WHAT IS THE PROBLEM WITH BEING OVERWEIGHT?

• Obesity contributes to the formation of hernias because of the pressure created in the abdominal cavity by too much fat. As the pressure increases, it looks for a way to release and does this through the weakest point – a surgical scar.
• Most doctors measure obesity by a number called the Body Mass Index or BMI. This is calculated by taking your weight in kilograms and dividing it by your height in metres².
• If your BMI is > 35 i.e. you are obese, the surgery is far more difficult and the risks of complications are far higher. If your BMI is > 50 there is a 100% chance the hernia will come back after repair.
• If your BMI is between 35 and 50, I will recommend a period of weight loss before you have surgery. I will work with you and we will set a realistic goal. You will not need to get down to a supermodel weight but you will need to show a commitment to this process. Weight loss is never easy and I strongly recommend you seek professional help for this. There are many options available.
• Obesity surgery: For some patients with a BMI > 50, diet strategies do not work and they may contemplate obesity surgery. This can be successful. Obesity surgery when there is a large incisional hernia present is not straightforward. A great deal of thought needs to be put into this decision and it is not suitable for everyone.

SMOKING IS BAD TOO

You will not undergo incisional hernia surgery while you are still smoking. There is strong evidence that smoking leads to poor wound healing and failure of the repair. Many studies show that even stopping for one month before surgery makes a big difference to complications.

Ideally, it would be great if you could stop smoking for good, but for this operation to be successful you need to stop smoking one month before and two months after the surgery.

There is lots of help available and nicotine patches are OK to use prior to surgery. Electronic cigarettes are just as bad as smoking regular cigarettes. See your GP for alternatives or call the Quitline (13 18 48) if you wish to seek advice.

CONTROL OF DIABETES

It has long been understood that good control of diabetes is vital prior to major surgery to prevent wound infection and improve healing. I will be checking your HbA1C (blood test to measure your overall control). If it is over 8, I will ask you to see a diabetic specialist to improve your levels. Remember that weight loss will improve your diabetes and in some instances will cure it.

WHAT CAN YOU DO TO HELP LOWER THE RISKS OF SURGERY AND HAVE THE BEST OUTCOME?

Exercise or Prehabilitation

There is lots of good evidence that light exercise prior to surgery helps to reduce the risk of having complications after. Ideally, you should be trying to walk about 20-30 minutes at a moderate pace every day. I understand that for many hernia patients this is not possible but any physical activity will help. I will give you some exercises that I think are good. Remember that even small amounts of exercise help.

You could try:

• Walking around the block – even 10 minutes helps
• Riding an exercise bike or walking on a treadmill while watching TV
• Water exercises in a swimming pool (I can give you an exercise sheet for this)
• Use your Smartphone and set alarms to remind you to take some deep breaths or go for a walk
• See a physiotherapist or gym trainer to give you some other ideas.

Medications and supplements

I recommend that you take:

• A multivitamin every day prior to your surgery (purchased from the chemist or the supermarket, any brand)
• A probiotic like Inner Health™ (from the chemist). There is lots of evidence to suggest this decreases the risk of post-op infections.
• Fibre supplement like Metamucil or Benefiber. These can be taken in capsule or drink form and are excellent to keep the bowels moving regularly prior to surgery. This takes a lot of strain off your abdominal wall

Diet

It is very important that you eat a healthy diet prior to surgery and for the rest of your life. Your body relies on what you put into it so it can heal and high protein food just before the surgery is very important. Most people think that they understand about healthy eating but it is rare that they have the full story. Typically, Australian’s eat far more than their body needs. Good nutrition is so much more than just avoiding fatty foods. I recommend that you see a dietitian prior to surgery for abdominal wall reconstruction so you can understand the principles of healthy eating.

WHAT TESTS MIGHT I HAVE BEFORE AN OPERATION IS CONSIDERED?

Planning for a big incisional hernia repair requires a number of tests. You must be medically and physically fit to undergo an operation of this calibre.

Some of the tests you can expect to have may include but are not limited to:

Blood Tests

Full blood count, Kidney and Liver function tests. If you are diabetic, you will have your HbA1C checked with a blood test and it should be less than 8. If you have been a smoker, I will check a urine test to make sure there are no traces of cigarette smoke in your body.

CT scan of the abdomen

Scan performed to inspect the state of the muscles of the abdominal wall and measure how far apart they are. It will also assess how much of the bowel is outside the abdominal cavity. This scan is also done to look for any undiagnosed problems in the abdomen like gallstones and tumours.

Colonoscopy

Bowel cancer is relatively common in our society (1 in 12) and if you have not had a colonoscopy (a telescope passed around the large bowel) this will be done to ensure you do not have an undetected cancer.

Heart and lung tests

These will be performed to assess your fitness for major surgery. This will depend on your age and other health problems. The tests may be an ultrasound of the heart (Echocardiogram), lung function tests and exercise tests. You may be asked to see a heart or lung specialist.

Just before the operation

Hospital

The hospital and my office will call you the day before your operation to confirm your admission time.

Fasting

You must have nothing to eat or drink for six hours prior to surgery. (You may take sips of water up until 2 hours before the operation and you may take your medications with a sip of water). You must not chew gum or smoke on the day of the operation.

Shaving and showering

You do not need to shave any body hair from your abdomen before the surgery. If needed, I will do this with sterile clippers after you are asleep, just before the surgery commences. This gives the lowest chance of infection.

There is no evidence to suggest that having a shower in antiseptic prior to surgery decreases infection rates so just shower normally on the morning of surgery. Do not use any perfume.

Make up, nail polish and jewellery

I understand that some women feel quite anxious about going without their make up. Most of your body will be covered during the operation so it is important that the anaesthetist can see your face clearly. Your colour can be a good monitor of how much oxygen you are getting. For this reason, it is best to come to theatre with a clean, make up free face.

Nail polish is OK with me as long as you keep it clear on your fingernails. Coloured nail polish can interfere with the device we use to measure the oxygen in your blood. For many women, having a pedicure the day before the surgery is a good way to relieve some anxiety.

Any jewellery you are comfortable with removing, you should leave at home. If you would like to leave your wedding ring on, you may, but this will be covered with tape for the duration of the surgery.

Glasses and contact lenses

You should remove your contact lenses prior to coming to the hospital. You don’t need to bring your glasses to the operating theatre. Just put them with your belongings and they will be given back to you in the ward.

False teeth, caps, crowns

Don’t take your teeth out before you come to the operating theatre. They will usually be removed by the anaesthetist after you go to sleep. Keeping your teeth in will help the anaesthetic doctor get a good seal on your mouth with the oxygen mask. Your teeth will be well taken care of during your operation and returned to you in recovery before anyone can see you.

Preparations at home

Ensure that you have someone to care for small children for a little while to take the pressure off your recovery. If you are handy in the kitchen, try to cook and freeze some easy meals to have on hand for when you do not feel like cooking. Another option is to consider ordering precooked meals from companies like Lite n’ Easy. Consider hiring some help around the house for a few weeks after the surgery or enlist willing (or unwilling) relatives to help out. Make sure all your bills are paid ahead or on automated payments to reduce the things you have to think about in the recovery period.

Medications

• Aspirin is usually fine to continue taking before the surgery.
• If you are on blood thinners such as Warfarin, Plavix, Iscover, Clopidogrel, Pradaxa, Dabigatran, Rivaroxaban, Xarelto or anti-inflammatory drugs (Brufen, Mobic, Voltaren, etc), they can cause bleeding during surgery. I will advise you about what to do with these drugs prior to the operation. You must let me know about these drugs and the decision to stop them is based on each individual patient’s needs.
• Diabetic medications: I will give you advice on whether to take your diabetic medications on the morning of surgery or not. Some diabetics will be admitted the night before the operation and be looked after by a diabetic doctor.
• If you are on Prednisone, you should not stop this drug suddenly.
• Cholesterol lowering medication should not be taken when you are fasting.

• If you are taking any complementary medications e.g. St John’s Wort, fish oil or garlic, you should stop these tablets one week before surgery as they may result in excess bleeding.
• Continue to take all other medications, even on the morning of surgery, with a small sip of water.

Other things to know

• You must bring all relevant x-rays to the hospital with you.
• You should also abstain from drinking alcohol 24 hours prior to any surgery and before that, no more than two standard drinks a day.
• Bring all your current medications with you to the hospital.
• You will wear a hospital gown for the first few days but have comfortable pyjamas on hand along with personal toiletries, small change for newspapers etc.
• Bring something to do –       DVDs, books, laptops. Alternately, you can use hospitalisation as an opportunity to rest completely without distractions of the outside world.
• Do not bring large amounts of cash or valuables.