General & Minimal Invasive Surgery

LAPAROSCOPIC INGUINAL HERNIA REPAIR

Patient Information From Surgeons & PARKVIEW HOSPITAL

Laparoscopic Inguinal Hernia Repair

About your hernia and laparoscopic repair:

What is a hernia?

• A hernia is a gap or space in the strong tissue that holds muscles in place. A hernia

occurs when the inside layers of the abdominal muscle have weakened, resulting in a

bulge or tear.In the same way that an inner tube pushes through a damaged tire, the

inner lining of the abdomen pushes through the weakened area of the abdominal

wall to form a small balloon like sac. This can allow a loop of intestine or abdominal

tissue to push into the sac. The hernia can cause discomfort, severe pain, or other

potentially serious problems that could require emergency surgery.

• Both men and women can get a hernia.
• You may be born with a hernia (congenital) or develop one over time.
• A hernia does not get better over time, nor will it go away by itself. There are no

exercises or physical therapy regimen that can make a hernia go away.

How do I know if i have an inguinal hernia?

• The common areas where hernias occur are in the groin (inguinal), belly button

(umbilical), and the site of a previous operation (incisional).

• It is usually easy to recognize a hernia. You may notice a bulge under the skin.

You may feel pain or discomfort when you lift heavy objects, cough, strain during

urination or bowel movements, or during prolonged standing or sitting. Other times

a hernia may be detected by your doctor on a routine physical examination.

• The pain may be sharp and immediate or a dull ache that gets worse toward the end

of the day.

• Severe, continuous pain, redness, and tenderness are signs that the hernia may be

entrapped or strangulated. Another sign of this is if the bulge used to come and

go, but now is stuck out. These symptoms are cause for concern and you should

immediately contact your physician or surgeon.

About hernias

Approximately 600,000 inguinal or groin hernia repair operations are performed

annually in the United States. Some are performed by the conventional “open”

method. Some hernia repairs are performed using a small telescope known as a

laparoscope. If your surgeon has recommended a hernia repair, this brochure can help

you understand what a hernia is and what your treatment options are.

What causes an inguinal 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. Anyone can develop a hernia at any age.

Most hernias in children are congenital. In adults, a natural weakness or strain from

heavy lifting, persistent coughing, difficulty with bowel movements or urination can

cause the abdominal wall to weaken or separate.

What are the advantages of laparoscopic inguinal

hernia repair?

Laparoscopic Hernia Repair is a technique to fix tears in the abdominal wall (muscle)

using small incisions, telescopes and a patch (mesh). Laparoscopic repair offers a

shorter return to work and normal activity for most patients.

Are you a candidate for laparoscopic inguinal hernia repair?

Only after a thorough examination can your surgeon determine whether laparoscopic

hernia repair is right for you. The procedure may not be best for some patients who have

had previous abdominal surgery, prostate surgery, or underlying medical conditions.

Laparoscopic Inguinal Hernia Repair

What preparation is required?

• Most hernia operations are performed on an outpatient basis, and therefore you will

probably go home on the same day that the operation is performed.

• Preoperative preparation includes blood work, medical evaluation, and an EKG

depending on your age and medical condition.

• After your surgeon reviews with you the potential risks and benefits of the

operation, you will need to provide written consent for surgery.

• It is recommended that you shower the night before or morning of the operation

with an antibiotic soap.

• 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 aspirin, blood thinners, anti-inflammatory medications (arthritis

medications) and Vitamin E may need to be stopped temporarily for several days

to a week prior to surgery. Your surgeon will discuss this with you and provide

instructions regarding your medications around the time of surgery.

• Diet medication or St. John’s Wort should not be used for the two weeks prior to

surgery.

• Quit smoking and arrange for any help you may need at home. Smoking may

increase the risk of the hernia recurring, or coming back after surgery. In some cases,

your surgeon may require that you quit smoking prior to surgery.

How is the procedure performed?

There are few options available for a patient who has a hernia.

• Use of a truss (hernia belt) is rarely prescribed as it is usually ineffective. It may

alleviate some discomfort, but will not prevent the possibility of bowel incarceration

or strangulation.

• Most hernias require a surgical procedure.
• Surgical procedures are done in one of two fashions:

1. The open approach is done from the outside through a three to four-inch incision

in the groin or the area of the hernia. 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. This technique can be done with a local anesthetic and sedation, using a

spinal anesthetic or a general anesthetic.

2. The laparoscopic hernia repair is done with the use of 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 cannulas are inserted which allow your surgeon to work “inside.” Three separate

quarter inch 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, and

it may be fixed in place using staples, adhesive sealant, or sutures. This operation is

usually performed with general anesthesia.

What happens if the operation cannot be performed or completed

by the laparoscopic method?

In a small number of patients the laparoscopic method cannot be performed. Factors

that may increase the possibility of choosing or converting to the “open” procedure

may include obesity, a history of prior abdominal surgery causing dense scar tissue,

inability to visualize organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made by your

surgeon either before or during the actual operation. When the surgeon feels that it is

safest to convert the laparoscopic procedure to an open one, this is not a complication,

but rather good surgical judgment. The decision to convert to an open procedure is

strictly based on patient safety.

After surgery

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.

• Once you are awake and able to walk, drink liquids, and urinate, you will be sent

home.

• With any hernia operation, you can expect some soreness mostly during the first 24

to 48 hours.

• You are encouraged to be up and about the day after surgery.
• With laparoscopic hernia repair, you will probably be able to get back to your

normal activities within a week. These activities include showering, driving, walking

up stairs, lifting, working and engaging in sexual intercourse.

• Call and schedule a follow-up appointment within 2 weeks after you operation.

Complications

What complications can occur?

• Any operation may be associated with complications. The primary complications of any

operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.

• There is a very low risk of injury to the urinary bladder, the intestines, blood vessels,

nerves or the sperm tube going to the testicle.

• Difficulty urinating after surgery can occur and may require placement of a catheter,

or tube to drain the bladder after surgery. You should ask your surgeon about ways

to prevent this from occurring before your operation.

• Bruising and swelling of the scrotum, the base of the penis, and the testicles is not

uncommon with open and laparoscopic repair. This will gradually resolve on its

own in the vast majority of patients.

• Any time a hernia is repaired it can come back. This long-term recurrence rate is

low in patients who undergo laparoscopic repair by an experienced surgeon. Your

surgeon will help you decide if the risks of laparoscopic hernia repair are less than

the risks of leaving the condition untreated.

• It is important to remember that before undergoing any type of surgery–whether

laparoscopic or open–you should ask your surgeon about his/her training and

experience with the operation.

When to call your doctor

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal or groin swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Inability to urinate
• Chills
• Persistent cough or shortness of breath
• Foul smelling drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids

This brochure is not intended to take the place of your discussion with your surgeon about

the need for laparoscopic inguinal hernia surgery. If you have questions about your need

for hernia surgery, your alternatives, billing or insurance coverage, or your surgeons

training and experience, do not hesitate to ask your surgeon or his/her office staff about

1. If you have questions about the operation or subsequent follow-up, please discuss them

with your surgeon before or after the operation.

Color images: Atlas of Minimally Invasive Surgery, Jones DB, et al. Copyright 2006 Cine-Med.

Additional instructions:

Requests for reprints should be sent to:

PARKVIEW SUPER

SPECIALITY HOSPITAL

HB 36 –A / 4,

HB Block, Sector III, Salt Lake

Kolkata700 106

PH: 033 4059 1111

www.parkviewhospital.in

LAPAROSCOPIC GALLBLADDER REMOVAL

Patient Information from Surgeons & PARKVIEW SUPER SPECIALITY HOSPITAL

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LAPAROSCOPIC GALLBLADDER REMOVAL

Gallbladder removal is one of the most commonly performed surgical procedures. Gallbladder removal surgery is usually performed with minimally invasive techniques and the medical name for this procedure is “Laparoscopic Cholecystectomy”.

About the gallbladder

What is the gallbladder?

• The gallbladder is a pear-shaped organ that rests beneath the right side of the liver.
• Its main purpose is to collect and concentrate a digestive liquid (bile) produced by the liver. Bile is released from the gallbladder after eating, aiding digestion. Bile travels through narrow tubular channels (bile ducts) into the small intestine.
• Removal of the gallbladder is not associated with any impairment of digestion in most people.

What causes gallbladder problems?

• Gallbladder problems are usually caused by the presence of gallstones which are usually small and hard, consisting primarily of cholesterol and bile salts that form in the gallbladder or in the bile duct.
• It is uncertain why some people form gallstones but risk factors include prolonged fasting or irregular meals. Gallstones are also more common as you get older and some people may have a family history of gallstones.
• There is no known means to prevent gallstones.
• These stones may block the flow of bile out of the gallbladder, causing it to swell and resulting in sharp abdominal pain, vomiting, indigestion and occasionally, fever.
• If the gallstone blocks the common bile duct, jaundice (yellowing of the skin) or pancreatitis can occur, much is a very serious surgical emergency.

How are these problems found and treated?

• Ultrasound is most commonly used to find gallstones.
• In a few more complex cases, another X-ray test such as a CT scan, MRCP or a gallbladder nuclear medicine scan may be used to evaluate gallbladder disease.
• Gallstones do not go away on their own. Some can be temporarily managed by making dietary adjustments, such as reducing fat intake. This treatment has a low, short-term success rate. Symptoms will eventually continue unless the gallbladder is removed. Treatments to break up or dissolve gallstones are largely unsuccessful.
• Surgical removal of the gallbladder is the time-honoured and safest treatment for gallbladder disease.
• Homeopathic or Naturopathy are not successful.

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About gallbladder surgery

What are the advantages of performing laparoscopic gallbladder removal?

• Rather than a five to seven-inch incision, the operation requires only four small openings in the abdomen.
• Patients usually have minimal post-operative pain.
• Patients usually experience faster recovery than open gallbladder surgery patients.
• Most patients go home the next day of the surgery and enjoy a quicker return to normal activities.

Are you a candidate for laparoscopic gallbladder removal?

Although there are many advantages to laparoscopic gallbladder removal, the procedure may not be appropriate for some patients who have severe complicated gallbladder disease or previous upper abdominal surgery. A thorough medical evaluation by your personal physician, in consultation with a surgeon trained in laparoscopy, can determine if laparoscopic gallbladder removal is an appropriate procedure for you.

What preparation is required for laparoscopic gallbladder removal?

The following includes typical events that may occur prior to laparoscopic surgery; however, since each patient and surgeon is unique, what will actually occur may be different:

• Preoperative preparation includes blood work, medical evaluation and an ECG depending on your age and medical condition.
• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
• It is recommended that you shower the night before or the morning of the operation.
• From midnight the night before the operation, you should not eat or drink anything. You may take medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as blood thinners need to be stopped temporarily for several days to a week prior to surgery. You must inform your surgeon during the first consultation.
• Quit smoking and arrange for any help you may need at home.

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How is laparoscopic gallbladder removal performed?

• Under general anaesthesia, so the patient is asleep throughout the procedure.
• Using a cannula (a narrow tube-like instrument), the surgeon enters the abdomen in the area of the bellybutton.
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient’s internal organs on a television screen.
• Other cannulas are inserted which allow your surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings.
• An X-ray called a cholangiogram may be performed during the operation to identify stones which may be lodged in the bile channels or to verify the anatomy of structures that have been identified.
• If the surgeon finds one or more stones in the common bile duct, he/she may remove them with a special scope, may choose to have them removed later through an endoscope placed through the mouth into the stomach using a procedure called ERCP or may convert to an open operation in order to remove all the stones during the operation.
• After the surgeon removes the gallbladder, the small incisions are closed with absorbable stitches or with surgical tape or glue.

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What happens if the gallbladder removal cannot be performed or completed by the laparoscopic method?

In a small number of patients, the laparoscopic method cannot be performed for gallbladder removal. Factors that may increase the possibility of choosing or converting to the “open” procedure may include a very inflamed and scarred gallbladder, obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather good surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

In general, conversion to open surgery is very rare. (Less than 1%)

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What to expect after surgery

What should I expect after gallbladder removal surgery?

1. Pain & Sickness: Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs. Transient or temporary nausea and vomiting may occur as a side effect of both the surgery and the medications used for anaesthesia. This tends to be limited to 1-2 days after surgery.
2. Diet: A normal diet is encouraged including a moderate amount of oil/butter. Eat a small amount of meal frequently. Some amount of gas or acidity may occur for which medication is given. All these symptoms usually resolve within a week or so. Take medication if there is constipation. Sight loss & appetite are expected.

Throat pain may occur due to an anaesthetic tube. A warm saline gargle is advised.

Right flank or shoulder discomfort or inability to sleep on the right side is temporary and a given analgesic is all that is needed.

3. Discharge: Most patients who have a laparoscopic gallbladder removal go home from the hospital on the next day of surgery once liquids are tolerated. Some patients remain in the hospital another night and go home the following
4. Activity: Activity is dependent on how the patient feels. Walking is encouraged and patients can go up and down stairs the day of surgery. Patients can remove the dressings and shower the day after the operation unless instructed otherwise. Dry yourself well.

Patients will probably be able to return to normal activities within a week’s time, including driving, light lifting and working.

In general, recovery should be progressive, once the patient is at home.

Most patients can return to work within seven days following the laparoscopic procedure depending on the nature of your job. Patients with administrative or desk jobs usually return in a few days while those involved in manual labour or heavy lifting may require a bit more time. Patients undergoing the open procedure usually resume normal activities in four to six weeks. Other aspects of recovery can be slower with an open operation.

5. Follow-up: Make an appointment with your surgeon within 2-3 weeks following your operation.
6. Combined / Combination: The onset of fever, yellow skin or eyes, worsening abdominal pain, distention, persistent nausea or vomiting, or drainage from the incision indicates that a complication or other problem has occurred. Your surgeon should be contacted in these instances.
7. Medication: All the medications should be taken as prescribed. In general, previous medications are to be restarted. Blood thinner is to be started as per the surgeon’s advice.

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What complications can occur from laparoscopic gallbladder removal?

While there are risks associated with any kind of operation, the vast majority of laparoscopic gallbladder removal patients experience few or no complications and quickly return to normal activities. It is important to remember that the training and experience of surgeons are important for better outcomes.

Complications of laparoscopic gallbladder removal (cholecystectomy) are infrequent but include bleeding, wound infection, hernias, blood clots, or heart problems. Unintended injury to adjacent structures such as the common bile duct and small intestine may occur and may require another surgical procedure to repair it.

When to call your doctor

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 100^o F
• Severe abdominal pain especially right flank causing difficulty in breathing
• Persistent nausea or vomiting and you are unable to drink liquids
• Increasing abdominal swelling
• Pain that is not relieved by your medications
• Chills with rigors
• Bleeding or purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger

Copyright: This Brochure has been modified from SAGES similar brochure.

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Additional instructions:

HB 36 –A / 4,

HB Block, Sector III, Salt Lake

Kolkata700 106                                                                         (First Page)

PH: 033 4059 1111                                www.parkviewhospital.in

PARKVIEW SUPER SPECIALITY HOSPITAL

Department of General & Laparoscopic Surgery of Parkview Hospital offers a wide range of comprehensive and high-quality surgical procedures. The department is well equipped with the latest technology and facilities, and is manned by experienced surgeons, nurses and technicians. General Surgery focuses on surgeries of the abdominal organs, breast, thyroid gland and hernias. Operations of the oesophagus, stomach, colon, liver, gallbladder, and bile duct are done with minimally invasive laparoscopic surgery.

Doctors