The following is a step by step demonstration of a typical umbilical hernia repair using pledgets:
Pledgets are small velour patches that are made of Teflon when used for surgery. They are very commonly used for cardiovascular surgery for example closing incisions made in the aorta or securing an artificial valve into the heart when a diseased valve is being replaced. The advantage of a pledget is that it works analogous to a washer that is commonly used with a screw in carpentry or mechanics. It increases the holding capacity of a suture just like a washer increases the holding capacity of a screw. In aortic surgery this is critical because the wall of the aorta is high pressure and high tension. Failures are catastrophic. By the way no sane cardiovascular surgeon would attempt a "tension free" repair of the aorta.
One of the mechanisms of hernia surgery failure is the suture failing to hold. In the past three years we have been doing pledgeted repairs of umbilical hernias and in this time have not seen a single failure. Our numbers are not large enough to publish yet but it is our intention to do this if someone else does not do it before us.
This patient has a typical umbilical hernia. It is not big enough to be seen in the first picture but the patient was very aware of if. If you look closely you will notice that his belly button does not go in especially when you compare it to the final picture.
On examination by the surgeon the hernia can be more easily demonstrated.
With the patient under general anesthesia a one inch incision is made just above the belly button and the hernia sac is dissected away from the surrounding tissue. Very commonly this sac is removed but we find that the patient is more comfortable after surgery if we simply invert it and stuff it back into the abdomen. This also protects the intestines from developing adhesions with traumatized tissue. Here an instrument is inside the hole in the fascia which is the hernia. Through this hole is where the intestine will poke out and can become strangulated. Our job is to close this hole.
Repair of this hernia only required two stitches. You can see one pledget on the far ends of both stitches. There is another pledget on the near end of each stitch which is obscured from view. The stitches are tied and then cut short completing the repair of the fascia defect. A local anesthetic is then injected into the fascia around the hernia repair. We do not inject local into the skin of these hernias because we have found that it can cause necrosis of the skin and because it is not needed.
Finally the skin is closed with a dissolving stitch just underneath the surface of the skin. The patient woke up with no pain, looked at his surgery and was very pleased. He saw us for his post operative check the day after surgery then was on a plane flying back to Florida that afternoon.
The advantage of a pledgeted umbilical hernia repair is low recurrence rate, excellent comfort and no mesh.
"Milan—Chronic groin pain after hernia surgery is now considered the most important issue facing inguinal hernia surgeons and their patients. Yet, there is still much uncertainty surrounding what causes the pain and how to prevent it." - Victoria Stern, General Surgery News
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