Hernia Surgery, Gallbladder Surgery; New Strategies - Dr Mizelle D’Silva

Acute care surgery involves emergency surgical coverage for urgent, time-sensitive surgical conditions to patients who are injured or have life-threatening or potentially life-threatening emergency surgical conditions. With added expertise and advancements in technology, there are new innovative ways to manage surgical emergencies hence enabling us to provide the best appropriate surgical care to patients. Some of the common conditions treated include appendicitis, cholecystitis, obstructed/strangulated hernia, intestinal obstruction or perforation, soft tissue infections, etc.

Given this article, we will discuss some of the new strategies in acute care hernia and gall bladder surgery.

Gall Bladder Surgery

Laparoscopic cholecystectomy after its inception in 1985 has slowly become the gold standard for treating gallbladder diseases. The standard of treatment for acute cholecystitis has traditionally always been cholecystectomy. However, the timing of surgery is debatable. There are many proponents of early surgery while some others propose late surgery after 6 - 8 weeks. Another issue is how early is early really! Some surgeons propose surgery within 24 hours while some extend that duration up to 72 hours.

Surgery in the scenario of acute cholecystitis is technically demanding as marked inflammation causes distortion of anatomy and adhesions of surrounding structures to the gallbladder. Operating in these conditions can lead to a risk of bleeding and bile duct injury. Various bail-out strategies are reported when operating on an inflamed gallbladder. Maintaining a low threshold for conversion to open surgery and being willing to perform a subtotal instead of total cholecystectomy are some of them.

In patients who are not candidates for surgery, drainage of the gallbladder may be urgently required to prevent severe complications of sepsis etc. Some of these procedures include percutaneous cholecystostomy, percutaneous transhepatic gallbladder drainage, endoscopic nasobiliary drainage, endoscopic ultrasound-guided gallbladder drainage, and surgical cholecystostomy. However, surgery is the only definitive treatment. The introduction of 3D vision may help to better identify the structures at the porta. A novel imaging modality called indocyanine green (ICG) fluorescence cholangiography has been used during laparoscopic cholecystectomy and may offer better visualization of the biliary anatomy during dissection.

ICG is rapidly excreted in bile, thus helping identify the gallbladder and bile ductal anatomy before clipping the cystic duct. By applying new innovative strategies, it is possible to safely and effectively perform gall bladder surgery in the acute setting.

Hernia Surgery

Hernia repairs are one of the commonest surgeries performed the world over. Hernias are managed electively in most cases. In case of an emergency, the principles of hernia remain constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. There are different techniques developed to perform hernia surgery.

Open surgery performed most commonly by the Lichtenstein repair is the commonest surgery performed for inguinal hernias. Other surgeries include laparoscopic transabdominal preperitoneal repair (TAPP) and totally extraperitoneal repair (TEP). In patients who arrive in an acute setting initially open surgery was thought to be the only alternative however with added expertise laparoscopic and robotic surgery are also feasible. In patients with obstructed or strangulated hernias, robotic/laparoscopic surgery aid in the reduction of the obstructed bowel/omentum along with an assessment of its viability. The decision on placing a mesh varies based on the level of contamination. Some authors have reported a reverse strategy that involves conversion from open to laparoscopy for strangulated hernias.

Laparoscopic surgery has been applied to ventral hernias as well. It involves an intraperitoneal onlay mesh (IPOM) which can give rise to complications of adhesions, fistulae, etc. Enhanced-view totally extra-peritoneal (eTEP) is a novel approach for the repair of ventral hernia which was introduced by Belyansky et al. The main feature lies in placing the mesh in a large retro rectus-pre-peritoneal space instead of intraperitoneally. Adding component separation in the form of transversus abdominis release (TAR) for a large hernia has made this procedure more attractive. It has many advantages over both open and laparoscopic IPOM repair. It can be used to easily manage unusual lateral, incisional, and recurrent hernias. It enables placement of a large mesh from one linea semilunaris to the other, from epigastrium to cave of retail. The cost of the mesh (polypropylene vs. composite) is reduced and so also complications such as adhesion formation and enterocutaneous fistula.

Furthermore, it allows the restoration of the linea alba. However, it requires a thorough understanding of the abdominal wall anatomy along with advanced training in laparoscopy and intracorporeal suturing. In some cases, these procedures can be performed in elective and emergency settings, thus improving overall outcomes.

Acute care surgery should be included as part of general surgical training to enable surgeons to better manage surgical emergencies using the best possible advancements available so as to optimize patient outcomes.

Disclaimer: The views expressed in this article are of the author and not of Medical Dialogues. The Editorial/Content team of Medical Dialogues has not contributed to the writing/editing/packaging of this article.