New hernia repair technique easier on patients, doctors
Nov. 24, 2003

By RASHA MADKOUR
Knight Ridder Newspapers

KRT PHOTO A hernia repair patch.

DETROIT — When Patrick Sexton went for his annual checkup, his doctor told him that a hernia spotted the year before had become more pronounced and that he needed to get it repaired.

Sexton, a retired businessman from Troy, Mich., wanted to hold off the surgery until the winter, when he wouldn’t be as active. He frequents the gym four times a week and is an avid gardener. But his doctor warned him of severe complications that could result from delaying treatment. Untreated hernias can cause fatal puncturing of organs in the abdomen.

So on July 10, Sexton underwent a procedure that veteran surgeons describe as the most dramatic change in hernia repair methods in decades. Compared with other techniques, the new mesh repair technique is easier for surgeons, cheaper for hospitals and less painful for patients.

Surgeons use a plastic mesh to patch the hernia. The patch helps the body heal by acting as a matrix for tissue ingrowth. Though mesh has been used to repair hernias for about 25 years, the newer three-dimensional configuration — the PROLENE Hernia System — was developed recently by engineers who knew the benefit of repairing defects from the inside, instead of from the outside. The benefits have been proven over time. In a study of 1,100 patients monitored for the five years since the product’s release, only three saw hernias return.

Hernias develop when an organ in the abdomen — often the intestine — bulges through a weak area of the abdominal wall’s connective tissue. In the United States, three-quarters of a million adults and children a year undergo surgery to fix this problem, which can be inherited or acquired because of strenuous activity. Hernias mostly occur in or around the groin, abdomen and navel.

Hernias may exist for weeks or years before they need to be repaired. The most dangerous potential complication for untreated hernias is strangulation, which occurs when a part of the organ gets stuck and shrivels because the blood supply is cut, leaving a potentially fatal hole.

Unlike the traditional approach, known as tension repair, which has a recovery period of four to six weeks, the mesh repair method has patients back to normal activity seven to 10 days later.

Sexton, 64, was referred to Dr. John Murphy, a specialist in hernia repair surgery who uses the three-dimensional patch. The device — which costs $100 to $125 per circle — consists of a two-layered piece of mesh connected by a button. It comes in three sizes, ranging in length from 3.94 inches to 4.92 inches.

The larger portion is positioned to lie against the inner abdominal wall and is held in place by the pressure of the abdomen. The smaller part patches up the outer abdominal wall and requires minimal stitching to keep it in place. The button acts as a plug.

Murphy, director of Michigan’s Troy Hernia Clinic at Beaumont Hospital, compared the process to fixing a flat tire.

Putting a reinforcing patch on the inside of the abdomen distributes pressure over a larger area, making the repair stronger. The alternative is patching the hole from the outside alone, which concentrates the pressure on a small, specific area. The hernia system sandwiches weak tissue between two layers of mesh, Murphy said.

The mesh also supplements potentially weak areas of the abdominal wall, minimizing the chances of getting another hernia in the same area, Murphy said.

After the mesh is in place, surgeons glue the skin together. Tissue then grows into the mesh, leading to faster healing and less pain.

“It certainly provides more patient comfort,” Murphy said of the hernia system. More than one-fourth of patients take no pain medication after surgery, he added.

A day after his surgery, Sexton said he felt a little discomfort and soreness, but was well enough to drive. “I haven’t been off my feet at all,” he said. Sexton stopped taking pain medication a day later.

The three-dimensional mesh procedure has a recurrence rate of less than 1 percent and takes 15 to 20 minutes to complete. By contrast, hernias treated by tension repair have a 10 percent chance of returning, and the operation takes 45 minutes to an hour. In tension repair, surgeons push the herniated tissue back and stitch the abdominal wall tissue together. The cost for all the procedures is the same, but a shorter operating time saves hospitals money. Running an operating room costs $20.50 a minute, Murphy said. That translates into $410 for 20 minutes, compared with $1,230 for an hour.

Although mesh repair is used in 60 percent to 85 percent of hernia treatments, it took nearly a decade to catch on.

“The bottom line is, surgeons are reluctant to change techniques” and are cautious about adopting new methods, Murphy said.

A past president of the American Hernia Society said one of the advantages of mesh repair is that it is easy to learn and do.

“The thing that makes mesh so wonderful is that all surgeons can have good results,” said Dr. Robert M. Zollinger Jr., a professor of surgery at Case Western Reserve University School of Medicine in Cleveland.

Another repair option, used 10 percent to 15 percent of the time and gaining popularity, is laparoscopic surgery. A thin tube with a tiny television sensor on its end is inserted through a small hole in the patient’s abdominal wall. Surgeons perform the procedure by watching a television screen.

A piece of mesh is placed behind the muscle to patch the hernia from the inside. This method can take an hour and may require a patient to stay in the hospital overnight. The recurrence rate is about 3 percent.

Dr. Gerri Pawlik said that if a patient has a returning hernia or hernias on both sides, “it really makes sense to do a laparoscopic repair.” In the case of a recurring hernia, using a laparoscope allows surgeons to avoid contact with scar tissue, reducing the risk of nerve injury, said Pawlik, a surgeon at Oakwood Hospital in Dearborn, Mich. For repair on patients with bilateral hernias, “it’s very simple to do them both laparoscopically and simultaneously,” she said, rather than making two incisions for open mesh repair.

For Cleveland’s Zollinger, laparoscopic repair using mesh has “two small disadvantages and one big advantage.” One drawback is that the procedure is performed under general anesthesia, which is slightly more risky than local anesthesia because it temporarily paralyzes and puts patients to sleep, rather than simply numbing a specific area. The other is that it requires more expensive equipment.

“The real advantage of laparoscopic repair is less pain, which translates into faster return to work,” Zollinger said. The procedure is minimally invasive and, on average, patients resume normal activity five to seven days after surgery.

Yet he points out that doctors set the recovery time, which varies by patient. “It’s an unknown for the patient, so they rely on the surgeon’s advice” on when to resume normal activity, Zollinger added.

Hernia patient Paul Nefouse called Troy’s Murphy the day after his surgery to ask whether he was supposed to feel discomfort. “I was 100 percent pain-free. That is not an exaggeration,” said Nefouse, 54, who underwent mesh repair in September.

Nefouse, a Bloomfield Hills, Mich., resident, owns a golf accessories company in Royal Oak, Mich., and is an avid player.

“When I used to swing, my hernia would pop out and I used to shove it back in,” he said. Then he began to realize that each time the bulge would get bigger.

He waited six months before taking steps to repair his hernia.

“I had this idea in my mind that I would get laid up, which is totally untrue,” he said. “You don’t have to be off your feet for six weeks; you’re not bedridden. You’re not supposed to lift heavy objects, but you can live a normal life the day after the surgery.

“If people do have hernias, they should definitely demand this particular procedure. It’s effective,” Nefouse said. “I’d have it done again and again if I had to.”