off (strangulation). If this happens, you will need an immediate operation.

Benefits and Risks of Your Operation

Benefits—An operation is the only way to repair a hernia. You can return to your normal activities and, in most cases, will not have further discomfort.

Risks of not having an operation— The size of your hernia and the pain it causes an increase. If your intestine becomes trapped in the hernia pouch, you will have sudden pain and vomiting and require an immediate operation.

possible risks include return of the hernia; infection; injury to the bladder, blood vessels, intestines, or nerves; and continued pain at the hernia site

Expectations

Before your operation—Evaluation may include blood work, urinalysis, ultrasound, or a CT scan. Your surgeon and anesthesia provider will review your health history, home medications, and pain control options.

The day of your operation—You will not eat or drink for six hours before the operation. Most often, you will take your normal medication with a sip of water. You will need someone to drive you home

Your recovery—For a simple repair, you may go home the same day. You will need to stay longer for complex repairs

Call your surgeon if you have severe pain, stomach cramping, chills with a high fever (higher than 101°F), odor or increased drainage from your incision, or no bowel movement for 3 days.

The Condition, Symptoms, and Diagnostic Tests

The Condition

The Hernia

An umbilical hernia occurs when part of the intestine or fatty tissue bulges through the muscle near the belly button (navel, umbilicus). Most (9 of 10) umbilical hernias in adults are acquired. This means that increased pressure near the umbilicus causes an umbilical hernia to bulge out. The most common symptoms are: A reducible hernia can be pushed back into the opening or decrease in size when lying flat. When intestine or abdominal tissue fills the hernia sac and cannot be pushed back, it is irreducible or incarcerated. A hernia is strangulated if the intestine is trapped in the hernia pouch and the blood supply to the intestine is cut off. This is a surgical emergency. Herniorrhaphy is the surgical repair of a hernia. Hernioplasty is surgical repair of a hernia with mesh inserted to reinforce the weak area.

Symptoms

The most common symptoms of a hernia are:

Bulge in the abdominal area that often increases with coughing or straining

Pain or pressure at the hernia site

Increasing sharp abdominal pain and vomiting can mean that the hernia is strangulated. This is a surgical emergency and immediate treatment is needed.

Common Tests

History and Physical

The site is checked for a bulge.

Additional Tests (see Glossary)

Other tests may include:

Ultrasound

Computerized tomography (CT) scan

Blood tests

Urinalysis

Electrocardiogram (ECG)—for patients over 45 or if high risk of heart problems

Keeping You Informed

Who Gets an Umbilical Hernia?

Ten percent of all hernias in adults are umbilical. Umbilical hernias can suddenly bulge out. They occur more often in adults over 60 years when the muscles start to weaken

Some risk factors are

• Older age—muscles become weaker

• Overweight and obesity—increased weight places pressure on abdominal muscle

• Chronic straining

• Family history

• Ascites: excess fluid in the space between the tissues lining the abdomen and abdominal organs; may be due to alcoholism

• Pregnancy, particularly multiple pregnancies

The Surgical and Nonsurgical Treatment

Surgical Treatment

The type of operation depends on hernia size and location, and if it is a repeat hernia (recurrence). Your health, age, and the surgeon’s expertise are also important. An operation is the only treatment for a hernia repair. Your hernia can be repaired either as an open or laparoscopic approach. The repair can be done by using sutures only or adding a piece of mesh.

Open Hernia Repair

The surgeon makes an incision near the hernia site, and the bulging tissue is gently pushed back into the abdomen. Sutures or mesh are used to close the muscle.

For a suture-only repair: The hernia sac is removed. Then the tissue along the muscle edge is sewn together. The umbilicus is then fixed back to the muscle. This procedure is often used for small defects.

For an open mesh repair: The hernia sac is removed. Mesh is placed beneath the hernia site. The mesh is attached using sutures sewn into the stronger tissue surrounding the hernia. The mesh extends 3 to 4 cm beyond the edges of a hernia. The umbilicus is fixed back to the muscle. Mesh is often used for large hernia repairs and reduces the risk that a hernia will come back again.

For all open repairs, the skin site is closed using sutures, staples, or surgical glue.

An open repair may be done with local anesthesia and sedation given through an IV.

Laparoscopic Hernia Repair

The surgeon will make several small punctures or incisions in the abdomen. Ports or trocars (hollow tubes) are inserted into the openings. Surgical tools and a lighted camera are placed into the ports. The abdomen is inflated with carbon dioxide gas to make it easier for the surgeon to see a hernia. Mesh may be sutured or fixed with staples to the muscle around the hernia site. The port openings are closed with sutures, surgical clips, or glue.

Nonsurgical Treatment

Watchful waiting is not usually recommended except for very small umbilical hernias. A surgical repair is recommended for adults who have symptoms, incarceration, thinning of the skin, or uncontrollable ascites. Because abdominal muscles weaken with age, the hernia can increase in size, and there is a risk of incarceration and strangulation. Abdominal binders that apply pressure and push back the bulge will not repair a hernia



Keeping You Informed

Open versus Laparoscopic

There is no significant evidence on the best technique to repair an umbilical hernia, and more study is needed. The type of repair may also depend on the size of the hernia.

When comparing open mesh repair with laparoscopic mesh repair, there is no difference in the length of hospital stay or recurrence rate. There is a slightly lower wound complication rate, including seromas, hematomas, and infection, with laparoscopic repair. Both types of operations have similar long-term results.

Open repairs can be done with local anesthesia instead of general anesthesia and are frequently done as outpatient procedures.

The use of mesh provides a stronger repair and decreases the rate of recurrence.

An open repair may be done with local anesthesia and sedation given through an IV.

suture repair will result in a small incision around the hernia site. Laparoscopic repairs usually have 3 to 4 smaller scars at the site of the entry ports

Risks of this Procedure

Risks Based on the ACS Risk Calculator

Risks from Outcomes Reported in the Last 10 Years of Literature Percent for Average Patient Keeping You Informed
Wound Infection: Infection at the area of the incision or near the organ where the surgery was performed Open 1.2% Laparoscopic 0.9% Antibiotics and drainage of the wound may be needed. Smoking can increase the risk of infection.
Complications: Including surgical infections, breathing difficulties, blood clots, renal (kidney) complications, cardiac complications, and return to the operating room Open 2.2% Laparoscopic 3.4% Complications related to general anesthesia and surgery may be higher in smokers, elderly and/or obese patients, and those with high blood pressure and breathing problems. Wound healing may also be decreased in smokers and those with diabetes and immune system disorders.
Pneumonia: Infection in the lungs Open 0.1% Laparoscopic 0.2% Movement, deep breathing, and stopping smoking can help prevent respiratory infections.
Urinary tract infection: Infection of the bladder or kidneys Open 0.1% Laparoscopic 0.4% Drinking fluids and catheter care decrease the risk of bladder infection.
Venous thrombosis: A blood clot in the legs that can travel to the lungs Open 0.1% Laparoscopic 0.3% Longer surgery and bed rest increases the risk. Getting up, walking 5 to 6 times per day and wearing support stockings reduce the risk.
Death Less than 1% Your surgical team is prepared for all emergency situations.
Immediate postoperative pain There is no difference in pain scores when comparing suture vs. mesh vs. laparoscopic repair by postoperative day The laparoscopic approach avoids a long incision. There may be a feeling of tightness in your abdomen because the muscle has been pulled together. Your pain will be managed with nonsteroidal anti-inflammatory medications and by resting and avoiding straining or lifting.
Recurrence: A hernia can recur after the repair Suture repairs 0% to 14% Mesh repairs 0% to 3% The use of mesh or another type of patch repair appears to reduce the rate of recurrence. 11 Obesity, diabetes, and smoking can affect wound healing and increase recurrence rates. 12 Laparoscopic repair is recommended for recurrent hernias because the surgeon avoids previous scar tissue and larger hernias. 13-14 There is a higher rate of recurrence in older men with laparoscopic repair
Heart complication: Includes heart attack or sudden stopping of the heart Less than 1% Problems with your heart or lungs can be aggravated by general anesthesia. Your anesthesia provider will take your history and suggest the best option for you.
Renal (kidney) failure: Kidneys no longer function in making urine and/or cleaning the blood of toxins Less than 1% Preexisting renal conditions; fluid imbalance, Type 1 diabetes; over age 65; antibiotics; and other medications may increase the risk.

Expectations: Preparing for Your Operation

Preparing for Your Operation

Home Medication

Bring a list of all of the medications, vitamins, and any over-the-counter medicines that you are taking. Your medications may have to be adjusted before your operation. Some medications can affect your recovery and response to anesthesia. Most often, you will take your morning medication with a sip of water.

Anesthesia

Let your anesthesia provider know if you have allergies, neurologic disease (epilepsy, stroke), heart disease, stomach problems, lung disease (asthma, emphysema), endocrine disease (diabetes, thyroid conditions), or loose teeth; use alcohol or drugs; take any herbs or vitamins; or if you have a history of nausea and vomiting with anesthesia. An identification (ID) bracelet and allergy bracelet with your name and hospital/clinic number will be placed on your wrist. These should be checked by all health team members before they perform any procedures or give you medication. Your surgeon will mark and initial the operation site.

If you smoke, you should let your surgical team know, and you should plan to quit. Quitting before your surgery can decrease your rate of respiratory and wound complications. Quitting also increases your chances of staying smoke-free for life. Resources to help you quit may be found at www.facs.org/ patient education or www.lungusa.org/stop-smoking

Length of stay

If you have local anesthesia, you will usually go home the same day. You may stay overnight if you have a repair of a large or incarcerated hernia. A laparoscopic repair may result in a longer anesthesia time. Complications such as severe nausea and vomiting or an inability to pass urine may also result in a longer stay

What You Can Expect

An identification (ID) bracelet and allergy bracelet with your name and hospital/clinic number will be placed on your wrist. These should be checked by all health team members before they perform any procedures or give you medication. Your surgeon will mark and initial the operation site.

Fluids and Anesthesia

An intravenous line (IV) will be started to give you fluids and medication. For general anesthesia, you will be asleep and pain-free during the operation. A tube may be placed in your throat to help you breathe during the operation. For spinal anesthesia, a small needle with medication will be placed on your back alongside your spinal column. You will be awake during the operation but pain-free

The Day of Your Operation

You should not eat or drink for at least 6 hours before the operation.

You should bathe or shower and clean your abdomen, especially around the umbilical area, with a mild antibacterial soap.

You should brush your teeth and rinse your mouth with mouthwash.

Do not shave the surgical site; the surgical team will clip the hair near the incision site

What to Bring

Insurance card and identification

Advance directives (see Glossary)

List of medicines

Loose-fitting, comfortable clothes

Slip-on shoes that don’t require that you bend over

Leave jewelry and valuables at home

After Your Operation

You will be moved to a recovery room where your heart rate, breathing rate, oxygen saturation, blood pressure, and urine output will be closely watched. Be sure that all visitors wash their hands.

Preventing Pneumonia and Blood Clots

Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in your lungs, and pneumonia. Every hour, take 5 to 10 deep breaths and hold each breath for 3 to 5 seconds. When you have an operation, you are at risk of getting blood clots because of not moving during anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased by getting up and walking 5 to 6 times per day, wearing special support stockings or compression boots on your legs, and, for high-risk patients, taking a medication that thins your blood.

Questions to Ask


About My Operation:

What are the side effects and risks of anesthesia?

What technique will be used to repair the hernia (laparoscopic or open; mesh or with sutures)?

What are the risks of this procedure for me?

Will you be performing the entire operation yourself? After Your Operation

What level of pain should I expect and how will it be managed? You will be moved to a recovery room where your heart rate, breathing rate, oxygen saturation, blood pressure, and urine output will be closely watched. Be sure that all visitors wash their hands.

How long will it be before I can return to my normal activities (work, driving, lifting)?

May I have my hernia repaired during a gastric bypass surgery?

Your Recovery and Discharge

Your Recovery and Discharge

Thinking Clearly

If general anesthesia is given or if you are taking narcotics for pain, it may cause you to feel diff erent for 2 or 3 days. You may have trouble remembering and feel tired. You should not drive, drink alcohol, or make any big decisions for at least 2 days.

Nutrition

When you wake up from the anesthesia, you will be able to drink small amounts of liquid. If you do not feel sick, you can begin eating regular foods

Continue to drink about 8 to 10 glasses of water each day.

Eat a high-fi ber diet so you don’t strain while having a bowel movement.

Activity

Slowly increase your activity. Be sure to get up and walk every hour or so to prevent blood clot formation

You may go home the same day for a simple repair. If you have other health conditions or complications, such as nausea, vomiting, bleeding, or infection after surgery, you may stay longer.

Work and Return to School

After recovery, you can usually return to work within 2 to 3 days.

You will not be able to lift anything over 10 pounds, climb, or do strenuous activity for 4 to 6 weeks following surgical repair of an umbilical hernia.

Lifting limitation may last for 6 months for complex or recurrent repairs

Wound Care

Always wash your hands before and after touching near your incision site.

Do not soak in a bathtub until your stitches, Steri-Strips®, or staples are removed. You may take a shower after the second postoperative day unless you are told not to.

Follow your surgeon’s instructions on when to change your bandages.

A small amount of drainage from the incision is normal. If the dressing is soaked with blood, call your surgeon.

If you have Steri-Strips in place, they will fall off in 7 to 10 days.

If you have a glue-like covering over the incision, allow the glue to fl ake off on its own.

Avoid wearing tight or rough clothing. It may rub against your incisions and make it harder for them to heal.

Protect the new skin, especially from the sun. The sun can burn and cause darker scarring.

Your scar will heal in about 4 to 6 weeks and will become softer and continue to fade over the next year.

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Bowel Movements

Avoid straining with bowel movements by increasing the fiber in your diet with high- fiber foods or over-the-counter medicines (like Metamucil® and FiberCon®). Be sure you are drinking 8 to 10 glasses of water each day

Pain

The amount of pain is different for each person. The new medicine you will need after your operation is for pain control, and your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia

When to Contact Your Surgeon

Contact your surgeon if you have:

Pain that will not go away

Pain that gets worse

A fever of more than 101°F or 38.3°C

Continuous vomiting

Swelling, redness, bleeding, or bad-smelling drainage from your wound site

Strong or continuous abdominal pain or swelling of your abdomen

No bowel movement 2 to 3 days after the operatio

Pain control

Everyone reacts to pain in a different way. A scale from 0 to 10 is used to measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted into your abdomen during the procedure. Moving and walking help to decrease the gas and the shoulder pain. 3 Extreme pain puts extra stress on your body at a time when your body needs to focus on healing. Do not wait until your pain has reached a “10” or is unbearable before telling your provider. It is much easier to control pain before it becomes severe

Common Medicines to Control Pain

Narcotics or opioids are used for severe pain. Possible side effects of narcotics are sleepiness; lowered blood pressure, heart rate, and breathing rate; skin rash and itching; constipation; nausea; and difficulty urinating. Some examples of narcotics include morphine, oxycodone (Percocet®/Percodan®), and hydromorphone (Dilaudid®). Medications can be given to control many of the side effects of narcotics.

Non-Narcotic Pain Medication

Most non-opioid analgesics are classified as non-steroidal anti-inflammatory drugs (NSAIDs). They are used to treat mild pain and inflammation or combined with narcotics to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the digestive tract, and fluid retention. These side effects usually are not seen with short- term use. Let your doctor know if you have heart, kidney, or liver problems. Examples of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot).

Pain Control without Medicine

Splinting your stomach by placing a pillow over your abdomen with firm pressure before coughing or movement can help reduce the pain.

Distraction helps you focus on other activities instead of your pain. Listening to music, playing games, or other engaging activities can help you cope with mild pain and anxiety. Splinting Your Stomach

Guided imagery helps you direct and control your emotions. Close your eyes and gently inhale and exhale. Picture yourself in the center of somewhere beautiful. Feel the beauty surrounding you and your emotions coming back to your control. You should feel calmer.