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Southern Ocean County Hospital would like to thank everyone who e-mailed questions for this edition of Ask-The-Expert and would like to especially thank Dr. Grachev for taking part in the program.

November : Minimally Invasive Surgery

Question 1
I had a hernia operation two years ago and they said it was minimally invasive laparoscopic – and now it’s starting to hurt again. Can a hernia operation come undone after two years of no problems?

Thank you for a very good, practical question. Can a hernia reoccur after two years of laparoscopic repair? The answer is yes. The recurrence rate is relatively low. There are many large series of inguinal herniorraphy patients with recurrence rates of 1% to 3%. The true life time recurrence rate is probably around 5%, but may be higher. The rate of recurrence after second repair is definitely higher and may approach 10% in groin hernia.
Recurrent inguinal hernia, particularly an early recurrence, is frustrating for both surgeon and patient. You should know that hernia recurrence is a possibility at any point in their lives.

In terms of recurrence rates, an open anterior repair and laparoscopic, posterior repairs are probably equivalent.

Recurrence rate of open ventral, incisional herniorrhaphy with use of prosthetic mesh up to 24%, with laparoscopic approach is decreased to 1-9%.

There are multiple risk factors for poor healing that can lead to hernia recurrence. Diabetes mellitus, wound infection, obesity, smoking, cough, vascular disease, connective tissue disorders, ascites, glucocorticoids and immunosuppression, technical problems are all implicated in poor wound healing and hernia recurrence.

Like primary hernias, the hallmark of recurrent inguinal hernia is a bulge in the groin and ofen extending down into the scrotum.The degree of symptoms varies from none to severe. It is important to distinguish recurrent hernia from chronic groin pain-inguinodynia. This is often described as a “ twinge” or an “ electric shock “ that begins in or near the scar and goes on to the lateral scrotum or medial thigh. It is often triggered by certain movements or activities, but it is not associated with a bulge on the affected side.Its cause is sometimes difficult to determine.There are patients who clearly develop pain from neuroma or nerve entrapment. In others, the pain is secondary to chronic groin strain.

Physical exam by surgeon or imaging of the groin can be helpful to find out what is hurting again.

Question 2
I had an anal fissure operation several years ago and now my doctor wants me to have a colonsocopy but I’m afraid that putting something in there can re-injure me. Is there a danger to a colonoscopy if you’ve had an operation to remove an anal fissure?

Colonoscopy can be used in the evaluation of patient with healed fissure. If patient is not in pain or discomfort, can tolerate digital rectal examination and a fissure cannot be appreciated on inspection, it is safe to perform colonoscopy.

Anal fissures are a relatively common anorectal disorder. The most common symptoms associated with anal fissures are anal pain with defecation and bright red rectal bleeding typically coating the stool or seen on the toilet tissue. Risk factors for anal fissure include childbirth, alteration of bowel habits including constipation and diarrhea, and previous anorectal disease or surgery. Initially, the patient develops a tear of the anorectal mucosa.This tear is exacerbated by spasm of anorectal muscle that increased tear upon further defecation and result in ischemia to the anorectal region. There are evidence that anal fissures are ischemic ulcers.

Fissures can be divided into primary and secondary types. Primary are the direct result of trauma to the anal canal.

The majority of acute anal fissures heal spontaneously. 30% will progress to a chronic fissure at which point healing will occur only 20% to 30% of the time with medical therapy. The mainstay of surgical therapy for anal fissure is a lateral sphincterotomy, which will provide healing in 98% of patients with low recurrence rate.

Question 3
I’ve been having pain in my lower right abdomen and I think it might be my appendix. If I have to have my appendix out, how will I know if I am a candidate for minimally invasive?

Appendicitis is a common acute abdominal emergency in the United State. If somebody have chronic pain in lower right abdomen, better to be evaluated by physician to rule out other diseases. Laparoscopic appendectomy is an excellent approach for the treatment of acute appendicitis. In particular, persons who are obese and women of childbearing age may benefit the most from a laparoscopic approach.

The value of laparoscopic appendectomy for complicated appendicitis, such as perforation, abscess, or peritonitis is controversial.

Relative contraindications to laparoscopic appendectomy include cardiopulmonary instability and extensive previous abdominal surgery, which may preclude safe trocar placement.

Dr. Grachev's answers are informational only and should not be used as a diagnosis or for treatment. Please talk to your physician about official diagnosis of your condition and treatment.