Outpatient Surgical Procedures
Also called “Day Surgery” or “Ambulatory Surgery” these procedures require general anesthesia or IV sedation (more than just local anesthesia), but do not require an overnight hospital stay. Minimally invasive surgery procedures are applied to a growing variety of procedures, and they are ideal for the outpatient setting.
General Comments About Hernias:
The primary source of a hernia is a tear in the strength layer of the abdominal wall, called fascia. Fascia gives structural support to the muscles. When the fascia is torn, the muscles retreat to where there is fascial support. This is why you can’t exercise (strengthen muscle) to improve a hernia. Damaged or torn fascia requires surgical intervention. In fact, hernias can get worse with exercise as you increase your internal, intra-abdominal pressure and push more tissue out.
With time, the hernia can get larger and entrap internal fat or even parts of your intestine. If intestine is trapped in the hernia sac, it is called incarceration and requires immediate evaluation at the emergency room. The reason for this is that incarcerated bowel can result in a cut-off blood supply leading to intestinal strangulation, which means the tissue is ischemic or non-viable. Both incarceration and strangulation are indications for emergency surgery. I recommend elective hernia repair for this reason, whenever possible.
Inguinal Hernias
The inguinal hernia repair procedure is one that has had notable technological advances in recent years due to the ability to perform a minimally invasive repair by use of laparoscopy. I still perform open inguinal hernia repair in select cases but laparoscopic repair is associated with less postoperative pain and faster recovery, so most patients who are good candidates for laparoscopy choose this approach.
Ultimately, we discuss the options and choose the best procedure for you together.
- Location: in the groin regions, above the crease that is between the lower abdomen and upper thigh, left or right of pubic bone.
- Characteristics: Soft, but feels firmer than the surrounding area fat. The skin over the lipoma is normal and not inflamed.
- Pain: Usually not painful, but can be sensitive to touch if next to a nerve.
- Size: Ranges quite a bit, but the ones that can be removed in the office are usually up to about an inch in diameter.
The inguinal region is an area of anatomic weakness of the fascia. In males, testicular descent into the scrotum occurs during the final stages of fetal development and the path to the scrotum may not fully close (yes, infants can be born with hernias). Even if this tract closes, this area is still weaker than other areas of the abdominal wall.
Women also get inguinal hernias as the layers of muscle and fascia become a single layer to insert into the pubic bone and this layer can be weaker than the rest of the abdominal wall.
Yes, even small hernias can get incarcerated, and over time hernias will continue to increase in size.
Infection:
There is small risk of infection with any procedure. Preoperative IV antibiotics, given just before surgery are routinely administered to minimize any risk for infection.
Bleeding:
There are blood vessels that are observed and in the area of dissection, however working around them is standard during surgery and expected blood loss is minimal – less than a vial of blood that one would give for lab draws.
Hernia recurrence:
Studies have shown that inguinal hernia recurrence is comparable regardless of whether they are done as a laparoscopic procedure or open procedure. Individuals with other medical conditions are at increased risk for hernia recurrence, however the greatest incidence of recurrence is associated with obesity.
Chronic pain:
There is a 1 % chance of chronic pain after inguinal hernia surgery regardless of whether an open or laparoscopic procedure is done. This incidence is due to the inguinal region having several nerves that supply sensation to the area – these are the ilio-hypogastric, ilioinguinal, and genitofemoral nerves. 99% of patients do just fine. For the 1% of patients where chronic pain develops there are measures we can take to manage and treat the pain. These include topical anesthetic ointments, scar tissue steroid injections, and rarely- neurectomy (resection of nerve segments).
Mesh complications:
What we refer to as “mesh” is the woven synthetic material that is used to reinforce the abdominal wall where there is absence or weakness of fascia. There are advertisements on TV these days by law firms looking for potential litigation cases to bring against the makers of hernia repair mesh. This is a complex subject which I will reduce to a relatively simple answer.
Mesh has been used for hernia repair for many decades. Overall, the advent and use of hernia mesh has been tremendously beneficial in lowering hernia recurrence rates. The vast majority of hernia surgeons use mesh for hernia repair. There were various kinds of mesh used in the past, some which may have had good logic for their use at the time but have not had good outcomes, such as heavy-weight meshes that were associated with increased pain or light-weight meshes that could tear with time and result in hernia recurrence. In my 20+ years of practice, I have used a medium weight polypropylene mesh and have had reliable, good results.
Allergic reactions to mesh are reported at 1 out of 100,000-200,000. There are many additional types of meshes with various benefits and weaknesses, but these are beyond the scope of our discussion here.
Laparoscopic Inguinal Hernia Repair with Mesh Procedure
What to expect the day of procedure:
- Pre-procedural prep: In anticipation of general anesthesia, nothing to eat after midnight prior to surgery. Clear liquids up to 2 hours prior to surgery.
- Surgery will take 1-1 ½ hours depending on features of the hernia and whether the hernia is only on one side or bilateral.
- You will be asked to present to the surgery center 1 hour prior to procedure or hospital 2 hours prior to procedure.
- The preop nurse will place an IV and start mediations.
- Then the anesthesiologist and OR nurse will bring you into the operating room.
- The anesthesiologist will provide general anesthesia, which means you will be completely asleep for the surgery and you will there will be a temporary breathing tube in your airway.
- Sterile skin prep is applied to the surgical area once you are asleep.
- Three small incisions are made, one at the umbilicus and two on either side of the lower abdomen and tubes called “trochars” are placed via which carbon dioxide is introduced to create an internal “tent” and then the camera and instruments are placed.
- The inner lining of the abdominal cavity, called the peritoneum is opened, and mesh reinforcement is placed to cover the hernia fascial defect, then the peritoneum is replaced.
- The three small incisions are then closed with sutures that are dissolvable and Steri-strips (reinforced tapes) and band-aids are applied as dressings.
- You will be transported to the recovery room and this is where you are carefully observed as you wake up fully, which is usually about a 1 hour process.
Post-procedural care:
- Shower and remove the band-aids in 48 hours and allow the Steri-strips to fall off on their own. The Steri-strips can be removed if they are still on the skin after 7 days.
- Schedule a telemedicine or in-office post-procedural visit for 10-14 days weeks.
- Diet: A light dinner is recommended after surgery then you can eat a regular diet the following day.
- Activity: It is better that you do not stay in bed other than for sleep as getting up and walking around at home helps with blood circulation in your legs and taking deep breaths prevents pneumonia.
- Lifting restrictions: Avoid lifting greater than 20 lbs for one month.
- Pain control: Stronger, narcotic pain medications are required for 2-4 days and then a combination of Tylenol and Ibuprofen/Advil/Motrin can be used for less severe pain.
- Return to work: Most people are feeling only minor discomfort by one week after surgery and are no longer taking narcotics, so if you have a sit-down job returning to work at that point may be possible, but it is reasonable to take 2 weeks off and return to work earlier if you are feeling well. Lifting restrictions are no greater than 20 lbs for one month from surgery date, and my office will write a note for work to that effect if you have a physically demanding job.
Gallbladder Disease and Gallstones
I perform a minimally invasive gallbladder removal called Laproscopic Cholecystectomy. This approach uses 4 small incisions to access the gallbladder and is associated with significantly less pain and faster recovery than open surgery. I have performed more than 1000 laparoscopic gallbladder removals over the 20+ years of being a surgeon and am confident in being able to provide a safe operation for you.
- Location: Right upper abdomen, can radiate along the rib cage and to the mid-back.
- Pain: Onset of pain typically takes place 30 minutes-4 hours after meals, especially fatty or rich meals. Pain may awaken you from sleep. If the pain lasts more than several hours or is associated with nausea and vomiting, an urgent medical evaluation may be required.
- Associated Symptoms: Abdominal bloating, abdominal pressure sensation, nausea and/or vomiting. In severe cases, fever, chills, sweats, jaundice, dark urine or light-colored stools.
Gallbladder inflammation is called Cholecystitis, and can be caused by a number of factors:
- Gallstones: Gallstones are hard particles that build up in your gallbladder, and may create a blockage. They are the most common reason for gallbladder inflammation, infection and bile duct blockage.
- Acalculous Cholecystitis: The gallbladder is not a well-vascularized structure and can become infected even in the absence of gallstones, often when there are concurrent medical conditions. The symptoms and management are the same as cholecystitis with gallstones.
- Bilary Dyskinesia: Biliary dyskinesia refers to the condition where the gallbladder wall does not function normally and the gallbladder does not contract or empty its content in response to a cholecystokinin challenge.
- Gallbladder Polyps: Gallbladder polyps are growths within the lining of the gallbladder. Multiple, smaller polyps are usually cholesterol deposits with no associated cancer risk. Solitary polyps may be pre-cancerous growths.
- Solitary Large Gallstones & Gallbladder Cancer: Large, solitary gallstones can be associated with gallbladder cancer. They can cause chronic irritation of the gallbladder lining and we think that over the years the gallstones takes to develop, this can create abnormal cellular changes in the lining of the gallbladder that leads to cancer. Gallbladders with gallstones larger than 1.5 cm, even when not associated with pain, should be removed surgically.
The risks of most surgical procedures include infection, bleeding and anesthesia.
Specific to gallbladder surgery, common bile duct injury and bile leak and notable potential risks, but there is less than 1% chance of these.
I have performed more than 1000 laparoscopic gallbladder removals over the 20+ years of being a surgeon and am confident in being able to provide a safe operation for you.
The most common new symptom patients report after gallbladder removal is diarrhea. In all cases that I have seen, it is a short lived condition. The reason for diarrhea seems to be due to your system adjusting to the constant bile flow to the intestine instead of having a temporary storage location. The vast majority of patients do not experience this. If there is postoperative diarrhea, it lasts for several weeks, is self-limited, and resolves on its own without treatment. In very small percentage of patients there is need for a bile-salt binding agent called cholestyramine that is taken before meals to prevent diarrhea. The need for cholesytramine is usually for approximately one month.
You should expect to resume a normal diet after surgery and, if fatty foods were avoided prior to gallbladder surgery, a normal diet without avoidance of rich foods is expected.
Laparoscopic Cholecystectomy
- At your office visit, you will be instructed which of your usual medications you can take on the day of surgery and when to begin your preoperative overnight fast.
- On the day of surgery, you will meet the anesthesiologist and the operating room nurse. In the operating room there will also be a surgical tech.
- Once you are asleep and all safety precautions are addressed, we start surgery by first insertion of the small tubes that allow a controlled pressure of carbon dioxide to be introduced to create a tent to work in, and then a camera or laparoscope and additional instruments are placed. The gallbladder is removed and placed in a sterile pouch and then brought out of the abdomen via the umbilical incision.
- The gallbladder is sent for pathology evaluation to make sure there are no unexpected findings or abnormal cells lining the gallbladder.
- The incisions are closed with sutures that are under the skin (subcuticular) and dissolvable so that there is minimal scarring from the incisions. On the skin “Steri-strips” or reinforced tapes are applied that reinforce the skin closure. Then Band-aids are applied to each site.
Recovering at home:
- What does recovery look like?:
Although your surgery can be done safely as an outpatient, day surgery, you will need time to recover at home. You will need to rest at home for the first few days until you are off the stronger, narcotic pain medications. Please see the section on postoperative pain control and constipation. - Expected Pain:
Most patients are off their narcotic pain medications in 2-4 days and are on regular Tylenol with Ibuprofen for pain control. - Diet:
Keep well-hydrated post operatively. A light diet of soups/sandwich/rice is recommended on the night of surgery given the anesthesia exposure, but you can start a regular diet the next day. - Activity:
We ask that you restrict your lifting to up to 20 lbs for 4 weeks from the day of surgery in order to prevent hernias, especially at the umbilical region where the largest of the small incisions is located. - Follow Up:
You should call the office for a follow-up appointment 1-2 weeks after surgery and at that visit, I will make sure that you are recovering as expected, that the incisions are healing well, go over your pathology report and answer any questions you may have.
