Open Preperitoneal Hernia Repair

You are having an open preperitoneal inguinal hernia repair with mesh. This type of repair is the preferred repair in most circumstances. It involves using mesh to patch the hernia from the inside. This repair has been described using several names including OPP (Open Preperitoneal), TREPP (Trans Rectus Sheath Preperitoneal), and fast recovery inguinal hernia surgery.  

 

The procedure:

A small incision is made in the groin and the muscle above the hernia is spread to allow us to get into the space just inside the hernia hole. We pull the hernia contents that have bulged through this hole back into the abdomen where they belong and place the mesh on the inside of the muscles covering the hole or holes in the abdominal wall. We usually use a mesh manufactured by Bard called Ventrio ST- the mesh used is usually 11x14cm in size. This allows coverage of the three areas in the groin that most commonly are involved with hernias. The mesh is secured using a dissolvable stitch in one location (Cooper’s ligament). Otherwise, it is quite secure in this space sandwiched between layers of the abdominal wall. The surgery is usually less than an hour long for one side or 1.5 hours for both

 

Anesthesia:

This procedure is typically done with IV sedation (similar to the anesthesia for a colonoscopy) and local numbing medication. Occasionally, an airway will be used to help control breathing. This can sometimes be determined at the time of your consultation and other times will be determined by the anesthesiologist depending on your needs during surgery. It is rare that we need general anesthesia for this procedure. Muscle paralysis is not used, unlike laparoscopic or robotic-assisted surgery.

 

Why we recommended this repair:

We tend to recommend this repair to most patients whose medical history allows because it is best to repair a hernia with mesh on the inside of the hernia hole (like patching a tire from the inside rather than the outside). This results in the lowest possible chance a hernia comes back after surgery – likely less than 1%. Because of the technique used where we make a small incision in the groin and spread muscle rather than cutting muscle, it is the least invasive approach possible with the quickest recovery and the least amount of postoperative pain. 90% of patients do not require opioid pain medications after surgery and can get back to work within a few days of surgery as long as they do not have a very physical job. We have found that when we avoid general anesthesia when appropriate, patients have reduced post op pain and quicker recovery.

 

A note on mesh:

Patients often ask us “Is mesh safe?” The mesh we use has been used millions of times and is well tolerated by patients. There are lawsuits related to a specific type of mesh that was taken off the market several years back. We do not use this mesh. There are other concerns related to where mesh is placed in the groin. In the case of inguinal hernia repair, this usually relates to stitching and placing mesh over the area of the three nerves in the groin. When one of these nerves is inadvertently injured, patients can develop chronic pain. In the case of open preperitoneal inguinal hernia repair, we are placing the mesh on the inside of the hernia hole- this allows us to stay away from the area where most of the nerves course. This is one of the major benefits of repairing a hernia from the inside. Additionally, when using a foreign material like mesh, there is a chance that material becomes infected. Your body can’t defend infection in a foreign material as well as it can in our own bodies. Fortunately, this is very rare (about 1 in 5,000) but can result in the need for the mesh to be removed.

 

Risks of surgery:

During your appointment, you discussed the risks of surgery. Every surgery comes with risk, but we do everything we can to minimize the chance that you have a complication related to one of these risks. 

  1. Hernia recurrence 1/100 – Hernias can come back after repair. After open preperitoneal inguinal hernia repair, the risk of recurrence is about 1-3%. This means that 97-99% of patients will not need another operation for their inguinal hernia.
  2. Infection 1/200 – If an infection occurs after surgery, it is usually a skin infection and is well treated with a short course of oral antibiotics. If the mesh becomes infected, it can require removal. This is exceedingly rare at ~1/5,000.
  3. Chronic pain 1/300 – As mentioned during your consultation, chronic pain is less of a risk when we repair inguinal hernias from the inside, but it is impossible to completely avoid the risk of some discomfort extending beyond the normal recovery period. The risk of chronic pain is less than 1/300. If this happens, we work closely with our patients until they get better. In our experience, this usually resolves by itself and rarely requires surgical intervention to fix.
  4. Bleeding 1/400 – The risk of any significant bleeding after inguinal hernia repair is less than 1/400 and this is kept very low risk when patients adhere to activity restrictions in the first couple weeks after surgery.
  5. Complication requiring additional surgery – about 1/400 patients require a second operation after their first operation to fix bleeding or an intestinal issue. While this is not common, we take a very proactive approach in order to speed up the healing process.

 

Preparing for surgery: 

  • Please continue to be as active as you normally are. It is safe to exercise as long as you do not have pain with your activities. 
  • Make sure you have acetaminophen (tylenol) and ibuprofen (motrin, advil) at home as these medications are typically all that is needed to treat post-operative pain.
  • No bowel prep is needed before surgery. 
  • You will likely need to have a Covid test within 72 hours before surgery. Our medical assistants give you instructions on how best to arrange this at the time of your consultation. 
  • Depending on what facility you are having surgery in, another step is required prior to surgery: 
    • Newton-Wellesley Hospital – Our medical assistants will schedule you a pretesting phone appointment and we will contact you regarding the scheduling of this appointment. 
    • BOSS– You were given a sheet detailing what you need to do to register prior to surgery. 
    • Surgical Center of NH at Derry – You will receive an email or text from the surgery center itself to register as a new patient.  

 

The day of surgery: 

  • Please arrive promptly at the time you are given as a lot has to happen before you are wheeled into the operating room.
  • You will get an IV, meet the team (including the preoperative nurses, the OR nurse, the anesthesiologist or nurse anesthetist), and see your surgeon and physician assistant in preparation for surgery. 
  • After surgery, you will spend about 1-2 hours in the recovery room before you go home. 

 

After surgery: 

  • Take acetaminophen and ibuprofen together every 6 hours for the first 2-5 days for pain control. 
  • Avoid any activity more strenuous than casual walking for two weeks after surgery.
  • Remove bandage (if present) 48 hours after surgery. 
  • Please see these instructions for more details on your post-operative care.
  • A note on resuming exercise after the 2 week recovery period: Once you are two weeks out from surgery, you can start testing different activities. Approach activities slowly until you are sure they don’t cause you sharp pain. Any activity that causes sharp pain at the incision should be avoided. If you feel well and are active throughout one day, it is normal to feel more sore the next day while you continue to recover. You didn’t hurt yourself so long as you don’t push through an activity that’s causing you pain while doing it. Ultimately, the goal after you are fully recovered is to get you back to all of your activities without restriction. For most of our patients who have this type of surgery, they are back to most of their pre-op activities about 1 month after surgery.  

 

We hope this information has helped you prepare for your upcoming hernia surgery. If you have any questions about the above information, please call our office at 617-466-3373 to set up a follow up appointment so that we can ensure all of your questions are adequately answered and you feel comfortable prior to your surgery.