Spigelion Hernia

Let me share with you one interesting case which I did last week.

65 year old lady came with pain in right side of lower abdomen. She had this pain off & on since past 6 months. She was treated as acidity, colitis etc by other doctors who treated her.

Lady was very intelligent & told me she would feel some bubbling voice with some lumpy feel in the area during episode of pain.

I suspected Spigelian Hernia which was confirmed on ultrasonography.

Let me brief you about this entity.

Spigelian Hernia was first described by Mr. Adriaan van den Spiegel, a surgeon- anatomist from Brussels in 1645.

It is an extremely rare amongst other hernia. The incidence is said to be one case in a million populations. Usually, a surgeon would see one case in life time. I am fortunate to see five cases so far.

This Hernia is difficult to diagnose as it does not present as swelling on the surface like other Hernia. In fact, it burrows between two muscles. An intelligent patient will perceive a gurgle from the trapped intestine like this patient.

We did laparoscopic surgery through three small holes & cured her. She was discharged in one day & fully functional in a week.

I am posting a laparoscopic picture of the same.

Recurrent Hernia

Let me share with you a case of recurrent Hernia I show last week, which I am planning to fix it shortly.

A gentleman in his forties presented with abdominal swelling for last four years.

He had undergone Laparoscopic repair of a hernia around his navel in 2006.

This is a case of recurrent Hernia.

Hernia is known to recur in 5 to 20 % of cases.

The important causes are

• Improper selection of case, like patient who had cough & not treated adequately before surgery.
• Patient develops cough after surgery, not aggressively treated.
• Patient is obese or puts in lot of weight after surgery.
• Patient continue smoking after surgery
• Some surgical pitfalls like, wrong selection of procedure, wrong size of mesh, inadequate fixation of mesh, wound infection etc.

The Best Surgery for Hernia is First surgery. If it is done properly, Hernia does not recur.

Recurrent Hernia is difficult to repair & carry more chances of re-recurrence.

We are planning to do TAR procedure ( Transverse Abdominis Release ), a complex but good procedure to give him durable repair. I will come back to you once it happens.

Abdominal Wall Reconstruction

Traditionally, Hernia was considered as a structural defect, wherein a hole in the muscles was stitched or patched.

The concept of Hernia has changed. There is not only a structural defect but also functional derangement, which needs to be looked into.

Modern Hernia surgeon will do a repair that restores structure as well as Function.

Abdominal wall has many important functions, to name few,

• It protects various abdominal viscera like intestine, stomach etc. from injury. It contracts & forms a shield during blow to the abdomen.
• Normal tone of abdominal muscles balances against the contraction of spine. People with very large Hernia, often get backache.
• We need a systematic contraction of our abdominal muscles during normal activities like passing urine, stools. A lady while delivering child needs to push with powerful contraction of muscles. All these activities we unknowingly do with what is known as Valsalva’s manuvre.
• When we eat, after a while we feel full, this is known as end point of satiety. When our stomach gets full, it touches abdominal wall. There are receptors in the wall, which send signals to brain & we reach the end point of satiety and stop eating.

Modern hernia surgery involves procedures which will reconstruct the abdominal wall almost like it existed before development of Hernia. All the deranged functions are restored & patient starts feeling normal.

APHSCON 2016 Conference Japan

I was invited by Asia Pacific Hernia Society for attending their conference, “APHSCON 2016”, which was held in Tokyo, Japan on 27th, 28th & 29th October 2016.

The conference was held in Tokyo Dome Hotel.

I presented three papers

• Concept of Component Separation & Transverse Abdominis Release
• Trans-fascial Hernia
• Video presentation on different techniques of Component Separation

Also moderated one session

• Groin Hernia Repair: Reduced Port, Laparoscopic Repair and Sacless Lipoma

It was a great experience & an honor to present my work in an international conference in front of stalwarts in the field of hernia. I interacted with many surgeons from different countries, namely Japan, Singapore, Middle East, Germany, Switzerland, UK & many more.

This was my academic feast, but besides I thoroughly enjoyed the hospitality of Japanese.

I observed many peculiarities from Japanese, which will have deep impression on my mind forever.

• Punctuality: The entire conference had an excellent time management, all sessions started & completed in time, not a very common occurrence in India.
• Cleanliness: All the roads were cleaner than some of our houses. Every house or society would clean not only their premises but also an adjoining part of road, we could not see anyone littering. I was quite impressed when I saw an old lady picking any litter with a fork & collecting in a bag on her shoulder.
• We travelled in sky liner trains. Local trains were absolutely on time, we were given a boggy number & seat number. No chaos, everyone would queue up & board the trail only after the passengers get down. Railway platform, again were very clean. See more pictures—
• The culture & customs were very impressive, Humility, Courtesy, Helpful nature were some of the very obvious qualities, I saw.
• Tokyo had many high-risers, many pieces of marvelous architecture----see pictures
• Tokyo sky tree, the world’s highest tower was standing high, as if claiming the height that Japan has achieved in a span of last 70 years or so. It was a magnificent show after complete sabotage (Physical, mental, emotional, and financial) by nuclear bomb explosion in 1944.
• Today, Japan has world leaders like Panasonic, Sony, Toyota & many more brands

Even though, India has travelled almost same distance since independence, what a difference!! Let us learn from Japan & make India reach similar heights.

Namaste, Japan!!!!