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About Dr. Neeraj

Neeraj-Rayate

A best cadet and a best outgoing student of school; Dr. Neeraj Rayate graduated from Dr. V. M. Medical College, Solapur in merit. He served as a medical officer to Government of Maharashtra at its remote primary health center in Jalgaon district for one year. He then completed his Masters in Surgery from Government Medical College & Civil Hospital, Sangli. He is also a diplomat of national board, New Delhi; in Surgery. He then was a popular teacher in Surgery at Dr. V. M. Medical College, Solapur for 2 years. His urge for excellence brought him to Pune.Read the Rest…

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Postoperative Ventral Wall {Incisional} Hernia

  1. Introduction
  • It is the result of a failure of fascial tissues to heal & close following laparotomy.
  • Such hernias can occur after any type of abdominal wall incision, although highest incidence is seen with midline & transverse incision.
  • Laparoscopic port sites may also develop hernia defects in the abdominal wall fascia.
  1. Incidence & Etiology
  • Modern rates of incisional hernia ranges from 2% to 11%
  • Once belived that the majority of incisional hernia present within first 12 months following laparotomy, long term data indicate that at least one – third will present 5-10 years post-operatively.
  • Multiple risk factors exist for development of an incisional hernia.
  1. Patient Specific – Advanced Age, Malnutrition, Presence of Ascites, Corticosteroids use, DM, Cigarette Smoking, Obesity, Wound Infection.
  2. Emergency sx is known to increase risk of incisional hernia.
  3. Surgeon Specific – Wound closure under excessive tension are prone to fascial closure disturbance. Therefore continuous closure is advocated to disperse the tension throughout the length of the wound.
  1. Clinical Manifestation
  • Patient complains of bulge in abdominal wall originating deep to the skin scar
  • Symptoms will usually be aggravated by coughing or straining as the hernia contents protrude through abdominal wall defect.
  • In large ventral hernias, skin may present with ischemic or pressure necrosis leading to frank ulceration.
  • May present with incarceration causing bowel obstruction, it may be associated with a history of repected mild attack of colicky dull abdominal pain & nourea consistent with incomplete bowel obstruction
  1. Examination
  • On examination the hernia is usually easy to identity & the edges of the fascial defect can often be defined by palpation.
  • Entire abdominal wall along the length of the incision should be inspected & palpated carefully as multiple hernia are often present in
  • CT-scan of abdomen is best way to visualize intra-abdominal contents within the hernia sac.
  1. Treatment
  • Treatment of ventral hernia is operative repair & three general classes of operative repair have emerged in modern era.
  1. Primary Suture Repair
  2. Open Repair With Prosthetic Mesh
  3. Laparoscopic Incisional Hernia Repair
  1. Laparoscopic Incisional Hernia Repair
  • In this technique, the defect is repaired posteriorly & no dissection within the scarred layer of anterior fascia required.
  • It also allows identification of additional hernia defect in ant. Abdomen wall.
  • One of the challenging aspect of the Laparoscopic repair port access into a peritoneal cavity that has been previously operated.
  • In general , access can be obtained for needle insufflations via the left upper quadrant, placing the port along ant. Axillary line to avoid
  • Then instruments are inserted.
  • Next challenge is lysis of adhesions.
  • Goal is to provide 3-4 cm circumferential area of overlap for the mesh patch beyond the edge of ventral hernia defect.
  • The sac is retracted & excised from within the hernia.
  • Outline of defect is then drawn on ant. Abdomen wall. Edges are confirmed from within the abdomen cavity.
  • While adhesiolysis can be performed at typical pneumoperitoneum pressure of 15 mm Hg, sizing the mesh should be done with abdomen fully deflated.
  • If the mesh is measured with abdomen fully distended, it will be lax once the pneumo is released & patient may feel as if their hernia was never fixed.
  • Mesh is cut to fit this defect with a margin of 3-4 cm each side to provide adequate coverage & to minimize tension.
  • Non-absorbable sutures are placed around the circumference of the mesh & tied. The mesh is rolled so that ant. Surface lies inside the roll &mesh is inserted through 10-12 mm port.
  • Once un-rolled mesh is positioned. A transfascial suture passer can be introduced through small stab incision placed around the marked border.
  • Suture passer retrives the long end of sutures & ends are tied at skin level at 4-6 patient around the repair.
  • After all suturs tied, cut & buried subcutaneously, laparoscopically placed tacks or staples can be used to futher fasten the mesh to ant. Abdominal wall.
  • Post-op patient should be instructed to wear abdominal binders-particularly if a large defect has been repair in an effort to obliterate dead space & prevent seroma formation.
  1. Complications
  • Shares general complication of laparoscopy including port-site herniation vascular injury from trocar placement & inadvertent bowel injury during adhesiolysis.
  • Mesh placed during Laparoscopy are prone to infection.
  1. Pros & Cons of Laparoscopic Ventral Hernia Repair
  1. Pros
  • Accurately identifies all fascial defect
  • May identity unsuspected intraperitoneal pathology
  • Approaches fascia through clean field.
  1. Cons
  • No possible to revise contour of abdomen wall
  • Adhesiolysis may be difficult with increase potential for enterotomy.
  • Hard to get good fixation for defect at margin of abdomen cavity.
  1. Notes
  • In this the mesh is placed directly in contact with the viscera. As in open in lay repairs this carries the risk of development of chronic inflammation, fistula, infection & mesh migration
  • To minimize this, dual sided mesh prosthses have been developed, these implants are coated with materials designed to prevent adhesion

Hemorrhoidectomy

  1. Introduction
  1. Hemorrhoids are consider the natural anal cushions
  2. They are made up of  arterio-venus communication, smooth muscle & elastic connective tissue in submucosa that normally reside in the left lateral, right posterolateral & right antero lateral anal canal.
  1. Classification
  1. Internal Hemorrhoids
  1. Reside above the dentate line & are covered by transitional and columnar epithelium.
  2. Grading

Grade 1 – Painless bleeding with defecation

Grade 2 – Hemorrhoids protrudes through anal canal at the time of defecation but spontaneously reduce.

Grade 3 – Protrudes bleeds but they must be manually reduced.

Grade 4 – Permanently fixed below dentate line & cannot be manually reduced.

  1. External Hemorrhoids

Dilated vascular plexus located below the dentate line & covered by squanous epithelium.

  1. Mixed – Composed of both internal & external.
  2. Anal skin tags are discrete folds of skin located at the anal verge, they are end results of resolved thrombased external hemorrhoids or more rarely may be associated with inflammatory bowel disease.
  1. Evaluation
  • Internal hemorrhoids are most common source of rectal bleeding.
  • Internal hemorrhoids cannot be detected by digital examination diagnosis can only be made by anoscopy.
  • In high patient like age >40 years, family h/o colorectal neoplasm or change of bowel habits, colonoscopy is mandatory.
  1. Treatment
  1. Initially regulation of diet & avoidance of prolonged straining at the time of defecation comprise the treatment of symptoms of bleeding & protrusion.
  2. Increase fiber content of diet at least 25-35 gm daily with raw vegetables, fruits , whole grain etc.
  3. If bleeding & protrusion persist, however, the hemorrhoids should be treated surgically.
  4. Circular stapled hemorrhoidectomy is a newer technique indicated for the elective treatment of circumferential 3rd & 4th degree hemorrhoids that are not permanently prolapsed due to scar.
  5. Steps
  1. Place a purse – string suture incorporating the muscosa of the anal canal with a stapled circumferential muscosectomy at a level 4-5 cm above dentate line.
  2. This is performed under regional anesthesia with minimal morbidity in experienced hands.
  3. Complications
  • Bleeding if stapled line is incomplete
  • Pain if staple line is to close to the dentate line.
  • Rectovaginal fistula if purse string captures the rectovaginal septum.
  • Complete closure of rectum
  • Return of symptoms if purse string is incomplete.
  1. Thrombased internal hemorrhoids will sclerose & may not require surgery. If symptoms persist , a three quadrant hemorrhoidectomy may be necessary. If necrstic tissue is present at time of acute thrombosis, emergent excisional hemorrhoidectomy is necessary.
  2. Thrombosed external hemorrhoids
  • External venous plexus is located at the anal verge & encircles the anal canal.
  • A segmental thrombosis is contined to the anoderm & perianal skin & does not extend above the dentate line.
  • The problem present with c/o painful perianal mass. The overlying skin may be stretched to 2 cm or more. Pain usually peaks within 48 hours & generally becomes minimal after 4th day.
  • If untreated, the thrombus is absorbed within a few weeks. The pressure of underlying clot will occasionally cause the adjacent skin to become necrotic & clot will be extruded through the area of necrosis.
  • Patient of thrombosed hemorrhoid is aimed at relief of pain. For mild symptoms, mild analgesia, sitz bath, proper anal hygiene & bulk producing agents will suffice.
  • For serve pain, excision of thrombosed hemorrhoids may be beneficial.
  • As numerous vessels are involved, it is necessary to excise the entire mass along with overlying skin & soft tissue,. The wound is left open without packing

Laparoscopic Inguinal Hernia Repair

  1. Introduction

Hernia is defined as an area of weakness or complete disruption of fibromuscular tissue of body wall causing protrusion of abdominal contents. Hernia in latin means “A Rupture”.

  1. Epidomology

Of all groin hernias, 95% are hernias are of inguinal region with the remainder being femoral hernia. Inguinal Hernia is 9 times more common in men than women. Although femoral hernias are found more in females, the inguinal hernia is still the most common hernia in women.

  1. Anatomy of Groin

Inguinal region has 2 rings, 2 boundaries & 2 borders.

  1. 2 Rings
  2. Internal Ring – A deep ring is formed by a normal defect in transversalis fascia through which spermatic cord in men & round ligament in women pass out into the abdomen from the extraperitoneal  plane.
  3. External / Superficial Ring – It is inferior and medial to the internal ring & represents an opening of aponeurosis of external oblique. Spermatic cord passes through external ring before entering the scrotum in males.
  4. Anterior boundary is the external oblique & posterior boundary is transversalis fascia with some contribution from aponeurosis of transverses abdominis muscle.
  5. Inferior border is imparted by inguinal & lacunar ligament. Inguinal ligament represent the interior extension of external oblique aponeurosis & extends from anterior superior Iliac spine to pubic tubercle.
  6. Superior border is formed by arching fibers of internal oblique.
  7. Transversus abdominis muscle & its fascia represent true floor of inguinal canal.
  8. Deep to floor there is inferior epigastric artery & vein, genitofemoral lateral femoral cutanesus nerve.
  1. Anatomical Classification
  1. Indirect Inguinal Hernia – Develops lateral to inferior epigastric vessels.
  2. Direct Inguinal Hernia – Develops medial to inferior epigastric vessel. Thus they are found in Hesselbachs Triangle.

Hesselbachs Triangle

  • Lateral border is by interior epigastric artery
  • Medial border is by lateral border of rectas sheath
  • Base by inguinal ligament

Etiology

  1. Primary etiology of indirect inguinal hernia appears to be patent processus vaginalis, which in essence represent a hernia sac. Not every person with petent processus vaginalis develops hernia. Some predisposing factors are pregnancy, COPD, abdominal ascitis patient undergone peritoneal dialysis, chronic constipation.
  2. More common in chronic smokers because cigarette causes connective tissue disruption.
  1. Clinical Manifestation
  • The most common presenting symptomatology for a groin hernia is a dull feeling of discomfort or heaviness in the groin region that is exacerbated by straining the abdominal musculature, lifting heavy object or defecating.
  • With a reducible hernia, the feeling of discomfort resolves as the pressure is releaved when the patient stops straining the abdominal muscles.
  • Pain often worse at the end of day.
  • An incarcerated hernia occurs when the hernia contents are trapped in hernia defect so that contents cannot be reduced.

Physical Examination

On physical examination a visible bulge can be seen at the hernia site which increases on increase in intraabdominal pressure like coughing.

  1. Treatment
  1. Treatment of all hernia regardless of their location or type is surgical repair.
  2. Groin repair can be done under local general or regional (spinal or epidural) anesthesia.
  3. Laparoscopic repair are generally done under general anaesthesia to provide complete muscle relaxation needed to achieve insufflation of the preperitoneal or peritoneal sac.
  4. There are three techniques in Laparoscopic Hernia Repair.

Transabdominal preperitoneal repair

  • This technique was the 1st Laparoscopic hernia repair to be performed.

Steps

  • Ports are entered through the umbilicus & then laterally on either side the rectus muscle.
  • Both inguinal regions inspected, median & medial umbilical ligament and lateral umbilical fold are identified.
  • Parietal layer of peritoneum incised superior to hernia defect & reflected interiorly exposing epigastric vessels, cooper’s ligament & public tuberule
  • In Direct Hernia
In Direct Hernia

In Indirect Hernia

Peritoneal sac is pulled back within peritoneal cavity

Peritoneal sac retracted of the cord structures & pulled back within peritoneal cavity

  • A large polypropylene mesh is placed between peritoneum & transversalis fascia that covers the inguinal floor, inguinal ring & femoral canal.
  • Mesh is tacked to public tuberule medially, Cooper’s ligament interiorly & artery superior iliac spine laterally
  • Peritoneal flap is closed over the mesh
  • Risk with this procedure is, mesh is in direct content with the bowel & significant concern has been raised about potential for intra – abdominal adhesions post-op.
  1. Total Extraperitoneal Approach

It is most popular method. This is performed entirely within the preperitoneal space & does not involve peritoneal cavity. Surgeon carefully develops a plane between peritoneum posteriorly & abdomen wall anteriorly & thus insufflates the preperitoneal sac.

Steps –

  • Incision is made interior to the umbilicus & ant. Rectus sheath on ipsilateral side is incised.
  • Rectus is retracted laterally & preperitoneal space is bluntly dissected to allow placement of a port to facilitate insufflations
  • Large prosthetic mesh is placed through laparoscopic port into the preperitoneal space & it is then postioned deep to the hernia defect.
  1. Intraperitoneal onlay mesh repair
  • It is simplified version of TAP repair
  • In this we enter the peritoneal cavity but we do not create a peritoneal flap.
  • Rather a large mesh is simple stapled directly to post. to peritoneum
  • Disadvantage – 1) Direct contact with bowel high chances of adhesions & possible erosion of the mesh into the bowel content. 2) In large hernia, the mesh & peritoneum may herniated through the defect together.
  • These days a anatomical 3D mesh is used to cover the defect. This doesn’t require a fixation device like tacker.

 

  1. Complications of laparoscopic hernia repair
  1. Recurrance – It is rare, but when it occurs is often secondary to deep infection undue tension on repair or tissue ischemia, patient who are over active in the immediate post-op setting.
  2. Seroma form in dead space remaining from wide dissection during hernia repair. Sometime in Laparoscopic Hernia Repair as the sac in as it is, filling of sac with seroma type fluid leads to pseudohernia.
  3. Infection – Mainly from skin
  4. Haematoma
  5. Neuralgia
  1. Often neuralgia will follow the known distribution of the regional nerves, including branch of genitofemoral nerve & lateral femorocutaneous nerves.
  2. In Laparoscopic Herniorraphy lateral femorocutaneous nerve is more commonly injured.
  3. Nerves can also be intentionally sacrificed with a result. There is depriration of sensation along nerve distribution mainly inner upper thigh & hemiscrotum.
  1. Bladder Injury
  2. Testicular Injury
  3. Vas Deferens Injury

Laparoscopic Cholecystectomy

  1. Introduction

First Endoscopic Cholecystectomy was performed in 1985 by Erich Muhe of Boblingen, Germany. Shortly pioneers in France & USA coupled with a CCD video camera with a laparoscopy to allow entire surgical team to view the operative field.

  1. Indication for Cholecystectomy
  1. Symptomatic Cholelithiasis
  1. Biliary Colic
  2. Acute Cholecystitis

     2. Choledocholithiasis

      a) Gall Stone Pancreatitis

      b) Cholangitis or Obstuctive Jaundice

  1. Asymptomatic Cholelithiasis – Prophylatic Cholecystectomy for Asymptomatic Cholelithiasis can be justified in certain circumstances, such as

     

     

    1. With sickle cell disease : Pt. with sickle cell disease often have hepatic or vaso-occlesive crises that are difficult to differentiate from acute cholecystitis,
    2. Bariatric surgery, In bariatric pt. there is increase in possibility of development of gall stone due to rapid weight loss,
    3. Cholelithiasis with diabetes mellitus to avoid complications after acute attack
    4. Cholelithiasis with porcelline gall bladder – it’s a premalignant condition
  2. Acalculous Cholecystitis
  3. Gall Bladder Dyskinesia
  4. Gall Bladder Polyp – 10mm in diameter
  1. Symptoms

Biliary colic is typically a severe and episodic right upper abdomen or epigastric pain that can radiate to the back.

Attacks frequently occur post prandially or awakens patients from sleep. Post prandial pain is associated with high fat diet.

Once Patients has these symptoms, there are 80%  chance that they may have complications. Complication may result from obstruction of gall bladder outlet causing acute cholecystitis or migration of stone into CBD.

  1. Signs
  1. Tenderness in epigastrium and right hypochondrium.
  2. Icterus in care of obstructive jaundice.
  3. Fever
  1. Investigations
  1. Laboratory test of patient with biliary disease includes Total Bilirubin, Alkaline Phosphatase, Transaminase, Amylase, Lipase .
  2. Elevated liver function may suggest biliary obstruction.
  3. Elevated Amylase & Lipase suggest pancreatitis.
  4. The only diagnostic imaging study necessary prior to Laparoscopic Cholecystectomy is ultrasound of abdomen, which demonstrates size, number of stones, thickness of gall bladder, diameter CBD.
  5. When Ultrasound is negative despite typical biliary symptoms. CCK- stimulated HIDA scan demonstrating a low gall bladder ejection fraction with or without pain reproduction suggest of gall bladder dyskinesia.
  1. Contraindication of Laparoscopic Cholecystectomy
  1. Absolute

Patient not fit for anaesthesia

Refractory Coagulopathy

Diagnosed of gall bladder ca.

  1. Relative
  1. Previous upper abdomen surgery
  2. Cholangitis
  3. Diffuse peritonitis with hemadynamic compromise – This represents a surgical emergency in which attempting Laparoscopic Cholecystectomy is not prudent, because etiology in not clear or sure &  pheumoperitoneum may lead to vascular collapse.
  4. Cirrhosis / Portal Hypertension
  5. Chronic Obstructive Pulmonary Disease
  6. Cholecystrenteric Fistula
  7. Morbid Obesity
  8. Pregnancy
  1. Advantages & Disadvantages of Laparoscopic Cholecystectomy compared to Open Cholecystectomy

‚ÄčAdvantages

Limitations

  1. Less pain
  2. Smaller incision
  3. Better cosmesis
  4. Shorter hospitalization
  5. Earlier return to full activity
  6. Decreased costs
  1. Lack of depth perception
  2. Adhesion / Inflommation limit use
  3. More difficult to control haemorrhage
  4. Decreased tactile discrimination
  5. Potential co2 insufflation complications
  1. Complications
  • Bile duct injury
  • Bile leak
  • Retained stones
  • Wound infection
  • Incisional hernia
  • Preumoperitonium related

     I.   New Techniques to Perform Cholecystectomy

  1. Single Port Laparoscopic Surgery – All operative instruments & devices through a single skin incision, usually at the umbilicus
  2. Notes [Natural Orifice Translumenal Endoscopic Surgery] 

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