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Hernia Procedures

Hiatus hernia

Laparoscopic surgery, also called keyhole surgery (when natural body openings are not used), bandaid surgery, or minimally invasive surgery (MIS), is a surgical technique. Medically, laparoscopic surgery refers only to operations within the abdomen or pelvic cavity. Laparoscopic surgery belongs to the field of endoscopy.

Cholecystectomy as seen through a laparoscope

A laparoscope consists of a Hopkins rod lens system , that is usually connected to a videocamera- single chip or three chip, a fibre optic cable system connected to a 'cold' light source, halogen or xenon, to illuminate the operative field, inserted through a 5mm or 10mm canula to view the operative field. Additional 5- 10mm thin instruments can be introduced by the surgeon through side ports. Rather than a 20 cm cut as in traditional cholecystectomy, two to five cuts of 5-15 mm will be sufficient to perform a laparoscopic removal of a gallbladder. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space.

This approach is intended to minimise operative blood loss and post-operative pain, and speeds up recovery times. However, in some cases the pain caused by the carbon dioxide leaving the body is severe and painkillers have little or no effect. The restricted vision, difficult handling of the instruments (hand-eye coordination), lack of tactile perception and the limited working area can increase the possibility of damage to surrounding organs and vessels, either accidentally or through the difficulty of procedures.

The first transatlantic surgery ever performed was a laparoscopic gallbladder removal.

Herniorraphy

Herniorraphy (Hernioplasty, Hernia repair) is a surgical procedure for correcting hernia. A hernia is a bulging of internal organs or tissues, which protrude through an abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at the site of a previous surgery.

Herniorraphy is a very common operation and can be performed in a day surgery setting. Almost 700,000 are performed each year in the United States. During the procedure the surgeon pushes the protruding organs or tissue back behind the muscle wall and then repairs the torn muscle with stitches or a piece of mesh held in place with staples.

Inguinal hernia

Surgical correction of inguinal hernia is now often performed as an ambulatory or "day surgery" procedure. A workable technique of repairing hernia was first described by Bassini in the 1800s; the Bassini technique was a "tension" repair,in which the edges of the defect are sewn back together without any reinforcement or prosthesis. This is a 'herniorraphy'. Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and severe post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's Ligament/McVay repair. An operation in which the hernia sac is removed in addition to tension repair is described as a 'herniotomy'.

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within a week or two of operation. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair.

In recent years, much like in all other areas of surgery, laparoscopic repair of inguinal hernia has emerged as an option. "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia. It is usually more expensive and consumes more OR time than open repair, carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs.

In the UK a government committee called NICE re-examined the data on laparoscopic and open repair (2004). They concluded that there is no difference in cost, as the increased costs of operation are offset by the decreased recovery period. Recurrence rates are identical. They found that laparoscopic repair results in a more rapid recovery and less pain in the first few days. They found that lap repair has less risk of wound infection, less bleeding and less swelling after surgery (seroma). They also reported less chronic pain, which can last for years and in one in 30 patients can be severe. A recent, large American study found that recurrence within two years of operation after lap repair was 10% compared with 4% after open surgery. Both of these results however are considered poor by international standards and suggest that the surgeons were inexperienced, particularly in lap repair.

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