By Nora Fullington, MD, FACS
The term “laparoscopic surgery” refers to making small incisions in the abdominal wall – just large enough to allow a camera to be placed into the belly and the use of long thin instruments to perform surgery. This is opposed to what’s commonly referred to as “open surgery” where a cut is made large enough to allow the surgeon to look in with their own eyes to accomplish the task. Because of this basic idea, when patients hear “laparoscopic” they often think “minimally invasive” and when they hear “open” they think “maximally invasive.” Surgeons think the same way most of the time.
Laparoscopic approaches are often the least invasive – this is the case in colon surgery, gallbladder surgery, appendix surgery for example – any surgery that takes place deep within the abdomen. When it comes to hernia surgery, however, where the problem is within layers of the abdominal wall, “open” surgery can be the least invasive, and therefore allow patients to have an easier recovery and less complications.
A hernia is a hole or defect in the strength layer of the abdominal wall – called the fascia. When you have a hernia, contents from inside the abdomen can bulge through this defect in the abdominal wall creating a bulge under the skin. The most common areas for this to occur are in the groin and at the belly button. To repair a hernia, we most commonly recommend the use of mesh to patch the hernia hole. Mesh is placed within layers of the abdominal wall and acts as a scaffold for your body to build scar onto. This scar-mesh combination patches the defect and prevents abdominal contents from bulging out.
Similar to patching a tire, mesh can be placed on the inside or outside of the defect. For most groin hernias, the best place for mesh is underneath the abdominal wall, patching the hernia hole from the inside. This is most commonly accomplished through laparoscopic surgery. Patients receive general anesthesia where they go completely asleep and require a breathing tube. Small incisions are made in the mid belly and the abdomen is inflated with gas so the hernia can be repaired from an approach inside the belly. This is an excellent way to get mesh into this inside position and perform a long lasting hernia repair with great results. This approach is especially helpful in patients who have more weight in their abdominal wall and in whom any open surgery would be much more challenging and possibly require a larger incision. Robotic hernia surgery is performed in the exact same way as laparoscopic hernia surgery, using an expensive robot which offers the advantage of 3D visualization of anatomy, much like we have with open surgery.
For most patients, there is another approach that allows placement of mesh on the inside of the hernia defect. This is through one small incision in the groin – an “open” surgery. While commonly practiced in Europe, this approach is not yet widely taught to surgeons in the US. This approach involves a very small incision in the groin a little bit above and to the side of the hernia bulge. The muscles in this area are not cut but instead are spread to allow access to the layer of the abdominal wall that is just inside the where the hernia hole is located. Mesh is placed into this space to patch the hernia hole from the inside – in the exact same position as it would be in a laparoscopic surgery. This open approach, as compared to laparoscopic surgery, does not typically require general anesthesia and surgery only goes as deep as is needed to get the mesh into this position rather than getting into the abdominal cavity. Only one incision is made in the area of the repair as opposed to the laparoscopic approach where incision sites higher in the belly could be at risk of developing hernias in the future. All of these are significant advantages over the laparoscopic approach when it comes to patient experience, recovery, and minimized risk of complications. In this case, this type of “open” surgery is the least invasive approach while still accomplishing the best possible repair.
Similarly, when repairing a hernia at the belly button, if a patient is thin enough and the hernia hole is small enough, this is best accomplished through a small incision at the belly button and placement of mesh into the space on the inside of the hernia hole. When a hernia is larger and needs larger mesh, laparoscopic surgery may be needed.
Boston Hernia confirmed these outcomes when they studied different approaches to hernia repair. This work was published in the prominent Journal of Hernia and is available here.
When evaluating which type of hernia repair is best for each patient, many factors come into consideration including the patient’s medical and surgical history, body shape, and hernia size and location. For many reasons discussed above, we often recommend an open repair as the least invasive approach with the best results and fastest recovery. Ultimately, the best repair will be different for each patient, and care should be tailored to the individual. At Boston Hernia, we pride ourselves on being able to offer the highest level of care through many different surgical approaches. We partner with our patients to assess each patient’s unique characteristics to help us determine which surgery will provide the best repair and quickest recovery.
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Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia. He started his practice as a general surgeon in 2001, and in 2012 he transitioned to focus on the care of hernia patients. In 2018, he co-founded Boston Hernia, an ambulatory surgery practice focused exclusively on hernia surgery. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon, where she performed hundreds of laparoscopic hernia repairs, to Boston Hernia where she was intensively trained by Dr. Reinhorn in the open preperitoneal and Shouldice techniques. Together with their physician assistant team, they perform approximately 800 hernia surgeries every year. Both surgeons offer a tailored approach for each patient, taking into account individual patient factors to decide if surgery is recommended or not, what type of repair (open, laparoscopic, mesh, non-mesh) is best, and what type of anesthesia is safest. At Boston Hernia, our focus is on each individual patient and continuously improving our own surgical techniques and outcomes. We do this by participating in various hernia societies, studying our own outcomes through a national database, and publishing our data to influence the care of hernia patients nationally and internationally. Boston Hernia is an affiliate practice of the Mass General Brigham system. In addition to operating at Newton-Wellesley Hospital, a Mass General Brigham Hospital, we offer care at ambulatory surgery centers in Waltham, MA and Derry, NH.