http://www.dnevnik.co.yu/arhiva/15-12-2001/Strane/mozaik.

htm
NOVI SAD, SUBOTA, 15. DECEMBAR, 2001. GODINE

LEKAR

NOVOSTI U HIRURGIJI
Mrežica doskočila kili
Do nedavno hernija se lečila samo klasičnom operacijom kod koje je oporavak pacijenta bio bolan i dug. - Ugradnjom
specijalne mrežice u velikoj meri se sprečava ponovno javljanje kile, a pacijent odlazi kući odmah ili sutradan posle
zahvata

Za sve one koji su imali kilu ili herniju oporavak posle hirurškog zahvata ostao je u
neprijatnom sećanju, pre svega, zbog velike boli koja je pacijenta pratila danima. Da
bude još gore, bruh se često ponovo javljao. Od nedavno oba ova problema uspešno se
rešavaju novom operativnom tehnikom i ugradnjom specijalne mrežice koja jača
oslabljeno mesto na trbušnim mišićima. U Institutu za hirurgiju Kliničkog centra Novi Sad
nedavno je izvedena pokazna operacija preponske kile ovom tehnikom. NJu je uradio
hirurg doc. dr Radovan Cvijanović koji je prvi u ovoj ustanovi ovladao ovom značajnom
novinom.
- Kila nastaje zbog slabosti mišića prednjeg trbušnog zida - objašnjava dr Cvijanović. - U
kilnoj kesi može da se nađe crevo ili masno tkivo. U nekim slučajevima, može da se vrati
nazad u trbušni zid, kod uklještene kile to nije moguće. U prvom slučaju, kila treba da se
operiše, kada se pacijent odluči na to. U drugom slučaju, operacija je hitna, jer može
doći do gangrene creva.
Najčešće se kila javlja u preponama,češće kod muškaraca nego kod žena. Pacijenti
ponekad pokušavaju da je se reše nošenjem pojasa za bruh, ali ni na ovaj način, kao ni
lekovima, kila ne može da se reši. Jedino operacijom bruh može da se izleči. Do nedavno
ovaj zdravstveni problem rešavao se samo klasičnim zahvatom.
-Mana ovakvog zahvata je bila što je zbog zatezanja i prišivanja mišića za ligament
dolazilo do velikog postoperativnog bola- kaže doc. dr Cvijanović. - Privlačenjem mišića
ligamentu slabi se deo iznad ovog mesta, pa je često dolazilo do ponovnog nastanka kile.
Zato pacijenti kažu da im se bruh vratio, a u stvari se radi o novom bruhu na
oslabljenom mestu. Oporavak posle klasične operacije je znatno duži u odnosu na novu
tehniku sa specijalnom mrežicom.
Već nekoliko godina preponska kila se rešava zahvatom bez privlačenja i zatezanja
mišića, prekrivajući otvor na kili mrežicom. Ona služi kao armatura kroz koju uraste
vezivno tkivo, ojača ovaj predeo, što u velikoj meri onemogućava pojavu nove kile.
Postavljanje mrežice može da se uradi laparoskopski, kada se ona postavlja sa
unutrašnje strane trbušne šupljine, ili spolja - kroz rez. Najnovija generacija mrežica
sačinjena je od takvog materijala oji ne izaziva odbacivanje. Kako nema postoperativnog
bola, oporavak je brz, pa pacijent već sutradan posle operacije može da se vrati
svakodnevnim aktivnostima. Zahvat može da se uradi i u lokalnoj anesteziji, a tada
bolesnik sam ustaje sa operacionog stola i odlazi kući. Postoperativni rezultati su mnogo
bolji nego kod klasične operacije, a ponovno javljanje kile je retko. Nažalost, pacijent
mora da plati mrežicu koja staje 450 maraka.k

http://www.medicinenet.com/hernia/article.htm

What is a hernia?

A hernia is an opening or weakness in the muscular structure of the wall of the abdomen. This defect
causes a bulging of the abdominal wall. This bulging is usually more noticeable when the abdominal
muscles are tightened, thereby increasing the pressure in the abdomen. Examples of activities that
can worsen a hernia are lifting, coughing, or even straining to have a bowel movement. Imagine a
barrel with a hole in its side and a balloon that is blown up inside the barrel. Part of the inflated balloon
would bulge out through the hole. The balloon going through the hole is like the tissues of the
abdomen bulging through a hernia.
Symptoms of a hernia include pain or discomfort and a localized swelling somewhere on the surface of
the abdomen or in the groin area.

Serious complications from a hernia result from the trapping of tissues in the hernia -- a process called
incarceration. Trapped tissues may have their blood supply cut off, leading to damage or death of the
tissue. The treatment of incarceration requires surgery.

Hernia repair: Also called a herniorrhaphy, a surgical repair of a hernia. Hernia repair may be done
under local or general anesthesia using a conventional incision or a laparoscope.

The alternative term "herniorrhaphy" comes from hernio-, referring to a hernia + the Greek rhaphe, a
seam = putting a seam (or suture) in a hernia.

Hernia: A general term referring to a protrusion of a tissue through the wall of the cavity in which it is
normally contained.

More specifically, a hernia often refers to an opening or weakness in the muscular structure of the wall
of the abdomen. This defect causes a bulging of the abdominal wall. This bulging is usually more
noticeable when the abdominal muscles are tightened, thereby increasing the pressure in the
abdomen. Examples of activities that can worsen a hernia are lifting, coughing, or even straining to
have a bowel movement. Imagine a barrel with a hole in its side and a balloon that is blown up inside
the barrel. Part of the inflated balloon would bulge out through the hole. The balloon going through the
hole is like the tissues of the abdomen bulging through a hernia.

Symptoms of a hernia include pain or discomfort and a localized swelling somewhere on the surface of
the abdomen or in the groin area.

Serious complications from a hernia result from the trapping of tissues in the hernia -- a process called
incarceration. Trapped tissues may have their blood supply cut off, leading to damage or death of the
tissue.

The treatment of incarceration requires immediate surgery.

For a full article on this subject, see Hernia.

Doctors' Views

Hernia Repair…Laparoscopy Success

UTRECHT, NETHERLANDS-As medical technology progresses, changes in the techniques used to

perform medical procedures are inevitable.

The laparoscope is a tube-like viewing instrument used to inspect, biopsy, and repair tissues inside of
the abdomen. Procedures utilizing a laparoscope require only small incisions (less than an inch) for
the instrument to be inserted into the cavity of the abdomen. This technique reduces healing and
recovery time while minimizing scars on the skin.

Dr. Mike S. L. Liem and others at the University Hospital Utrecht in the Netherlands reported their
treatment of 487 patients for hernia of the groin using the laparoscope and compared results with 507
patients using traditional open surgical repair. (New England Journal of Medicine 1997;336:1541- 7)

Dr. Liem's study found that the patients who had undergone repair with the laparoscope recovered
more rapidly than those who had open surgical repair. The average time to resume normal daily
activity was 6 days using the scope versus10 days with open surgery. The average time to return to
work was 14 days compared to 21 days. The average time to resume athletic activity was 24 days
versus 36 days.

Dr. Liem's study also found that the patients who had undergone repair with the laparoscope had
fewer recurrences (3 percent) than those who had open surgical repair (6 percent).

Whether laparoscopic groin hernia repair by the laparoscope method will now become accepted as
both effective and safe long-term awaits further study.

"Scope" procedures for removal of the gallbladder, evaluation and repair of the ovaries, lungs,
stomach, colon, and joints are now commonplace in community hospitals. As modern surgical
methods and technology evolve, various traditional surgical procedures may become more amenable
to scope methods. There are already reports of successful heart operations using scope techniques!

GENERIC NAME: ALUMINUM HYDROXIDE - ORAL (uh-LEW-mih-num

hi-DROX-ide)

BRAND NAME(S): Alu-Cap, Alu-Tab, Amphojel, Dialume

Medication Uses | Other Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes | Missed Dose | Storage

USES: Aluminum hydroxide is an antacid. It reduces stomach acid relieving heartburn and indigestion.
It is used to treat an upset stomach, ulcers, hiatal hernia or other digestive problems.

OTHER USES: This medication may also be used to treat high phosphate levels.

HOW TO USE: Take this medication as directed usually between meals and at bedtime. Do not take
more than is prescribed. Too much antacid can actually increase the amount of acid the stomach
produces.

SIDE EFFECTS: This medication is generally well tolerated. Loss of appetite or constipation may
occur. Notify your doctor if you develop: vomit that looks like coffee grounds, dark tar-like stools. If you
notice other effects not listed above, contact your doctor or pharmacist.

PRECAUTIONS: Tell your doctor if you have: stomach disorders, allergies (especially drug allergies).
This medication should be used only if clearly needed during pregnancy. Discuss the risks and
benefits with your doctor. Small amounts of this medication may be excreted in breast milk. Consult
your doctor before breast-feeding.

DRUG INTERACTIONS: Tell your doctor of any over-the-counter or prescription medication you may
take, especially of: iron, oral anti-diabetic medication, tetracycline, digoxin. Antacids can interfere with
the absorption of many other drugs. Be sure to check with your pharmacist before taking antacids with
any other medication. Do not start or stop any medicine without doctor or pharmacist approval.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room
immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian
residents should call their local poison control center directly. Symptoms of overdose may include
constipation.

Where are hernias located?

The most common location for hernias is the groin (or inguinal) area. There are several reasons for
this tendency. First, there is a natural anatomical weakness in groin region, which results from
incomplete muscle coverage. Second, the upright position of human posture results in a greater force
occurs at the bottom of the abdomen (at the bottom of the barrel), thereby increasing the stress on
these weaker tissues. The combination of these factors over time breaks down the support tissues
enlarging any pre-existing hole, or leading to a tear, resulting in a new hole. Several different types of
hernia may occur, and frequently coexist, in the groin area. These include indirect, direct, and femoral
hernias, which are defined by the location of the opening of the hernia from the abdomen to the groin.
Another type of hernia, called a ventral hernia, occurs in the midline of the abdomen, usually above
the navel (umbilicus). This type of hernia is usually painless. Hernias can also occur within the navel
(umbilical hernia).

How is a hernia repaired?

A hernia repair requires surgery. There are several different procedures that can be used for fixing any
specific type of hernia. In a standard repair, following appropriate anesthesia and sterilization of the
surgical site, an incision is made over the area of the hernia and carried down carefully through the
sequential tissue layers. The goal is to separate away all the normal tissue and define the margins of
the hole or weakness. Once this has been achieved, the hole is then closed, usually by some
combination of suture and a plastic mesh. When a repair is done by suture alone, the edges of the
defect are pulled together, much like sewing a hole together in a piece of cloth. One of the problems
with this approach is that it can put excessive strain on the surrounding tissues through which the
sutures are passed. Over time, with normal bodily exertion, this strain can lead to the tearing of these
stressed tissues and the formation of another hernia. The frequency of such recurrent hernias,
especially in the groin region, has led to the development of many different methods of suturing the
deep tissue layers in an attempt to provide better results.

In order to provide a secure repair and avoid the stress on the adjacent tissue caused by pulling the
hole closed, an alternative technique was developed which bridges the hole or weakness with a piece
of plastic-like mesh or screen material. The mesh is a permanent material and, when sewn to the
margins of the defect, it allows the body's normal healing process to incorporate it into the local
structures. This has proved to be a very effective means of repair.

After the hernia repair is completed, the overlying tissues and skin are surgically closed,
usually with absorbable sutures.

What kind of anesthesia is used for hernia surgery?

Fortunately, most hernia repairs (except in children) can be done with a variety of anesthetic methods.
With modern general anesthetic techniques and monitoring, general anesthesia (inducing "sleep") can
be very safe. However the surgery can also be performed under local anesthesia or regional
anesthetics, often at the same time using sedation medications to help relax the patient. The specific
type of anesthetic for an individual patient is selected after careful evaluation of the patient's general
health and individual concerns.

Can strengthening the muscles make a hernia go away?

Unfortunately, exercising to improve a hernia are likely to aggravate the condition. The hernia exists
because of a localized absence of muscle and supporting structure. Exercise can strengthen the
surrounding muscles, thereby worsening the localized weakness and increasing the pressures inside
the abdomen. The result is that more tissue can be forced through the defect and enlarge the hernia.

Should all hernias be repaired?

In general, hernias that are at risk for complications, cause pain, or limit activity, should be repaired. If
they are not repaired, there is a risk that an emergency procedure may be required at a later date.
This can be particularly difficult if timing is an issue around personal plans or during foreign travel.

Sometimes, a hernia can be temporarily controlled by wearing a belt-like device that applies external
compression, which pushes the tissues back into the abdomen and holds them there. This device is
called a truss. The truss must be carefully applied on a daily basis. It should only be used for selected
situations following careful evaluation by a doctor.
How can I tell if a lump or swelling is a hernia?

Not all lumps or swellings on the abdominal wall or in the groin are hernias. A doctor should evaluate
any such swelling. Other possible causes include growths or enlarged lymph nodes. These problems
require entirely different types of evaluation and treatment.

Hernia At A Glance
 Symptoms of a hernia include pain or discomfort and a localized swelling somewhere on the
surface of the abdomen or in the groin area.
 There are many different types of hernias.
 Serious complications from a hernia result from the trapping of tissues in the hernia
(incarceration), which can result in the damage of death of the tissue.
 Hernia repair and the treatment of hernia complications require surgery.

What other types of hernias are there?

Epigastric, umbilical, incisional, lumbar, internal, and Spigellian hernias all occur at different sites over
the abdomen in areas that are prone to anatomical or structural weakness. With the exception of
internal hernias (within the abdomen), these hernias are commonly recognized as a lump or swelling
and are often associated with pain or discomfort at the site. Internal hernias can be extremely difficult
to diagnose until the intestine (bowel) has become trapped and obstructed because there is usually no
external evidence of a lump.

What about the use of a laser in hernia repair?

This is a relatively common question. It arises because, for a time, there were some surgeons
marketing "Laser Hernia Repair." While a laser may have been used to make the incision and to
separate the tissues, the laser really has no application in the repair of a hernia. It is impossible to
perform the necessary structural repair with a laser, which is essentially a cutting tool. Hopes that
somehow an incision made with a laser would significantly reduce pain have not been confirmed. This
is probably because no matter how the incision is made, the majority of the post surgical pain arises
from the deeper structures that require suturing.

http://www.hernia.org/faq.html

I had my hernia repaired somewhere else.

How long before I can do things again?
Everybody does hernias differently - and with
different levels of expertise - and the results are
very widely varied. Although our patients are able
to do whatever they like as soon as they like,
elsewhere it can take weeks or months to get back
to normal. We cannot tell you what to expect, only
the surgeon who did it can. You must ask him.
I do not have a 'bulge' and my doctor does not know if this is a
hernia or not.
How can I be sure?
The 'bulge' is a very common symptom of hernia, but
not all hernias have bulges ... and
not all groin pain is hernia.
To find out with more certainty in cases that are difficult to
distinguish, you should be seen by a hernia specialist. For
more information on confusing cases of groin injury click
 here for the section on Sport, Groin Pain and Hernia
My Family Doctor says:
"If it doesn't hurt you, just leave it alone and see what
happens."
.

Is this really good advice?

We would not seek to contradict any
doctor, but we are increasingly coming to
the view that this can be very bad advice.

As hernia specialists, we know that

hernias ONLY tend to get worse and
every day we leave them untreated, we
run the risks of complications setting in
as well as facing a larger operation
eventually.

The ONLY advice that should be given

once a hernia is diagnosed is to get it
repaired as soon as possible.

Where, say, only old-fashioned or inferior

techniques of hernia repair are available,
the advice to avoid surgery because that
kind of operation really WOULD pose a
serious risk to the patient, might have
some unfortunate merit.
However, if the patient has access to the kind of
specialised operation described here, it is very rare that a
case exists where the patient should NOT have the hernia
repaired as soon as possible.

Many of the giant, even inoperable, hernias we see

started off being ignored due to such well-meaning
advice by their doctor.
Apart from the risks of strangulation, hernias can just get bigger and bigger, and BIGGER!

This hernia, like all hernias, started off as a small bulge by his navel. It did not hurt him and
he decided to accept the common, yet mistaken belief that there was no reason to undergo
surgery "yet".

Of course, as it became larger, he still chose to put off dealing with it until it reached this
stage, which was really not at all sensible. Sadly, we see cases like this all the time.

This is pretty graphic evidence why we feel as we say above, that the ONLY advice that
should be given once a hernia is diagnosed is to get it repaired as soon as possible.
By the way, we have seen hernias get much bigger, even than this one!

What are the SYMPTOMS of a hernia - Is what I have found a hernia?

Unless you are a doctor, do not try self-diagnosis. The reasons are many, including that
there are several possible symptoms, some or none - or any mixture of which you may
have and may detect. However, what you have might be something else entirely and by
you thinking (perhaps incorrectly) that you can diagnose it as a hernia, you may be putting
something else at great risk of going untreated - perhaps with dangerous consequences.

If you have symptoms indicating something is not right, then SEE A DOCTOR who can
diagnose it for you properly. No other course is sensible.

I thought that KEYHOLE surgery was the best technique available.

Do you agree?
Keyhole (laparoscopic) surgery represents a great advance in many areas of surgery, such
as ovaries, throats, knees, etc.

For hernia, though, we find that results that are as good or better can be achieved without
the risks of keyhole surgery. Furthermore, our preferred approach does not need general
anaesthesia. Keyhole surgery can only be done with general anaesthesia or spinal
injections, which carry additional risks.

We stress that different ideas and beliefs by surgeons are healthy in order to make the
changes that lead to advances and improvements. Although there are some eminent
proponents of keyhole hernia repair, we do more of these tension-free hernia repairs than
any hospital in the entire world, so we could use any technique known to surgical science.
Our conclusions are, therefore, based upon very significant experience.
l have a HIATUS hernia.
What can I do to relieve the symptoms? Is surgery unavoidable?
There are many ways of dealing with HIATUS hernia, apart from surgery and many types
of surgery now available

What is a 'SPIGELIAN' Hernia?

 All the names of the different hernias really relate
only to where they are on the body, a rough guide to
which is shown here.

Spigelian hernia is much less common than others,

but is - nevertheless - still a hernia in the abdominal
wall, slightly to the side of the upper abdomen. It is,
like the others, an opening of a 'window' in the wall
tissue which needs to be closed by surgery. For all
other aspects, what you see on our web site is the
same information for all the abdominal wall hernias,
including these.

We repair these hernias in almost exactly the same

way as we repair the others, with a tension-free
reinforcement. The operation is safer, the recovery is
much faster and the long-term outcome better.

Once the diagnosis has been confirmed one should

have the surgery and, if at all possible, by a hernia
specialist who uses this modern technique routinely.

My child has a hernia.

What needs to be done about it and who do I need to see?
Paediatric hernia must never be ignored. Things
happen much faster in children and delay in treating a
child's hernia that may NEED treatment (not all of
them do) could cause harm now and damage the
child's development. You must find out.
Click here for information about paediatric hernia

Why is the whole subject of hernia RECURRENCE

so important ?
"A surgeon can do more for the community by
operating on hernia cases and seeing that his
recurrence rate is low than he can by operating on
cases of malignant disease"
Sir Cecil Wakely
President: Royal College of Surgeons (Eng) 1948

The hernia repair performed at this The same is true of the breakdown of the
Centre enables us to be confident scar in the abdominal wall from an
against recurrence 'for life'. incision for a previous operation for some
Unfortunately, however, repairs other problem. This is called an
performed elsewhere are not this 'incisional' hernia. Thus the 'recurrent'
reliable and failures can and, all too hernia and the 'incisional' hernia are very
often, do occur at any time in the similar in many respects, including the
patient's lifetime. difficulties in effecting a reliable repair.

Unfortunately, there are also cases of

When a hernia repair operation
breaks down (i.e. a 'recurrent'
hernia) further repair operations are
more difficult than the first and, to
make matters worse, the chances of
success actually diminish with each
successive attempt at repair.
'multiple hernias' and of combinations of
all the above, such as 'multiple,
RECURRENT hernias'. These cases
pose many difficulties to most surgeons
and are, all too often, not successfully
repaired.

Perhaps this is why Sir Cecil made the above historical statement on
the subject of recurrences!

Difficulties With The Generally-Used Method

Not only are the tissues in the

The 'front' approach of recurrent hernia
abdominal wall more scarred and
repair carries the further risk in the case
therefore potentially harder to work
of a male patient of damage to the
on, but recurrent repair operations
blood supply to the testicle when
suffer a significant failure rate.
cutting through scar tissue in that area,
which can lead to a patient losing a
Subsequent repairs of recurrent
testicle as a result.
hernias by the usual anterior (front)
approach are followed by further
Because of this, together with the fact
recurrence in 20% and more of cases
that the common approach is followed
over the years. In some cases this is a
by an increasing incidence of
serious hazard and multiple
recurrence, we prefer an entirely
recurrences fare even worse, even
different and better method of repair in
exceeding a 50% chance of failure!
which we specialise.
(See below)

The British Hernia Centre Method

Our operation is performed via an What of REALLY complex cases?

incision higher than the previous
one(s) and the hernia itself is Depending on how complex the case,
approached from behind the weakness we can still perform some recurrent
in the abdominal muscles. There is,
therefore, no need to cut through
scar tissue and the described risks to
the testis do not apply.
The hernia opening is then completely
covered by a mesh 'veil' applied from
the inside, making it virtually
impossible for a further recurrence to
take place. In effect, the whole area of
abdominal wall surrounding the hernia
site(s) becomes reinforced without
really involving the area(s) previously
operated upon.
Is recovery much slower?
Because our technique avoids the
usual, high levels of tissue trauma and
the repair is 'tension-free' (in the same
way as is described earlier for the less
complex repairs), there is surprisingly
little discomfort and recuperation is
just as rapid as after our 'simpler'
hernia repairs.
Patients are expected to be as active as
possible from the first day i.e.
walking 1 to 2 miles, swinging a golf
club (or similar activity) and return to
completely normal routine, work
etcetera, often in 4 to 7 days.
hernia repairs under local anaesthesia,
although the more problematic and
most complex cases are performed by
this particular procedure with the help
of just a light, general anaesthetic.
Factors that decide the approach
include how long the patient has left the
hernia untreated, how many times it has
already been repaired, how large it is
and so on.
In the vast majority of cases, even the
more complex ones, the patient still
leaves the same day and is 'dressed for
dinner' that same evening. Only in the
most challenging of cases is there a
need for overnight hospital stay, and
even then normally for only one night.
A prior examination will determine
which is the most suitable course for
each case.
We have a technique perfectly suited
to each individual case and in which
we have gained unique experience.
The extremely large number of hernia
cases seen each year at The British
Hernia Centre, added to the experience
of thousands of cases we have already
performed, puts us in a singular position
to offer this superior technique of repair
for the more complex cases.

Instead of the recurrence rates previously deemed the 'norm', of 20 to 50

% or more, a recent study* of cases performed at The British Hernia Centre
has shown a recurrence rate with our repair of recurrent hernias (including
complex, multi-recurrent cases) of LESS THAN 1%
For the first time, the success rate for MULTI-RECURRENT hernias
is as low as for PRIMARY (first-time) hernias!