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P A I N
M A N A G E M E N T
almost exclusively use an open approach, which results in a nice, flat
abdominal wall. However, since laparoscopic surgeries do produce
less pain and discomfort, there's less peritoneal trauma. Virtually all
my inguinal and hiatal hernias I repair laparoscopically. The only time
I use an open approach (with hiatal hernia) is when there's an especially hostile abdomen due to previous operations."
Dr. Voeller agrees. "With inguinal hernias, if there have been previous surgeries in the area, or if there's a lot of scarring, it probably
should be an open surgery unless the surgeon is very experienced at
laparoscopy," he says.
2. Mesh
The trend in recent years has been toward using less-dense material, and as little of it as possible, since, as noted above, the less foreign material you introduce to the body, the less pain there tends to
be. The downside: Using less and lighter material makes it harder to
handle and position the mesh. And heavier patients may still require
heavier material.
In some cases, you may be able to get away with absorbable mesh,
or even no mesh at all. "I'm able to repair the majority of the hiatal
hernias without mesh in a tension-free manner," says Dr. Ross. "When
I need mesh for reinforcement, depending on the size of the defect, I
use an absorbable biosynthetic mesh composed partly of porcine
small intestine submucosa.
"Sometimes I use ePFTE (expanded polytetrafluoroethylene)
impregnated mesh with an antiseptic for diaphragmatic hernias
that can't be approximated," says Dr. Ross. "It's more expensive
and the operative times are longer, but studies have shown it
results in significantly lower numbers of recurrences."
When dealing with hiatal hernias that require mesh reinforcement,
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | A U G U S T 2013
