Laparoscopic Hernia Repair: A brief information

Laparoscopic Inguinal Hernia Repair
WHAT IS A HERNIA?
• An abdominal hernia is an abnormal protrusion of an abdominal organ through an abnormal defect in the wall of the abdominal wall.. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems like intestinal obstruction/gangrene that could require emergency surgery.




1:abdominal wall;2:intestines,3:hernia
• Both men and women can get a hernia.
• You may be born with a hernia (congenital) or develop one over time (acquired).
• A hernia does not get better over time, nor will it go away by itself (only surgical cure is there there is no role of medications).
What are the symptoms?
• The common areas where hernias occur are in the groin (inguinal), umbilicus (umbilical), and the site of a previous operation (incisional).


• You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting. The hernia usually protrudes during strenuous activity and settles back in abdomen during rest. But sometimes it may not go back(persistent swelling).
• The patient may have dull ache or sharp shooting pain.
• Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. This is a sign of emergency .
WHAT CAUSES A HERNIA?
The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness present from birth(congenital hernia).



Anyone can develop a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting(sportsmen), persistent coughing(ASTHMA/COPD patients), constipation or difficulty in urination(prostatic enlargement ) can precipitate the hernia.
WHAT ARE THE ADVANTAGES OF LAPAROSCOPIC HERNIA REPAIR?
Laparoscopic Hernia Repair is a technique which covers the defect in the parietes using key holes, telescopes and a mesh(prolene mesh/biodegradable mesh). If may offer a quicker return to work and normal activities with a decreased pain for some patients.
ARE YOU FIT FOR LAPAROSCOPIC HERNIA REPAIR?
As the laparoscopy involves insufflations of carbon dioxide gas in abdomen and general anaesthesia ; general fitness is must.Those patients who are not candidates for the laparoscpy can be offered open repair under local inguinal block or spinal/epidural anaesthesia.
Procedure prior to Laparoscopy:

• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as antiplatelet agents will need to be stopped temporarily for several days to a week prior to surgery( with the consultation with In-house physician).
• You may be administered enema in night time before the day of the surgery.
HOW IS THE PROCEDURE PERFORMED?
I. The open approach is done from the outside with 5-7 cm incision in the groin. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole as shown in figure(Lichensteins tension free hernia repair).



II. The laparoscopic hernia repair. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.
Other tubes are inserted which allow your surgeon to work "inside." Three or four small incisions are usually necessary. The hernia is repaired from behind the abdominal wall. A small piece of surgical mesh is placed over the hernia defect. This operation is usually performed with general anesthesia





WHAT HAPPENS IF THE OPERATION CANNOT BE COMPLETED BY THE LAPAROSCOPY?
In a small number of patients the laparoscopic method cannot be performed. The factors which may cause difficulty in progress are obesity,presence of scar tissue because of previous surgeries,difficulty in dissection because of incarcerated bowels etc..
When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment.
WHAT SHOULD I EXPECT AFTER SURGERY?
• Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
• You will be transferred to your ward in the evening and allowed sips of fluids in the same day usually.The next day usually the normal diet is started.
• With laparoscopic hernia repair, you will probably be able to get back to your normal activities within 3-4 days. These activities include showering, driving, lifting, working and sexual intercourse.
WHAT COMPLICATIONS CAN OCCUR?
• Few complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.
• There is a slight risk of injury adjacent organs like urinary bladder, the intestines, blood vessels, nerves.
• Difficulty urinating after surgery is not unusual and may require a catheter into the urinary bladder for as long as one week(especially in patients with prostatic enlargement; we usually do both prostate surgery and hernia repair simultaneously in cases where the prostate is the precipitating factor) .
• Recurrence can occur.(Although with the mesh repair it is less common still it is a rare possibility).
WHEN TO CALL AN EMERGENCY

• Persistent fever over 101 degrees F (39 C)
• Bleeding/Local groin swelling
• Persistent Pain/nausea or vomiting
• Inability to urinate
• Pus discharge from any incision/Redness surrounding any of your incisions that is worsening or getting bigger
• Abdominal distension

Angiokeratoma of the scrotum:Associated with Varicocele

A 28 year old gentleman presented to us with recurrent bleeding from left hemiscrotum.
He gave no history of trauma. He was married with 2 children and had undergone varicocelectomy surgery 10 years back .
On examination he had grade 3 varicocele on left side and grade 1 varicocele on right side .He had 2-5 mm dark red coloured papules on his left hemiscrotal skin.The dermatologist diagnosed it as Fordyces spots.



In this case we assumed varicocele to be a precipitating factor as Fordyces spots were concentrated on only left hemiscrotum and the varicocele was also Grade 3 severity on left hemiscrotum.

He was taken up for bilateral microsurgical varicocelectomy and will be referred to the dermatologist for probable Laser therapy (CO2).

stricture urethra: a review

Urethral stricture is an abnormal narrowing of the urethra (the tube that releases urine from the body).



Causes, incidence, and risk factors
The most common cause of anterior urethral stricture is infections.Sexually transmitted diseases can cause infection of the urethral glands(for ex.Bulbo-urethral glands) and resultant inflammation and fibrosis of the region
Other common causes are Balanitis Xerotica Obliterans/lichen sclerosis which can lead to stricture of the whole urethra(pan urethral stricture).This disease usually involves the glans,meatus and the penile pendular urethra.Usually shrunken atrophic glans with meatal narrowing with whitish patches are found on the glans The involvement due to Lichen Sclerosis can be more proximal on the penile skin and pendulous urethra, which is more common than previously thought. Although penile skin may appear normal, microscopic involvement may be present. Moreover it is known that endoscopic manipulation of meatus involved with Lichen Sclerosis also has a potential of disseminating the disease into proximal urethra causing pan-urethral stricture
The trauma either direct because saddle injury or pelvic trauma incurred during the road traffic accidents can cause anterior and posterior urethral injuries and stricture respectively.
The instrumentation (traumatic or repeated) can also lead to trauma. The carcinoma bladder patients who undergo repeated intervention are more prone. Also prostatic enlargement patients who undergo endoscopic prostatectomies are also prone for stricture especially if the gland size is big because the dwelling time of the instruments inside body will be higher in such cases.This will also make urethra more prone for instrumentation leading to stricture.


Symptoms




1)dysuria, weak interrupted stream,urgency,urge incontinence,frequency
2)Recurrent Urinary Tract Infections
3)Hematuria
4)Retention of the urine
5)Urinary incontinence
6)Renal function deterioration



Signs and Tests
A physical examination may reveal the following:
1) Hardness (induration) on the under surface of the penis
2) Whitish Patches on glans,meatal narrowing,shrinkage and atrophy of the glans indicative of Balanitis Xerotica Obliterans
3) Sometimes urethrocutaneous fistula can be found
4) Evidence of pelvic fracture/scars of previous Supra Pubic Catheter placement can also be found.
•
Sometimes the exam reveals no abnormalities:
Tests include the following:
1) Urinary flow rate
2) Post-void residual (PVR) measurement
3) Urinalysis /Urine culture
4) Tests for chlamydia and gonorrhea
5) A retrograde urethrogram to confirm diagnosis



6) Urethroscopy

Treatment
Placement of a suprapubic catheter , which allows the bladder to drain through the abdomen, may be necessary to alleviate acute problems such as urinary retention and infection especially after trauma .

Surgical options vary depending on the location and length of the stricture.

Visual internal urethrotomy may be all that is needed for small stricture. A urethral catheter is left in place after the procedure for anywhere from 3 -10 days .This duration varies from surgeon to surgeon But everybody would agree on principle that prolonged catheterization doesnot prevent the chance of urethral stricture recurrence

An open urethroplasty may be performed for longer stricture by removing the diseased portion or replacing it with other tissue. The results vary depending on the size and location of stricture, the number of prior therapies, and the experience of the surgeon.



Buccal Mucosal Graft Interposition in one case of anterior urethral stricture

In some patients of failed urethroplasties or where the patient is not a good candidate for surgery or even in primary cases stenting is a worthwhile option.The stent is made up of Nickel Titanium Alloy (Memokath 044) and has only a few side effects.The stent is inserted in urethra with the telescope and then expanded with the warm saline irrigation.It expand from 24 to 44 CH.The stent is available from 3 to 7 cms in length.This stent equally easy to remove.















Photograph of the urethral stent placed in long segment urethral stricture



There are no drug treatments currently available for this disease. If all else fails, a urinary diversion -- appendicovesicostomy (Mitrofanoff procedure) -- may be performed to allow the patient to perform self-catheterization of the bladder through the abdominal wall.

spontaneous urinoma with no apparent aetiology in a young girl mimicking a retroperitoneal mass

A 21 year old patient came to us with history of having been operated outside for ? twisted ovarian cyst.



Pre-operative ultrasound (Before first surgery) showing cystic mass




The laparoscopy was abandoned because contrary to their expectations they found retroperitoneal mass on the right side of the retroperitoneum.
She came to us with a post-operative contrast enhanced CT Scan which revealed urinoma near middle of the right ureter and diffuse ascites. The urinoma was encapsulated in thick capsule (? Chronic process).







On clinical examination she was looking ill and frail. She had loose motions(? Pelvic collection induced).
Her vitals though were maintained except for tachycardia.She had normal hematological and biochemical parameters. Her abdomen was mildly distended with urinary leakage through one of the ports.
She was taken up for Retrograde Pyelography which showed mid-ureteric disruption and dye leaking into a diffuse cavity.The patient was made prone for percutaneous nephrostomy drainage.
Right Percutaneous Drainage was performed through a midcalyceal approach for possible antegrade stenting sometimes in future.
She started draining around 100 ml of urine per hour through the nephrostomy and her leakage of urine through the port and the abdominal distension subsided.Her loose motions also subsided
The very next day she started looking fresh and was back to her normal routine.
She is planned to undergo an evaluation after a period of 6 weeks hoping that till that time the urinoma would subside and the inflammatory reaction would also subside.Then a definitive plan for ureteric reconstruction will be taken up.
This is a rare case of spontaneous urinoma at level of mid-ureter with no apparent aetiology clinically,history and imaging wise.
Having searched the English Literature the urinoma spontaneous in this location was found to be very rare --due to abdominal aortic aneurysm or retroperitoneal fibrosis.In this case both the factors were not seen on CT scan.The possibility of tuberculous lymphadenopathy involving the ureter causing ischemic necrosis of that particular segment leading to spontaneous urinoma is being kept in mind.
She will be investigated for quantiferon TB TEST in the interim .With all said and done probably exploration after 6 weeks and biopsy of the region only might give a definitive clue.

Conservative management of colo-vesical fistula

A 55 year old lady presented with history of pneumaturia and occasional passage of fecal matter per urethra since 8 days.She was a known case of carcinoma endometrium operated 18 years back with Total Abdominal Hysterectomy followed by chemotherapy and radiotherapy.She was asymptomatic for 10 years then she started leaking ? fecal matter per urethra.She was taken up for endoscopic intervention after which the fecal leakage stopped. She is a known case of diabetic-fairly controlled,hypertension on medications.She was investigated for cystoscopy(diagnostic) which revealed a fistula 2 cm away from the left ureteric orifice cranially and laterally.The fistulogram showed leakage of the contrast into the sigmoid colon. She was given option of open repair of colo-vesical fistula but she preferred an endoscopic approach over open repair.The patient was explained the chances of success and failure and then was taken up for endoscopic repair. She was kept on liquid diet before the planned surgery and also given Peglec for bowel preparation. On the day of surgery , the prophylactic antibiotics were administered and the cystoscopy was started. The fistula was identified in the same position.It was cauterised on all sides with ball electrode with resectoscope instrument. After cauterising the ureteric orifices were cannulated with ureteric catheters and the cauterised mucosa was re-inforced with Fibrin Glue(Mixture of Fibrinogen and thrombin-Tisseel by Baxter).A total of 4 ml quantity was required.The bladder was kept deflated after the injection. The sealing of the fistula tract was confirmed endoscopically and then Foleys catheter was introduced. The plan is to keep patient on NBM for 24 hours and further 24 hours on liquids and then ensure she will not suffer from constipation further.The bladder will be kept deflated for a period of 4 weeks.