General Surgery

General Surgery is a medical specialty concerned with the treatment of a variety of disorders frequently requiring surgery. A board–certified general surgeon is required to complete five years of additional training after receiving the medical doctor degree. This training involves learning how to evaluate a patient’s medical condition and determining whether surgery is the best type of treatment available.

A general surgeon receives extensive training in specific surgical procedures, pre–surgical patient consultation, and patient follow–up care. Some of the more common problems treated by a general surgeon are, thyroid tumors, breast tumors, gallbladder disease, colon tumors, appendicitis, and hernias.

Vascular Surgery is considered a super–specialty of general surgery. A vascular surgeon treats medical problems involving blood vessels (both arteries and veins). These problems usually are related to blockage or aneurysms, most often caused by atherosclerosis, or injury.

Laparoscopic Surgery is a new method for treating some surgical problems. It offers some benefits in recovery in that the skin incisions are not as large, but the goals of the operation are the same as the traditional methods, and it is associated with the same risks. Hospitalization time is usually shorter because general, vascular and laparoscopic surgery is a medical specialty. Patients are most often referred to our practice by another physician when the referring physician feels that surgery may be indicated. Sometimes a patient will have a medical condition that he or she perceives requires a surgical solution. Our office will gladly accept appointments for surgical procedures without a referral from your primary care physician. Generally, surgeons do not treat general medical problems in that case your general medical needs can best be served by a qualified primary care physician. Out office staff has been instructed to only accept patients requiring the professional skills of a qualified surgeon. Should a general medical problem arise during the course of your surgical treatment, we will work closely with your family physician or internist to assure that you receive prompt, courteous professional care.

The Viewing Wand is particularly useful when constant reference to the pre–operative image is necessary. Locating small lesions no longer requires large exposures. After inputting all the diagnostic images into the work station, the wand is simply pointed at the head, the lesion located, the approach an trajectory planned and a minimally invasive approach option chosen. As one proceeds into the brain using the wand the exact present location in terms of the diagnostic image, is displayed on the computer screen. It will be possible to eventually input a host of data like physiological functions, angiograms and so on. Thus one can avoid dangerous areas. There is minimal disruption of normal brain, while approaching the tumor. This technique ensures accuracy and precision is the ability of a device to locate a point in space. Precision is the ability to return to a specific location. Constant checking and rechecking is possible. Like a spacecraft checking its position continuously by the Global Position Satellite, one knows exactly where one is at any point of time.

Tomorrow’s surgeon may or may not be familiar with different types of blades and suture materials. If he or she cannot point, click and drag with a computer mouse he/she will soon fade into oblivion. In an ever increasing competitive world one has to keep running just to stay in the same place! The difference between the have (internet access) and the has not will be so much, that natural selection will result in survival of the fittest!

 

A hernia occurs when there is a weakening in the abdominal wall. This weakening of the natural support allows abdominal contents (bowel) to slide into the hole (referred to as the “Defect”). If part of the bowel slides through and gets caught (incarcerated), it can be painful and dangerous since the blood supply can be jeopardized. You may feel or see a pouching out (lump or swelling) of the belly or groin area, or you may feel and see nothing at all. Hernias are more noticeable when standing, coughing and straining, and may disappear when lying down. They sometimes can be pushed in with the finger, but all should be examined by a physician.

 

 

The groin area is the most common site of a hernia (80%), hernias in this area are called inguinal hernias. But hernias can occur below the groin area (femoral), at the belly button (umbilical), in the abdominal area and at sites of prior surgery (incisional).

 

Men, women, and children of any age can get hernias. They can occur because you were born with a natural weakness in the abdominal wall, or from a weakness acquired with age. Contributing factors include previous surgery in the abdominal area, excessive weight gain, pregnancy, constipation, infection, malignancy, or trauma. Strenuous physical activity including heavy lifting may also be a contributing factor.

 

Hernias don’t go away. All defects, even ones that show no symptoms (“Asymptomatic”), should be surgically corrected since the risks of surgery are much less than the risks to you of not fixing the hernia. Once you develop symptoms, surgical repair is mandatory. Small asymptomatic hernias can sometimes be pushed back into place by your doctor, but surgery is the only way to really fix a hernia.

 

There are two main ways to surgically fix a hernia: open repair and minimally invasive laparoscopic repair.

 

This type of repair involves making a cut (incision) over the hernia, carefully dissecting through the body tissues and closing the area of weakness. Usually a mesh (composed of gortex, teflon or other material) is sewn into place over or under the weakened area to make it stronger and to prevent recurrence. After the repair, the incision is closed and covered with bandages and tape.

 

Local anesthesia (lidocaine, mepivacaine) is commonly used to prevent you from feeling pain during the procedure. In addition, the anesthesiologist gives a mixture of short–acting sedating medications to provide comfort. Occasionally spinal or general anesthesia may be required for larger hernias or more complicated cases. Postoperative pain may be managed with a combination of intravenous, intramuscular and oral painkillers. You may have some trouble urinating for the first 12–24 hours following the procedure.

 

The main disadvantage of the open technique is that it can cause considerable pain. You may not be able to return to work for a week or longer and full activity may not be possible for up to six weeks. Swelling and black and blue discoloration of the wound site is common. Repairs of repeat inguinal hernias, and two sided repairs, are much more painful and have a much longer recovery period.

 

A small incision at the area of the belly button (umbilicus) is made through which a telescopic device called the Laparoscope, is inserted. Your surgeon looks through the laparoscope and at a magnified image projected onto a video monitor. A balloon device is used to carefully open up the area to be repaired, and the area is inflated with carbon dioxide so that the surgery can be safely performed. Your surgeon passes instruments through small incisions (one–fourth to one–half inch) to dissect body tissues and to repair the hernia. A mesh to strengthen the weakness is fixed into place with titanium staples to strengthen the area and prevent recurrence of the hernia. After the repair, local anesthesia is given at the incision sites to minimize pain and all of the small incisions are closed and covered with steri–strips or Band–AIDS.

 

There are 2 choices today for the repair of an inguinal hernia. Namely Laparoscopic or Open Laparoscopic Repair.

With the minimally invasive approach the surgery is performed through 3 small incisions. A balloon is placed beneath the abdominal muscles and the hernia is reduced into the space created. A mesh patch is then placed over the defect and tacked to the surrounding ligaments and muscles with titanium tacks. Pro’s include limited postoperative pain and early return to work in as few as 3–4 days. Early return to full activities by 2 weeks. 5 year results reveal recurrence rate around 2% must be performed using a general anesthetic.

 

Hernia repair can now be performed with the aid of a small camera called a Laparoscope. This allows the surgeon to use small incisions to place the instruments and mesh needed to repair a hernia. The first incision is made below the belly button.

 

A balloon is then placed beneath he abdominal muscles and inflated to create a working space. Two additional 1/2 inch incisions are made below the belly button. After the hernia sac is returned below the muscles a mesh patch is placed over the hernia defect and tacked to the surrounding ligaments and muscle with titanium tacks. The incisions are then closed with a single dissolvable suture.

 

The advantage of laparoscopic repair is the quicker recovery. Most patients return to work between 1–2 weeks depending on the amount of lifting required. No heavy lifting greater than 20 pounds is advised for the first 2 weeks. You may resume normal activities the same day, including walking up stairs, and may shower the following day. Driving should wait until there is minimal discomfort, usually 4–5 days.

 

Anyone with an inguinal or groin type hernia can be repaired with the laparoscopic technique unless there has been previous surgery in the middle of the lower abdomen, the patient is unable to tolerate a general anesthetic due to medical illness, or the hernia is too large (such as those that remain in the scrotum). A patient with a previous hernia repair, or a hernia on both sides is an excellent candidates for this procedure.

 

A general anesthetic is used to allow complete relaxation of the abdominal muscles. This results in nausea for some patients as the main side effect. The anesthesiologist will discuss other risks with you at the time of the procedure.

 

As with any surgery we always worry about the risk of bleeding or infection where the surgery was performed (less than 1%). Additionally, with hernia surgery there is a risk of injury to the spermatic cord which carries the blood supply and sperm tube, which could result in sterility if injured on both sides or can cause changes in the testicles such as pain, swelling or shrinkage (less than 1%). The patch which is placed is artificial and can become infected requiring treatment with antibiotics or even removal. There is an approximately 1% recurrence rate in the immediate postoperative period with the 5 year results about 2%.

 

With the open or traditional approach an incision is made in the groin over the site of the bulge. The muscle layers are divided to reach the neck of the hernia which is then reduced into the abdomen. The muscle layers are then reap–proximated and a patch material is placed over the repair to help prevent a recurrence.

 

Pro’s include known long term results with a recurrence rate approximately 2–5% may be performed with a local, spinal or general anesthetic. Con’s include increased discomfort in immediate postoperative period. Time–off of work approximately 2–4 weeks. 

 

The gallbladder is a small, pear–shaped organ that lies just beneath the liver in the upper right part of your abdomen. The gallbladder collects and stores bile, a digestive juice produced by the liver, and excretes it (through the common bile duct) into the intestines. The purpose of bile is to help digest large fatty meals.

 

Sometimes, stones (usually made of cholesterol, bile salts and lecithin) form in the gallbladder and block its outlet, causing pain (Biliary colic) or inflammation and infection (Cholecystitis). Sometimes the stones move out of the gallbladder but get stuck in the common bile duct, and can cause inflammation of the pancreas (Pancreatitis), fever, or jaundice (yellow color in the skin and eyes). Pain usually begins after a meal and may become severe and constant. There may be more symptoms after eating fatty foods. Other symptoms may include bloating, belching, vomiting, and indigestion. Some patients have no symptoms.

 

Diagnosis is most often made by ultrasound, the same technique used to visualize fetuses in pregnant woman. With this technique, a detailed image of the gallbladder contents, including stones, can be produced.

 

Men, women, and children can all get gallstones. They appear to be more common in obese women over the age of 40. Native Americans and Hispanics may also have higher rates. The overall incidence is 1 out of 1000 people. Women who exercise regularly may reduce their chance of getting gallstones.

 

The causes are still mostly unknown, although it is presumed that changes in the composition of the bile substance and failure of the gallbladder to empty properly are contributing causes.

 

Medication and adjustments in the diet (low fat) can help alleviate some of the symptoms. However, if stones block the gallbladder outlet or are lodged in the bile duct, surgery is indicated. Patients who have symptoms, even minor ones, have a diseased gallbladder should strongly consider surgery. For patients with no symptoms, there is a significant risk that the first attack will be severe and require hospitalization, for this reason, such patients should also consider surgery. Furthermore, patients who are at increased risk for infection (such as diabetics or people undergoing chemotherapy) should consider removal of a diseased gallbladder. For these patients, a severe and acute attack may be very dangerous.

 

There are two ways to perform gallbladder surgery: Open Cholecystectomy or Laparoscopic Cholecystectomy.

 

An abdominal incision is made to expose the gallbladder, located under the right portion of the liver. The gallbladder with its stones is removed. Once the gallbladder has stones, it is diseased and cannot be left behind. Removal of gallstones alone is not standard accepted practice. Usually an X–ray test called the Intra–operative Cholangiogram is done during the surgery to see if gallstones are also in the common bile duct. If this test shows stones, then the common bile duct is explored and these stones are removed. Local anesthesia is given at the incision sites to help reduce pain, the incisions are all closed, and a dressing is applied.

 

General anesthesia is the preferred technique to make the patient comfortable and pain free. Postoperative pain may be managed with an epidural or by Patient Controlled Analgesia (PCA) where the patient activates a device to deliver a dose of intravenous painkiller. In addition, injections and oral painkillers are administered.

 

The most common side effects from the surgery and anesthesia are pain from the abdominal incision, nausea and vomiting, sore throat, muscle aches, tiredness and a general feeling of illness. Recovery usually takes several days to a week in the hospital. Patients are usually out of work 2–3 weeks and usually cannot resume significant physical activity for 6–8 weeks.

 

A telescopic instrument called a laparoscope is inserted into a small incision at the belly button (umbilicus). The laparoscope is connected to a tiny video camera which projects a magnified view of the operative site onto video monitors. These video monitors help your surgeon perform the surgery. Carbon dioxide is passed through the laparoscope to fill the abdominal cavity, providing your surgeon with a better view. Small abdominal incisions (one–fourth to one–half inch) are usually made near the primary one at the umbilicus to pass in special surgical instruments with which the operation is performed and the gallbladder removed. The common bile duct is usually examined with use of an Intra–Operative Cholangiogram (see above) to make sure that no stones have migrated into the duct.

 

If this occurs, stones within the bile duct can be removed laparoscopically by a surgeon with specific expertise using a sophisticated instrument called a Choledochoscope. During the surgery all contents of the abdominal cavity can be viewed and examined through the laparoscope, increasing the safety of the procedure and aiding in the diagnosis of other diseases. Local anesthetic is given at the incision sites to help prevent pain and the small incisions are all closed and covered with steri–strips or Band–AIDS.

 

General anesthesia is the preferred technique to assure optimal operating conditions and a pain–free and comfortable state. Postoperative pain is usually managed with combinations of small doses of intravenous and oral painkillers. The most common side effects after surgery and anesthesia include nausea and vomiting, sedation, sore throat, generalized muscle aches, aches in the shoulder blades and back of neck from the gas (from nerve stimulation caused by the C02 gas used to inflate the abdomen), and mild pain from the incisions.

 

You will probably be able to go home after a few hours or early the next day once you can tolerate food and drink. If you are over age 65, have major health problems, have acute infection of the gallbladder (cholecystitis), or have prolonged surgery, you may need a longer time for recovery. Either way, you will probably be able to resume normal activities within the week after surgery although you may feel tired.

 

The Main Advantages of the Laparoscopic Technique are the following:

Four small scars instead of one large abdominal scar.

Reduced postoperative pain.

Shorter hospital stay – able to leave the same day or early next day.

Shorter recovery time – days instead of weeks – and a quicker return to normal daily activities and work.

Post Surgery

It is important to follow your doctor’s instructions after the surgery. Feelings of queasiness, nausea and/or vomiting, muscle aches and gas pains, and pain from the incisions will dissipate over the next 3–4 days. Medication can be given to ease these side effects. Acetaminophen and ibuprofen help with the gas pains. Feelings of malaise and tiredness may last for 2–4 weeks. Although most people feel better within a few days, you may need to take it easy for two to four weeks.

 

Comparison between Laparoscopic Cholecystectomy & Open Cholecystectomy

If performed by surgeons who are expert in this area, laparoscopic cholecystectomy is safer than open cholecystectomy. Common bile duct injury may occur more often using laparoscopic technique than the open technique, depending on the skill and expertise of the surgeon. However, other complications such as infection, pneumonia, and phlebitis (clots in the legs) are less common than in the open technique. Your surgeon may need to convert it to an open procedure in cases of anatomic difficulties or uncertainties, though in experienced hands this chance is less than 1%.

 

 

Ask your surgeon to explain the surgical procedure. For example, if something is going to be repaired or removed, find out why it is necessary to do so. Your surgeon can draw a picture or a diagram and explain to you the steps involved in the procedure. 

 

There are many reasons to have surgery. Some operations can relieve or prevent pain. Others can reduce a symptom of a problem or improve some body function. Some surgeries are performed to diagnose a problem. Surgery also can save your life. Your surgeon will tell you the purpose of the procedure. Make sure you understand how the proposed operation fits in with the diagnosis of your medical condition.  

Sometimes, surgery is not the only answer to a medical problem. Medicines or other non–surgical treatments, such as a change in diet or special exercises, might help you just as well or more. Ask your surgeon or primary care doctor about the benefits and risks of these other choices. You need to know as much as possible about these benefits and risks to make the best decision.

 

One alternative may be “ waiting an observation,” in which your doctor and you check to see if your problem gets better or worse. If it gets worse, you may need surgery right away. If it gets better, you may be able to postpone surgery, perhaps indefinitely.  

Ask your surgeon what you will gain by having the operation. For example, a hip replacement may mean that you can walk again with ease.

 

Ask how long the benefits are likely to last. For some procedures, it is not unusual for the benefits to last for a short time only. There might be a need for a second operation at a later date. For other procedures, the benefits may last a lifetime.

 

When finding out about the benefits of the operation, be realistic. Sometimes patients expect too much and are disappointed with the outcome, or results. Ask your doctor if there is any published information about the outcomes of the procedure.  

All operations carry some risk. This is why you need to weigh the benefits of the operation against the risks of complications or side effects. Complications can occur around the time of the operation. Complications are unplanned events, such as infection, too much bleeding, reaction to anesthesia, or accidental injury. Some people have an increased risk of complications because of other medical conditions.

 

In addition, there may be side effects after the operation. For the most part, side effects can be anticipated. For example, your surgeon knows that there will be swelling and some soreness at the site of the operation.

 

Ask your surgeon about the possible complications and side effects of the operation. There is almost always some pain with surgery. Ask how much there will be and what the doctors and nurses will do to reduce the pain. Controlling the pain will help you be more comfortable while you heal, get well faster, and improve the results of your operation. 

 

Based on what you learn about the benefits and risks of the operation, you might decide not to have it. Ask your surgeon what you will gain‘”or lose‘”by not having the operation now. Could you be in more pain? Could your condition get worse? Could the problem go away? 

Getting a second opinion from another doctor is a very good way to make sure having the operation is the best alternative for you. Many health insurance plans require patients to get a second opinion before they have certain non–emergency operations. If your plan does not require a second opinion, you may still ask to have one. Check with your insurance company to see if it will pay for a second opinion. If you get one, make sure to get your records from the first doctor so that the second one does not have to repeat tests.  

Most surgeons practice at one or two local hospitals. Find out where your operation will be performed. Have many of the operations you are thinking about having been done in this hospital? Some operations have higher success rates if they are done in hospitals that do many of those procedures. Ask your doctor about the success rate at this hospital. If the hospital has a low success rate for the operation in question, you should ask to have it at another hospital. Until recently, most surgeries were performed on an inpatient basis and patients stayed in the hospital for one or more days. Today, a lot of surgeries are done on an outpatient basis in a doctor's office, a special surgical center, or a day surgery unit of a hospital. Outpatient surgery is less expensive because you do not have to pay for staying in a hospital room.

 

Ask whether your operation will be done in the hospital or in an outpatient setting. If your doctor recommends inpatient surgery for a procedure that is usually done as outpatient surgery, or just the opposite, recommends outpatient surgery that is usually done as inpatient surgery, ask why. You want to be in the right place for your operation. 

Anesthesia is used so that surgery can be performed without unnecessary pain. Your surgeon can tell you whether the operation calls for local, regional, or general anesthesia, and why this form of anesthesia is recommended for your procedure.

 

Local anesthesia numbs only a part of your body for a short period of time, for example, a tooth and the surrounding gum. Not all procedures done with local anesthesia are painless.

 

Regional anesthesia numbs a larger portion of your body, for example, the lower part of your body for a few hours. In most cases, you will be awake with regional anesthesia.

 

General anesthesia numbs your entire body for the entire time of the surgery. You will be unconscious if you have general anesthesia.

 

Anesthesia is quite safe for most patients and is usually administered by a specialized physician (anesthesiologist) or nurse anesthetist. Both are highly skilled and have been specially trained to give anesthesia. 

Your surgeon can tell you how you might feel and what you will be able to do or not do for the first few days, weeks, or months after surgery. Ask how long you will be in the hospital. Find out what kind of supplies, equipment, and any other help you will need when you go home. Knowing what to expect can help you cope better with recovery.

 

Ask when you can start regular exercise again and go back to work. You do not want to do anything that will slow down the recovery process. Lifting a 10–pound bag of potatoes may not seem to be “too much” a weak after your operation, but it could be. You should follow your surgeon's advice to make sure you recover fully as soon as possible. 

For temporary relief, one could try limiting one’s activities, go on light duty, and avoid heavy work. Wearing a truss or binder, gives only temporary relief, and is only recommended for those unfit for surgery. The only treatment is surgery. There are many different surgical techniques, some of which are noted for minimal post–operative discomfort, faster recovery, and lasting relief. Briefly, there are 2 main ways of fixing a hernia – (1) the traditional method of a large open incision, (2) the laparoscopic method, with miniature incisions, tracers, a telescope and a camera. Discuss with your doctor. See other pages of this web–site, then come consult with us, especially if you have a complex or recurrent or bilateral inguinal hernia, or if you want to return to work quickly. 

The hand pain in Rheumatoid Arthritis (RA) may originate from a large variety of causes, chief among which are the inflammation of the synovial membranes. In rheumatoid arthritis this tissue becomes inflamed and instead contributes to the destruction of the joint and its adjacent ligaments (which are the stays that effectively constrain the joint and render it stable but mobile). As the joints and ligaments decay, the joints may become unstable and deviate or adopt abnormal attitudes or positions, putting increasing strain on the remaining ligaments. Such inflamed and swollen joints are painful in their own right, and some pain may arise from the joint surfaces or from the capsule that surrounds the joint including the ligaments that bear abnormal strains. Surgery in this condition has several aims. Some feel that when the joints begin to deviate, corrective surgery to the ligaments and soft tissues (as opposed to bone) may allow realignment of the joint surfaces and prevent the erosion of those surfaces that comes from chronic malignant. This surgery was particularly appropriate for the metacarpophalangeal joints (at the junction between fingers and palm) which commonly deviate away from the thumb side of the hand, sometimes well before the joints themselves require replacement.

 

It should however be borne in mind that other causes of pain occur in rheumatoid arthritis in the hand, and important amongst these are nerve compression pains from swelling of adjacent joints or tendons, and subsequent compression of the nearby nerves. A good example of this is rheumatoid arthritis associated carpal tunnel syndrome. Any one suffering from rheumatoid arthritis with any new type of hand pain should be evaluated by a hand specialist or rheumatologist where possible, and regular checks by a rheumatologist or hand surgeon are sensible; in this condition. The individual indications for surgery for pain may then be discussed in detail.

 

The MCP (metacarpophalangeal)joints are the knuckle joints where the finger joins the palm. The PIP joints (proximal interphalangeal) are the middle joints of the fingers.

 

MCP replacement with prostheses is most commonly undertaken for advanced rheumatoid arthritic change with deviation and loss of function at these joints.

 

General anesthesia is commonly used to provide optimal operating conditions for the procedure and a pain–free state. Local anesthesia is added in the areas of the incisions to provide pain relief after the surgery. Any additional postoperative pain can be alleviated with small doses of intravenous, intramuscular or oral painkillers. Side effects from the anesthesia and surgery can include sleepiness, nausea or vomiting. Medication can be given to treat all of these conditions. As with the open method, urinating may be affected. You should be able to go home a few hours after your surgery is finished.

 

The main advantage of the laparoscopic technique is that it avoids painful incisions. Pain and discomfort are dramatically less than with the open technique. A secondary advantage is that both sides can be examined during a single surgery. Most patients are able to return to work within 72 hours and resume full or nearly full physical activity by one week. 

 

You will need an escort to take you home after the surgery because you may still feel sleepy after the anesthetic. It is also a good idea to have someone with you for 12 to 24 hours to make sure that you can eat and drink normally. Side effects from the anesthesia and surgery include pain, muscle aches, abdominal swelled, stomach queasiness, nausea and/or vomiting, headache, somnolence or sleepiness, and sore throat (from the breathing tube). Mild pain and anti–nausea medications are given to all patients to help minimize this tendency and minor discomforts. All of these side effects will dissipate over the next few days.

 

Most patients need a few days to recover and get their strength back. Full activity in both open and laparoscopic procedures is encouraged after 48 hours, though the amount any patient can do is dependent on the type of procedure performed and individual responses to pain.

 

You will need to make an appointment with your surgeon for 1 week after the surgery to follow–up and check on your healing. There are 2 choices today for the repair of an inguinalhernia. Namely laparoscopic or Open Laparoscopic Repair.

 

With the minimally invasive approach the surgery is performed through 3 small incisions. A balloon is placed beneath the abdominal muscles and the hernia is reduced into the space created. A mesh patch is then placed over the defect and tacked to the surrounding ligaments and muscles with titanium tacks. Pro's include limited postoperative pain and early return to work in as few as 3–4 days. Early return to full activities by 2 weeks. 5 year results reveal recurrence rate around 2% must be performed using a general anesthetic 

A hernia is a weakness, or defect, in the lining of the abdominal muscles. This can be something you are born with or something that develops with time due to continued straining on the muscle lining from lifting, coughing, sneezing, etc. Eventually there will be a large enough defect to allow abdominal contents, such as fat, fluid or intestine, to enter into the opening. This will result in a visible bulge in the skin in the area involved. For most people this is the inguinal, or groin region. Other areas are the belly button, abdominal midline, or previous surgical scar, in addition to some other rare locations. 

Hernia repair can now be performed with the aid of a small camera called a Laparoscope. This allows the surgeon to use small incisions to place the instruments and mesh needed to repair a hernia. The first incision is made below the belly button. A balloon is then placed beneath he abdominal muscles and inflated to create a working space. Two additional 1/2 inch incisions are made below the belly button. After the hernia sac is returned below the muscles a mesh patch is placed over the hernia defect and tacked to the surrounding ligaments and muscle with titanium tacks. The incisions are then closed with a single dissolvable suture. 

The advantage of laparoscopic repair is the quicker recovery. Most patients return to work between 1 – 2 weeks depending on the amount of lifting required. No heavy lifting greater than 20 pounds is advised for the first 2 weeks. You may resume normal activities the same day, including walking up stairs, and may shower the following day. Driving should wait until there is minimal discomfort, usually 4 – 5 days.  

Anyone with an inguinal or groin type hernia can be repaired with the laparoscopic technique unless there has been previous surgery in the middle of the lower abdomen, the patient is unable to tolerate a general anesthetic due to medical illness, or the hernia is too large (such as those that remain in the scrotum). A patient with a previous hernia repair, or a hernia on both sides is an excellent candidates for this procedure.  

A general anesthetic is used to allow complete relaxation of the abdominal muscles. This results in nausea for some patients as the main side effect. The anesthesiologist will discuss other risks with you at the time of the procedure.  

As with any surgery we always worry about the risk of bleeding or infection where the surgery was performed (less than 1%). Additionally, with hernia surgery there is a risk of injury to the spermatic cord which carries the blood supply and sperm tube, which could result in sterility if injured on both sides or can cause changes in the testicles such as pain, swelling or shrinkage (less than 1%). The patch which is placed is artificial and can become infected requiring treatment with antibiotics or even removal. There is an approximately 1% recurrence rate in the immediate postoperative period with the 5 year results about 2%.  

With the open or traditional approach an incision is made in the groin over the site of the bulge. The muscle layers are divided to reach the neck of the hernia which is then reduced into the abdomen. The muscle layers are then reap–proximated and a patch material is placed over the repair to help prevent a recurrence.

 

Pro's include known long term results with a recurrence rate approximately 2–5% may be performed with a local, spinal or general anesthetic. Con's include increased discomfort in immediate postoperative period Time off of work approximately 2–4 weeks.  

The groin area is the most common site of a hernia (80%), hernias in this area are called inguinal hernias. But hernias can occur below the groin area (femoral), at the belly button (umbilical), in the abdominal area and at sites of prior surgery (incisional).  

Men, women, and children of any age can get hernias. They can occur because you were born with a natural weakness in the abdominal wall, or from a weakness acquired with age. Contributing factors include previous surgery in the abdominal area, excessive weight gain, pregnancy, constipation, infection, malignancy, or trauma. Strenuous physical activity including heavy lifting may also be a contributing factor.  

Hernias don’t go away. All defects, even ones that show no symptoms (“Asymptomatic”), should be surgically corrected since the risks of surgery are much less than the risks to you of not fixing the hernia. Once you develop symptoms, surgical repair is mandatory. Small asymptomatic hernias can sometimes be pushed back into place by your doctor, but surgery is the only way to really fix a hernia.

Surgical repair of hernias

There are two main ways to surgically fix a hernia: open repair and minimally invasive laparoscopic repair.

 

Open Surgical Repair of Hernia

This type of repair involves making a cut (incision) over the hernia, carefully dissecting through the body tissues and closing the area of weakness. Usually a mesh (composed of gortex, teflon or other material) is sewn into place over or under the weakened area to make it stronger and to prevent recurrence. After the repair, the incision is closed and covered with bandages and tape.

 

Local anesthesia (lidocaine, mepivacaine) is commonly used to prevent you from feeling pain during the procedure. In addition, the anesthesiologist gives a mixture of short–acting sedating medications to provide comfort. Occasionally spinal or general anesthesia may be required for larger hernias or more complicated cases. Postoperative pain may be managed with a combination of intravenous, intramuscular and oral painkillers. You may have some trouble urinating for the first 12–24 hours following the procedure.

 

The main disadvantage of the open technique is that it can cause considerable pain. You may not be able to return to work for a week or longer and full activity may not be possible for up to six weeks. Swelling and black and blue discoloration of the wound site is common. Repairs of repeat inguinal hernias, and two sided repairs, are much more painful and have a much longer recovery period.

 

By far the commonest replacement joint is made from Silicone rubber and was designed by Dr. Al Swanson from Grand Rapids Michigan. It is beautifully simple, acting as a flexible hinge. Because of its structure it does not accurately replicate the biomechanics of the joint it replaces, and so full function is never restored. In addition it is made of a friable material and for this reason it is subject to attritional wear. Most surgeons therefore use it almost exclusively in the low demand low load hands of rheumatoid patients where it can be very successful indeed.

 

In addition the joint has no inherent lateral stability, which is not a problem in the MCP because the adjacent joints bolster it, but in the PIP it can pose problems resisting lateral stress.

 

Many of us believe that the ideal range of motion after an MCP joint replacement is about 30 to 40 degrees, compared with 90 degrees in the unaffected hand. Many other designs have been tried and continue to be developed but none have achieved the wide acceptance of the Swanson Implant.

Ligaments and Tendons in Rheumatoid Arthritis 

The hand pain in rheumatoid arthritis (RA) may originate from a large variety of causes, chief amongst which are the inflammation of the synovial membranes. Synovium is specialized tissue that allows gliding to occur and which secretes the lubricant and nutrient synovial fluid essential to normal joint function and the function of some tendons. In rheumatoid arthritis this tissue becomes inflamed and instead contributes to the destruction of the joint and its adjacent ligaments (which are the stays that effectively constrain the joint and render it stable but mobile). As the joints and ligaments decay, so the joints may become unstable and deviate or adopt abnormal attitudes or positions, putting increasing strain on the remaining ligaments. Such inflamed and swollen joints are painful in their own right, and some pain may arise from the joint surfaces or from the capsule that surrounds the joint including the ligaments that bear abnormal strains.

 

Surgery in this condition has several aims. Some believe that in particular circumstances there is a place for “Prophylactic” or preventative surgery in which the destructive diseased synovium is removed to prevent its adverse effect on adjacent tissues. Further, some feel that when the joints begin to deviate, corrective surgery to the ligaments and soft tissues (as opposed to bone) may allow realignment of the joint surfaces and prevent the erosion of those surfaces that come from chronic malalignment. This surgery was particularly appropriate for the metacarpophalangeal joints (at the junction between fingers and palm) which commonly deviate away from the thumb side of the hand, sometimes well before the joints themselves require replacement.

 

It should however be borne in mind that other causes of pain occur in rheumatoid arthritis in the hand, and important amongst these are nerve compression pains from swelling of adjacent joints or tendons, and subsequent compression of the nearby nerves. A good example of this is rheumatoid arthritis associated carpal tunnel syndrome. Any one suffering from rheumatoid arthritis with any new type of hand pain should be evaluated by a hand specialist or rheumatologist where possible, and regular checks by a rheumatologist or hand surgeon are sensible; in this condition. The individual indications for surgery for pain may then be discussed in detail.

 

I recently underwent surgery for the removal of what was diagnosed as “Rudimentary extra digits”..What exactly causes this abnormality: is it common?...

 

The condition you describe is of extra digits on the little finger side of the hand, or ulnar border. Often known as supernumery digits, these are commonly found in the site you describe and are often removed at or just after birth by ligation with a thread. This is not a method one recommend’s because it leaves a small bobble of skin and can (rarely) cause dangerous undetected bleeding when the digit separates. The digits are usually attached by a slight stalk, rather than truly articulating with the rest of the skeleton: hence the ease of removal. Many people who have had them treated this way are unaware they have had extra digits.

 

The condition can have a hereditary element, and is more prevalent amongst African Americans, but affects all races. Search for it in reference libraries under polydactyly, post–axial polydactyly or ulnar border polydactyly.

 

 

A new, effective way to treat gall–bladder disease and speed up the process of recovery.

 

If your doctor has suggested surgery to remove your gall bladder, you have probably heard about an innovative procedure called laparoscopic Cholecystectomy, or ‘Lap chole’ for short. The procedure is a “Less invasive” type of gall–bladder surgery that you might consider if your surgeon feels you are an appropriate candidate. Since incisions are extremely small with less invasive procedures, discomfort after surgery is reduced and recovery is shortened.

 

 

To remove the gallbladder, the surgeon makes four tiny incisions in the abdomen–one near the navel. Unlike the seven – inch incision required for open surgery, these four incisions do not traumatize muscle tissue, so patients experience much less pain after surgery and usually can resume normal activities within one week.

 

A thin tube or “Tracer” is inserted in the navel incision. Through this tube, the surgeon inserts the laparoscope, which consists of a small video camera and light source. The camera sends actual images to monitor allowing the surgeon to “See” inside the body.

 

Trocars are placed in the other three incisions. The surgeon uses these openings to insert the instruments necessary to perform the procedure. Instruments called “Graspers” for example, hold the gallbladder in place. A device using a laser beam or electric current detaches the gallbladder while sealing tissue to control bleeding. Finally, the gallbladder is withdrawn through the trocar near the navel. While each case has unique characteristics, the procedure is performed under general anesthesia, takes about an hour, and requires a 24–hour hospital stay.

 

Immediately following the surgery, patients can expect to have symptoms, such as nausea, while the body recovers. A diet free from fatty food is recommended for the first week following surgery. Within a week, patients will also see the surgeon for a check–up. Full activity can be resumed as soon as patients feel comfortable.

 

 

More and More Patients are Choosing Laparoscopic Cholecystectomy

Gallbladder surgery is one of the most commonly performed procedures in America. In fact, studies indicate that one in ten Americans will experience gallbladder problems during his or her lifetime. More than half a million people have gallbladder surgery every year, and today as many as 90% of the operations are done laparo–scopically.

 

The widespread acceptance of the Laparoscopic Cholecystectomy procedure stems from its patient benefits. Patients experience less postoperative pain, minimal scarring, and recover faster than with open surgical procedures.

A new, effective way to treat hernias and speed recovery

If your doctor has suggested surgery for the repair of your hernia, you may be considering an innovative new procedure called Laparoscopic Hernioplasty. Called “Lap hernia” for short, the procedure is a “Less invasive” type of surgery. Since incisions are extremely small with less invasive procedures, discomfort after surgery is reduced and recovery is shortened.

 

 

To repair the inguinal hernia laparo–scopically, the surgeon makes three small incisions in the patient’s abdomen. Unlike the three–inch incision made in traditional open surgery, these incisions do not traumatize muscle tissue, so patients experience much less pain after surgery and return to normal activity within a week.

 

Next, the surgeon inserts a thin tube, or trocar, into each of the abdominal incisions. A laparoscope, which consists of a small video camera and light source, is inserted near the navel. The camera sends actual images to a monitor, allowing the surgeon to “See” inside the body.

 

A variety of surgical instruments access the hernia site through the second and third tubes. Through one tube a surgeon uses a “Grasper” manipulate the tissue surrounding the hernia and to position a mesh patch that covers the opening in the muscle wall. Through the other tube the surgeon attaches the mesh patch to the wall with staples or sutures. The mesh becomes a strong and permanent part of the abdominal wall. While each case is unique, the procedure can take less than an hour and usually requires no overnight stay. It is performed under general anesthesia.

 

The pain from the small incision is usually gone in a day or two, and at the point, it is possible to resume normal activities such as driving a car or returning to light work. Full activity is frequently permitted within about two weeks, but a check–up in the surgeon’s office is recommended before resuming strenuous activities such as heavy lifting or participating in sports.

 

 

Hospital stay Usually same dayprocedure Usually same dayprocedure 

Recovery Time As little as 1 week 4–6 weeks

Scarring 3 small marks 3 – inch scar

Postoperative pain Minimal Significant

 

Hernia repair is one of the most commonly performed surgeries all over the world. Close to half a million are done in the United States alone – many using less invasive techniques. In fact, the number of lap hernias being performed is expected to double in the next year. The rapid growth of the lap hernia procedure stems from its many patient benefits reduced pain and scarring and quicker recovery. Although long–term results on the efficacy of this procedure will not be conclusive for another year or two, early data indicates it produces favorable clinical results