Our goal is to ensure the best possible experience for our patients; from your first call our physicians will work together to ensure a seamless patient care experience.
We work together to coordinate all aspects of your care:
- Postoperative care
- Appropriate insurance pre-authorization/billing
- Compiling employer leave/short term disability paperwork when appropriate.
If you don’t find answers to your questions below, please call 302-892-2100 and we will be happy to assist you!
What to Expect
I have been recommended for abdominal wall reconstruction, how do I get scheduled?
After meeting all your doctors, scheduling can usually proceed at the end of your last doctor’s visit. Abdominal wall reconstruction is usually an elective procedure and coordination with the hospital and both the plastic and general surgeons. Expect to wait about 4 to 12 weeks to get on the schedule. This will allow you to visit with your family doctor and any other specialty doctors you may have such as a cardiologist that can discuss how they can help optimize your other medical conditions prior to surgery.
If you use tobacco, this will give you a chance to stop all nicotine products prior to your surgery for at least 3 weeks. If you need help with smoking cessation, please visit your primary care provider.
The week before surgery…
You may be asked to stop taking aspirin, products that contain aspirin, or certain blood thinner medications. Some diet and herbal supplements must be stopped two weeks prior to surgery. Check with your doctor about which medications can be taken the morning of surgery. If you are a smoker, try to quit or reduce your smoking as much as possible. Arrange for someone to take you to the hospital the day of surgery, and home afterwards. You may want to arrange for someone to stay with you for a few days following surgery, especially if you are having open surgery.
The day before surgery…
Your doctor may ask you to drink a laxative to cleanse your intestines.
Your doctor may tell you not to eat after a certain time, and to drink only clear liquids until midnight before the surgery.
Pack an overnight bag if you are staying in the hospital. Leave valuables such as rings and watches at home.
When you return home after hernia surgery, it will take several days to recover from laparoscopic surgery and possibly longer if you have had open surgery.
What can I expect the day of surgery?
You will need to be at the hospital at least 2 hours prior to your scheduled procedure. If your procedure is not scheduled as the first procedure of the day, you will be given I time to arrive at the hospital. This time is based on an estimate of when your surgery may start, but in the course of the day it may be quite a bit longer.
At the hospital you will meet a team of nurses who will make sure all your paperwork and pre-operative testing is in order. When ready you will be asked to go to the prep and holding area where you will have a chance to meet your anesthesia care team. You will also see your surgeons at this time to go over any last minute questions should you have any.
You anesthesia team will start your IV, provide you with a dose of antibiotics and prepare your epidural catheter if you are having one.
How long will I be in the hospital?
This can depend on many factors but is typically 5 – 7 days. The first few days after surgery will be in the surgical ICU or a transitional surgical unit depending on the hospital that your surgery is at. Here you will have one nurse that cares for you and only one other patient so that close monitoring of your cardiovascular, pulmonary and kidney function can be optimized. During this time you will often have a tube in your stomach that comes out your nose referred to as an NG tube. This will be removed by your doctor as you start to exhibit functional recovery of your intestines. This may take 3 to 5 days. You will also have a urinary bladder catheter referred to as a foley catheter to monitor your urine output. This may stay in for also 3-5 days.
After a few days in the ICU setting you will be transferred to a regular surgical floor hospital bed. This is where you will stay for the remainder of your stay. During this time you will have your NG and foley catheters removed and if you had an epidural it will also be removed about 4 – 5 days after surgery. Starting the first day after surgery you should be sitting in a chair out of bed and by days 3-5 you should be walking around the hospital outside your room. Once your bowel recovery has returned and you are eating solid food and controlling your pain with oral medications it will be time to leave the hospital.
Most patients go home at this time, but elderly patients, patients with minimal support systems at home, and obese patients may find that a transition to an extended care facility (nursing home) may be more appropriate for one or two weeks. This is usually recognized early and discussion with a social worker will help clarify a plan.
I am home, what can I expect?
When you go home you will have a surgical incision that is closed with absorbable sutures and requires almost no care. You will be expected to shower and wash your incision with soap and water. You may have a surgical binder that can be used to help provide pressure to your abdomen, most patients find this helpful. You may have a visiting nurse sent out to your house to check up on you.
You will also go home with as many as 5 drainage tubes, there are often referred to as JP drains. These were placed at the time of surgery below your skin and help prevent fluid collections that can lead to infection or poor healing and will stay in place for 2 or 3 weeks after your surgery. These tubes usually create the most anxiety about going home for most patients. You will be taught how to care for them. They do not need a bandage although many patients like to put a gauze pad over the site where they come out the skin, it is not necessary. Sometimes the drainage tubes leak a little fluid around the site where they come out the skin, if this occurs a gauze pad or sanitary napkin may be used to prevent any soilage to your clothes or bed linens. These tubes are sutured in place and will be removed at your post-surgical visits usually at your plastic surgeons office. Despite the suture these tubes can be inadvertently removed at home during sleep or by getting caught on something and pulled out. If this should occur there is no emergency. If the tube is partially pulled out, feel free to completely pull it out and place a gauze pad over it. If you do not feel comfortable pulling the tube out the rest of the way, just place a gauze pad over the entry site and treat it like the other tubes. Set up a doctor’s visit in the next several days to have it removed completely, a tube partially out is of no consequence. In the past, all surgical tubes functioned this was, they were known as passive drains.
When you go home, you can go up and down stairs and walk outside the house. You may ride in a car. Consider going out to lunch if you feel up to it.
Once your drainage tubes are all removed you will be asked to start physical therapy (PT). Initially this has to do with increasing your exercise tolerance for walking and to improve range of motion of your abdomen. This will progress to core strengthening during your course of PT so that by 12 weeks after surgery you should be doing sit-ups unassisted. At this time you will have no lifting restrictions. Many surgeons after hernia repair place life-long restrictions on how much weight you can lift in order to prevent a hernia recurrence. After abdominal wall reconstruction, we expect you to be active, and with no restrictions. We feel this is one of the great benefits of having abdominal wall reconstruction instead of hernia repair.
Most patients stay out of work from 3 – 8 weeks. This is variable based on many factors. Discuss with your doctors when a good return to work date should be for you.
What are the potential complications of ventral hernia repair, are they different for abdominal wall reconstruction?
All ventral hernia repairs have essentially the same types of risk factors that can occur. Patients often think that smaller surgery means less risk. Although this may be true in some instances, it is not true of all the potential risks.
Hernia recurrence – Small hernias may be successfully repaired with some of the procedures as mentioned above. For larger and recurrent hernias undergoing repair through traditional methods, published recurrence rates are between 20 and 40% and even higher. We feel that there are many outcomes that define success with ventral hernia surgery but none can be quite as important as eliminating the reason why you did the surgery in the first place. In our first 200 patients, our recurrence rate is less than 2 percent. This was published in the Journal Hernia in March 2013. Other groups performing abdominal wall reconstruction have published hernia recurrence rates around 5%, and although better than 20%, we are all still working toward 0%.
Injury to abdominal contents (example – bowel or bladder) – This complication can be very worrisome as it can lead to the need for secondary surgery and infection. Part of the procedure for fixing all hernias is to safely place the abdominal contents back in the abdomen and not in the hernia. This entails the surgical division of adhesions. Adhesions, or scar, can be present in any abdomen but are more dense and difficult for the surgeon to divide in patients that have undergone numerous previous operations or have had an abdominal infection previously. Predicting the density of your adhesions prior to surgery is difficult and can often lead to increased time in the operating room if they are dense. When dividing any adhesions, the scar can tear the outer covering of the intestines, colon or bladder and sometimes tear a full thickness hole. If this occurs during surgery, it can be repaired and in some instances require the need to have a segment of intestine or colon removed and then reattached. This may make your post-operative recovery a few days longer in the hospital. In rare instances this repaired area can leak or lead to a fistula (a connection of the intestine with the wound surface). This would most likely require further surgery. Although these complications can occur with any ventral hernia repair, they are often less likely to be recognized with small incisional surgery or laparoscopic approaches. Abdominal wall reconstruction through a large incision thus helps to minimize these missed intra-operative injuries.
Delayed or late injury to the abdominal contents can occur when mesh erodes in the intestine well after the procedure is completed. This complication was seen with more dense mesh material years ago and is still seen today when these mesh materials are placed next to the bowel and abdominal contents. At Christiana Hernia Center for abdominal wall reconstruction we do not place an mesh next to the abdominal contents but in a separate layer above them. We feel that this technique minimizes the delayed risks seen with most other hernia repairs.
Abdominal Compartment Syndrome – In patients with very large hernias, placing all the abdominal contents back in to the abdomen can create a situation where there just is not enough space for all the intestines. This is often recognized near the end of your procedure when the last muscle layer is being closed. This may necessitate the need for your surgeon to leave a portion of your muscles not completely re-approximated and having the underlying mesh perform properly so as a hernia does not develop in the future.
But in the immediate few days after surgery, swelling of the abdomen (which is normal) may swell to a point where there is just too much tension inside the abdomen. This puts undo strain on the urinary system and the diaphragm which can lead to pulmonary compromise. This is very rare, but if needed, monitoring can be performed to recognize this problem so that early intervention can help eliminate the long term problems. In some situations, an extra few days on a breathing machine may be indicated.
Wound infection – Any surgical procedure even with small incisions can get infected. Many factors can lead to a wound infection including but not limited to contamination at the time of surgery, patient immune compromised and patients factors such as tobacco use. All patients will receive intravenous antibiotics just prior to the surgical incision and these may be continued for several days after surgery to help minimize this risk.
Poor wound healing or dehiscence – Small incisions tend to heal better than large incisions and with abdominal wall reconstruction you will have a large incision. Healing of larger incisions is usually related to blood supply. Blood supply is compromised in patients with obesity and with tobacco use. When using our approach, we use a perforator sparing technique that keeps areas of the incision connected to the blood supply below them. We ask that all nicotine be stopped 3 weeks prior to surgery to maximize your success. If your wound does not heal properly it may need the use of bandages, of further surgery to help it to heal. The plastic surgeon at our hernia center also specializes in wound care, and we can help manage this problem if it occurs without the need to send you to a different center.
Renal failure – After any abdominal operation there is oozing of blood and serum and swelling that is expected to occur. This shift of your body fluids can mean that your kidneys don’t have extra fluid to make in to urine. Close monitoring of your urine output and your body’s electrolyte status will be followed to keep your kidneys functioning properly. In rare instances, despite monitoring and the adjustment of IV fluids your kidneys can develop signs of failure. A kidney specialist (nephrologist) is often helpful if this situation occurs to help prevent any long term kidney damage.
Bleeding – Bleeding may occur with any surgery and unrecognized bleeding at surgery is more likely seen with small incision surgery or minimally invasive approaches. With an open abdominal wall reconstruction, unrecognized injury to blood vessels is rare but given the size of the incision and dissection of the approach some oozing of blood does occur and the need for transfusion of blood is sometimes indicated.
Seroma – A seroma is a collection of the plasma or non- cellular portion of blood that seeps out after surgery. This is more common with larger incisions than with smaller procedures and during your surgery you may have 3 to 5 drainage tubes placed to prevent this complication. Your drainage tubes typically stay in place about 2 weeks after surgery. Even with this approach a seroma can recur and require the need to be aspirated in the office setting and in some situations require a secondary surgery where drains are placed again. In rare instances with a recurrent seroma, a surgical opening of the wound and placement of a negative pressure dressing may also be used.
Deep venous thrombosis – Blood clots may form during any period of inactivity. If these clots move from the legs to the lungs they can lead to pulmonary embolism. Pulmonary embolism may in rare instances be fatal. At surgery this can occur even with very short procedures done in an outpatient setting. Longer surgeries with a slower recovery may have a higher incidence of deep venous thrombosis. Precautions are taken before, during and after your surgery to help prevent this. These include pneumatic compression boots which massage your leg muscles and the use of anticoagulant medicines.
Pneumonia – The ability to cough and deep breath is essential to making sure that your lungs do not fill with mucous and become a place where bacteria can become stagnate and lead to lung infections. Any surgery where an incision and muscle is cut can lead to the patient having a difficult time clearing their lungs of mucous. Pain after abdominal surgery is a major contributing factor. For abdominal wall reconstruction we recommend that our patients consider epidural anesthesia as a means of minimizing post-operative pain. We have found that adequate epidural anesthesia in the post-operative period can minimize this complication.
Pre-existing pulmonary disease such as asthma or COPD, and morbid obesity are also post -operative risk factors that can lead to pulmonary compromise and pneumonia.
Frequently Asked Questions
“What billing or insurance information will I receive?”
As long as you have obtained any referrals (if required by your insurance carrier) and provided our office with the appropriate billing/insurance information we will take care of the rest. We work directly with the carrier to pre-certify and bill any procedures.
In the unlikely instance we need anything additional we will contact you directly in a timely manor.
“How long will it take to get things settled with the insurance company?”
Typically after a patient is home it will take 2 weeks to gather and coordinate the appropriate codes to provide to the payor after which the payor will process and pay the claim. Each payor has different terms but it typically will be paid within 90 days.
If the payer requires any additional information from the physicians we work diligently to provide them an immediate response to further delay the process.
“Why am I getting bills from physicians?”
Typically you may receive a bill from the physician(s) and/or hospital once your payer has processed and paid the claim, upon which any remaining balance, copayments or deductibles will be billed to the patient.
“I received a notice that my insurance company has paid on my bill, but I can’t understand how they calculated their payment amount. Do you know?”
Insurance companies pay based on their set allowances and percentages for your individual health plan. These vary from plan to plan.
Patient balances come from one or a combination of the percentage that patient is responsible for as well as copayments and deductibles.
While we are always happy to try and assist and/or route you to the appropriate party to help you, these types of questions are typically best answered by the insurance plan/payer directly.
It is always best to contact your payor prior to your procedure and find out what you will be responsible for based on your plan.