Dr. Mahesh Channappa

For straightforward inguinal hernias and many umbilical hernias, standard laparoscopic repair using TEP or TAPP produces excellent outcomes and the additional complexity and cost of robotic-assisted surgery is not justified. But there is a specific category of hernia cases where robotic assistance changes what is technically achievable, and these are the cases where I bring the Da Vinci robotic platform into the operation at Aster CMI Hospital, Bengaluru. Large incisional hernias represent the clearest case for robotic assistance. An incisional hernia that develops at the site of a previous large abdominal incision may involve a defect that is many centimetres wide, potentially with multiple separate defects across the old wound, and significant scarring from the previous surgery that makes dissection and tissue mobilisation demanding. Achieving a tension-free fascial closure in this setting, often requiring component separation where the layers of the abdominal wall are divided and mobilised to bring them together across the defect, is technically among the most demanding operations in hernia surgery. The robotic system provides three-dimensional high-definition visualisation of the operative field, multi-articulating instrument movements that replicate the natural range of motion of the human wrist in ways that straight laparoscopic instruments cannot, and a magnified, stable view that reduces surgeon fatigue during long reconstructive procedures. Recurrent hernias where a previous repair has left scarring and altered the normal anatomical planes also benefit from the precision that robotic assistance provides. For any hernia patient who has been told their case is complex, who has had a previous hernia repair that failed, or who has a large incisional hernia, a consultation at Aster CMI Hospital, Sahakar Nagar, Bengaluru, will establish whether robotic repair is the appropriate approach.

A hernia becomes a surgical emergency when the tissue that has protruded through the abdominal wall defect becomes trapped and cannot be pushed back (incarceration), and particularly when the blood supply to that trapped tissue is cut off (strangulation). Without blood supply, the trapped tissue begins to die within hours, and if bowel is involved, this can rapidly become a life-threatening situation. The warning signs of a strangulated hernia are specific and important for every hernia patient to know before they happen. Sudden, severe pain at the hernia site that is distinctly more intense than any discomfort you have experienced from it before is the cardinal symptom. The hernia bulge becomes hard, tender to touch, and cannot be reduced back into the abdomen, even with gentle pressure in the lying-down position. Nausea and vomiting often accompany this, and if bowel is obstructed, the abdomen may become distended. If you experience these symptoms, do not wait until morning, do not take a painkiller to see if it settles, and do not wait for a routine appointment. Go to Aster CMI Hospital's emergency department or call immediately. Time is the critical variable in strangulation: the longer the tissue is without blood supply, the more extensive the damage, and the more complex the surgical repair. A strangulated hernia that reaches the operating table within a few hours may require nothing more than releasing the trapped tissue and repairing the hernia. One that has been developing for twelve hours or more may require resection of necrotic bowel in a contaminated surgical field, which significantly increases both the complexity of the operation and the risk of complications and hernia recurrence.

TEP and TAPP are both minimally invasive laparoscopic techniques for inguinal hernia repair that achieve the same end result: a mesh patch placed in the preperitoneal space behind the abdominal wall to reinforce the hernia defect from behind. The difference is in how that space is accessed. In TEP, Totally Extraperitoneal repair, I work entirely in the space between the inner surface of the abdominal muscles and the peritoneum without ever entering the peritoneal cavity itself. A balloon dilator or surgical dissection creates the working space, and the entire procedure stays outside the peritoneum. This has the advantage of avoiding the peritoneal cavity, which reduces the risk of injury to intra-abdominal organs and the formation of adhesions, though TEP requires a steeper learning curve because the working space is more confined. In TAPP, Transabdominal PrePeritoneal repair, I enter the peritoneal cavity first through three laparoscopic ports, and then incise the peritoneum to access the preperitoneal space where the mesh is placed. TAPP gives a wider working field and is technically more familiar to surgeons who are experienced in standard laparoscopic surgery of the abdomen, and it is particularly useful in patients with previous lower abdominal surgery or complex groin anatomy where the preperitoneal space may be more difficult to develop from the outside. Both techniques produce equivalent long-term recurrence rates in experienced hands and offer the key advantage of laparoscopic over open inguinal hernia repair: bilateral hernias can be repaired through the same three small incisions in a single anaesthetic, with one recovery period rather than two. At Aster CMI Hospital, Sahakar Nagar, Bengaluru, I select TEP or TAPP based on each patient's hernia anatomy, body habitus, and previous surgical history.

Not all hernias require immediate surgery, and I want to be honest about this because the fear of an unnecessary operation is one of the most common reasons patients delay consulting a surgeon when they feel a hernia. There is a legitimate role for watchful waiting in specific situations: minimally symptomatic inguinal hernias in older patients with significant heart, lung, or other medical comorbidities where the anaesthetic and surgical risk is meaningfully elevated may reasonably be observed if the hernia is not growing and not causing functional limitation. Small asymptomatic umbilical hernias with no symptoms and stable size are similarly candidates for clinical monitoring rather than immediate repair. However, these are the exceptions, not the rule. For the majority of patients, I recommend elective hernia repair for three interconnected reasons. First, hernias do not heal spontaneously. The weakness in the muscle wall that allows tissue to protrude does not close on its own, and most hernias enlarge progressively over time. Second, the risk of a hernia becoming complicated, either by trapping the protruding tissue (incarceration) or cutting off its blood supply (strangulation), is real and cannot be predicted in advance. Strangulation transforms what would have been a day-case laparoscopic repair into a complex emergency operation with significantly higher morbidity. Third, elective laparoscopic hernia repair at Aster CMI Hospital, Bengaluru is very well tolerated: most patients go home the same day, are active within days, and return to desk work within a week. The risk of watchful waiting is that a straightforward operation becomes a complicated emergency. For most patients with hernias, earlier elective repair is the right decision.