Inguinal Region – Anatomy, Peritoneal Landmarks, Infraumbilical Fossae

Anatomy of the Inguinal Region

The ‘Myopectineal Orifice of Fruchaud’

Henry Fruchaud
Henry Fruchaud

All groin (inguinofemoral) hernias originate in a single weak area called the myopectineal orifice. This oval, funnel-like, ‘potential’ orifice formed by the following structures, makes the ‘myopectineal orifice of Fruchaud’.

-Henry Fruchaud

Boundaries

  • Superiorly Internal oblique and transversus abdominis muscles.
  • Inferiorly Superior pubic ramus.
  • Medially Rectus muscle sheath.
Myopectineal orifice of Fruchaud
Myopectineal orifice of Fruchaud

The Peritoneal Landmarks

Median Umbilical Ligament:

This ligament ascends in the median plane from the apex of the bladder to the umbilicus. It represents the obliterated allantoic duct and its lower part is the site of the rare urachal cyst.

Medial Umbilical Ligament

This ligament represents the obliterated umbilical artery on each side and can be traced down to the internal iliac artery.

Lateral Umbilical Ligament

It is the ridge of peritoneum, which is raised by the inferior epigastric vessels.

These ligaments delineate the infraumbilical fossae

The Infraumbilical ligaments
The infraumbilical ligaments

The Infraumbilical Fossae

These fossae are important for surgeons-

  1. Delineate the sites of groin herniation.
  2. An important landmark for orientation during hernia repairs.

Supravesical fossae:

The infraumbilical area between the median and medial umbilical
ligaments. This is the site for the origin of the supravesical hernia.

Medial Umbilical fossae

The infraumbilical area between the medial and lateral umbilical
ligaments. This is the site for the origin of the femoral and direct inguinal hernia.

Lateral Umbilical fossae

The infraumbilical area lateral to the lateral umbilical ligament. This is
the site for the origin of the indirect inguinal hernia.

Hesselbach’s Triangle (by Franz Caspar Hesselbach)

1.Superolateral boundaryInferior epigastric vessels
2Medial boundaryRectus sheath
3.Inferior boundaryCooper’s ligament/
Inguinal ligament

It is the site for direct hernia

Hesselbach’s triangle
Hesselbach’s triangle

Iliopubic Tract

The iliopubic tract is a thickened lateral extension of the transversalis fascia, which runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine. It is intimately associated with the inguinal ligament. It is anterior to the Cooper’s ligament and posterior to the inguinal ligament. The iliopubic tract separates the internal ring from the femoral canal. It is visualized as a fibrous (white) tract.

Transversalis Fascia (of Gallaudet)

This fascia is a two layered structure (bilaminar). The anterior layer is adherent to the rectus abdominis muscle. The posterior layer lies in between the anterior layer and the peritoneum. It divides this space into an anterior (vascular space) and a posterior (Space of Bogros). Medially it is continuous with the space of Retzius. One should work in the space of Bogros to prevent unnecessory oozing.

Prevesical space of Retzius

The preperitoneal space that lies deep to the supravesical fossa and the medial umbilical fossa is the prevesical space of Retzius (Described in 1858, by Swedish anatomist Anders Retzius). This space contains loose connective tissue and fat.

Important structures in this space are:

Arteries

  1. External iliac artery
  2. Inferior epigastric artery and its branches

Veins

  1. External iliac vein
  2. Inferior epigastric veins
  3. Deep venous circulation

Nerves

  1. Lateral femoral cutaneous nerve
  2. Genitofemoral nerve
  3. Femoral nerve
  4. Ilioinguinal nerve
  5. Iliohypogastric nerve
  6. Lymphatics and lymph nodes

Vitamin D deficiency – Surgeon’s Perspective: Dr R Padmakumar et al.

Vitamin D deficiency in a Surgeon’s perspective is relevant in

  • Parathyroid surgery
  • Bariatric surgery
  • Gallbladder surgery
  • Primary hyperthyroidism

Introduction:

Vitamin D is a fat soluble vitamin and produced by skin (from cholesterol) when exposed to ultraviolet B radiation (“sunshine vitamin”) and also obtained from dietary sources, including supplements. Most important components, vitamin D3 (cholecalciferol) comes from fortified foods, animal foods (fish, eggs and liver) and can be made internally when skin is exposed to ultraviolet (uv) radiation from the sun and vitamin D2 (ergocalciferol)

  • Deficiency: 25 (OH) D levels below 12 ng/ml
  • Inadequate: 25 (OH) D levels between 12-20ng/ml
  • An adequate: 25 (OH) D levels between 20-50ng/ml
  • Excessive: 25 (OH) D levels over 50nglml

Excessive intakes of vitamin D can lead to high levels of calcium (hypercalcemia). The symptoms of this are weakness, confusion, constipation, loss of appetite and development of painful calcium deposits. To avoid this, advice to keep the supplement intake below the tolerable upper limits.

Functions:

The need for vitamin D goes way beyond preventing and treating rickets. Various researchers have claimed that vitamin D benefits are associated with the following:

  1. Enhancing intestinal absorption of calcium and phosphorus
  2. Prevention of osteoporosis and osteopenia
  3. Allowing proper functioning of parathyroid hormone
  4. Lowering blood pressure in people with hypertension
  5. Lowering incidence and severity of cardiovascular disorders
  6. Decreasing the incidence of type 2 diabetes: research has shown that those with blood vitamin D level over 25ng/ml had a 43% reduced risk of developing type 2 diabetes compared with those with levels under 14ng/ml
  7. Decreasing inflammation: research has shown a decrease in levels of C-reactive protein , a marker of inflammation , with increased levels of vitamin D to just below 21ng/ml
  8. Reducing risk of allergies in children and adolescents
  9. Prevention of dental caries
  10. Prevention and treatment of depression
  11. Possibly helping with erectile dysfunction (ED)
  12. Regulating cholesterol levels in the blood: it has been shown that without adequate sun exposure, vitamin D precursors turn to cholesterol instead of vitamin D
  13. Decreasing mortality rate of certain cancers
  14. Increase immunity
  15. Deficiency in pregnancy may lead to gestational diabetes, pre eclampsia and small infants

Deficiency : Causes:

  1. Inadequate sun exposure
  2. Limited oral intake
  3. Impaired intestinal absorption
  4. Primary hyperparathyroidism
  5. After bariatric surgery
  6. After Gallbladder surgery
  7. Parathyroid removal
    • Accidental during thyroid surgery
    • For parathyroid adenoma or hyperplasia

Correlation of calcium level in vitamin D deficiency

  • If parathyroid function is normal
  • When primary hyperparathyroidism

In vitamin D deficiency due to reduced oral intake or reduced sun exposure ,Vitamin D level and calcium level will be low with normal parathyroid function. Calcium level will be high and vitamin D will be low when primary hyperparathyroidism exists.

Primary hyperparathyroidism

  • There is high calcium level in the blood
  • May present with parathyroid tumor
  • High PTH takes calcium from the bone and shut down calcium absorption
  • There will be low vitamin D

Obesity and after bariatric surgery

Research has begun to show a relationship between BMI and vitamin D deficiency. A study done on 2,187 overweight and obese subjects, found that those with a BMI above 40 had 18% lower serum vitamin D levels than those with a BMI under 40. Some possible reasons for this are lower intakes of vitamin D , less exposure to sunlight (uv) radiation and a higher distribution volume of vitamin D . Even with exposure to sunlight, there remains a risk for deficiency.

Morbid obese patients have a higher incidence of high PTH and low vitamin D even before surgery compared with normal individuals.

In gastric bypass: low calcium absorption due to bypassed duodenum and jejunum may be the cause.

In sleeve gastrectomy the vitamin D and calcium level are maintained within normal limits compared to bypass surgery.

Gall bladder Disease and vitamin D deficiency

Low vitamin D may cause gallbladder stone formation

Gall bladder removal may reduce vitamin D and magnesium levels. This may be due to reduced absorption of fat soluble vitamins (D, E, A and K).

People with compromised liver or digestive function are often vitamin D deficient. Exposure of skin to the sun’s UVB rays enables body to manufacture vitamin D. However, this process occurs in the liver and kidneys. Here people with a sluggish liver often do not manufacture vitamin D adequately.

Treatment

  1. Sun rays exposure
  2. Increased oral supplements
  3. When the blood level of vitamin D is below 30 ng/ml, a minimum of 1,000 IU/day will be needed for children and 1,500 to 2,000 IU/day of vitamin D3 for adults.
  4. Another rule of thumb is for every 1 ng/ml increase in blood level one need is an additional 100IU/day.
  5. In obese patients , with malabsorbtion syndromes and patients on medications affecting vitamin D metabolism, it is advised to have a higher dose (two to three times higher , atleast 6,000-10,000IU/day) of vitamin D to treat deficiency to maintain a 25(OH)D level above 30ng/ml, followed by maintenance therapy of 3,000-6,000IU/day.
  6. After parathyroid removal , may be wise to have a concomitant replacement of vitamin D with calcitriol (0.25-1mcg/day). Dependence on calcium supplementation for more than 6 months shows permanent hypoparathyroidism; which will necessitate continued use of such medications.

Advantages of Laparoscopy – Laparoscopy set to replace Traditional Treatment

Doctors, patients and their bystanders can now relax. The conventional methods of open surgery by cutting and stitching body parts are soon going to be extinct. Thanks to the advancement of Science and Technology in the medical field.

Laparoscopy

As the name suggests ‘Laparo’ means abdomen, ‘Scopy’ means vision. The surgeon visualizes the inner parts of the patients body through the laparoscope which is a small cut (incision 5-10 mm) on the abdomen. The magnified (up to 20 times larger) vision of the interior parts through the telescope is quite different from the traditional open surgery. Due to the small incision inflicted on the patients, it is also known as Minimally Invasive Surgery (MIS), Band – aid surgery and rarely pin hole surgery.

Origin and History

The first laparoscopic surgery was performed in dogs in 1902 by George Kelling of Dresden Germany. The first laparoscopic surgery in humans was conducted by Hans Christian Jacobaeus of Sweden in 1910. The first laparoscopic Cholecystectomy (removal of gallbladder) in humans was done in 1987 in France. The introduction of high definition camera, medical monitor and good electro surgical units made the procedure easier. In India the procedure is in practice for the past 20 years and is getting popular due to its very high advantages over conventional surgery.

How it works

The laparoscope, a telescopic rod lens system, is put through the small incision made around the umbilicus of the patient. The system is connected to a video camera (single chip or three chip). A fiber optic cable system connected to a ‘cold light source (halogen or xenon)’ is used to illuminate the operative field. The patient’s abdomen is distended with carbon dioxide gas to create a working and viewing space for the surgeon. Carbon dioxide is used as it is familiar to the human body and gets removed by the respiratory system if it gets absorbed through tissue. The surgical equipments are introduced into the abdomen through two 3mm incisions (punctures) made near the earlier entry. The skilled surgeon, by looking at the monitor can perform surgery with precision and perfection.

Advantages of Laparoscopic Surgery

Since only two or three tiny incisions are made in the abdomen the patient feels less pain. It reduces blood loss, compared to traditional open surgery. There is less need for blood transfusion, hence less chance for acquiring infection like Hepatitis B, HIV, Malaria etc. There is significant reduction in scar and wound infection. Scant use of antibiotics and painkillers is possible unlike in open surgery. Hospital stay for patients is limited to one or two days. Shorter hospital stay means less burden for the patient and relatives. Unlike open surgery, fast recovery through laparoscopic method saves money and consumption of medicines. The patients can return to normal work and profession within a shorter period. As external snitching is completely avoided, Laparoscopic method provides excellent cosmetic outcome. The diseased organ is tackled inside the abdomen and intestines are not brought out to be in contact with outside environment as in open surgery. Hence chance of adhesion (sticking together of intestines) is minimized in laparoscopy to the least.

Laparoscopy enables doctors for better diagnosis. Since the organs are seen in magnified form, the surgeon performs with high precision. There is less chance of contact with blood and tissue fluids. Hence less chance for surgeon and staff to contract dreaded infections.

The surgeon can visualize the entire abdominal cavity of the patients, by just turning the telescope in all directions. Laparoscopic method helps in detecting alternate pathology than one which is entertained pre operatively; which is not possible in open surgery due to limited access and vision. As one can start feeding the patient early in laparoscopy, the gastrointestinal problems are also minimized and nutrition is well maintained. Finally patients is highly benefitted. Use of advanced energy sources like harmonic scalpel reduces tissue damage and hence the resultant recovery time and tiredness.

Prospective fields of Laparoscopy

Laparoscopic treatment and surgery are ideal in the case of removal of gallbladder (laparoscopic cholecystectomy) , appendix ovary, uterus etc. It is very good for, hernia repair, bowel surgery and surgery on kidney and for surgery for weight reduction. The term Arthroscopy refers to the keyhole procedure for treatment of bone and joint problems and thoracoscopy for the procedure in chest.

How can the diseased organs be taken out through small opening ?

Usually the organs or affected parts removed are not too big. An appendix, gall bladder, cyst wall etc. are of small size which can come out through the one 10mm Incision made earlier. For females, specimen like uterus comes out through the vagina without any need for abdominal incisions. If necessary, using instruments like morcellator the specimen can be sucked out in smaller pieces completely.

Is cancer treatment possible?

Laparoscopic treatment has many advantages in detecting and removing tumors. Eight major scientific studies have proved that laparoscopic surgery is better than open surgery for surgically treating cancer. Postoperative complications in lungs, veins, intestines etc are significantly reduced by the fact that patients are not confined to bed after laparoscopy. As wounds are less, patients need not wait for the wounds to heal and early initiation of chemotherapy is possible. Waiting for wound healing makes the microscopic reminant Cancer to grow before chemo tackles it. Cancers of uterus, intestine, kidney etc. are tackled laparoscopically all over the world. Laparoscopy avoid major negative laparotomies which increase the tiredness, sickness of patients when the tumour is not surgically removable.

Hernia surgery

Hernia is protrusion of contents of abdomen through defect in abdominal wall. The treatment is to repair these defects by supporting with a mesh. In conventional surgery one has to cut all layers of the abdominal wall to place this mesh; obviously causing major wound, pain and sometimes weakening of tissues. In laparoscopy the procedure is done through 1 cm incision much away from the defect and a much larger mesh can be placed right at the place of starting of hernia. Being more physiological, the outcome is superior with very very less chance of recurrence compared to open surgery. No need for 3-6 months rest as in open surgery. Even multiple hernias can be tackled through the single 1cm incision plus two 3 mm punctures rather than cutting long at each place.

Obesity & Diabetic Surgery

Laparoscopic method may be the only safe option in bariatric surgery. Bariatric surgery is considered when the body mass index (BMI) is more than 35. It is really difficult to perform open surgery in obese patients and they go in for respiratory and wound complications. Highly desirable results are obtained by a laparoscopic approach which gives a very good access to the stomach.

Laparoscopic bariatric surgery brings back obese patients to normalcy by getting rid of the extra fat which was causing various medical illness like diabetes, high blood pressure, high cholesterol, cardiac illness , breathing difficulty , joint pain, cancers , infertility etc. Key hole surgery gives excellent result in attaining long term resolution of Diabetes Type II.

Gynecology & infertility

All gynaec procedures can be performed very successfully by laparoscopy and gives much better results in infertility. Taking out baby (Cesarean) may be the only procedure which may necessitate a wound. Opening abdomen for the removing uterus or cyst of any size is unnecessary as the laparoscopic surgery accomplish better outcome.

Thyroid surgery (Endoscopic Thyroidectomy)

The surgical solution available in most of the places is open thyroidectomy which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsighty scar which is not acceptable, especially for women. The endoscopic thyroidectomy – the keyhole or minimally invasive technique is a very good alternative to other methods. It gives excellent cosmetic outcome especially when done by an axillary approach. It gives equal or even a better surgical outcome as far as the actual thyroid nodule management is considered.

The earlier belief was that the endoscopic no neck scar option for thyroid swellings are applicable to lesions of less than 4 cm size. But we have observed that swellings of size of even 12 – 15 cm can be tackled very successfully through this method. The only pre-requisite will be a surgeon with good experience, in both laparoscopic surgeries and thyroid surgeries. Any kind of pathologies like benign or cancerous nodules, thyoiditis can be safely tackled by endoscopic thyroidectomy.

Thoracoscopy

Key hole surgery is an excellent method for treating disease in the chest. Lung cancers, & recurrent pneumathorax (air leak) , chest wall tumors and infection can be tackled through 1 cm cut using telescopic system. In conventional surgery (Thoracotomy) the 30-40 cm incision with rib cutting-mainly for access and vision cause extreme discomfort to patient at every breath for at least six months. The procedures can be performed with high precision and perfection with out these troubles when performed by the thoracoscopic method.

Previous Surgery & Associated medical Illness

Previous open surgery or laparoscopy in not a contra indication for laparoscopy. Medical illness like diabetes, Hypertension, asthma, cardiac illness though increase risk for anaesthesia the laparoscope surgery can be performed comfortably without increasing the risk . Less need for confinement to bed in laparoscopy actually reduces the post op complications in these patients with comorbid illness. Laparoscopic surgeries can be performed under regional anaesthesia (spinal / epidural) when general anaesthesia cannot be given.

What are the risks in Laparoscopy?

Laparoscopic procedures do not carry any additional risks, as nothing which can harm the body is used . Surgery related risks are very minimum compared to open surgery. The safety of the patient and the precision in treatment have increased manifold with the availability of ultrasonic and radio frequency instruments. Keeping blood in reserve is mostly not needed unlike in open surgery. Pain and infection after surgery is extremely rare for the patients in laparoscopy. The diseased organ is removed completely and no chance of recurrence of the problem, only because procedure was done laparoscopically.

There is no need for physical rest for the patient and can resume normal diet in twelve hours. No special preparation is required prior to laparoscopy. Four to six hours of fasting which mandates anaesthesia requirements is sufficient.

Training

A good hand, eye coordination is required for laparoscopy. Lack of trained surgeons in laparoscopy is a major problem in India like other parts of the world. After sustained training to surgeons with easy availability of sophisticated instruments; major hospitals are now getting fully equipped to handle laparoscopic surgery. Surgeons should not give a prolonged illness & discomfort by a wound when patient comes for an illness which can be cured by surgery in 24hrs. Every surgeon should learn Laparoscopy and practice it. Lap surgery has taken away the fear of surgery-the pain. It is very pleasing to see patients walking around even on the 1st day after undergoing major surgery laparoscopically . But open surgery patient is confined to bed and require many persons to help, even to move.

Financial advantage

Through laparoscopic surgery costs higher than open surgery, it has its own advantages financially. For laparoscopic surgery, a patient need not stay in the hospital for more than two days. It will be week long stay in the hospital for open surgery. Prolonged stay in hospital incurs expenses for accommodation, food, medicine etc. The patient after laparoscopic surgery can join work much sooner than those undergoing open surgery. This will have an impact on the income of family. The expenses incurred for bystanders and their availability are minimized in the case of laparoscopy. These indirect expenses definitely over weighs the apparent direct cost for laparoscopy.

The wound related problem like infection, adhesion and hernia leads to further expenses in open surgery group even later.

Tummy Tuck Hanging Abdomen

Tummy Tuck Abdominoplasty for Treatment of Hanging Abdomen

Tummy Tuck or Abdominoplasty is a surgical procedure which is performed to remove excess fat and skin from the abdomen and to tighten the abdominal wall muscle and fascia.

Hanging Abdomen - Tummy Tuck to remove excess fat

Hanging abdomen with an apron is unsightly and uncomfortable for any woman. Not able to wear the dress of their choice is so depressing to anyone. The self esteem gets down with every morning seeing the self profile. But they can be happy that there is a sure way out.

Causes of hanging abdomen

  1. Overweight or Obesity : General adiposity (excess fat) as part of increase in Body Mass Index can cause an increase in abdominal circumference. The ideal BMI is 18-23. Once it is above 23 till 27.5 it is overweight and 27.5 onwards is obesity. BMI is calculated as weight in Kg/Ht in M2 e.g. If a person has 100kg weight and 2m height, BMI= 100kg/ 2m x 2m=25 Kg/M2
  2. Truncal Obesity (Abdominal obesity) : Increasing abdominal obesity is more dangerous than the overall increase in weight. Ideally, the abdominal circumference at umbilical level should be below 80 cm in women. The increase in BMI and abdominal circumference leads to various medical illness like Diabetes, hypertension (increase in blood pressure), dyslipedemia (increase in cholesterol), sleep apnea (breathing difficulty/ snoring with respiratory arrest), PCOS (Polycystic ovarian disease) and fatty liver. It also increase the risk of cancers of breast and ovary.
  3. Divarication Recti (separation of muscles of abdominal wall) : This happens mainly and commonly following pregnancy when there is excessive stretch of abdominal wall muscles making it fall apart from the midline. This leads to bulging of abdomen and patient will have a state similar to pregnancy look. This is highly distressing to any woman. The abdominal bulge will be such that it projects out and comes anterior than breast level in a profile view.
  4. Ventral Hernia : Muscle defect with herniation/ projection of abdominal contents in to the sac formed at the muscle weakness. The intestines or omentum get trapped in this defect and can cause life threatening problems.
  5. Sagging Fat and Skin : The lower abdominal wall fat and skin is redundant (extra) and hangs down in an unsightly manner. The skin sagging may be unrelated to the muscle weakness. The pulling down of the abdominal wall by the weight of this apron itself will be causing discomfort and muscle weakness. The disfigurement in these patients is unexplainable.

Hanging Abdomen can be Treated

Patients need to consult a surgeon who is well-versed with the problem and its corrective measures. Detailed physical examination with abdominal girth, height, weight, BMI, BP, Pulse, oxygen saturation to be checked. The co-existing problems like diabetes, hypertension, snoring, respiratory difficulty with walking, menstrual irregularities, stress incontinence and psychological problem (mainly depression).

Dr R Padmakumar speaks on Tummy Tuck
Dr. R. Padmakumar | Keyhole Clinic, Kochi | VPS Lakeshore, Kochi | +91 944 723 0370
Talk on Tummy Tuck/Abdominoplasty

Assessment

The psychological impact of these illness on the patient is very significant. They will be always worried about and other is depression seeing the bad body contour every day. Being not able to wear the dress they like and not able to move around comfortably also keeps them introverts and less sociable. Many jobs also demand people with normal BMI and body shapes. Even promotions are jeopardized by these abnormalities. The associated medical problems and the need for medication for the same will also be making patients uncomfortable and dissatisfied in life.

Treatment Options

Those who have increased BMI should be advised for weight reduction. To a good extend it is possible by diet regulations and exercise. There are some drugs available to reduce weight but it helps in reducing weight around 4-5 kg only. Those with higher BMI will be benefitted by intragastric balloon placement or by bariatric surgery of which sleeve gastrectomy is the best. Abdominal obesity also gets controlled to a great extent by these procedures.

Divarication of recti (the separation of muscle in the central abdomen), the ventral hernia and sagging skin with fat (the abdominal apron) needs tummy tuck (abdominoplasty). The exercises to tone the abdominal wall, weight reduction or application of any kind of solutions or application of slim devices like vibrators are not going to give any kind of benefit to these patients.


Tummy Tuck/Abdominoplasty Procedure

Pre-hospitalization

The procedure of tummy tuck involves a pre-hospitalization checkup including blood tests. Ultrasound abdomen is performed to rule out any other surgical problem in abdomen like an ovarian cyst or gallbladder stones which can be talked at the same time. The necessary consultations will also be done with other specialists as needed.

Operation

The operation is done under anesthesia, either general or regional, so that patient will be comfortable. The incision will be made at the lowest skin crease of abdomen to give excellent cosmetic outcome. The skin and subcutaneous fat will be mobilized. The muscles which are far apart will be brought together. In case of hernia a net like material (mesh) will be used to give additional strength. The excess fat and skin will be removed and wound closed. The wound closure is also done in a careful manner with no stitches outside. This also will add to the perfect healing with very minimal scar. The scar will be completely hidden by the smallest of dress.

Post Surgery

Patient needs to be in hospital for 2-3 days and can resume normal activities after that. All kinds of job can be started within two weeks time. Wearing an abdominal binder during this period will give additional comfort.

Tummy Tuck Procedure Outcome

The outcomes are such great that patients get immediate results and regain self esteem. The profile changes and any modern dress will suit the person. The medical issues related to the divarication like dragging pain in abdomen and backache due to the abnormal posture and weight of ventral hernia will also get resolved. In those with higher BMI and sagging abdomen the procedure to reduce weight (sleeve gastrectomy) is done along with the tummy tuck thereby avoiding scars of the bariatric surgery and unnecessary second hospitalization. Combination of these procedures is an innovative method developed at our center to give maximal benefit for patient with superior quality of life.

Hiatal Hernia – Diagnosing, Treatment, Symptoms, Causes

A hiatal hernia is a condition developed when the upper part of the stomach bulges through an opening in the diaphragm. The diaphragm is a muscle that separates the abdomen and chest. It has a small opening through which the food tube passes and connecting to the stomach. In a hiatal hernia, the stomach pushes up through the opening in the diaphragm and bulges into the chest. The bulging of stomach to the chest can cause food and acid back up into the esophagus causing heartburn.

Symptoms of hiatal hernia

  • Heartburn
  • Backflow of food and liquids into the mouth
  • Backflow of stomach acid into the esophagus
  • Difficulty swallowing
  • Chest or abdominal pain
  • Shortness of breath
  • Vomiting of blood
  • Passing of black stools

Causes

A hiatal may be caused by:

  • Age-related changes in the wearing the muscles of the diaphragm
  • Injury to the area after trauma or surgery
  • Birth defects with an unusually large hiatus
  • Persistent and intense pressure on the surrounding muscles of the diaphragm
  • Obesity

Diagnosing Hiatal Hernia

The doctor performs an endoscopy to diagnose the condition. The procedure involves inserting a thin flexible tube with a camera attached to inside of the esophagus and stomach and check for inflammation. Other test includes x-ray of the upper digestive system and esophageal manometry to measure the rhythmic muscle contractions and coordination and force exerted by the muscles of the esophagus when food is swallowed.

Treatments

Medications are prescribed to ease the symptoms including recurrent heartburn and acid refluxes and production. Medication along with little lifestyle modification is advised by the doctor and these changes include:

  • Consume several smaller meals rather than a few large meals
  • Avoid fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine that trigger heartburn
  • Avoid lying down right after a meal
  • Have the dinner at least two to three hours before bedtime.
  • Maintain a healthy weight or reduce the excess weight
  • Stop smoking and alcohol consumption
  • Elevate the head while lying
  • Perform any kind of physical activity or exercises at least 5 days a week

Surgical treatment options include pulling back the bulged abdomen into the stomach and reconstructing an esophageal sphincter. In laparoscopic surgery a laparoscope is used, which is a thin long tube that has a camera attached to its end to view the irregularities inside the abdominal cavity. The surgeon makes a small incision and inserts the laparoscope to investigate the abnormality and later few more small incisions are made to insert the surgical tools and perform repair of the required organs and muscles. The surgeon pulls back the bulged stomach from the diaphragm and closes the incision. If necessary, the surgery is also performed by making a single incision in the chest wall and the procedure is termed as thoracotomy.

Inguinal Hernia – Symptoms, Causes, Diagnosis, Treatment

What is Inguinal Hernia?

The inguinal canal is a short passage that is about four to six centimeters in length located just above the inguinal ligament and extends medially and inferiorly through the inferior part of the abdominal wall. Structures pass from the abdominal wall to the external genitalia through this canal. In men, the spermatic cord passes to the testis through the inguinal canal. In women, the ligament that supports the uterus is present in the inguinal canal.

Inguinal hernia is a condition that occurs when abdominal tissues, such as part of the intestine, protrudes through a weak spot of the inguinal canal. Inguinal hernia can occur in both men and women. The resultant bulge caused by the inguinal hernia can lead to pain and discomfort during movement especially when you cough, bend, or lift a heavy object.

The inguinal hernia can be classified into following:\

  • Indirect inguinal hernia: commonly found hernia in new born babies. The hernia will be formed lateral to the blood vessels when the inguinal canal is not fully developed.
  • Direct inguinal hernia: Direct inguinal hernia is found in adults in the middle from the blood vessels.
  • Incarcenated hernia: When the abdominal get stuck in the groin, then the hernia is known as incarcerated hernia.
  • Strangulated hernia: Strangulated hernia is more severe and stops the blood flow to the small intestine and has to be treated immediately.

Symptoms of inguinal hernia

Inguinal hernia symptoms include:

  • Bulge : A bulge in the groin area on either side of the pubic bone. This can be more obvious couging or straining.
  • Burning Sensation : Burning or aching sensation at the bulge
  • Groin Pain and Discomfort : Pain or discomfort in the groin especially when bending over, straining, coughing or lifting
  • Dragging Sensation : Heavy, dragging sensation at the groin
  • Groin Weakness : Groin weakness or pressure
  • Pain and swelling : Protruding intestine that descends into the scrotum causes occasional pain and swelling around the testicles.

Incarcerated Hernia

A hernia can become incarcerated. This happens if the hernia becomes trapped in the abdominal wall. This can lead to bowel obstruction that leads to severe pain, inability to have bowel movement, nausea, vomiting.

Strangulated Hernia

Strangulated hernia occurs when the incarcerated hernia becomes strangulated and blood flow to the tissue that is trapped is cut. Unless treated, a strangulated hernia can be life threatening and is a surgical emergency.

Symptoms of an incarcerated or strangulated hernia include:

  • Nausea and vomiting.
  • Fever
  • Sudden Pain and tenderness that quickly intensifies
  • Bulge that turns red, purple or dark
  • Inability to move the bowels or pass gas

Causes of inguinal hernia

Some of the factors that lead to inguinal hernia are discussed below:

  • Increased pressure within the abdomen
  • Weak tissues and muscles in the abdominal wall
  • Straining during bowel movements
  • Strenuous activity
  • Pregnancy
  • Chronic coughing or sneezing

Treatment for inguinal hernia

Laparoscopic hernia surgery can be performed that is minimally invasive with less pain and discomfort. The surgeon initiates the surgery by administering a dose of general anesthetic to relax the muscles and to put the patient in sleep like state. The surgeon makes a small incision in the abdomen and is inflated with air to get a clear view of the internal abdominal cavity. A laparoscope (a thin long tube with a camera attached to its end) is inserted through the incision that allows the surgeon to view enlarged images of the organs and abdominal cavity that is connected through the monitor. After inspection, more incisions are made and other surgical repairing tools are inserted through the incisions into the abdominal cavity. A mesh is positioned in the weak spot of the inguinal canal to reinforce the abdominal wall. Later the incision are stitched and closed.

Laparoscopic hernia surgery can be categorized into two techniques:

  • Transabdominal preperitoneal (TAPP) – In TAPP hernia surgery, a small flap of the lining is peeled back from the hernia and a mesh is placed that acts as a support to the abdominal wall. This mesh acts as a barrier and prevents further thrusting of the abdominal tissues into the inguinal canal.
  • Totally extraperitoneal (TEP) – TEP technique involves refurbishing the hernia without inward bounding of the peritoneal cavity.

Other Hernias

Hernia can be of different types and the most important among them are

Laparoscopic Hernia Surgery

Hernia is the abnormal squeezing out of an organ or fatty tissue through a weak spot of the wall of the cavity where it normally resides. A hernia can be caused by pressure and a weakness or opening of the muscle or fascia where the pressure pushes the organ or tissue through the weak spot or opening. The weak areas can include the groin, umbilicus, site of a previous abdominal incision, etc. Anything that cause an increase in pressure in the abdomen can cause hernia, which may include coughing or sneezing persistently, constipation or diarrhea, lifting heavy objects, etc. Poor nutrition, smoking, obesity are some factors that can cause muscle weakness and make hernias more likely. Other risk factors for hernia include COPD, pregnancy, peritoneal dialysis, age related wear and tear of the abdominal wall, inactivity, etc.

Hernias most commonly develop in the abdomen, specifically the groin. A weakness in the abdominal wall can evolve into a localized hole or defect, and through this defect the abdominal organs or adipose tissue may protrude. Hernias can be of different types. Hernias may not be life threatening, but they don’t go away unless treated. Hernia surgery may be required to prevent potentially dangerous complications.

Hernia can be of different types and the most important among them are

Hernia should be treated as they may rise many other complications including blockage in the organ and prevent blood flow and also affects the functioning of the organ. Strangulation of hernia causing stop to blood flow require immediate removal as they may lead to life threatening condition. Hernia causes pain and discomfort in the abdominal area while prolonged standing, walking and bending over to lift objects.

What is Laparoscopic Surgery or Keyhole Surgery?

In Laparoscopic Surgery or Keyhole Surgery the surgeon uses an instrument called a laparoscope. The laparoscope is a thin instrument that uses light at the end of the scope. The laparoscope is passed through small incisions (two to four) made at the abdominal wall. As opposed to conventional surgery or open surgery, where a large cut is made at the abdominal wall, laparoscopic surgery or keyhole surgery uses very small incisions, and hence the name Keyhole Surgery. It is also called Minimal Access Surgery or Minimally Invasive Surgery

A Laparoscope

Keyhole surgery is a minimally invasive surgical method with few small incisions with less tissue disruption. The surgeon inserts tiny camera attached instruments to view the abnormality caused by the hernia and carefully inserts other surgical tools to remove the hernia without damaging any other internal organs in the area. The camera captures pictures and the surgeon view the enlarged images of the organs through a monitor attached and perform the surgery through the images transmitted to video monitors.

Advantages of Laparoscopic Surgery or Keyhole Surgery

Laparoscopic surgery or keyhole surgery of hernias has a number of advantages over open surgeries. These include:

  • Reduced Postoperative Pain and discomfort after the surgery
  • Faster healing and recovery from surgery and thus faster return to work
  • Reduced Hospital Stay
  • Minimal scars as the surgery is minimally invasive
  • Less chance for infection

How Keyhole or Laparoscopic Hernia Repair is performed?

The surgeon initiates the surgery by administering a dose of general anesthesia to relax the muscles and to put the patient in a sleep like state. Three small incisions are made in the abdominal wall with less bleeding and a balloon dilating device is passed to separate the peritoneum from the muscle layer. Once separated the balloon is replaced with a laparoscopic port and the abdomen is insufflated with CO2. A long thin tube like structure with a camera attached to one of its end (laparoscope) is inserted into the space to view the internal organs through a connected monitor. The images guide the surgeon throughout the surgery. Next the peritoneum is then gently pushed away from the muscle layer to reveal the sac of hernia and is pulled back into position. After repositioning the abdominal bulge a flexible polypropylene mesh is placed on the spot to cover the hole in the muscle. The mesh is fixed with tiny absorbable tacking devices. Lastly the incisions are closed with dissolving sutures.

Laparoscopic surgeries/ keyhole surgeries provide you the best experience of the surgery due to the less pain and blood loss during the surgery.

Type 2 Diabetes Surgery – Laparoscopic Surgery for Diabetes

Type 2 Diabetes Surgery – Type 2 diabetes mellitus (T2DM) is a common disease associated with numerous complications. Obesity is the leading cause of the increased incidence of type 2 diabetes mellitus in both developed and developing countries. Obesity and overweight have in the last decade become a global problem – according to the World Health Organization (WHO). There are many risk factors for type 2 diabetes.

It is an astonishing fact that the number of people having Diabetes Mellitus (DM) is increasing day by day. Asians have higher incidence of Diabetes, due to genetic reason. Life style changes and food habits contribute to this increase. Diabetes affects all organs in the body like eye, brain, heart, kidney & limb vessels. These lead to early death.

  •  Heart attack at an early age
  •  Stroke
  •  Kidney disease leading to kidney failure, which may require dialysis. 45% of dialysis patients are contribution of diabetes.
  •  Nerve damage which can lead to digestive and bladder problems sexual dysfunction and numbness or tingling in the legs.
  •  Foot problems including ulcers and poor circulation that can lead to amputation.
  •  Eye complications such as glaucoma, cataract, and retinopathy, that can lead to blindness

International Diabetic federation has approved bariatric surgery as preferred and effective treatment of diabetes; benefits of surgery being long lasting remission of diabetes; control of other associated illnesses and cost effectiveness.

NEJM (New England Journal of Medicine) rates metabolic surgery to cure Diabetes as the most important innovation of 2012.

About the Surgical Procedure – Keyhole Surgery for Type 2 Diabetes Resolution

Type 2 Diabetes is the result of

  •  Increased demand for insulin due to higher quantity of food eaten.
  •  Reduced production of insulin due to fat deposition in pancreas or pancreatic cell hypo function
  •  Glucose supply from liver (neoglucogenesis) due to fatty liver and
  •  Most importantly insulin resistance (the insulin available in the body is not able to take care of the glucose due to excess fat in the body).

It is now clear the intestinal hormone (GLP1) levels can regulate the insulin production in pancreas. Hence by increasing GLP1 level in the gut, diabetes can be controlled. GLP1 is produced in large quantities by terminal portion of small intestine. Partially digested food reaching this region increases the production of this hormone. There are other neurohormonal gut mechanisms as well, working in favour to control of diabetes.

By keyhole surgery the stomach size is brought down hence excess food intake will be reduced and gastric emptying is accelerated. Last portion of small intestine is brought towards the stomach that helps in bringing partially digested food into the small intestine rapidly, thus increasing GLP1 level and there by increasing insulin levels. Obese diabetics require modified sleeve gastrectomy alone while non obese diabetics require sleeve gastrectomy and ileal interposition. The weight reduction and associated fat loss will also increase insulin activity. These surgeries are found to increase insulin performance and give long standing resolution of diabetes.

Different Keyhole Surgeries for Resolution of Obesity

 Laparoscopic Sleeve Gastrectomy ( > 30 BMI Patients).

Laparoscopic Gastric Banding.

Gastric Bypass.

Modified sleeve gastrectomy & Ileal Interposition (25 to 30 BMI patients).

Intragastric Balloon for Weight Reduction

 Click here to Read on Intragastric Balloon Placement.

Is Type 2 Diabetes Surgery feasible for you?

These procedures are helpful in patients with Type 2 diabetes, in whom pancreas is capable of producing good level of insulin. These are having much better result in those with more than ideal weight and in those with diabetes of shorter duration (few years) than in those who have already damaged their end organs like kidney, eye, heart, etc. So it is better to undergo this procedure before pancreas fails significantly and before end organs damage starts. It is highly appreciable for a diabetic patient to know that cure is possible. In Type I diabetes (where pancreas is not functioning at all or has antibodies against insulin) these surgeries are not helpful.

85% to 90% of diabetic patients treated by these surgeries are cured of diabetes. Other 10 to 15% also could reduce their medications significantly. In addition to diabetic control the other benefits are loss of excess weight and control of cholesterol, sleep apnoea, joint pains, cardiac disease, hypertension, kidney disorders, eye problems etc. It definitely improves quality of life and reduces cancer risk, infertility & mortality (early death).

All these procedure are done under general anaesthesia and patient will be observed for 4 days in hospital. These are done by laparoscopic and minimally invasive methods using equipments like staplers & harmonic scalpel. Hence, patients will be highly comfortable and can resume normal activity in a few days time.

Introduction to Hernia

Repair of inguinal hernia is one of the commonest surgical procedures performed worldwide. The lifetime risk for men is 27% and for women, it is 3 %.

“No disease of the human body, belonging to the province of the surgeon, requires in its treatment, a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its variants.”

Sir Astley Paston Cooper, The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, Cox, London, 1804.

“I know more than hundred surgeons whom I would cheerfully allow to remove my gallbladder but only one to whom I should like to expose my inguinal canal.”

Sir Henage Ogilvie

History of Hernia Repair

YearProponent and Procedure details
1884Edoardo Bassini
Introduced the modern era of herniorrhaphy.
Bassini’s method relies on a musculoaponeurotic repair to reconstruct the inguinal canal.
1945Edward Earle Shouldice
Four layer repair
1958Francis C. Usher
Used polypropylene as first successful synthetic prosthesis.
1964Irving L. Lichtenstein
Tension free open mesh repair. Till now it is the standard evidence-based operation.
1973Rene Stoppa
GPRVS (Giant Prosthetic Reinforcement of Visceral Sac) / Open preperitoneal mesh repair (Significantly reduced recurrence rate for multi-recurrent groin hernias). He reiterated the advantages of posterior approach.
1982Ralph Ger
The first laparoscopic hernia repair by approximating the internal ring with stainless steel clips.
1992Maurice E. Arregui and Yves Marie Dion TAPP(Transabdominal preperitoneal repair)
1992Ferzli et al., Dulucq, Himpens, and McKernan & Laws, TEP(Total extraperitoneal repair)

Both the techniques of laparoscopic hernia repair reproduce the concept of Stoppa, by placing a large mesh in the preperitoneal space to cover half of the abdominal wall and all the weak areas (Myopectineal orifice of Fruchaud) including area of internal ring, Hasselbach’s triangle and the femoral ring with/without obturator opening. Both TAPP and TEP are now accepted as evidence based treatment for inguinal hernias equivalent to Lichtenstein’s procedure.