Hernia Surgery in Reno
Better Results, Faster Recovery, More Durability, More Comfort
American Hernia Society member
With respect to most types of hernia repairs, Drs. Sasse and Rembetski’s philosophy is that a minimally invasive approach is the best, most comfortable, most effective, and most durable repair. All three surgeons have decades of experience with hernias of all types.
In recent years Dr. Sasse has contributed to the growing expertise in component separation technique of large, complex, and recurrent ventral hernias, and he frequently performs these complex abdominal wall reconstructions. Dr. Sasse teaches a cadaver lab on such techniques to visiting surgeons from around the country, offering these courses at the University of Nevada School of Medicine.
Patients can learn more about what types of hernia repairs Dr. Sasse performs at his practice in Reno, NV by viewing the procedures in the dropdown menu below. Patients can also schedule an in-person consultation to speak with Dr. Sasse about hernia surgery.
Hiatal Hernia Surgery
What is a hiatal hernia?
Many Reno patients have been told that they have a hiatal hernia. Sometimes the information they have been given, both by doctors and laypeople, is confusing. So, let’s talk a little bit about what a hiatal hernia is:
The easiest way to think about a hiatal hernia is first to understand what is the “hiatus” and what is a “hernia.” The hiatus in this case refers to an opening or a valve that is present where the esophagus transitions into the stomach. This transition occurs right at the diaphragm, which is a broad muscle that separates the chest cavity from the abdominal cavity. The diaphragm is the muscle with which we breathe and it creates the bellows effect for our lungs to move air in and out. Imagine swallowing some food, and that food then passes down the tube of the esophagus until it reaches the transition point into the stomach. That transition point occurs right at the hiatus.
The hiatus can be thought of as a circular ring of muscle from the diaphragm that acts as a valve to limit the acids and the digesting food that is already in the stomach from traveling back up to the esophagus. Stomach acid feels fine when it is in the stomach, but when it refluxes upward through that valve and into the esophagus it burns the esophageal lining, and causes the common symptom of “heartburn.”
If the hiatus muscle or hiatus valve is working properly, then all the food we eat travels down and empties right into the stomach without difficulty, and does not reflux back up into the esophagus or give us heartburn or regurgitation. Now when that hiatal muscle or valve becomes weakened, faulty, or enlarged, it no longer serves as an effective valve. We can still usually eat food pretty well, and it empties down into the stomach, but because the valve is loose, or floppy, or not functioning well, stomach acid – and even sometimes food contents – reflux back upward into the esophagus. Hence, when we have a hiatal hernia or a weakening of the hiatal muscle, we may experience more heartburn or regurgitation symptoms.
Now the confusing parts are that lots of people have a hiatal hernia when we go look with an x-ray study or with an endoscopic test (passing a lighted flexible digital scope or camera down the esophagus and into the stomach). But sometimes these people don’t have any symptoms of heartburn or reflux. That doesn’t mean there isn’t some reflux or stomach acid coming upwards, but they just don’t really sense it or feel it until it gets much more severe.
Likewise, some people do have heartburn or reflux symptoms, but when we go looking for evidence of a weakened muscle or hiatal hernia, we don’t really find it. Instead, we find what appears to be a pretty normal looking hiatus. This is all just part-and-parcel of the wondrous uniqueness of every human being. Lots of anatomical diseases are like this. Sometimes, especially in the gastrointestinal system, the problems or symptoms have more to do with the way the parts work and function day-to-day, and less to do with the fact that they are abnormally formed or stretched or weakened. This is sometimes referred to as “functional” abnormality, as opposed to “anatomical” abnormality.
So, if you have been told you have a hiatal hernia and you have heartburn or reflux, then you might have a problem that could one day be repaired or could be treated with medications. It is almost never an urgent problem, but something to look into in time.
When are Hiatal Hernias Important?
Hiatal hernias are important when they become symptomatic or if you are having stomach surgery for another reason.
Most of the time if a person has a hiatal hernia, one of two things has happened: they either had an endoscopy or an upper gastrointestinal series x-ray study for other reasons, and were told that this was an incidental finding, or they were having specific symptoms of heartburn or indigestion that prompted an evaluation.
In the vast majority of cases, people who have reflux symptoms or indigestion symptoms and have a hiatal hernia can be treated with medications. There are very effective medications to block the acid production and relieve those symptoms. These are two basic categories – the first are called H2 antagonists, or H2 blockers, which block histamine receptors. The most common of these are Tagamet and Pepcid. These are over-the-counter medications that are very effective at reducing the acid production, and reducing the sensation of heartburn.
The second type of medication is an even stronger blocker of acid production, and these are called proton pump inhibitors. There are many brand names including Nexium, Omeprazole, Aciphex, Prilosec, and Protonix.
Between them, those two classes of medications do a great job at treating the symptoms, and most people never need surgery.
However, in a few cases, the hiatal hernia itself becomes larger. This muscular ring or valve gets looser and looser and some of the actual stomach itself bulges up or “herniates” up through the valve, and up into the chest cavity. When this happens, the symptoms can become more severe and surgery is often required.
The surgery to fix a large or highly symptomatic hiatal hernia is performed by a skilled laparoscopic surgeon with a laparoscopic, or minimally invasive technique, usually using five small, 5-10 mm incisions and a laparoscope. Usually, the surgery is performed in an hour or so, and the procedure can be outpatient or done with an overnight hospital stay. In some cases, people stay in the hospital longer if they are elderly, or there are other medical or surgical considerations.
GERD & Esophageal Cancer
Hiatal hernias and gastroesophageal reflux disease (GERD) are also related to the growth of abnormal cells in the esophagus that have a risk of turning into esophageal cancer. While only a small percentage of people with GERD would ever progress to develop esophageal cancer, it remains a risk that requires follow-up surveillance endoscopy tests. When the stomach acid has been refluxing and irritating the esophageal lining, some of the cells start to become abnormal, and are called Barrett’s metaplasia or Barrett’s esophagus. Barrett’s metaplasia can progress on to actual esophageal cancer over the years, so a gastroenterologist should follow you with periodic endoscopies and biopsies to make sure that there is no development of cancer.
Often times if a person has Barrett’s esophagus, the surgery to repair the hiatal hernia should be done, even if the symptoms are not so severe. This is because surgically repairing the hiatal hernia is probably more effective at stopping the progression of the Barrett’s metaplasia than treatment with medications alone.
There are a few other cases in which surgery is required for hiatal hernias. These would include people who have developed a lot of scarring, or stricturing or narrowing of the esophagus due to repeated acid reflux, or people whose symptoms are just not controlled at all, even with the use of the modern medicines described. In either of these cases, a person may be better served with a laparoscopic hiatal hernia repair operation.
Surgical Repair of Hiatal Hernias
Nissen fundoplication.
Thal fundoplication.
Laparoscopic fundoplication and hiatal hernia repair procedures.
If you have symptoms of severe reflux, or have been told that you have a severe hiatal hernia that requires surgery, then it may help for you to know a little bit more about the surgical procedures to repair hiatal hernias.
The most common type of repair of hiatal hernias nowadays is performed with a laparoscopic, or minimally invasive technique. Dr. Sasse performs lots of these in his practice and generally uses a technique called laparoscopic Nissen fundoplication. This technique involves placing a camera, or laparoscope, that is 5 mm in diameter, and the use of long, thin laparoscopic instruments to conduct the procedure.
The operation really has two parts to it. The first part is to tighten the actual hiatal muscles or valve. This is done with stitches that pull the muscles together to recreate the circle that comprises the valve. The second part of the procedure involves wrapping a portion of the loose, floppy, and redundant upper stomach around the area of the gastroesophageal junction to provide some further reinforcement of the valve and give it more strength and effectiveness. This part of it is referred to as “the wrap.”
Over time, it has been shown that this one-two punch of first tightening the muscles and second, wrapping some of the extra stomach tissue, creates a more effective, and more long-lasting repair than doing one or the other by itself.
The vast majority of people can expect the heartburn or reflux to resolve after laparoscopic Nissen fundoplication.
Side Effects of Nissen Fundoplication or Hiatal Hernia Repair
There are some side effects to laparoscopic Nissen fundoplication, which include a sensation of bloating and gaseous distention. Often people find it harder to belch out air that they have swallowed during meals or drinking liquids, so sometimes the air we swallow bubbles around in our stomach and intestines, but is not easily belched up. It is something a lot of us don’t think about, but if the valve is newly tightened and the gas cannot easily travel back upward and out the mouth, then we may have a sensation of gas bloating in our abdomen.
Other potential side effects would include the possibility of the valve being “too tight,” at least for a time in the beginning. This can make it a little bit difficult to swallow hard foods like bread or meat. Things can feel like they “get stuck” as they are traveling down the esophagus. Usually this sensation is present in the early weeks after a laparoscopic Nissen fundoplication, but it gradually resolves with time as the surgical swelling goes down.
Diet after Hiatal Hernia Repair
The feeling of food getting stuck is the reason that I advise patients to start on a liquid diet right after surgery and then gradually progress on the thickness of the foods in their diet every week. For example, I recommend clear liquids the first week, full liquids or thick liquids the second week, soft mushy foods (like scrambled eggs) the third week, and then only in the fourth week to begin experimenting with regular consistency foods. In this way, people avoid the sensation that food that they have eaten gets stuck and causes them discomfort due to the tightness of the valve.
In truth, it is usually a good thing for the valve to be a bit tight in the beginning, because over time it tends to loosen somewhat. Over the years the valve repair can weaken somewhat and, in a few people, the reflux symptoms can return. Studies vary, but as many as 20-30% of people will experience weakening of the valves to the extent that they seek medical or surgical attention for it over the course of 10 years. (Think of hip replacement surgery and many other types of operations that have good-but-not-perfect durability. They do wear out over time and sometimes have to be re-done or performed again surgically.)
There are other versions of the hiatal hernia repair that are sometimes part of the surgical armamentarium. For example, if a person has very poor strength of their esophagus and have some difficulty swallowing anyway, then a looser, or less complete type of wrap is performed. Sometimes this is referred to as a Thal fundoplication procedure. It still involves the tightening of the hiatus muscles, but the “wrap” is done without a full 360 degree wrap of the stomach tissue, but more of a 180 degree wrap. The idea here is to make the valve less tight, and minimize difficulty swallowing and eating.
In rare cases, open surgery is required for the hiatal hernia repairs or fundoplication procedures. The only times I generally encounter this situation is when it is a revision or re-operative fundoplication procedure. Since I see a lot of complex and advanced gastrointestinal disorders, I am often referred patients who previously had laparoscopic Nissen fundoplication or similar procedures, but now have a recurrent hiatal hernia and reflux.
Most of the time, I am still able to perform the procedure with the laparoscopic, or minimally invasive approach, but sometimes the scar tissue is too dense or too difficult to work with laparoscopically, and we must make an open standard incision. This generally leads to a somewhat longer recovery time of several days in the hospital, and several more weeks of soreness and fatigue and so forth that leads to more time off from work, and more time for a full recovery.
Revision fundoplication procedures or revision hiatal hernia repairs are not extremely common, but do sometimes help greatly when a person has experienced recurrence of their hiatal hernia and of their symptoms. And most of the time, a very effective and satisfactory hiatal hernia repair and fundoplication can be accomplished with the revision procedure.
Incisional Hernia Repair
Dr. Sasse was one of the pioneering surgeons who developed and perfected minimally invasive approaches to incisional hernia repairs. In the past (and still today for many surgeons and centers), incisional hernia repairs have meant an open incision with all of its attendant risks, wound healing difficulties, infection problems and prolonged recovery time. In more recent years, surgeons with advanced, minimally invasive technology have developed and perfected methods of repairing incisional and ventral hernias, without large incisions.
Dr. Sasse was one of the pioneering surgeons to develop a laparoscopic technique involving placement of bilaminar mesh, and using anchoring transfascial sutures to give a durable, long lasting, and comfortable repair. His work with bilaminar mesh material that discouraged adhesion formation has led to reduction of scar tissue formation and minimized the risk of scar tissue related symptoms or erosion.
As Dr. Sasse says “Minimally invasive repairs of ventral incisional hernias represents one of the true revolutions in surgery in terms of a real benefit to patients.” As numerous studies, including his own, demonstrate, minimally invasive repairs of ventral and incisional hernias result in excellent repairs with less pain, and markedly less recovery time. There is also a reduced risk of non-healing wounds and wound infections owing to the tiny incisions of the minimally invasive, or laparoscopic technique.
Inguinal Hernia Surgery
Over the last fifteen years Dr. Sasse has gained a great deal of experience with hernia repairs of all types. He spent years training at the University of California, San Francisco during a time when the pioneering efforts of laparoscopic inguinal hernia repairs were going on.
Dr. Sasse developed one of the largest volume practices of laparoscopic preperitoneal inguinal hernia repairs thereafter. The technique utilized most often by Dr. Sasse, the laparoscopic preperitoneal technique is performed as an outpatient as a 30 minute procedure with less postoperative discomfort than conventional repairs.
“The best hernia surgeon is one who is versatile, familiar with every technique.” says Dr. Sasse. He has performed thousands of inguinal hernia repairs and has a large referral practice for recurrent hernias, and difficult to solve hernias that have failed previous attempts by other surgeons. He has performed open inguinal hernia repairs with and without mesh, extra peritoneal, preperitoneal and intraperitoneal repairs and developed a thorough expertise. In most cases, Dr. Sasse can solve a difficult hernia with a minimally invasive approach.
Recurrent Inguinal Hernias
“Recurrent inguinal hernias are one of the most common types of recurrent hernias and something that I see very often in my practice. The most common situation is that of a person who had an open or conventional technique repair of an inguinal hernia years ago, and now a bulge has recurred, sometimes with associated pain. In the vast majority of cases, the best solution is a surgical repair that now utilizes a minimally invasive approach. The laparoscopic preperitoneal approach is most commonly employed in this situation, and with great success. It has a number of advantages, including less pain, less recovery time and a high chance of creating a durable, lifelong repair. In these cases I can avoid the previous surgical scar tissue, avoid the open incision and dissection, and approach the problem in the preperitoneal position or behind the muscles where the planes are fresh and undisturbed. This approach involves less trauma and less bleeding, in essence a less invasive procedure.”
“In other cases, recurrent inguinal hernias have previously been repaired by intra-abdominal or preperitoneal techniques with an open or laparoscopic approach. The repair for a recurrent hernia may require an open technique or approaching the situation through a previous approach. Each case must be approached with careful consideration of what was done previously, and how best to achieve the best results in the future. In most cases this can be accomplished with a minimally invasive solution and provide a durable, long term repair.”
Femoral Hernia Surgery
A femoral hernia is an uncommon type of groin hernia that is often in the same location, or general area, as an inguinal hernia. It usually presents with a bulge or pain in the groin region, but is often somewhat lower anatomically as it protrudes inferior to, or lower than, the inguinal ligament. A minimally invasive repair works nicely, and Dr. Sasse has experience with laparoscopic repairs using lightweight mesh fabric. Femoral hernias are diagnosed somewhat more urgently, as they are more likely to incarcerate and cause real pain. If you do experience severe pain in the groin, and a bulge or lump that is tender and cannot be reduced or pushed back in, it is important to call your doctor and be seen at an emergency room or physician’s office. Certainly if you experience vomiting, and have a painful bulge, you need to go to the emergency room and contact Dr. Sasse or your surgeon. Most people recover nicely from femoral hernia surgery and return to their activities in a short period of time – over the course of two weeks following a laparoscopic repair.
Umbilical Hernia Surgery
Umbilical hernias are one of the most common types of hernias occurring from a congenital weakness at the umbilicus. Many people have small umbilical hernias that can enlarge over time with age or as a result of weight gain or pregnancy. The types of repairs involved vary often from surgeon to surgeon. The most common type, historically, has been to make an incision and dissect downward through the subcutaneous tissues to the level of the fascia or muscle, and place some sutures to re-approximate the tendinous fascial edges, and close the hole or defect. These hernias are often quite small, and this technique is often successful. However, in modern America many people gain weight over time, and these hernias have a high recurrence rate when closed with a simple suture closure technique. This has led many surgeons to place mesh fabric material, or move to a minimally invasive approach. Dr. Sasse will discuss with each patient the individual’s options. Often times the best solution is a minimally invasive surgical approach with placement of a lightweight mesh fabric material on the inside. This creates a wider overlap, and more secure and durable repair of the hernia in many cases. It is quite suitable for people who are overweight, and usually remains durable even if people gain weight in future years (something that happens to a great many of us). The laparoscopic repair is often useful because the internal visualization that occurs during the surgical procedure sometimes leads to a better, more thorough understanding of the hernia. Sometimes there are weakened areas or hernias that are just beginning to form above or below the area of the bulge. This becomes especially important if there is a scar involved. Sometimes people have a bulge at the umbilicus, but it is more accurately called an incisional hernia. These are usually best served with a minimally invasive approach with mesh repair.
Abdominal Hernia Surgery
Panniculectomy / Abdominoplasty (The so-called “Tummy-Tuck”) and Abdominal Wall Stabilization
In many cases the abdominal wall problem is more complex than a simple or straightforward hernia. There may be a large abdominal skin and soft tissue pannus that needs to be addressed. There may be skin changes occurring, and there may be pulling, pain, and disfiguration associated with a large pannus. This is often seen after a large amount of weight loss; it can occur as a result of weight loss surgery, or as a result of intentional or unintentional weight loss or body habitus change for any reason.
In most cases the required approach to permanently stabilize the abdominal wall involves a combination of repairing the muscular or fascial hernia defect with a ventral incisional hernia repair, in combination with removal of the excess skin and soft tissue in a technique traditionally referred to as panniculectomy and abdominoplasty.
Stemming from his work with hernia surgery and bariatric surgery, Dr. Sasse has a great deal of expertise with abdominal wall stabilization in these complex situations. Most often the procedure results in permanent and durable abdominal wall stabilization, with a final repair of the hernia, as well as the complete removal of the abdominal wall excess skin and soft tissue. While there is a cosmetic benefit for patients, there is also a benefit in that the technique provides the best, most durable stabilization of the abdominal wall for years to come.
Recurrent Ventral Incisional Hernias
Why do hernias recur and what is the best way to repair them?
There are quite a few reasons why hernias can recur. Historically, the most common reason has been that there has been too much tension on the tissues that were approximated. Over time this tension, or pressure becomes too great and the approximated tissues begin to split apart again. This phenomenon is very common, and anything that causes increased pressure in the abdomen- including lifting, coughing, sneezing, laughing, pregnancy, and weight gain- will cause more tension on the closure. And remember, any tissues that a surgeon reapproximates will never be as strong as when Mother Nature built it.
Tension eventually will pull apart a closure, but what are others reasons why hernias can recur? Most of these reasons have to do with the causes of increased pressure that are describe above. Activities that we as humans do, and, especially in this day and age, weight gain that stretches out the abdominal wall muscle and fascia. Think of a balloon stretching further and how thin the balloon gets as it expands.
The reapproximation of muscular and fascial tissues was once thought to be the best way to repair hernias. However, a recognition that the tension created often leads to an eventual recurrence led to the development and better understanding of what we call “tension free repairs.” In reality, what this often means is that we don’t sew back together the muscles and tendons that have split apart. Instead, we simply find a new way to create a solid abdominal wall, most often by placing mesh fabric material to cover the area of weakness created when the tissues split apart.
Sometimes there are technical considerations also for the recurrence of hernias, but these are a lot less common than people typically think. Often times, non-surgeons and lay people will find fault with the type of sutures used, or the type of mesh used, or the geometrical placement of the mesh given the size and shape of the hernia defect. While theoretically all of these types of things could play a role in a specific instance, for the most part they are not the major contributing cause to hernias recurring, perhaps with one exception. The exception, in my mind, comes from a technical problem when the surgeon is unable to overlap the mesh fabric material widely enough beyond the edge of the hernia defect.
It has really only been studies from recent years that have pointed out the importance of placing mesh at least several centimeters beyond the edge of the fascial defect and then anchoring that mesh with some strong transfascial sutures (the kind that go all the way through the abdominal wall and anchor the mesh out wide beyond the hernia defect). The cases of hernia recurrences I have seen that involved this sort of problem ended up recurring, in part due to the pressure factors on the abdominal wall that I listed above, but also in part because the mesh itself did not appear to be widely overlapping the fascial defect nor sufficiently anchored out beyond this edge of the hernia. So the combination of factors led to the mesh wadding up in the middle of the hernia and bulging right out with the rest of the tissues. A repeat repair simply required placing new mesh fabric material that covered more widely out beyond the fascial defect to get a satisfactory result.
How best to repair recurrent hernias?
In my view, the best repairs are those that are durable and successful, satisfactory to the patient, and minimally invasive or at least the least invasive that can be done. So with the principle of minimally invasive hernia repair in the background, the vast majority of recurrent hernias can and should be fixed with a minimally invasive surgical approach. A great number of the incisional and ventral hernias which have recurred that are sent to me can be fixed nicely with a minimally invasive laparoscopic hernia approach. The mesh fabric material can be widely overlapped. The key principles outlined above can be adhered to and a very satisfactory repair can be obtained without any significant open incision and with very little risk of complications.
One consideration that this type of technique brings to the discussion is the likelihood of a smaller, softer bulge persisting after the hernia is repaired. Keep in mind that in most cases it is not advantageous to make a big cut and attempt to perform a reapproximation of the muscle and tendon which have torn. This leads to a lot of tension and pain, not to mention risk of infection and a high chance of recurrent hernia. However not repairing that muscular and fascial separation means that the full strength of the abdominal wall that Mother Nature provided is no longer in force. What one is relying on instead is the mesh fabric material, well anchored and well overlapped, and the soft tissues of the skin and subcutaneous layers, which don’t provide much strength. The result is that the hernia can be fully “repaired” and strong, durable, comfortable and pain free. It will prevent the worst complications of hernias, incarceration or strangulation, and it will serve the person well, however it may not provide the cosmetic result that a person is expecting if they are not warned the mesh can still bulge to some degree. The alternative to accepting this bulge is to go ahead and perform a concomitant open closure of the muscle and tendinous tissues, but then this gives up the minimally invasive benefits and involves higher amounts of pain, recovery time and complications risk. In most cases this residual bulge can be minimized, but it is likely to be present to some degree.
An additional bit of advice is to mention to every patient after hernia repair that it is imperative they work hard to keep their weight right where it is or even lose pounds in most cases. Weight gain over the years and over the decades causes many harmful effects, but chief among them in this area is the increased risk of hernia recurrence. So any hernia program must also make mention of and provide advice for maintaining one’s weight over the long term. It is vitally important to the person’s health and not offering that advice means ignoring the chief reason why the hernia might fail and require further surgery down the road in life.
In summary, hernias recur for a variety of reasons, but most of them stem from the pressure or tension that is placed upon the repair by activities that we do in everyday life such as lifting, coughing, sneezing, laughing and the like. A lot of hernias recur because weight gain leads to stretching out of the abdominal wall tissues. Technical considerations of the mesh and sutures can play a role in a small number of cases. The best repair for recurrent hernias is nearly always a minimally invasive approach with a wide overlap of the new mesh fabric material and hardy transfascial anchoring sutures (I usually place them several centimeters out beyond the fascial defect in a north, south, east and west configuration through all the layers of the abdominal wall to provide good, sturdy, durable fixation. In most cases this results in a very satisfactorily and minimally invasive repair that will last a person a lifetime with the least risks and the minimum of discomfort.
Recurrent ventral incisional hernias can be among the most challenging hernias to repair. In most cases the previous repair was done with an open technique and often involves the use of mesh materials. Attempting a repeat tear can involve significant surgical trauma and recovery time. The approach most often taken by myself, emphasizes the focus on minimally invasive techniques. In most cases a laparoscopic or minimally invasive approach can be undertaken without reopening the old scar and without incurring the risks associated with the open repair technique, which would include infection and non-healing wounds. The goal of surgery is to create the most comfortable and durable repair possible. In most cases the mesh material chosen is specifically selected because of the weight and bilaminar nature of it, which involves two thin sheets of material: A soft mesh material combined with an anti-adhesion barrier layer. This bilaminar mesh material reduces the chance of adhesions or scar tissue forming from the intra-abdominal organs to the mesh. Minimizing this scar tissue formation brings benefits not only in terms of comfort, but also in minimizing the risks of erosion and pain. The mesh material is anchored with transfascial sutures that keep the mesh permanently in position and provide a wide overlap beyond the hernia defect to prevent recurrence.
Each case of recurrent ventral or incisional hernia requires a careful approach and the careful kind of consideration that an experienced hernia surgeon can offer. I have a great deal of experience with all types of hernia repairs and can help guide a person toward choosing the repair that will be the most comfortable, most durable, most effective and the least invasive.
*Dr. Sasse helped pioneer the technique of laparoscopic incision hernia repair and published an influential paper in the peer review literature on this subject. In his study, many of the patients undergoing incision hernias repairs with the laparoscopic technique were in fact undergoing recurrent incisional hernia repairs.
