Minimally invasive abdominal and visceral surgery

Inguinal hernias, particularly in men, are among the most common conditions treated by visceral surgeons. The exact causes are unknown. It is thought that connective tissue weakness is at least partly responsible. Inguinal hernias are often noticed by chance. For example, when showering, you may feel a swelling in the groin area, which may not be painful. Or there may be swelling and/or discomfort in the groin when coughing, sneezing, straining or lifting heavy loads. After a quick internet search, many people will immediately suspect a hernia and will either see their GP or go directly to a surgeon. In most cases, the diagnosis is easily arrived at through careful questioning and clinical examination of the patient. If in doubt, it makes sense to perform an ultrasound examination of the area.

If the diagnosis of an inguinal hernia has been made and the patient has some pain or discomfort, the treatment is always surgical repair. The most serious complication is an incarcerated or strangulated inguinal hernia. A strangulated hernia is rare, but it can occur in both large and small hernias. This is why surgery is usually recommended to repair an inguinal hernia.

In most cases a laparoscopic inguinal hernia repair can be performed, which is a minimally invasively procedure. These days, mesh is almost always used in both open (conventional) and laparoscopic repairs of inguinal hernias in adults. The advantages of a laparoscopic mesh repair are the rapid return to physical activity (depending on pain levels) and the fact that the risk of hernia recurrence is negligibly small if the correct surgical technique is used. The procedure is usually performed under general anaesthesia. The procedure can only be performed under spinal or local anaesthesia if an open (rather than laparoscopic) technique is used. A unilateral hernia repair (on one side) takes about 30 to 60 minutes, and a bilateral repair (on both sides) takes about 45 to 90 minutes. Approximately 20–30% of patients have bilateral hernias. The hospital stay is usually one to two nights, depending on the general condition and age of the patient.

© By Dr Mischa C. Feigel

Everyone has haemorrhoids. They are normal vascular structures located under the anal mucosa that play an important role in stool control, including differentiation between wind and stool. However, the term ‘haemorrhoids’ is also used to mean the disease that occurs when these structures become enlarged, extend out of the anal canal, and start to cause mechanical and other problems. Symptoms include bleeding (fresh, bright red blood) during bowel movements, itching, and protrusion of the haemorrhoids or the anal mucosa from the anus (haemorrhoidal or mucosal prolapse). If these symptoms occur frequently and are disturbing to the individual (including in terms of anal hygiene), symptomatic treatment should be commenced (e.g. ointment, suppositories, treatment of any constipation, etc.).

If the symptoms do not disappear or recur within six to eight weeks (bleeding in particular), a rectal ultrasound must be performed. This can be done by a visceral surgeon. In people aged over 50, a colonoscopy must be performed by a gastroenterologist. The bleeding may be caused by haemorrhoids, but other sources of bleeding must always be excluded (particularly colorectal cancer or inflammation). If the diagnosis of haemorrhoidal or mucosal prolapse is confirmed, treatment may be conservative, symptomatic, interventional (rubber band ligation, especially for small haemorrhoids) or surgical, depending on the level of discomfort. Larger haemorrhoids and/or mucosal prolapses usually require surgical treatment. Different treatments may be used depending on the size and extent of the findings.

Nowadays the standard surgical treatment is stapled transanal mucosectomy, as developed by Longo. In this method, the haemorrhoids are ‘lifted’ back into the anal canal by means of a special circular stapler, without removing the haemorrhoids per se. The blood supply to the haemorrhoids is severely restricted in this very gentle and relatively painless procedure. This causes the haemorrhoids to shrink within a few weeks, while remaining in place. In addition, the procedure is performed via the anal canal, which is why there are no wounds visible from the outside. Physiologically, the Longo procedure makes much more sense than removing the haemorrhoids, as this can be very painful for a long time and the anal wounds take some weeks to heal. Anal procedures can be performed under general or spinal anaesthesia. The Longo procedure for haemorrhoids takes about 15 to 30 minutes. There is usually a hospital stay of one night. Care must be taken to ensure that bowel movements are soft following the procedure.

© By Dr Mischa C. Feigel