Inguinal Hernias surgery in Bangalore & Cost


Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms (mrcs) Is one of the leading GI surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous  Inguinal Hernia  patients in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

  For appointments Call Now ! –+91-9972446882 .

Laparoscopic inguinal hernia surgery in Bangalore

The true incidence and prevalence of inguinal hernia are unknown. According to the Healthcare Cost and Utilization Project (HCUP), 826,000 inguinal hernia repairs were performed in the United States in 2003, of which 215,000 were bilateral. Laparoscopic studies have reported rates of contralateral defects as high as 22%, with 28% of these going on to become symptomatic during short-term follow-up. The male-to-female ratio is greater than 10:1. Lifetime prevalence is 25% in men and 2% in women. Two thirds of Inguinal Hernia are indirect. Nearly two thirds of recurrent hernias are direct. Inguinal Hernia have an approximate incidence of incarceration of 10%, and a portion of these may become strangulated. Recurrence rates are less than 1% in children and vary in adults according to the method of hernia repair.

B. Terminology and anatomy 

  • Direct hernias are those in which viscera protrude through a weakness in the posterior inguinal wall. The base of the hernia sac is medial to the inferior epigastric vessels through the Hesselbach triangle, which is limited by the inferior epigastric artery, the lateral edge of the rectus sheath, and the inguinal ligament.
  • Indirect hernia sacs pass through the internal inguinal ring lateral to the inferior epigastric vessels and lie within the spermatic cord. The sac is covered by cremaster muscle fibers.
  • In combined (pantaloon) hernias, direct and indirect hernias coexist.
  • A sliding hernia (usually indirect inguinal in location) is a hernia in which a part of the wall of the hernia sac is formed by an intra-abdominal viscus (usually colon, sometimes bladder). In a Richter hernia, part (rather than the entire circumference) of the bowel wall is trapped. A Littré hernia is one that contains a Meckel diverticulum. An Amyand hernia is one that contains the appendix.
  • Incarcerated hernias cannot be reduced into the abdominal cavity, whereas strangulated hernias have incarcerated contents with vascular compromise. Frequently, intense pain is caused by ischemia of the incarcerated segment for Inguinal Hernias surgery in Bangalore .

C. Diagnosis of Inguinal Hernia

Clinical presentation of Inguinal Hernia

Most Inguinal Hernia present as an intermittent bulge that appears in the groin, usually related to exertion or long periods of standing. The patient may complain of unilateral discomfort without noting a mass. Often, a purposeful Valsalva maneuver can reproduce the symptoms for Inguinal Hernias surgery in Bangalore. In infants and children, a groin bulge often is noted by caregivers during episodes of crying or defecation. Rarely, patients present with bowel obstruction without noting a groin abnormality. All patients with a small-bowel obstruction must be questioned carefully and examined for hernias.

Physical examination of Inguinal Hernia

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The main diagnostic of Inguinal Herniamaneuver for Inguinal Hernia is palpation of the inguinal region. The patient is best examined while standing and straining (cough or Valsalva) for Inguinal Hernias surgery in Bangalore. Hernias manifest as bulges with smooth, rounded surfaces that become more evident with straining. The hernia sac can also be examined more clearly by invaginating the hemiscrotum to introduce an index finger through the external inguinal ring. This may become uncomfortable for the patient and is unnecessary if an obvious bulge is present.Incarcerated Inguinal Hernia present with abdominal distention, nausea, and vomiting due to intestinal obstruction.

 Radiographic evaluation of Inguinal Hernia

 . X-ray studies are rarely indicated. Ultrasonography or CT scanning may occasionally be used to diagnose an occult groin hernia, particularly in the obese patient. Plain abdominal x-rays may verify intestinal obstruction in cases of incarceration.

D. Differential diagnosis of Inguinal Hernia

Inguinal Hernia should be distinguished from femoral hernias, which protrude below the inguinal ligament. Inguinal adenopathy, lipomas, dilation of the saphenous vein, epididymitis, testicular torsion, groin abscess, and vascular aneurysms/pseudoaneurysms all should be considered in appropriate situations.

E. Treatment of Inguinal Hernia

Preoperative evaluation and preparation. Most patients with hernias should be treated surgically, although “watchful waiting” may be appropriate for individuals with asymptomatic hernias or elderly patients with minimally symptomatic hernias. Associated abnormalities that can increase intra-abdominal pressure (such as chronic cough, constipation, or bladder outlet obstruction) should be evaluated and remedied to the extent possible before elective herniorrhaphy. In cases of intestinal obstruction and possible strangulation, broad-spectrum antibiotics and nasogastric suction may be indicated. Correction of volume status and electrolyte abnormalities is important when there is an associated small-bowel obstruction for Inguinal Hernias surgery in Bangalore.

Reduction. Temporary management includes manual reduction. In uncomplicatedof Inguinal Hernia cases, the hernia reduces with palpation over the inguinal canal with the patient supine. If this does not occur, the physician applies gentle pressure over the hernia with the concavity of the palm of his or her hand and fingers. The palm of the physician’s hand exerts a steady but gentle pressure and also maintains the direction to be followed: craniad and lateral for direct hernias, craniad and posterior for femoral hernias. If the herniated viscera do not reduce, gentle traction over the mass with compression may allow bowel gas to leave the herniated segment, making the mass reducible. Sedation and the Trendelenburg position may be required for reduction of an incarcerated hernia, but the difficulty of distinguishing between acute incarceration and strangulation should be noted: The inguinal canal can become quite tender with or without ischemic contents. When an incarcerated hernia is reduced nonsurgically, the patient should be observed for the potential development of peritonitis caused by perforation of a loop of strangulated bowel. If there is strong suspicion of strangulation, no attempt should be made to reduce the hernia because of the potential for en masse reduction of a gangrenous segment of bowel with the hernia sac.

Inguinal Hernias surgery in Bangalore

Choice of anesthetic. Local anesthesia, which has several advantages over general or regional (spinal or epidural) anesthesia, is the preferred anesthetic for elective open repair. Local anesthesia results in better postoperative analgesia, a shorter recovery room stay, and a negligible rate of postoperative urinary retention; it is the lowest-risk anesthetic for patients with underlying cardiopulmonary disorders. Commonly, a mixture of a short-acting agent (lidocaine 1%) and longer-acting agent (bupivacaine 0.25% to 0.50%) is used. The dose limits for local anesthesia are 4.5 mg/kg plain lidocaine or 7 mg/kg lidocaine with epinephrine and 2 mg/kg plain bupivacaine or 3 mg/kg bupivacaine with epinephrine. Use of local anesthesia for herniorrhaphy in our hospital is routinely supplemented by monitored anesthesia care and administration of intravenous midazolam and propofol. Virtually all patients who undergo hernia repair under local anesthesia can be managed as outpatients unless associated medical conditions or extenuating social circumstances necessitate overnight observation in the hospital. Laparoscopic hernia repair has been carried out under local or regional anesthesia but is more commonly done under general anesthesia.

Treatment of the hernia sac. The anatomy of the inguinal region is displayed as viewed by the operating surgeon in Figure 26-1. In indirect hernias, the sac is dissected free from the cord structures and cremasteric fibers. The sac should be opened away from any herniated contents. The contents are then reduced, and the sac is ligated deep to the internal ring with
an absorbable suture. Alternatively, the hernia sac may be invaginated back into the abdomen without ligation. Large, indirect sacs that extend into the scrotum should not be dissected beyond the pubic tubercle because of an increased risk of ischemic orchitis. Similarly, one should avoid translocating the testicle into the inguinal canal during hernia repair owing to the risk of ischemia. Cord lipomas are frequently encountered during repair and should be excised or reduced into the retroperitoneum to avoid future confusion with a recurrent hernia. Sliding hernia sacs can usually be managed by reducing the sac and attached viscera. Direct sacs are usually too broadly based for ligation and should not be opened, but instead are simply freed from attenuated transversalis fibers and inverted.In preperitoneal repairs, the sac is usually reduced but not ligated because the repair is situated between the peritoneum and abdominal wall.

Inguinal floor reconstruction. Some of Inguinal Herniamethod of reconstruction of the inguinal floor is necessary in all adult hernia repairs to prevent recurrence. Various techniques for inguinal floor repair are available, and factors that influence the choice of repair include the type of hernia as well as the surgeon’s preference and expertise. Three broad categories of repairs are available: primary tissue repairs, anterior tension-free mesh repairs, and preperitoneal repairs, including the laparoscopic approach for Inguinal Hernias surgery in Bangalore.

Primary tissue repairs. Primary repairs without mesh were the mainstay of hernia surgery for decades. The advantages of these repairs are simplicity of the repair and the absence of any foreign body in the groin. Disadvantages include higher recurrence rates (5% to 10% for primary repairs and 15% to 30% for repair of recurrent hernias) due to tension on the repair and a slower return to unrestricted physical activity. Consequently, the vast majority of hernia repairs performed today in the United States use some form of tension-free mesh technique. The principal features of the more commonly performed tissue repairs are the following:

Bassini repair. The inferior arch of the transversalis fascia or conjoint tendon is approximated to the shelving portion of the inguinal ligament (iliopubic tract) with interrupted, nonabsorbable sutures. The Bassini repair has been used for simple, indirect hernias, including Inguinal Hernia in womenfor Inguinal Hernias surgery in Bangalore.

McVay repair. The transversalis fascia is sutured to the Cooper ligament medial to the femoral vein and the inguinal ligament at the level of, and lateral to, the femoral vein. This operation usually requires placement of a relaxing incision medially on the aponeuroses of the internal oblique muscle to avoid undue tension on the repair. The McVay repair closes the femoral space and therefore, unlike the Bassini repair, is effective for femoral hernias.

Shouldice repair. In this repair, the transversalis fascia is incised (and partially excised if weakened) and reapproximated. The overlying tissues (the conjoint tendon, iliopubic tract, and inguinal ligament) are approximated in multiple, imbricated layers of running nonabsorbable suture. The experience of the Shouldice Clinic with this repair has been excellent, with recurrence rates of less than 1%, but higher recurrence rates have been reported in nonspecialized centers.

Open tension-free repairs. The most common mesh inguinal hernia repairs performed today are the tension-free mesh hernioplasty (Lichtenstein repair) and the patch-and-plug technique. In the Lichtenstein repair, a piece of polypropylene mesh approximately 5 × 3 in. is used to reconstruct the inguinal floor (Fig. 26-2). The mesh is sutured to the fascia overlying the pubic tubercle inferiorly, the transversalis fascia and conjoint tendon medially, and the inguinal ligament laterally. The mesh is slit at the level of the internal ring, and the two limbs are crossed around the spermatic cord and then tacked to the inguinal ligament, effectively creating a new internal ring of mesh. This repair avoids the approximation of attenuated tissues under tension, and recurrence rates with this technique have been consistently 1% or less. Moreover, because the repair is without tension, patients are allowed to return to unrestricted physical activity in 2 weeks or less. The mesh plug technique entails placement of a preformed plug of mesh in the hernia defect (e.g., internal ring) that is sutured to the rings of the fascial opening. An onlay piece of mesh is then placed over the inguinal floor, which may or may not be sutured to the fascia. Mesh plugs may be ideally suited for the repair of small, tight defects, such as femoral hernias. Another technique involves the use of a bilayer mesh in which the posterior leaflet is placed in the preperitoneal space and the anterior leaflet is sutured to the same layers as with the Lichtenstein repair for Inguinal Hernias surgery in Bangalore .

Laparoscopic and preperitoneal repairs. Approximatelyof Inguinal Hernia 15% of hernia repairs in the United States are now carried out using a laparoscopic preperitoneal approach. The laparoscopic hernia repair is based on the technique of Stoppa, who used an open preperitoneal approach to reduce the hernia and placed a large piece of mesh to cover the entire inguinal floor and myopectineal orifice. Preperitoneal hernia repairs may also be performed without mesh, an approach that is rarely used today for routine hernia repair but may be a good option in patients with strangulated hernias. Advantages of the preperitoneal approach in this setting are that it may facilitate reduction of the incarcerated or strangulated hernia contents and, if gangrenous bowel is found, resection can be carried out through the preperitoneal incision, whereas this is difficult to accomplish through a standard groin incision.

Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms (mrcs) Is one of the leading GI surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous  Inguinal Hernia  patients in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

For appointments Call Now ! –+91-9972446882 

 

In laparoscopic hernia repair, the preperitoneal space is reached either by a transabdominal [the transabdominal preperitoneal (TAPP) procedure] or a totally extraperitoneal (TEP) repair. With the TAPP repair, the peritoneal space is entered by conventional laparoscopy at the umbilicus, and the peritoneum overlying the inguinal floor is dissected away as a flap. With the TEP repair, the preperitoneal space is developed with a balloon inserted between the posterior rectus sheath and the peritoneum (Fig. 26-3). The balloon is then inflated to dissect the peritoneal flap away from the posterior abdominal wall and the direct and indirect spaces, and the other ports are inserted into this preperitoneal space without ever entering the peritoneal cavity. The advantages of the TAPP approach are that there is a large working space, familiar anatomic landmarks are visible, and the contralateral groin can be examined for an occult hernia. The advantages of the TEP repair are that the abdominal cavity is not violated, the peritoneum is not opened, much of the dissection is done byballoon, and the procedure can potentially be performed under regional anesthesia.

 

After laparoscopic dissection and reduction of the hernia sac, a large piece of mesh (6 × 4 in.) is placed over the inguinal floor. This is stapled superiorly to the posterior abdominal wall fascia on either side of the inferior epigastric vessels, medially to the Cooper ligament and the midline, and superolateral to the fascia above the internal ring. Staples must not be placed in or posterior to the iliopubic tract or lateral to the iliac crest because of the risk of neurovascular injuries to the ilioinguinal, genitofemoral, lateral femoral cutaneous, and femoral nerves as well as the external iliac vessels. Comparative studies of laparoscopic and open hernia repair have shown that laparoscopic repairs are associated with less postoperative pain and faster recovery than open repairs, but hospital costs have been higher for the laparoscopic technique. Operative times, complications, and recurrence rates (<3% for laparoscopic repair) have been similar. A meta-analysis of 29 randomized clinical trials comparing laparoscopic and open inguinal hernia repairs concluded that laparoscopic repair was associated with earlier discharge from hospital, quicker return to normal activity and work, and significantly fewer postoperative complications than open inguinal hernia repair. However, the operating time was significantly longer and there was a nonsignificant trend toward an increase in the relative odds of recurrence after laparoscopic repair (Br J Surg 2003;90:1479). Another randomized trial comparing open and laparoscopic mesh inguinal hernia repairs at 14 Veterans Affairs (VA) institutions concluded that the open technique is superior to the laparoscopic technique for mesh repair of primary hernias due to decreased recurrence (4% vs. 10.1%) and complication rates (33.4% vs. 39%) (N Engl J Med 2004;350:1819).

Special circumstances in which laparoscopic repair may also be favored include (1) recurrent hernias to avoid the scar tissue in the inguinal canal, (2) bilateral hernias, because both sides of the groin can be repaired with the same three small incisions used for the unilateral repair, (3) individuals with a unilateral hernia for whom a rapid recovery is critical (e.g., athletes and laborers), and (4) obese patients. Laparoscopic hernia repair is contraindicated in patients who have large scrotal hernias or who have undergone prior extensive lower abdominal surgery.

The Kugel repair is a preperitoneal repair in which a preformed polypropylene patch with a stiff ring around the edges is placed in the preperitoneal space through an open incision. The preperitoneal space is accessed through an oblique skin incision about 2 to 3 cm above the inguinal ring halfway between the anterior superior iliac spine and the pubic tubercle. After the preperitoneal space is entered, the peritoneum is dissected free by blunt dissection, and the hernia sac is gently reduced. The esh patch is then placed into the preperitoneal space to cover the hernia defect. The Kugel technique is a preperitoneal alternative to the laparoscopic repair that can be performed under local anesthesia.

Complications of Inguinal Hernia

.Surgical complications of Inguinal Hernia   include wound hematoma, infection, nerve injury (ilioinguinal, iliohypogastric, genital branch of the genitofemoral, lateral femoral cutaneous, femoral), vascular injury (femoral vessels, testicular artery, pampiniform venous plexus), vas deferens injury, ischemic orchitis, and testicular atrophy. Recurrence rates after tension-free mesh repairs for primary hernias are 1% to 2% or less.

Recurrent Inguinal Hernia are more difficult to repair because the scar makes dissection difficult and the disease process has continued. Recurrence within 1 year of initial repair suggests an inadequate initial attempt, such as overlooking an indirect hernia sac. Recurrence after 2 or more years suggests progression of the disease process that caused the initial hernia (e.g., increased intra-abdominal pressure, degeneration of tissues). Recurrences should be repaired because the defect usually is small with fixed edges that are prone to complications, such as incarceration or strangulation. Repair can be done by an anterior approach through the old operative field or by a posterior (open preperitoneal or laparoscopic) approach. Prosthetic mesh is almost always used to reinforce attenuated tissues unless the operative field is contaminated.

Watchful waiting  of Inguinal Hernia. Another option in patients with minimal symptoms and an easily reducible inguinal hernia is “watchful waiting,” consisting of routine follow-up with a health care professional. This strategy was compared to operative repair in a randomized trial, which concluded that this is an acceptable option for men with minimally symptomatic Inguinal Hernia and that delaying repair until symptoms increase is safe due to a low rate of incarceration. In this study, 23% of patients initially treated with “watchful waiting” crossed over to surgical treatment due to an increase in symptoms, most often hernia-related pain. Only one patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, corresponding to a frequency of acute intervention of 1.8/1,000 patient-years (JAMA 2006;295:285).

Cost of Inguinal Hernias surgery in Bangalore .

Average cost of Cost of Inguinal Hernias  treatment in Bangalore is approximately 40,000/- INR

 Inguinal Hernias surgery in India.

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Dr Adarsh M Patil 1 copyDr Adarsh M Patil mbbs ms (mrcs) Is one of the leading GI surgeons in Bangalore .15 years of experience in eminent hospitals like Manipal Hospital, Apollo Hospitals and Narayana Hrudalaya in Bangalore.

He has experience of treating numerous  Inguinal Hernia  patients in Bangalore .

He believes in that Patient safety comes first and strives to provide exceptional service to patients.

For appointments Call Now ! –+91-9972446882