Thomas Fairbank (1876-1961)
- “You can judge the worth of a Surgeon by the way he does a hernia” –
- Sir Harold Arthur ThomasFairbank was educated at Epsom College from which he gained an open scholarship to Charing Cross Hospital. He qualified as a doctor in 1898 and in 1899 as a dentist. He was appointed as orthopaedic surgeon to Charing Cross, the first appointment of its kind in London, and also to Great Ormond Street, where his particular study was of congenital dislocation of the hip. He was invited to take charge of an orthopaedic department at King's College Hospital and to act as consultant orthopaedic surgeon to the King Edward VII Hospital for Officers and to the Treloar Hospital at Acton.
- He was an honorary Fellow of the Royal Society of Medicine and president of its Orthopaedic and Children's sections. As president of the British Orthopaedic Association he was invited to give the Lady Jones Lecture at Liverpool in 1929, and was Robert Jones lecturer at the College in 1938; he was made an honorary MCh (Orth) Liverpool in 1939.
Sir Astley Paston Cooper, 1804.
- “No disease of the human body, belonging to the province of the surgeon, requires in its treatment,a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its variants.”
- Sir Astley's greatest contribution has probably been in the field of vascular surgery particularly on cerebral circulation. He was the first to demonstrate experimentally the effects of bilateral ligation of the carotid arteries in dogs and to propose treatment of aneurysms by ligation of the vessel. In 1805 he published in the first volume of Medico-Chirurgical Transactions an account of his attempt to tie the common carotid artery for treating an aneurysm in a patient.. Cooper was an indefatigable and original anatomist and identified several previously undescribed anatomical structures, many of which were named after him:
- Coopers fascia, a covering of the spermatic cord.
- Coopers pubic ligament, the superior pubic ligament.
- Coopers stripes, a fibrous structure in theulnar ligaments.
- Coopers ligaments, the suspensory ligaments of breasts.
He also described a number of new diseases, which likewise became eponymous:
- Coopers testis (neuralgia of the testicles)
- Coopers disease (benign cysts of the breast)
- Coopers hernia (retroperitoneal hernia)
- Coopers neuralgia (neuralgia of the breast)
Sir Henage Ogilvie (1887-1971).
- “I know more than hundred surgeons whom I would cheerfully allow to remove my gall bladder but only one to whom I should like to expose my inguinal region”
- Sir William Heneage Ogilvie, KBE, DM, MCH, FRCS,was a English surgeon at Guy's and the Royal Masonic Hospital in London. He served as an examiner in surgery for the universities of Oxford and Cambridge and as editor of the journal `Practitioner'. He was the vice-president of the Royal College of Surgeons in London. He wrote a number of surgical treatises, contributed chapters to textbooks on surgery, and published monographs on bone fractures and hernias. His description of Ogilvie's syndrome was the subject of a 1948 article.
- Ogilvie is most famous in surgery for his description of Ogilvies Syndrome which is often termed acute colonic pseudo-obstruction.
Here are some of Ogilvie's famous quotations;
"The instances when the first recognisable onset of cancer has followed almost immediately on some disaster, a bereavement, the breakup of a relationship, a financial crisis, or an accident, are so numerous that they suggest that some controlling force that has hitherto kept this outbreak of cell communism in check has been removed."(No Miracles Among Friends)
"I know more than 100 surgeons whom I would cheerfully allow to remove my gall bladder but only one to whom I would like to expose my inguinal canal."
"A misleading symptom is misleading only to one able to be misled.''
"The really idle man gets nowhere. The perpetually busy man does not get much farther.''
"Specialism is inevitable, and having accepted it we must examine its limitations....disease is no specialist. Patients do not consult us because certain organs are affected, but because they feel ill.''
"The science of experimental medicine is something new and sinister,''
"British surgery has always stood high because it can be claimed, and not without reason,that every surgical advance of major importance has come from this country.'' (BMJ 1954)
"A happy man never gets cancer'' (1950's)
A.V.Hospital has been accrediated with “Center of Excellance in Endohernia Surgery” by Hernia Society of India during the 11th Annual Conference of Hernia Society of India
A.V.Hospital is a Comprehensive Hernia Care Surgery center
The main concern among patients undergoing hernia surgery is the fear of recurrences.If you reach the point where you need hernia surgery, it’s important to go to a comprehensive hernia center to get the best of treatment. A.V.Hospital has been a referral center for many years for hernia surgery. It has performed maximum number of laparoscopic hernia repairs till date in the state.Almost all types of complicated and recurrent hernias has been managed by laparoscopic method.
With expertise in both minimally invasive surgery and large comprehensive surgery, this dedicated hernia center helps ensure the operation is done right the first time.The patients outcomes are comparable to international standards. Advances in minimally invasive surgery mean that, for many patients, hernia surgery is no longer a major operation that puts you in the hospital for a week to 10 days. Patients now typically go home after overnight stay.
- A.V.Hospital under BEST Institute and Research Center conducts training in laparoscopic surgery for General Surgeons once in 3 months with special emphasis on laparoscopic hernia surgery. This course duration of 15 days is attended by surgeons from different parts of India.This course includes live operative demonstration during which trainees get an opportunity to assist laparoscopic surgeries. It also includes lectures,didactic sessions,video demonstrations and hands on training on BEST endotrainers and Virtual reality Simulators.
- We are invited to several state and national conference to conduct laparoscopic skills courses for surgeons.
- Endotrainer Exercises on BEST endotrainers.This helps to develop hand eye co-ordinations and basic skills required for laparoscopic surgery
Virtual reality Simulators
- Available to much larger audience
- Provides a more realistic simulation
- More detailed dialogue and interaction
- Dr.M.Ramesh and Dr.Tulip are the author and co-authors of Video book Laparoscopic Hernia “The Good,The Bad and The Ugly”.
- This video book has demonstrations on all different types of laparoscopic hernia procedures. It has videos classified according to technical challenges. Detailed audio instructions are given about the tips and techniques used.To understand the principles of hernia surgery in a better way,this video book has animations explaining the instrument usage,surgical steps and complications. This has been appreciated by many and has helped thousands of surgeons to understand and get trained in the field of laparoscopic hernia surgery.
- Dr.M.Ramesh is the mentor for training in laparoscopic hernia program conducted by Coviedien. This PACE (Professional Affair and Clinical Education) program was a 2 day operative demonstration program which was attended by Surgeons all over the country.The trainees have a live experience of laparoscopic surgery and are given a comprehensive text book on laparoscopic hernia surgery written and edited by faculties of BEST Institute and Research Center.
- Demonstration and teaching of Principles of Laparoscopic Hernia Surgery in Operation theater
Contributions and Achievements in the field of Laparoscopic Hernia Surgery
Dr.M.Ramesh with other stalwart surgeons founded the Hernia Society of India, with a vision to disseminate knowledges and expertise in the field of Hernia surgery on our country. The Hernia Society of India is the National chapter of Asia Pacific Hernia Society.
A.V.Hospital has contributed a lot to the field of herniology. Dr.M.Ramesh has done pioneering work in the field of laparoscopic hernia surgery in the state of Karnataka. He was the first to start laparoscopic surgery for different types of hernia in the state.
Dr.M.Ramesh has conducted International and National Conferences in Hernia with many invited eminent international and national faculties.
The conference always involved live operative workshops,faculty lectures and hands on training on the BEST Institute designed endotrainers.The main intension behind these training sessions during conference is dissemination of knowledge to young surgeons.
The endotrainer sessions and exercises in the conferences had specially designed modules to train in laparoscopic inguinal and ventral hernia surgery.
- Didactic sessions,Endotrainer exercises,Lectures on Laparoscopic Hernia Surgery
Comprehensive text book on Laparoscopic Hernia Surgery
- Faculties from A.V.Hospital has been invited to deliver lectures in International and National Hernia conferences and courses.
- Dr.M.Ramesh, invited to Delhi to present lecture on “Management of Hernias during Bariatric Surgery” during the 11th Annual conference of Hernia Society of India in August 2017
- Dr.M.Ramesh was invited to Delhi to present lecture on “Role of Biofilms in Laparoscopic Ventral Hernia Repair” during the 11th Annual conference of Hernia Society of India in August 2017
- Dr.M. Ramesh is unanimously elected as Executive Committee Member of Hernia Society of India in August 2017 ,during the 11th Annual Conference of Hernia Society of India.
- Dr.M.Ramesh is invited as a Mentor and Teaching faculty during the Cadaveric workshop on Laparoscopic hernia at M.S.Ramaiah Medical college ,Bangalore in December 2015.This was attended by Surgeons across India to learn this advanced laparoscopic procedure.
- Dr.Ganesh Shenoy was invited to Yangoon,Myanmar to deliver lecture on “Laparoscopic Extraperitoneal Repair of Epigastric Incisional Hernia” during Asia Pacific Hernia Society Meeting in December 2015
- Dr.Ganesh Shenoy was invited to Sri Ramachandra Medical College , Chennai to deliver lecture on "Tailored approach in Management of Groin hernia” During the FALS HERNIA course June 2017
- Dr.Ganesh Shenoy , invited to Delhi to present Video demonstration of Laparoscopic Redo TAPP Mesh repair during the 11th Annual conference of Hernia Society of India in August 2017
- Dr.Ganesh Shenoy ,invited to Delhi to deliver lecture on “Mesh- Boon or Bane “during the 11th Annual conference of Hernia Society of India in August 2017
- A hernia occurs when an internal organ or other body part protrudes through the wall of muscle or tissue that normally contains it
- An abdominal hernia is an opening or weakness in the muscular structure of the wall of the abdomen. The peritoneum (lining of the abdominal cavity) protrudes through the opening and this defect causes a bulging of the abdominal wall.
- Most hernias occur within the abdominal cavity, between the chest and the hips.
What causes a hernia?( Formation of Hernia Animation )
- Inguinal and femoral hernias are due to weakened muscles that may have been present since birth, or are associated with aging and repeated strains on the abdominal and groin areas. Such strain may come from physical exertion, obesity, pregnancy ,frequent coughing, or straining on the toilet due to constipation.
- Umbilical hernias Adults may get an umbilical hernia by straining the abdominal area, being overweight, having a long-lasting heavy cough, or after giving birth.
- The cause of hiatal hernias is not fully understood but a weakening of the diaphragm with age or pressure on the abdomen could play a part.
What are the signs and symptoms of Hernia?
A hernia in the abdomen or groin can produce a noticeable lump or bulge that can be pushed back in, or that can disappear when lying down.
Laughing, crying, coughing, straining during a bowel movement or physical activity may make the lump reappear after it has been pushed in. More symptoms of a hernia include:
- Swelling or bulge in the groin or scrotum (the pouch that contains the testicles)
- Pain at the site of the bulge
- Pain while lifting weights
- Increase in the bulge size over time
- A dull aching sensation
- A sense of feeling full or signs of bowel obstruction
- In the case of hiatal hernias there are no bulges on the outside of the body. Instead, symptoms may include heart burn,regurgitation ,indigestion, difficulty in swallowing and chest pain.
What can be done to prevent Hernias?
- IMost of the factors that lead to the development of hernias are beyond the control of the individual. Some of those factors are inherited and develop as the individual grows. The arrangement of the local tissues and their thickness and strength may greatly affect the relative risk of developing a hernia over a lifetime.
But,there are some factors that can decrease the incidence of hernia
- Maintaining ideal body weight by eating a healthy diet and exercise
- Eating enough fruits, vegetables, and whole grains to avoid constipation.
- Using correct form while lifting heavy weights. Avoid lifting anything that is beyond your ability.
- See a doctor when you are ill with persistent coughs or sneezing.
- Don’t smoke, as the habit can lead to coughing that triggers a hernia.
Should all Abdominal Hernias be repaired?
- Other than umbilical hernias in babies, hernias will not disappear on their own.
- In general, hernias that are at risk for complications, that cause pain, or that limit activity should be repaired.
- Under certain circumstances the hernia may be watched and followed closely by a physician. These situations are unique to those individuals who are at high operative risks (i.e. those with severe heart or lung disease, or bleeding problems).
- Of course, even in the high risk person, if the symptoms become severe or if strangulation occurs, then an operation must be performed.
What can happen if a hernia is not treated?
- Over time, a hernia can grow larger and more painful or can develop complications.
- Complications of an untreated hernia may include:
- Obstruction (incarceration) – Part of the intestine becomes stuck in the hernia causing nausea,vomiting,abdominal pain, abdominal distension and a painful lump in the groin or abdomen.
- Strangulation – Part of the intestine is trapped in a way that cuts off its blood supply. In such cases, emergency surgery (within hours of occurring) is warranted to prevent tissue death.
How is a hernia diagnosed?
- It is usually possible to see or feel a bulge in the area where a hernia has occurred by physical examination. Part of a male’s typical physical examination for inguinal hernias includes the doctor feeling the area around the testicles and groin while the patient is asked to cough.
- In some cases, soft-tissue imaging like a Ultrasound scan or a CT scan will accurately diagnose the condition.
- We generally do imaging in inguinal hernias to rule out contralateral hernias and to know the size of prostrate in elderly individuals.In case of ventral hernias imaging will give us an idea about the size of the defect and its contents.
How is a hernia treated?
- Hernias typically do not resolve on their own and surgery may be the only way to repair them. However, your doctor will recommend the best therapy to address your hernia, and may refer you to see a surgeon. If the surgeon thinks it is necessary to repair your hernia then the surgeon will tailor the best method of repair that meets your needs.
- In the case of an umbilical hernia in a child, surgery may be recommended if the hernia is large or if it has not healed by the age of 4–5 years old. By this age, a child can usually avoid surgical complications.
- If an adult has an umbilical hernia, surgery is usually recommended because the condition will not likely improve on its own and the risk of complications is higher.
- One of two types of hernia surgery can be performed, depending on each patient’s case:
- Open surgery, in which a cut is made into the body at the location of the hernia. The protruding tissue is set back in place and the weakened muscle wall is stitched back together. A type of mesh is implanted in the area to provide extra support.
- Laparoscopic surgery involves the same type of repairs.It is done under General anesthesia. However, instead of a cut to the outside of the abdomen or groin, tiny incisions are made to allow for the insertion of telescope ,surgical tools and Mesh to complete the procedure.
What are the advantages of Laparoscopic Hernia Repair?
- Less post operative pain.
- Less bleeding.
- Shortened hospital stay.
- Quiker return to normal activity.
- Faster return to regular diet.
- Less infection.
- No big scars adding cosmesis.
What are the preoperative instructions?
- Some vital tests are required before surgery.
- After tests are done, a physicians or cardiologists fitness for surgery is obtained .
- Avoid any anticoagulant medications( Ecospirin, Clopidogrel etc) minimum 5 days prior to the surgery.
- Avoid alcohol and tobacco for few days before surgery.
- Follow your surgeons instructions for any prescribed medications
- One day prior to surgery the patient is not allowed to take anything orally except medicines, after midnight.
What are the post operative instructions to be followed?
- The patient is kept under observation in I.C.U for 2-4 hours and then shifted to the room.
- Patient is allowed oral liquids on the same day of surgery and can have breakfast from the next day morning.
- The patient is allowed to move and use the restroom on his own on the same day of the surgery.
- Routine physical activity like walking, climbing stairs etc can be resumed immediately following surgery.
- Strenous activity like lifting heavy weights and driving should be avoided 1 month following surgery
- Generally the patient is discharged the next day of the surgery.
- The dressings are removed during the first follow up visit which occurs after 7 days.
- The patient is instructed to carefully follow the diet instructions as provided by doctor.
- Medication chart is provided to the patient to ensure proper compliance of prescribed medications
- Regular follow up is advised
Laparoscopic Surgery for Inguinal and Femoral Hernia
There are two approaches in Laparoscopic Repair
- TAPP(Transabdominal Preperitoneal)
- TEP(Totally Extraperitoneal).
In both the approaches the Mesh is placed in the pre peritoneal space.In laparoscopic hernia surgery, a telescope attached to a camera is inserted through a small incision that is made under the patient's belly button. Two other small cuts are made (each no larger than the diameter of pencil eraser) in the lower abdomen. The hernia defect is reinforced with a 'mesh' (synthetic material made from the same material that stitches are made from) and secured in position with titanium tacks.
- Inguinal hernia- Direct and Indirect Hernia
- TAPP PLUG AND PATCH
- Bilateral hernias
Laparoscopic Surgery for Ventral Hernias
Ventral hernia includes
- Umbilical Hernia
- Incisional Hernia
- Epigastric hernia
- Spigelian Hernia
A laparoscope (a tiny telescope with a television camera attached) is inserted through a cannula (a small hollow tube). The laparoscope and TV camera allow the surgeon to view the hernia from inside. Any multiple defects or weakness of the abdominal wall can be assessed with this approach. The mesh is fixed under the hernia defect covering at least five centimetres beyond the edge of the defect. It is held in place with special surgical tacks and sutures. This is termed as Intra Peritoneal Onlay Mesh ( IPOM ) repair.This is performed under General anaesthesia.
- Umbilical hernia
- Incisional hernia
- Multiple hernias
- Swiss cheese defect
- Entry of mesh
- Large hernia darning with mesh
Laparoscopic Nissen’s Fundoplication for GERD/ Hiatus Hernia
Who are the Candidates for Surgery in GERD
- Complications of GERD not responding to medical therapy( eg: esophagitis , stricture, Barrett esophagus, recurrent aspiration or pneumonia)
- GERD symptoms interfering with lifestyle despite medical therapy
- GERD associated with paraesophageal hernia
- Need for continuous drug treatment in a patient desiring discontinuation of medical therapy ( eg : financial burden ,non compliance ,intolerance to medication , life style choice, young patient)
- Antireflux surgery (commonly reffered to as Nissen’s Fundoplication) involves reinforcing the “valve” between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus
- About 4 cms of the intrathoracic esophagus is mobilized intraabdominally and a tension free wrap of 1.5-2 cms of the fundus of the stomach is created at the lower end of the esophagus. We routinely perform this surgery by laparoscopic approach in which 5 tiny cuts are made over the abdominal wall to accomplish this procedure.
Animation of Fundoplication
What are the precautions to be followed after Surgery for GERD/Hiatus hernia
We will work with you to create a personalized treatment plan which will be given to you during your discharge from the hospital.
- Usually you should be on a liquid diet for a week following surgery in order to give time for the swelling or edema near the wrap site to resolve.
- Do not drink water immediately after a meal. You can do so after 45 minutes.
- Avoid carbonated beverages and smoking
- Chew your food slowly and thoroughly
- Have small portions of meals
- Do not sleep 2-3 hours after meals.
E-TEP Mesh Repair for Inguinal Hernias
E stands for "Extended or Enhanced view" TEP
Surgeons from A.V.Hospital who are known for there innovations and looking out for newer procedures for patients safety are the 1st in the state of Karnataka to perform this new extraperitoneal technique for Inguinal hernias. This technique was pioneered by Dr.Jorge Daes of Columbia.
E-TEP Technique for Inguinoscrotal hernias
The drawbacks of TEP Mesh repair for Inguinal hernias are
- Limited surgical field
- Restricted port set up
- Difficult in Previous pelvic surgery
- Difficult when the distance between umbilicus and pubic tubercle is short.
- Difficult in Obese patients,Large inguinoscrotal hernias and Incarcerated/Sliding hernias
The advantages of this new extraperitoneal technique are
- Extraperitoneal repair in patients with previous pelvic surgeries
- Extend the indications of TEP technique to more complex cases
- Obese patients and post bariatric patients
- Extend extraperitoneal repair to lumbar and ventral hernias
Component Separation Technique for Large Ventral hernias
This surgical procedure is used in very large ventral hernias with loss of domain.
This is a newer concept in Abdominal wall reconstruction.
This can be performed by the following methods
- Endoscopic with Open/Laparoscopic
- Anterior component seperation
- Posterior component seperation
- All the above with or without mesh reinforcement
- Approximation of rectus abdominis muscle complex
- Closure of linea alba following bilateral release of the external oblique aponeurosis and posterior rectus sheath
Very few institutions in the country are performing this procedure.This surgery has changed the concept and thought process of abdominal hernia surgery. Surgeons at A.V.Hospital are competent in performing this advanced procedure by laparoscopic technique.
Component Seperation technique performed for large ventral hernias with Loss of Domain
Faculty for Training in Endo Hernia Surgery
Dr. Ganesh Shenoy
MS, FMIS (RGUHS), FIAGES
Another of Dr. Ramesh’s understudies, Dr Ganesh Shenoy.K did his undergraduate training in Mysore Medical College, the first Medical College in Karnataka and Post graduate training in General Surgery at Goa Medical College, one of the first Medical colleges in Asia. After post-graduation, continued as senior resident in General Surgery at Goa Medical College.
He completed his Fellowship in Minimal Invasive Surgery (FMIS) from the prestigious Rajiv Gandhi University of Health Sciences (RGUHS) and Fellowship in Indian Association of Gastrointestinal Endosurgeons(FIAGES) at Coimbatore.