09 Jan 2021 My hernia came back!
The primary goal in hernia surgery is that the repair performed does not recur. Famous German surgeon Theodor Billroth (1829-1894) said in 1878 that “If we could artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernia would be discovered”, emphasizing that the secret of success in hernia surgery is in meshes. 140 years of endeavor continues. Until the 1950s, there was no significant improvement in mesh technology. In 1958, the American surgeon Francis Usher (1908-1980) used the first polypropylene polymer Marlex patch in hernia surgery and demonstrated good outcomes. German chemist Karl Ziegler invented the polypropylene polymer and received the Nobel Prize in Chemistry in 1963 for this invention. After that, rapid developments have happened in hernia surgery and the recurrence rates decreased significantly.
There are many reasons for recurrences. These are mainly can be classified as causes depending on the patient, the surgeon, the technique, and the mesh used. Technique-related recurrences take priority. Whether the repair is done by open or laparoscopic (Keyhole) method; The experience of the surgeon, selection of the appropriate technique, adequate dissection of the tissues, the use of appropriate meshes of suitable size and characteristics, the correct placement of the mesh, and its proper fixation affect the success.
Still, recurrences might occur. What to do when it comes back? According to the studies and guidelines published by the European Hernia Society; It is recommended that recurrent hernias should be operated by specialized hernia surgeons/centers. Doing so has a higher chance of success.
Another important guideline information is; for a recurrent hernia after an anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. There is an exception; in cases where the previously placed mesh will be removed, or if the additional intervention will be required (such as concomitant neurectomy), it might be necessary to re-operate from the previous surgical approach. If the mesh is shrunk, migrated, in contact with the intestine, causes chronic pain, or is infected, it must be removed. This can only be done by approaching the previous surgery plan. If there is chronic pain due to the previous repair, it might be necessary to remove the mesh and/or perform a neurectomy.
The causes of recurrence should be determined by performing a thorough physical examination before the operation, ultrasound, and even magnetic resonance imaging (MRI) when necessary. The previous hernia surgery report and the type of mesh used would provide valuable information. At the end of all these, the planning of the surgery should be done by discussing with the patient and giving detailed information. Good preparation should be made before the operation; Patients with diabetes should have blood sugar control, if there is obesity, weight should be lost, smoking should be stopped, a diet rich in vegetables and fruits, walking and exercise should be made applied.
If there is an infection, only the mesh must be removed and the repair should be left for another session. In the presence of chronic mesh infection, salvage of the mesh is not possible in most cases. The mesh should be removed completely. Once the infected mesh removed, placing a new mesh in the same session should not be done as the new mesh is likely to become infected! Once the infected mesh is removed, the infection in the wound will quickly clear up. No rush to repair. When the tissues heal, which is at the earliest 6 months, a repair can be scheduled.
Last word; If your hernia recurred, find a hernia specialist!
