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Hernia is a weakness in the abdominal wall (tummy) which leads to a bulge in the area. Most hernias are in in the groins or the middle of abdomen; around Umbilicus or upper abdomen.
Hernia may not give any problems to a person initially; however, pain and enlargement of the hernia lump generally occurs over some period of time. Some small hernias can give pain without any obvious lump.
A hernia can present at any age; in new born or elderly.
Its recommended that a person should get advice from a surgeon with specialist interest experience in hernia surgery. The hernia diagnosis will be confirmed and appropriate advice regarding conservative or surgical management will be provided to the individual.
In the past hernia surgery was carried out by trainee surgeons without supervision, which led to a high recurrence (hernia reappearing after the initial operation) of hernias.
Groin or Inguinal hernia surgery is one of the commonest operations performed in NHS, United Kingdom. More than 100, 000 operations are carried out yearly.
Laparoscopic approach is suitable for:
- First time one sided Inguinal hernia
- Inguinal hernia on both sides
- Recurrent hernia
- Complex groin hernias
- Femoral hernia
- Obturator hernia
- Umbilical hernia (large hernias)
- Incisional hernia (small or large hernias)
Hernia surgery is considered as real art among surgeons. It’s not uncommon to hear from surgeons themselves in surgical fraternity meetings, “I know 500 surgeons who can do my Gall Bladder surgery, but only one surgeon who can do my hernia operation.”
NICE UK Guidelines
- Laparoscopic Hernia Surgery being superior to open hernia surgery.
- This was also recommended that surgery should be performed with Laparoscopic approach for bilateral and recurrent inguinal hernias; especially TEP (Totally ExtraPeritoneal) approach was endorsed.
- It was recommended that surgeons well trained and with good experience in Laparoscopic hernia surgery should carry out these repairs
Professor Amir’s Trial for NICE
Professor Amir Nisar conducted a randomized trial as the sole operating surgeon operating on 40 patients in Royal Surrey County Hospital, Guildford, Surrey, England, United Kingdom under Professor Michael Bailey, the leading Hernia surgeon in Europe. The aim of the study was to assess the efficacy of laparoscopic and open approaches in unilateral inguinal hernias in the young, office going adults.
The outcome of the trial confirmed the superiority of the Laparoscopic approach over the open approach.
The results were presented to NICE (National Institute of Clinical Excellence), United Kingdom. These positive outcomes regarding the safety and efficacy of Laparoscopic TEP approach led to the next guidelines from NICE in 2004.
Current NICE Recommendations
NICE (National Institute of Clinical Excellence) final guidelines; 22nd September 2004, are strongly in favor of Laparoscopic Hernia Surgery.
Current NICE recommendations for Inguinal / Groin hernia surgery are:
- Laparoscopic TEP repair is the best approach for first time one-sided hernia (unilateral)
- Laparoscopic approach is the ideal for first time bilateral inguinal hernias (hernia in both groins)
- Laparoscopic approach is highly recommended for a recurrent hernia (hernia reappearing after surgery)
- It is strongly recommended that only the surgeons who are well trained and experienced in this surgery should carry out these operations
Current Status of Hernia Surgery
Laparoscopic Hernia surgery uptake among surgeons in United Kingdom, Europe, United States and Asia has been low. In United Kingdom and other countries dedicated training centers have offered courses and master classes to train the surgeons to be able to offer this surgery safely.
Minimal Access Therapy Training Unit (MATTU), Guildford, Surrey, United Kingdom has been the leading centers in training for Laparoscopic Hernia surgery, under the leadership of Professor Michael Bailey. This center not only trained surgeons of future from Europe, Asia, United States, Australia, and Africa, but also guided NICE (National Institute of Clinical Excellence), United Kingdom.
Professor Bailey’s Classic technique with some modification and improvements is now only practiced in Dubai, by his prodigy, Professor Amir Nisar.
The New Gold Standard
We believe that Mini-Scar-Less Totally ExtraPeritoneal repair (Amir’s MSL TEP repair) is the New Gold Standard
This has by far the best cosmetic results, quickest and relatively pain free recovery.
The accumulative length of the incisions for this operation is 1.1cm (11mm or 0.4 Inch) *.
In Amir’s MSL TEP repair the surgery inside is the same as the standard Totally Extra Peritoneal (TEP) repair. However, accumulative incision length is 4 cm (40mm or 1.6 inches) *.
Amir’s MSL TEP repair is the only surgical approach for hernia repair which generally does not require any post-operative restriction on mobility, exercise or lifting weight.
The available options for Laparoscopic hernia repair are:
Laparoscopic TEP (Totally ExtraPeritoneal) repair – The PREVIOUS Gold Standard
Laparoscopic TAPP (Trans Abdominal Pre-Peritoneal) repair
Needlescopic TEP (Totally ExtraPeritoneal) repair
Comparison of incision lengths
Open / Laparoscopic TEP / Amir’s MSL TEP repairs
Amir’s MSL TEP repair
*Unilateral and *Bilateral Herniae
Standard TotallyExtraPeritoneal (TEP) repair
Unilateral and Bilateral Herniae
Open Mesh Hernia repair
Open Mesh Hernia repair
*Unilateral; one sided hernia
*Bilateral; Hernias in both groins (2 hernias)
MiniScarLess (MSL) The Gold Standard
Professor Amir Nisar believes that Laparoscopic MiniScarLess (MSL) Totally Extra Peritoneal (TEP) Inguinal Hernia Surgery is the New Gold Standard.
Laparoscopic Totally Extra Peritoneal (TEP) groin hernia surgery has been the Gold standard for groin hernia surgery, being well established for 30 years.
Laparoscopic MiniScarLess (MSL) Inguinal Hernia Surgery is the New Gold Standard which offers the minimalistic approach out of all the treatments for inguinal hernia surgery available anywhere in the world. The cuts lengths, post operative pain, and the recovery time is far superior to all the other laparoscopic and robotic assisted approaches for inguinal hernia surgery.
Open inguinal /groin hernia surgery should ideally be avoided due to some of the risks and complications involved; like chronic groin pain. This has been the recommendation of NICE (National Institute of Clinical Excellence), United Kingdom. In Professor Amir’s opinion, “Robotic Assisted Inguinal/Groin Hernia Surgery” is an overkill, takes longer time to operate, has bigger scars and thus should be avoided.
Standard Laparoscopic Totally Extra Peritoneal (TEP) groin hernia surgery typically has an operative time of 30 minutes to 50 minutes (for one sided or both sided groin / Inguinal hernia under general anaesthetic.
Laparoscopic MiniScarLess(MSL) TEP Hernia Surgery is usually done as a day case operation for Uni and Bilateral Hernia Surgery. The operating time is 30 to 50 minutes. However, for relatives the overall wait time seems much longer. Patient’s journey to theatre includes, going down to the receiving are in theatre (5-30 minutes stay), anaesthetic time in theatre (10-30 minutes), Positioning of patient and theatre set up (5-15 minutes in theater), Extubation / bringing the patient out of anaesthesia (5-30 minutes), Observation in recovery area (15-45 minutes). Overall time spent in theatre complex is 60 – 180 minutes excluding operating time.
Once patient returns to the ward, he/she still remains sleepy / woozy despite being awake and communicable for another hour or two; depending on the type of anaesthesia and pain killers administered during and after surgery.
The patient’s expected recovery journey is explained below.
In most cases after a standard Laparoscopic Inguinal Hernia (TEP) surgery there may be variations and one will need to be mindful of variations in recovery and should not hesitate consulting the operating surgeon.
The parameters for recovery are as follows:
To commence drinking and eating
Generally, 1-2 hours after returning to the ward. One is awake and starts with sips building up to free fluids and diet in a few hours.
Within an hour or two, building up to walking to wash room with supervision and support within four hours. Walks in corridors can be commenced after 4- 5 hours. Sitting on chair outside bed is preferred and recommended. Early mobilisation helps to expedite recovery.
a.) In an ideal world the pain should be 0/10. However realistically one can expect pain scores of 0-2/10 after Standard Laparoscopic Totally Extra Peritoneal (TEP) groin hernia surgery. Pain is generally in the groin and near belly button / umbilicus.
b.) One expects to have pain and discomfort for 3-6 days after surgery and requires regular pain killers for this period. After this period, only if one gets any further pain then one can continue taking pain killers for a longer period according to their situation.
c.) Though a person is reasonably comfortable by the end of first week, however, one can expect slight discomfort and at times pain for up to two weeks as one increases the activity while the healing is still going on in the body. Very few people may feel pain for up to three weeks or longer.
Opening bowels/going to the toilet
Passing water/urine commences within a few hours after surgery. Some elderly patients may have difficulty in passing urine after surgery and will be advised accordingly. This is more of a problem with open surgery but rarely seen after Laparoscopic surgery.
One will pass flatus /wind from the day of surgery or one day afterwards. Bowels will generally open day 2-5 after surgery.
On is less likely to get constipated after this surgery than other laparoscopic operations. Constipation is because of eating less during this period or due to taking painkillers after surgery. In cases of known history of constipation or not opening bowels after surgery, taking laxatives is advisable. Any laxatives that a patient is familiar with or the surgeon advising, will suffice.
A patient after Standard Laparoscopic Totally Extra Peritoneal (TEP) groin hernia surgery getting sudden left sided abdominal pain 4-5 days surgery is generally due to faecal loading and constipation. If worried, then medical advice from surgeon should be sought.
Discharge home/ stay in hospital
A few hours after surgery on the same day of operation or after one-night stay in the hospital. Generally, in Dubai, United Arab Emirates we keep the patients in the hospital for 1 night after surgery.
In United Kingdom most patients will be discharged home a few hours after the surgery.
If there were any complications during surgery, including conversion to an open operation during surgery or any observation of a problem needing addressing, one may need to stay in longer.
There are no dietary restrictions.
One starts from liquids from the day of surgery to normal food the same day.
Road travel restrictions
One can travel for reasonable distance by road on the day of surgery or the day afterward. Longer and bumpy journeys can cause discomfort but do not interfere with surgery or its outcome.
Return to air travel
Within 2-5 days after surgery as a passenger.
The personnel in aviation industry, especially pilots can return to flying after 2 weeks following the guidelines and clearance of their organization.
If in doubt then consult with your doctor.
Return to light exercise
From the day after surgery with light walks, but being sensible and slowing down or stopping if one feels pain or discomfort.
Return to moderate exercise
From 4-5 days after surgery onwards, once the patient is off the painkillers exercise can be started in the Gym.
One should exclude core exercises and those exercises requiring to hold breath and strain; like over head presses with weights and dead lift.
Return to heavy exercise
Generally patients are advised to take it easy for up to three weeks after a standard Laparoscopic hernia repair.
After Amir’s MSL (MiniScarLess) Laparoscopic Totally Extra Peritoneal (TEP) groin hernia surgery, there is no restriction on post-operative lifting of weight. The decision to slow down or stop heavy lifting is only based on the healing and pain due to it. There is no risk of recurrence. In some special circumstances the surgeon may advise the patients to go easy on heavy lifting for a period of 2 – 3 weeks after surgery.
Return to driving
Generally, when one is pain free and can focus on driving and road safely with a safe margin. Its variable and can be 4- 7 days after surgery with no complications. Insurance companies may not cover if one drives too early after surgery, while having pain.
Return to swimming
In the sea after 1 week
In the pool after 2 weeks
Return to work
Probably allowing 1 week after surgery will suffice in most cases. If the nature of work involves heavy lifting and outdoor activity then 10 days to 2 week would be sensible. The personnel in aviation industry, especially pilots can return to flying after 2 weeks following the guidelines and clearance of their organization.
If in doubt then consult with your doctor.