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Hernias, Heartburn, and Balloons Ahmed R Ahmed Consultant in Laparoscopic, Upper GI and Bariatric Surgery Clinical Lead – Bariatric Services Imperial College.

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Presentation on theme: "Hernias, Heartburn, and Balloons Ahmed R Ahmed Consultant in Laparoscopic, Upper GI and Bariatric Surgery Clinical Lead – Bariatric Services Imperial College."— Presentation transcript:

1 Hernias, Heartburn, and Balloons Ahmed R Ahmed Consultant in Laparoscopic, Upper GI and Bariatric Surgery Clinical Lead – Bariatric Services Imperial College London Director of Surgery Bupa Cromwell Hospital Weight Management Centre

2 You can judge the worth of a surgeon by the way he does a hernia Sir Thomas Fairbank

3 Inguinal hernia surgery– laparoscopic or open?

4 There is no doubt that the first appearance of the mammal, with his unexplained need to push his testicles out of their proper home into the air, made a mess of the three layered abdominal wall that had done the reptiles well for 200 million years William Ogilvie


6 The case for open repair

7 A common, established procedure Open repair is the preferred operation for primary inguinal herniorrhaphy by 86% of surgeons in the US. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in Surg Clin N Am 2003; 83:1045–51.

8 Short learning curve Cheap Less chance of recurrence Can be done under local anaesthetic Open herniorraphy

9 Laparoscopic repair is the technique safe? is the repair secure? are long-term morbidity rates better than in open repair? do patients return to normal activities and work earlier? and are there any additional benefits?

10 Is the technique safe? The EU Hernia Trialists Collaboration –Meta-analysis of 34 eligible trials (RCTs) with a total of 6804 patients. EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7. –Complications reduce with experience Laparoscopic complications show a marked improvement between the early and late 1990s with an incidence of 5.6% and 0.5%, respectively (P < 0.001). –Haematoma occurs more frequently after open surgery. –Testicular injury and wound infection is more common after open repair

11 34 TRIALS ANALYSED RECURRENCES Is the repair secure? Prof Grant. EU Hernia Trialists Collaborative. Br J Surg 2000; 87: 860–7. *10 RCTs comparing TAPP with open repair and 4 RCTs comparing TEP with open repair

12 Are postop morbidity rates better? 5-year follow-up of 400 patients treated with either Lichtenstein open mesh repair or TAPP repair –the incidence of permanent paraesthesia: 23% vs 3% –groin pain 10% vs 2% –all of the patients with pain and paraesthesia significant enough to affect their daily lives were in the open repair group Wellwood: Prospective randomized controlled trial of laparoscopic versus open inguinal hernia mesh repair: five year follow up. BMJ 326:1012, 2003

13 Do patients return to normal activities and work earlier? 27 RCTs have considered the speed of recovery and return to work. 24 of these report an earlier return to both activity and work in the laparoscopic groups compared with open repair. This is estimated to equate to an absolute difference of about 7 days in terms of time off work. McCormack K, Scott NW, Go PM, Ross S, Grant AM and EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Databases System Rev 2003(1); CD

14 Are there any additional benefits? Laparoscopic surgery allows bilateral hernias to be repaired through the same three small incisions –there is no increase in postoperative pain or recovery time The same advantages are apparent in the repair of recurrent hernias particularly when the recurrence has occurred more than once

15 Is laparoscopic repair cost effective? Both laparoscopic and open techniques can be routinely performed as day cases in fit patients Societal costs due to quicker recovery and return to employment show clear advantages for the laparoscopic repair. Hospital Episode Statistics 2001/2

16 Heartburn and Hernias

17 Hiatus (Paraesophageal) hernias Type 1 paraesophageal hernia

18 Paraesophageal hernias Type 2 hernia Type 3 hernia

19 Clinical features Asymptomatic Major Minor Emergency

20 Clinical features Asymptomatic –Stomach freely herniates and reduces through a open hiatus

21 Clinical features Major symptoms –Postprandial chest pain (74%) –Dysphagia (60%) –Anemia (30%) Strangulation > ischaemia > bleeding Venous engorgement > chronic oozing Camerons ulcer –Pulmonary problems (44%) Loss of intrathoracic volume aspiration

22 Clinical features Minor symptoms –Regurgitation (77%) –Heartburn (60%) –Nausea and/or vomiting (35%)

23 Clinical features Emergency = volvulus –Severe pain –Bleeding –Perforation > Peritonitis and sepsis* * 50% mortality rate > case for elective repair strangulation



26 Diagnostic Methods Upper gastrointestinal contrast study CT Gastroscopy





31 Controversies Do all paraesophageal hernias require repair?

32 Principles of surgical repair Standard principles of hernia repair apply: free the sac reduce the hernia repair the defect

33 How to close the crural defect? Primary suture cruroplasty

34 How to close the crural defect? Cruroplasty reinforced by mesh

35 Balloons and Weight loss

36 Weight loss - Treatment options Lifestyle Modifications e.g. diet and exercise Anti-obesity medications - Xenical ® (Orlistat/Alli) Surgery (in suitable patients – NOCE, NIH criteria)

37 Healthy Weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more) BARIATRIC SURGERY Weight loss GASTRIC BALLOON

38 The Intragastric Balloon An option between diets and surgical treatment

39 Treating obesity with an Intragastric Balloon The Intragastric Balloon is a weight-loss system Education about weight-loss The balloon itself

40 Who is suitable? Motivated, moderately obese adults. –BMI of 27 and over Prepared to make changes in eating habits and lifestyle Willing to work with medical team and attend meetings.

41 The procedure Step 1 Assessment Step 2 Insertion Step 3 Follow up Diet and changed eating habits Exercise Step 4 Removal Maintain weight-loss

42 Balloon removal Removal of the balloon follows the same simple procedure as placement A tube is passed into the stomach and the balloon is deflated The deflated balloon is then removed through the mouth Patients can usually return home within hours

43 Following the procedure Regular scheduled meetings with the team to continue education and support on new eating and exercise habits The balloon helps adjustment to reduced caloric intake by producing a feeling of satiety Kgs weight loss / 6 months

44 Life after balloon removal Balloon removal after six months Keep practicing the principles Keep meeting with the team Nutrition, balance, exercise Motivation remains the key to success

45 Benefits of the intragastric balloon programme –No surgery is required –No long-term use of pharmaceuticals –Feeling of satiety makes success more likely than other programmes –10-20Kgs / 6 months

46 Hard to control co-morbidities in lower BMI >Diabetes / Hypertension weight = control Intragastric balloon Possible indications

47 Weight loss to improve surgical condition in non bariatric operations > Orthopaedic surgery Joints Spine Intragastric balloon Possible indications

48 Infertility Effective weight loss > Improves women fertility Intragastric balloon Possible indications

49 Weight loss post pregnancy obesity > Woman should loose all the weight gain in pregnancy with breast feeding But... It is not what we see in consecutive pregnancies Intragastric balloon Possible indications

50 Aesthetics >Preparing for special happenings >Psychological well being > less risky than liposuction Intragastric balloon Possible indications

51 Lifestyle Surgical Treatment Balloon Excess Weight

52 52 Questions If you would like to schedule or refer a patient for consultation: Contact 108 Harley Street [ ]

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