With the reported increase in the number of COVID-19 cases in South Africa at the moment, elective surgery may have to take a backseat for a second time this year since a nationwide lock-down was introduced in March 2020.
The following is an extract from The Federation of Surgeons of South Africa consensus document detailing the various surgical categories and their classification in terms of treatment under lock-down regulations:
With the requirement for our profession to provide critical care services and the possibility
that our operating theatres may be converted into Intensive Care Units, it becomes our
collective responsibility to take appropriate steps to support measures that will “flatten the
curve”. This is a dynamic document with it’s recommendation being effective at the time of
issue and may be updated or changed at any time.
At this stage we do not propose a list of surgical procedures, but rather categories into which
we encourage surgical/ procedural teams classify their patients into. For the purposes of this
document we define elective and other surgery/procedures as follows:
Discretionary elective and Essential surgery is surgery that is scheduled in advance and
where postponement of the surgery/ procedure will not result in the patient’s outcome or
quality of life being significantly altered with a 3 month delay.
Essential surgery is a surgery that is scheduled in advance and where postponement of the
surgery will result in the patient’s outcome or quality of life being significantly altered if
extended past 2 weeks to 3 months.
Urgent, essential surgery is surgery that must be performed in order to preserve the patient’s
life or limb or prevent longer term systemic morbidity, but does not need to be performed
immediately and should be generally performed within 2 weeks.
Emergency surgery is one that must be performed without delay or until the patient is
medically stable; the patient has no choice other than to undergo immediate surgery if
permanent disability or death is to be avoided.
It is impossible to define the medical urgency of a case solely on whether a case is on an
elective surgery schedule. While some cases may be postponed indefinitely, the majority of
cases performed are associated with progressive diseases which by their nature will continue
to progress at variable, disease specific rates. Hence the judgement as to whether or not a
surgical intervention should take place can only be decided once numerous considerations
have been observed.
Given the uncertainties regarding the impact of COVID –19, delaying
some cases risks having them reappear as emergencies at a time when they will be less easy
to manage. FOSAS strongly urges communication and collaboration between hospital
clinicians and their administrative staff to consider the following recommendations:
- Hospitals and surgical teams should consider both their patient’s medical needs and
their logistical capacity to meet those needs in an appropriate time frame.
- The medical need for a given procedure should be established by a surgeon with
direct expertise in the relevant surgical speciality to determine which medical risks
will be incurred by a delay.
- Logistical feasibility for a specific procedure should be determined by management
personnel with an understanding of hospital and community limitations. This includes
facility resources (eg. beds, staff, equipment etc.) as well as the safety and well-being
of care providers and local community.
- Case conduct should be determined based on knowledge of national, regional and
local evolving conditions, recognizing that marked regional variation may lead to
significant differences in regional decision making.
- The risk to the patient should include an aggregate assessment of the real risk of
proceeding and the real risk of delay, including the expectation that a delay of
several weeks (or months) may be required to emerge from to an environment where
COVID – 19 is less prevalent.
In general, a day by day, evidence driven assessment of the changing risk-benefit
analysis will need to influence clinical care decisions and delivery for the foreseeable
future. Plans for case triage should avoid blanket policies and instead rely on data and
expert opinion from qualified (and well informed) clinicians and management teams
understanding all COVID–19 issues in play. Although COVID–19 is a clear risk to all,
it is but one of many competing risks for patients requiring surgical care. Thus, surgical
procedures should be considered not based solely on COVID–19 associated risks, but
rather on an assimilation of all available medical and logistical information.
Laparotomy is a type of open surgery of the abdomen to examine the abdominal organs.
Surgeons may use this surgery to diagnose and treat a variety of abdominal conditions.
Here, we look at the types and uses of laparotomy, as well as what people can expect during and after laparotomy surgery.
Laparotomy is a surgical procedure that involves a surgeon making one large incision in the abdomen.
Doctors use laparotomy to look inside the abdominal cavity to diagnose or treat abdominal health conditions.
Doctors may use laparotomy for a variety of reasons. It can help them diagnose or treat abdominal conditions, such as:
- abdominal pain
- abdominal trauma
- peritonitis, which is an inflammation of the inner lining of the abdomen
- a perforated organ in the abdomen
- infection in the abdomen
- internal bleeding
- the spread of conditions such as cancer or endometriosis
Females may have a laparotomy for a hysterectomy, which is the removal of the uterus, or for the removal of the ovaries or fallopian tubes.
There are different types of incisions for laparotomy:
- Midline: This incision runs down the middle of the abdomen. It is the standard incision for laparotomy. If people only need surgery for their upper abdomen, the incision will not run the whole length of the abdomen.
- Paramedian: A paramedian incision is a vertical cut that runs to one side of the midline. It allows a surgeon to access the kidneys and adrenal glands.
- Transverse: A transverse incision is a horizontal cut. Surgeons may choose to use this approach because it can cause less damage to the nerves supplying the abdominal muscle, and it heals well.
- Pfannenstiel: Surgeons may use a Pfannenstiel incision to access the pelvic region, such as in the case of an emergency cesarean delivery.
- Subcostal: A subcostal incision is a diagonal cut across one side of the upper abdomen. A surgeon may use a subcostal incision to access the gallbladder or liver on the right side or the spleen on the left side.
- Rooftop (chevron): If the surgeon makes a subcostal incision on each side of the body, the incisions may meet in the middle to make a rooftop incision.
Before the operation, a person can expect the following:
- a doctor will ask them not to eat for a certain number of hours before the operation
- a doctor may give them an enema beforehand, which empties the bowels
- the person may shower first with a surgical lotion, before putting on a theater gown
- a healthcare professional will shave any hair in the abdominal area
- an anesthetist will ensure that everything is ready for the operation and note any allergies that the person may have
During the operation, people will be under general anesthetic. A surgeon will make one incision to cut through the abdominal skin and muscle to reveal the organs in the abdomen.
They will then examine the organs to diagnose any issues. If they can make a diagnosis, surgeons may be able to treat the condition straight away.
For conditions that surgeons cannot immediately treat, people may require repeat surgery.
After the diagnosis and the completion of any possible treatment, the surgeon will sew up, or suture, the incision.
Following the operation, the person will slowly wake up from the anesthetic. They will remain in the hospital for immediate aftercare.
This aftercare may include:
- careful monitoring of temperature, pulse, breathing, and blood pressure
- assessment of the wound site and wound care, possibly including drainage
- a tube through the nose into the stomach to drain the stomach for a day or two, if necessary, to help the digestive tract recover
- the insertion of a urinary catheter to drain urine, if necessary
- intravenous fluids, as people may have to avoid eating and drinking for a few days
- regular pain relief medication to ease discomfort
- deep breathing, leg exercises, and walking the day after the operation to help reduce the risk of chest infections and blood clots
Some people feel nauseated after receiving an anesthetic. A doctor may be able to provide medication to relieve nausea.
Once the person is well enough to leave the hospital, a doctor will provide details of how to care for the abdominal wound at home.
The doctor will also provide any necessary medication and advice on how to rest and recover.
As people can undergo a laparotomy for a wide range of reasons, the recovery time can vary significantly among individuals. Many other factors, including the person’s age and overall health, will also determine how long it takes them to feel better.
People can take steps at home to rest and allow their body to recover. These include:
- resting as much as possible for days to weeks, depending on the doctor’s recommendation
- continuing to move around and do any exercises that a doctor has set
- getting other people to help around the home and with daily tasks, where possible
- following all dietary guidelines from a doctor
- taking medication as a doctor prescribes
- avoiding all heavy lifting, including pulling or pushing items, sexual activity, and swimming for 6 weeks
It is usual to feel tired with low energy during recovery, as the body is healing. It is also quite common to experience a wide range of emotions and have difficulty sleeping.
People may be unable to drive during recovery, either because they are allowing their body to heal or due to the medications that they are taking. A person can check with their doctor and inform their insurance company if this is the case.
It is important to contact a doctor as soon as possible if any signs or symptoms of infection appear around the wound site. These may include:
- increased pain or tenderness
- discharge from the wound site
- fever or chills
- vomiting or nausea
People should also seek medical help straight away if they have any symptoms of a blood clot, including:
- difficulty breathing
- chest pain
- severe leg pain
People can carefully follow the doctor’s instructions and ensure that they have a final checkup at the end of their recovery period.
As South Africa continues to focus on ploughing health, financial and human resources into the national response against the Covid-19 coronavirus, there is collateral damage in hospitals.
The pandemic has disrupted routine hospital services globally, and a new study estimates that 146 000 elective surgeries in this country could be cancelled as a result of the crisis – leading to patients facing a lengthy wait for their health issues to be resolved.
Worldwide, the CovidSurg Collaborative, a research network of 5 000 surgeons from 120 countries, has projected that based on a 12-week period of peak distribution to hospital services due to Covid-19, 28.4 million elective surgeries will be cancelled or postponed this year.
The modelling study, published in the British Journal of Surgery this week, shows that each additional week of disruption to hospital services will result in a further 2.4 million cancellations.
Led by researchers from the University of Birmingham, UK and the University of Cape Town (UCT), they collected detailed information from surgeons in 359 hospitals across 71 countries on plans for the cancellation of elective surgery.
This data was then statistically modelled to estimate the total number of cancelled surgeries across 190 countries.
The researchers projected that worldwide 72.3% of planned surgeries will be cancelled during the peak period of Covid-19 related disruption.
Most cancelled surgeries will be for non-cancer conditions. Orthopaedic procedures will be cancelled most frequently, with 6.3 million orthopaedic surgeries cancelled worldwide over a 12-week period. It is also projected that globally 2.3 million cancer surgeries will be cancelled or postponed.
In South Africa, more than 146 000 operations will be cancelled, including 12 000 cancer procedures. These cancellations will create a backlog that will need to be cleared after the Covid-19 disruption ends.
Professor Bruce Biccard, second chairperson in the department of anaesthesia and perioperative medicine at UCT, said: “Each additional week of disruption to hospital services results in an additional 12 000 surgeries being cancelled. Following the surge in the epidemic, we are going to need a continuous assessment of the situation, so that we can plan a safe resumption of elective surgery at the earliest opportunity.
DURING THE COVID-19 PANDEMIC ELECTIVE SURGERIES HAVE BEEN CANCELLED TO REDUCE THE RISK OF PATIENTS BEING EXPOSED TO THE VIRUS IN HOSPITAL
Aneel Bhangu, consultant surgeon and senior lecturer at the National Institute for Health Research
“Clearing the backlog of elective surgeries created by Covid-19 is going to result in a significant additional cost for the national health department. Government will have to ensure that the department is provided with additional funding and resources to ramp up elective surgeries to clear the backlog.”
Aneel Bhangu, consultant surgeon and senior lecturer at the National Institute for Health Research unit on global surgery at the University of Birmingham, said: “During the Covid-19 pandemic elective surgeries have been cancelled to reduce the risk of patients being exposed to the virus in hospital, and to support the wider hospital response, for example by converting operating theatres into intensive care units.
“Although essential, cancellations place a heavy burden on patients and society. Patients’ conditions may deteriorate, worsening their quality of life as they wait for rescheduled surgery. In some cases, for example cancer, delayed surgeries may lead to a number of unnecessary deaths.
A study in Wuhan, China’s COVID-19 epicentre suggests that having surgery during the coronavirus incubation period is likely to complicate or prolong your hospital stay. Researchers behind the first study of the effects of surgery on COVID-19 progression said that surgery might accelerate and worsen the disease.
Researchers from Renmin Hospital at Wuhan University and the University of Hong Kong found that 34 surgical patients who were later treated for COVID-19 complications had a 21% mortality rate, versus 2% for nonsurgical COVID-19 patients. Surgical patients also developed symptoms within two days of surgery compared to between five and eight days for the others.
“Surgery may not only cause immediate impairment of immune function but also induce an early systemic inflammatory response,” said lead researcher Shaoqing Lei.
The Times reports that says many hospitals in South Africa have postponed elective surgery, but authorities showed mixed reactions to the Chinese study. Mark van der Heever, spokesperson for the Western Cape Health Department, said the study sample was small and the patients involved had serious cancer procedures and even kidney transplants. “It is not relevant to our population or to any routine elective surgery,” he said.
However, “the department issued a public notice informing clients that … elective surgery will be cancelled”.
Netcare group medical director Anchen Laubscher said the hospital group is postponing all elective surgery, “provided that this will not result in the patient’s outcome or quality of life being significantly altered”.
Background: The outbreak of 2019 novel coronavirus disease (COVID-19) in Wuhan, China, has spread rapidly worldwide. In the early stage, we encountered a small but meaningful number of patients who were unintentionally scheduled for elective surgeries during the incubation period of COVID-19. We intended to describe their clinical characteristics and outcomes.
Methods: We retrospectively analyzed the clinical data of 34 patients underwent elective surgeries during the incubation period of COVID-19 at Renmin Hospital, Zhongnan Hospital, Tongji Hospital and Central Hospital in Wuhan, from January 1 to February 5, 2020.
Findings: Of the 34 operative patients, the median age was 55 years (IQR, 43–63), and 20 (58·8%) patients were women. All patients developed COVID-19 pneumonia shortly after surgery with abnormal findings on chest computed tomographic scans. Common symptoms included fever (31 [91·2%]), fatigue (25 [73·5%]) and dry cough (18 [52·9%]). 15 (44·1%) patients required admission to intensive care unit (ICU) during disease progression, and 7 patients (20·5%) died after admission to ICU. Compared with non-ICU patients, ICU patients were older, were more likely to have underlying comorbidities, underwent more difficult surgeries, as well as more severe laboratory abnormalities (eg, hyperleukocytemia, lymphopenia). The most common complications in non-survivors included ARDS, shock, arrhythmia and acute cardiac injury.
Interpretation: In this retrospective cohort study of 34 operative patients with confirmed COVID-19, 15 (44·1%) patients needed ICU care, and the mortality rate was 20·5%.
Funding: National Natural Science Foundation of China.
Shaoqing Lei, Fang Jiang, Wating Su, Chang Chen, Jingli Chen, Wei Mei, Li-Ying Zhan, Yifan Jia, Liangqing Zhang, Danyong Liu, Zhong-Yuan Xia, Zhengyuan XiaFull report in The TimeseClinical Medicine abstract
Due to the fact that the Department of Health has closed St Augustine’s hospital for any new patients, our practice has been forced to base ourselves at Umhlanga Hospital. This will enable us to treat relatively urgent cases, usually requiring admission (complying with DOH health care risk guidelines). All elective procedures have been curtailed at ALL hospitals.
We are available to assist referring practitioners with consultations for their patients. Urgent cases should be discussed with the receiving doctor directly.
The more elective consultations will involve a 3 step process, ie: an initial screening by the receptionist followed by a telephonic consultation with one of the accepting doctors and if the need then arises, a patient will be seen in person at the rooms or in hospital.
We remain at your service in these difficult and uncertain times.
Stay at home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention and call in advance. Follow the directions of your local health authority. Source: World Health Organisation
COVID-19 was first identified late last year as a cluster of pneumonia cases caused by a new coronavirus. Doctors have since learned that it’s a respiratory disease, one that especially reaches into your respiratory tract, which includes your lungs.
COVID-19 can cause a range of breathing problems, from mild to critical. Older adults and people who have other health conditions like heart disease, cancer, and diabetes may have more serious symptoms.
Here’s what the new coronavirus does to your lungs.
Coronavirus and Your Lungs
SARS-CoV-2, the virus that causes COVID-19, is part of the coronavirus family.
When the virus gets in your body, it comes into contact with the mucous membranes that line your nose, mouth, and eyes. The virus enters a healthy cell and uses the cell to make new virus parts. It multiplies, and the new viruses infect nearby cells.CONTINUE READING BELOW
Think of your respiratory tract as an upside-down tree. The trunk is your trachea, or windpipe. It splits into smaller and smaller branches in your lungs. At the end of each branch are tiny air sacs called alveoli. This is where oxygen goes into your blood and carbon dioxide comes out.
The new coronavirus can infect the upper or lower part of your respiratory tract. It travels down your airways. The lining can become irritated and inflamed. In some cases, the infection can reach all the way down into your alveoli.
COVID-19 is a new condition, and scientists are learning more every day about what it can do to your lungs. They believe that the effects on your body are similar to those of two other coronavirus diseases, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).
Mild and Moderate Cases
As the infection travels your respiratory tract, your immune system fights back. Your lungs and airways swell and become inflamed. This can start in one part of your lung and spread.
Doctors can see signs of respiratory inflammation on a chest X-ray or CT scan. On a chest CT, they may see something they call “ground-glass opacity” because it looks like the frosted glass on a shower door.
About 14% of COVID-19 cases are severe, with an infection that affects both lungs. As the swelling gets worse, your lungs fill with fluid and debris.
You might also have more serious pneumonia. The air sacs fill with mucus, fluid, and other cells that are trying to fight the infection. This can make it harder for your body to take in oxygen. You may have trouble breathing or feel short of breath. You may also breathe faster.
If your doctor takes a CT scan of your chest, the opaque spots in your lungs look like they start to connect to each other.
In critical COVID-19 — about 5% of total cases — the infection can damage the walls and linings of the air sacs in your lungs. As your body tries to fight it, your lungs become more inflamed and fill with fluid. This can make it harder for them to swap oxygen and carbon dioxide.
You might have severe pneumonia or acute respiratory distress syndrome (ARDS). In the most critical cases, your lungs need help from a machine called a ventilator to do their job.
Some people had a cough even after they recovered from COVID-19. Others had scarring in their lungs. Doctors are still studying whether these effects are permanent or might heal over time.
Source Credit: webMD Medical Reference Reviewed by Neha Pathak, MD on March 25, 2020 https://www.webmd.com/lung/what-does-covid-do-to-your-lungs#1
Alternative names: Hyperlipidemia, Hyperlipoproteinemia, Hypolipidemia, Hypolipoproteinemia
What are cholesterol disorders?
What are the signs of cholesterol disorders?
What causes cholesterol disorders?
How does my doctor tell if I have a cholesterol disorder?
How are cholesterol disorders treated?
What are cholesterol disorders?
Cholesterol is essential for life, and is found in the body cells of all animals, including humans. Your body needs cholesterol to work properly. Two cholesterol disorders are hyperlipidemia, and hypolipidemia.
Hyperlipidemia means you have an unusually high level of fat (lipids) in your blood. This puts you at risk for many health problems, including heart attack and stroke. It is sometimes called high blood cholesterol.
Hypolipidemia means you have an unusually low level of fat in your blood. It is sometimes called low blood cholesterol.
What are the signs of cholesterol disorders?
There are two basic kinds of cholesterol: LDL (low-density lipoprotein, or “bad cholesterol,”) and HDL (high-density lipoprotein, or “good cholesterol”).
In a patient with high blood cholesterol, LDL cholesterol builds up in the inner walls of the arteries that carry blood to the heart and brain. Although many people with high cholesterol levels have no symptoms, this narrowing of the arteries (arteriosclerosis) can cause angina (chest pain), heart attack, and stroke.
Low blood cholesterol rarely causes symptoms, but it may indicate the presence of another disorder.
What causes cholesterol disorders?
High blood cholesterol
When you eat meat, eggs, and dairy products – any food that comes from an animal – you are adding cholesterol to your blood. A diet high in saturated fat and cholesterol is just one thing that may cause high blood cholesterol. Other factors include:
- Being overweight
- Not exercising regularly
- Overuse of alcohol
- Family history. High blood cholesterol can be an inherited condition.
- Age and sex. As you age, your LDL (“bad cholesterol”) level rises. After age 55, women have higher LDL levels than men.
- Diseases like diabetes, hypothyroidism, Cushing’s syndrome, and kidney failure
- Medications like birth control pills, beta-blockers, estrogen, corticosteroids, and certain diuretics
Low blood cholesterol
Hypolipidemia can be caused by several things:
- Anemia (a low amount of red blood cells)
- Malnutrition, or a lack of food
- Liver disease
- The body being unable to absorb food (malabsorption)
- Rare genetic conditions, such as hypobetalipoproteinemia and abetalipoproteinemia
- Tangier disease
How does my doctor tell if I have a cholesterol disorder?
Blood cholesterol tests tell how much fat is in your blood. A total cholesterol level test measures both your LDL (low-density lipoprotein, or “bad cholesterol,”) and HDL (high-density lipoprotein, or “good cholesterol”) levels in milligrams per deciliter (mg/dL).
Normal total cholesterol levels are below 200 mg/dL. HDL levels should be above 40 mg/dL. Triglyceride levels also should be below 200 mg/dL.
How are cholesterol disorders treated?
High blood cholesterol
- Follow a healthful diet, eating foods low in total fat and saturated fat
- Maintain a healthful weight
- Exercise at least three times a week, for 30 minutes at a stretch
- Have your total cholesterol rechecked in one to two years if:
- Your cholesterol reading was above 240 mg/dL
- You have other risk factors for heart disease, such as high blood pressure, diabetes, or being overweight
- Statins lower LDL (“bad cholesterol”) levels
- Bile Acid Sequestrants (seh-KWES-trants) are sometimes prescribed with statins, and help lower LDL cholesterol levels
- Nicotinic (Nick-o-tin-ick) Acid lowers LDL cholesterol and triglycerides, and raises HDL (“good” cholesterol) levels
- Fibrates lower triglyceride levels, and may increase HDL levels
- Ezetimibe blocks cholesterol absorption, and lowers LDL cholesterol
Low blood cholesterol
Treatment focuses on the root causes of hypolipidemia
Side note: Gastric bypass surgery can help lower cholesterol and improve the ratio of total cholesterol to HDL (good) cholesterol (Surgery to Treat High Cholesterol?)
Thyroidectomy is the removal of all or part of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck. It produces hormones that regulate every aspect of your metabolism, from your heart rate to how quickly you burn calories.
Thyroidectomy is used to treat thyroid disorders, such as cancer, noncancerous enlargement of the thyroid (goiter) and overactive thyroid (hyperthyroidism).
How much of your thyroid gland is removed during thyroidectomy depends on the reason for surgery. If only a portion is removed (partial thyroidectomy), your thyroid may be able to function normally after surgery. If your entire thyroid is removed (total thyroidectomy), you need daily treatment with thyroid hormone to replace your thyroid’s natural function.
Why it’s done
A thyroidectomy may be recommended for conditions such as:
- Thyroid cancer. Cancer is the most common reason for thyroidectomy. If you have thyroid cancer, removing most, if not all, of your thyroid will likely be a treatment option.
- Noncancerous enlargement of the thyroid (goiter). Removing all or part of your thyroid gland is an option if you have a large goiter that is uncomfortable or causes difficulty breathing or swallowing or, in some cases, if the goiter is causing hyperthyroidism.
- Overactive thyroid (hyperthyroidism). Hyperthyroidism is a condition in which your thyroid gland produces too much of the hormone thyroxine. If you have problems with anti-thyroid drugs and don’t want radioactive iodine therapy, thyroidectomy may be an option.
- Indeterminate or suspicious thyroid nodules. Some thyroid nodules can’t be identified as cancerous or noncancerous after testing a sample from a needle biopsy. Doctors may recommend that people with these nodules have thyroidectomy if the nodules have an increased risk of being cancerous.
Thyroidectomy is generally a safe procedure. But as with any surgery, thyroidectomy carries a risk of complications.
Potential complications include:
- Low parathyroid hormone levels (hypoparathyroidism) caused by surgical damage or removal of the parathyroid glands. These glands are located behind your thyroid and regulate blood calcium. Hypoparathyroidism can cause numbness, tingling or cramping due to low blood-calcium levels.
- Airway obstruction caused by bleeding.
- Permanent hoarse or weak voice due to nerve damage.
How you prepare
Food and medications
If you have hyperthyroidism, your doctor may prescribe medication — such as an iodine and potassium solution — to regulate your thyroid function and decrease the risk of bleeding.
You may need to avoid eating and drinking for a certain period of time before surgery, as well, to avoid anesthesia complications. Your doctor will provide specific instructions.
Before your scheduled surgery, ask a friend or loved one to help you home after the procedure. Be sure to leave jewelry and valuables at home.
What you can expect
Before the procedure
Surgeons typically perform thyroidectomy during general anesthesia, so you won’t be conscious during the procedure. The anesthesiologist or anesthetist gives you an anesthetic medication as a gas — to breathe through a mask — or injects a liquid medication into a vein. A breathing tube will then be placed in your trachea to assist breathing throughout the procedure.
The surgical team places several monitors on your body to help make sure that your heart rate, blood pressure and blood oxygen remain at safe levels throughout the procedure. These monitors include a blood pressure cuff on your arm and heart-monitor leads attached to your chest.
During the procedure
Once you’re unconscious, the surgeon makes an incision low in the center of your neck. It can often be placed in a skin crease where it will be difficult to see after the incision heals. All or part of the thyroid gland is then removed, depending on the reason for the surgery.
If you’re having thyroidectomy as a result of thyroid cancer, the surgeon may also examine and remove lymph nodes around your thyroid. Thyroidectomy usually takes one to two hours. It may take more or less time, depending on the extent of the surgery needed.
There are several approaches to thyroidectomy, including:
- Conventional thyroidectomy.This approach involves making an incision in the center of your neck to directly access your thyroid gland. The majority of people will likely be candidates for this procedure.
- Transoral thyroidectomy. This approach avoids a neck incision by using an incision inside the mouth.
- Endoscopic thyroidectomy. This approach uses smaller incisions in the neck. Surgical instruments and a small video camera are inserted through the incisions. The camera guides your surgeon through the procedure.
After the procedure
After surgery, you’re moved to a recovery room where the health care team monitors your recovery from the surgery and anesthesia. Once you’re fully conscious, you’ll be moved to a hospital room.
Some people may need to have a drain placed under the incision in the neck. This drain is usually removed the morning after surgery.
After thyroidectomy, a few people may experience neck pain and a hoarse or weak voice. This doesn’t necessarily mean there’s permanent damage to the nerve that controls the vocal cords. These symptoms are often temporary and may be due to irritation from the breathing tube (endotracheal tube) that’s inserted into the windpipe (trachea) during surgery, or as a result of nerve irritation caused by the surgery.
You’ll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure or your doctor may recommend you stay overnight in the hospital.
When you go home, you can usually return to your regular activities. Wait at least 10 days to two weeks before doing anything vigorous, such as heavy lifting or strenuous sports.
It takes up to a year for the scar from surgery to fade. Your doctor may recommend using sunscreen to help minimize the scar from being noticeable.
The long-term effects of thyroidectomy depend on how much of the thyroid is removed.
If only part of your thyroid is removed, the remaining portion typically takes over the function of the entire thyroid gland, and you might not need thyroid hormone therapy.
If your entire thyroid is removed, your body can’t make thyroid hormone and without replacement you’ll develop signs and symptoms of underactive thyroid (hypothyroidism). As a result, you’ll need to take a pill every day that contains the synthetic thyroid hormone levothyroxine (Levoxyl, Synthroid, Unithroid).
This hormone replacement is identical to the hormone normally made by your thyroid gland and performs all of the same functions. Your doctor will determine the amount of thyroid hormone replacement you need based on blood tests.
Peripheral artery disease occurs when blood vessels in the limbs get clogged.
- The term peripheral vascular disease is commonly used to refer to peripheral artery disease or peripheral arterial disease (PAD), meaning narrowing or occlusion by atherosclerotic plaques of arteries outside of the heart and brain.
- Peripheral artery disease is a form of arterial insufficiency, meaning that blood circulation through the arteries (blood vessels that carry blood away from the heart) is decreased.
- Risk factors for peripheral arterial disease include high blood cholesterol, diabetes, smoking, hypertension, inactivity, and overweight/obesity.
- A small percentage of people over the age of 50 are believed to suffer from peripheral artery disease.
- The symptoms of peripheral artery disease depend upon the location and extent of the blocked arteries. The most common symptom of peripheral artery disease is intermittent claudication, manifested by pain (usually in the calf) that occurs while walking and dissipates at rest.
- Doctors may use radiologic imaging techniques including Doppler ultrasound and angiography to aid in the diagnosis of peripheral artery disease.
- Peripheral arterial disease can be treated by lifestyle alterations, medications, angioplasty and related treatments, or surgery. A combination of treatment methods may be used.
- Complications of peripheral artery disease include sores that do not heal, ulcers, gangrene, or infections in the extremities. In rare cases, amputation may be necessary.
- Having peripheral artery disease usually indicates the potential for arterial disease involving the coronary arteries within the brain.
- Other names that have been used to refer to peripheral vascular disease include:
- Atherosclerotic peripheral artery disease
- Hardening of the arteries
- Peripheral artery disease
- Poor circulation
- Vascular disease
Pain in the Legs (Claudication) Symptoms
- The severity of the peripheral artery disease, the location of the plaque, and the activity of the muscles determine the severity of symptoms and location of pain.
- Pain and cramping in the legs is the main symptom of claudication. The pain can be sharp or dull, aching or throbbing, or burning.
- Calf pain is the most common location for leg cramps.
- If the blockage or plaque formation is farther up the leg, the pain from claudication may be felt in the thigh.
- If the blockage is in the aorta (the main artery from the heart to the legs) then symptoms may include pain in the buttocks or groin or erectile dysfunction.
What is peripheral vascular disease (PVD)?
Peripheral vascular disease (PVD) refers to diseases of the blood vessels (arteries and veins) located outside the heart and brain. While there are many causes of peripheral vascular disease, doctors commonly use the term peripheral vascular disease to refer to peripheral artery disease (peripheral arterial disease, PAD), a condition that develops when the arteries that supply oxygen-rich blood to the internal organs, arms, and legs become completely or partially blocked as a result of atherosclerosis.
Are atherosclerosis and peripheral vascular disease related?
Atherosclerosis is a gradual process whereby hard cholesterol substances (plaques) are deposited in the walls of the arteries. This buildup of cholesterol plaques causes hardening of the artery walls and narrowing of the inner channel (lumen) of the artery. When this happens in the peripheral circulation, peripheral vascular disease is the result. The atherosclerosis process begins early in life (as early as teens in some people). When atherosclerosis is mild and the arteries are not substantially narrowed, atherosclerosis causes no symptoms. Therefore, many adults typically are unaware that their arteries are gradually accumulating cholesterol plaques. However, when atherosclerosis becomes advanced with aging, it can cause critical occlusive disease of the arteries resulting in tissue ischemia (lack of blood and oxygen).
Arteries that are narrowed by advanced atherosclerosis can cause diseases in different organs. For example, advanced atherosclerosis of the coronary arteries (arteries that supply heart muscles) can lead to angina, coronary heart disease, and heart attacks. Advanced atherosclerosis of the carotid and cerebral arteries (arteries that supply blood to the brain) can lead to strokes and transient ischemic attacks (TIA). Advanced atherosclerosis in the lower extremities can lead to pain while walking or exercising (claudication), deficient wound healing, and/or leg ulcers.
Picture of Carotid Artery Disease and Plaque Buildup
Picture of a Heart Attack (Myocardial Infarction) – Buildup of Cholesterol Plaque and Blood Clot
Atherosclerosis is often generalized, meaning it affects arteries throughout the body. Therefore, patients with heart attacks are also more likely to develop strokes and peripheral vascular disease, and vice versa.
What are the signs and symptoms of peripheral artery disease (PVD)?
Approximately half of people with peripheral artery disease do not experience any symptoms. For patients with symptoms, the most common symptoms are intermittent claudication and rest pain.
- Intermittent claudication refers to arm or leg pain or cramping in the arms or legs that occurs with exercise and goes away with rest. The severity and location of the pain of intermittent claudication vary depending upon the location and extent of blockage of the involved artery. The most common location of intermittent claudication is the calf muscle of the leg, leading to calf or leg pain while walking. The pain in the calf muscle occurs only during exercise such as walking, and the pain steadily increases with continued walking until the patient has to stop due to intolerable pain. Then the pain quickly subsides during rest. Intermittent claudication can affect one or both legs.
- Rest pain in the legs occurs when the artery occlusion is so critical that there is not enough blood and oxygen supply to the legs even at rest and represents a more serious form of the condition. The pain typically affects the feet, is usually severe, and occurs at night when the patient is lying down, face up.
Other symptoms and signs of peripheral artery disease include:
- Numbness of the legs or feet
- Weakness and atrophy (diminished size and strength) of the calf muscle
- A feeling of coldness in the legs or feet
- Changes in color of the feet; feet turn pale when they are elevated, and turn dusky red in dependent position
- Hair loss over the top of the feet and thickening of the toenails
- Poor wound healing in the legs or feet
- Painful ulcers and/or gangrene in areas of the feet where blood supply is lost; typically in the toes.
Who is at risk for peripheral artery disease (PVD)?
Peripheral artery disease (or peripheral arterial disease) that affects approximately 10 million adults in the U.S. About 5% of people over the age of 50 are believed to suffer from peripheral artery disease. Peripheral artery disease is slightly more common in men than in women and most often occurs in older persons (over the age of 50). The known risk factors for peripheral artery disease are those that predispose to the development of atherosclerosis. Risk factors for peripheral artery disease include:
- High blood cholesterol (elevated levels of the “bad” LDL cholesterol and triglycerides
- Low blood levels of the “good” HDL cholesterol
- Cigarette smoking
- Diabetes mellitus (both type 1 and type 2 diabetes)
- High blood pressure (hypertension) or a family history of hypertension
- A family history of atherosclerotic disease
- Chronic renal failure
- Overweight or obesity
- Physical inactivity
In peripheral artery disease, the risk factors are additive, so that a person with a combination of two risk factors — diabetes and smoking, for example — has an increased likelihood of developing more severe peripheral artery disease than a person with only one risk factor.
How does atherosclerosis cause disease?
Atherosclerosis causes disease in two ways. 1) Atherosclerosis can limit the ability of the narrowed arteries to increase delivery of blood and oxygen to the to tissues of the body during times when oxygen demand needs to be increased, for example, during exertion; or 2) complete obstruction of an artery by a thrombus or embolus (thrombus and embolus are forms of blood clots), which results in tissue death (necrosis). Exertional angina and intermittent claudication are two examples of insufficient delivery of blood and oxygen to meet tissue demand; whereas strokes and heart attacks are examples of death of tissue caused by complete artery obstruction by blood clots.
There are many similarities between coronary heart diseases (or coronary artery disease, which is atherosclerosis involving the arteries of the heart) and peripheral artery disease, and the two conditions may coexist in the same individual. For example, patients with exertional angina typically have no symptoms at rest. However, during exertion the critically narrowed coronary arteries are incapable of increasing blood and oxygen delivery to meet the increased oxygen needs of the heart muscles. Lack of blood and oxygen causes chest pain (exertional angina). Exertional angina typically subsides when the patient rests. In patients with intermittent claudication, the narrowed arteries in the lower extremities (for example, a narrowed artery at the groin) cannot increase blood and oxygen delivery to the calf muscles during walking. These patients experience pain in the calf muscles that will only subside after resting.
Patients with unstable angina have critically narrowed coronary arteries that cannot deliver enough blood and oxygen to the heart muscle even at rest. These patients have chest pain at rest and are at imminent risk of developing heart attacks. Patients with severe artery occlusion in the legs can develop rest pain (usually in the feet). Rest pain represents such severe occlusion that there is insufficient blood supply to the feet even at rest. They are at risk of developing foot ulcers and gangrene.
When atherosclerosis narrows the arteries, blood tends to clot in the narrowed areas, forming a thrombus, a type of blood clot (plural thrombi). Sometimes pieces of the blood clot break off and travel in the bloodstream until they are trapped in a narrower point in the artery beyond in which they cannot pass. A thrombus or piece of thrombus that travels to another point is called an embolus. Thrombi and emboli can cause sudden and complete artery blockage, leading to tissue necrosis (death of tissue due to lack of oxygen).
For example, complete blockage of a coronary artery by a thrombus causes heart attack, while complete blockage of a carotid or cerebral artery causes ischemic stroke. Emboli originating from atherosclerosis in the aorta (the main artery delivering blood to the body) can obstruct small arteries in the feet, resulting in painful and blue (cyanotic) toes, foot ulcers, and even gangrene.
What are collateral vessels or collateral circulation?
Sometimes, despite the presence of a severe blockage in an artery, the involved area does not become painful or lose its blood supply due to the presence of collateral vessels. Collateral circulation means that the particular area is supplied by more than one artery, so that that blockage of a single vessel does not result in a severe degree of blood loss. Collateral circulation can develop over time to help provide oxygenated blood to an area where an artery is narrowed. Doctors believe that regular supervised exercise can stimulate the growth and development of collateral circulation and relieve symptoms of intermittent claudication.
What are the other causes of peripheral vascular diseases (PVD)?
A number of conditions such as vasculitis may cause damage to blood vessels throughout the body. Injuries to blood vessels (from accidents such as auto accidents or sports injuries), blood-clotting disorders, and damage to blood vessels during surgery can also lead to inadequate blood supply to body tissues (ischemia).
Tissue ischemia can also occur in the absence of atherosclerosis or other abnormalities of arteries. One example of a condition in which the blood vessels themselves are not damaged is Raynaud’s disease, which is believed to occur due to spasms in blood vessels brought on by stress or a cold environment.
Since atherosclerosis of the peripheral arteries (PAD) is by far the most common cause of peripheral vascular disease, the rest of this article focuses upon peripheral artery disease.
Is there a test to diagnose peripheral artery disease (PVD)?
The doctor will perform a physical exam and look for signs and symptoms of peripheral artery disease, for example, weak or absent artery pulses in the extremities, bruits (sounds that can be heard through a stethoscope), blood pressure changes, and skin color and nail changes
In addition to the history of symptoms and the physical signs of peripheral artery disease imaging tests can be used in the diagnosis of the condition. Imaging tests include:
- Doppler ultrasound – This form of ultrasound (measurement of high-frequency sound waves that are reflected off of tissues) that can detect and measure blood flow. Doppler ultrasound is used to measure blood pressures behind the knees and at the ankles. In patients with significant peripheral artery disease in the legs, the blood pressures in the ankles will be lower than the blood pressure in the arms (brachial blood pressure). The ankle-brachial index (ABI) is a number derived from dividing the ankle blood pressure by the brachial blood pressure. An ankle-brachial index of 0.9 to 1.3 is normal, an ABI less than 0.9 indicate the presence of peripheral artery disease in the arteries in the legs, and an ABI below 0.5 usually indicates severe arterial occlusion in the legs.
- Duplex ultrasound – This is a color assisted non-invasive technique to study the arteries. Ultrasound probes can be placed on the skin overlying the arteries and can accurately detect the site of artery stenosis as well as measure the degree of obstruction.
- Angiography – An angiography is an imaging procedure to study the blood vessels of the extremities, similar to the way a coronary angiogram provides an image of the blood vessels supplying the heart. It is the most accurate test to detect the location(s) and severity of artery occlusion, as well as collateral circulations. Small hollow plastic tubes (catheters) are advanced from a small skin puncture at the groin (or the arm), under X-ray guidance, to the aorta and the arteries. Iodine contrast “dye,” is then injected into the arteries while an X-ray video is recorded. Angiogram gives the doctor a picture of the location and severity of narrowed artery segments. This information is important in helping the doctor select patients for angioplasty or surgical bypass (see below).
- Because X-ray angiography is invasive with potential side effects (such as injury to blood vessels and contrast dye reactions), it is not used for initial diagnosis of peripheral artery disease. It is only used when a patient with severe peripheral artery disease symptoms is considered for angioplasty or surgery. A number of different imaging methods have been used in angiography examinations, including X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans.
- Magnetic resonance imaging (MRI) angiography uses magnetism, radio waves, and a computer to produce images of body structures and has the advantage of avoiding X-ray radiation exposure.
What are the management and treatment guidelines for peripheral vascular disease (PVD)?
Treatment goals for peripheral artery disease include:
- Relieve the pain of intermittent claudication.
- Improve exercise tolerance by increasing the walking distance before the onset of claudication.
- Prevent critical artery occlusion that can lead to foot ulcers, gangrene, and amputation.
- Prevent heart attacks and strokes.
Treatment of peripheral artery disease includes lifestyle measures, supervised exercises, medications, angioplasty, and surgery.
- Smoking cessation eliminates a major risk factor for disease progression, and it lowers the incidences of pain at rest and amputations. Smoking cessation also is important to prevent heart attacks and strokes.
- A healthy diet can help lower blood cholesterol and other lipid levels and may help control blood pressure.
- Keep other risk factors, such as diabetes, lipid levels, and blood pressure under control by following medical advice regarding medications and lifestyle changes.
Proper exercise can condition the muscles to use oxygen effectively and can speed the development of collateral circulation. Clinical trials have shown that regular supervised exercise can reduce symptoms of intermittent claudication and allow individuals to walk longer before the onset of claudication. Ideally, your health care provider should prescribe an exercise program tailored to your specific needs.
Rehabilitation programs supervised by healthcare professionals such as nurses or physical therapists may help. Exercise at least three times a week, each session lasting longer than 30 to 45 minutes for the best results. Exercise usually involves walking on a monitored treadmill until claudication develops; walking time is then gradually increased with each session. Patients are also monitored for the development of chest pain or heart rhythm irregularities during exercise.
Medications to treat peripheral vascular disease (PVD)
While lifestyle changes may be enough treatment for some people with peripheral artery disease, others may require medication. Examples of medications used to treat peripheral artery disease include antiplatelet or anticlotting agents, cholesterol-lowering drugs such as statins, medications that increase blood supply to the extremities such as cilostazol (Pletal) and pentoxifylline (Trental), and medications that control high blood pressure.
- Antiplatelet medications (such as aspirin and clopidogrel [Plavix]) make the blood platelets less likely to stick to one another to form blood clots. Low-dose aspirin (81 to 325 mg/day) is usually prescribed indefinitely because it is also helpful in preventing strokes and heart attacks in patients with peripheral artery disease. Clopidogrel (Plavix) is an alternative to aspirin for those who are allergic or cannot tolerate aspirin. Antiplatelet medications also help prevent occlusion of blood vessels after angioplasty or bypass surgery.
- Anticoagulant medications act to prevent blood clotting. Both heparin and warfarin (Coumadin, Jantoven) are anticoagulant medications. Anticoagulants are sometimes prescribed for people with peripheral artery disease if they are at increased risk for formation of blood clots; these agents are used much less frequently than anti platelet agents in patients with peripheral artery disease.
- Cholesterol-lowering drugs of the statin class have been shown in numerous large clinical trials to help prevent heart attacks and strokes and prolong survival among patients with atherosclerosis. Statins have also been shown to slow the progression of peripheral artery disease, decrease arthrosclerosis in the arteries, and improve claudication symptoms.
- Cilostazol (Pletal) is a medication that can help increase physical activity (enabling one to walk a greater distance without the pain of claudication). Cilostazol works by causing dilation of the arteries and an increased supply of oxygenated blood to be delivered to the arms and legs. Cilostazol is recommended for some patients with claudication when lifestyle modifications and exercise are ineffective. Side effects are generally mild and include headache, diarrhea, and dizziness. Cilostazol should not be used in patients with heart failure because of concern over increased mortality in heart failure patients using medications similar to cilostazol.
- Pentoxifylline (Pentoxyl, Trental) improves blood flow to the extremities by decreasing the viscosity (“stickiness”) of blood, enabling more efficient blood flow. Side effects are fewer than with cilostazol, but its benefits are weaker and have not been conclusively proven by all studies.
- Drugs to control hypertension may also be prescribed. Current recommendations are to treat hypertension in patients with peripheral artery disease to prevent strokes and heart attacks.
Angioplasty to treat peripheral vascular disease (PVD)
Angioplasty, also known as percutaneous transluminal angioplasty, or PTA, is a nonsurgical procedure that can widen a narrowed or blocked artery. A thin tube (catheter) is inserted into an artery in the groin or arm and advanced to the area of narrowing. A tiny balloon on the tip of the catheter is then inflated to enlarge the narrowing in the artery. This procedure is also commonly performed to dilate narrowed areas in the coronary arteries that supply blood to the heart muscle.
Sometimes the catheter technique is used to insert a stent (a cylindrical wire mesh tube) into the affected area of the artery to keep the artery open. In other cases, thrombolytic medications (medications that dissolve blood clots) may be delivered to the blocked area via a catheter.
Angioplasty does not require general anesthesia. Usually, a local anesthetic at the area of catheter insertion and a mild sedative are given. Major complications of angioplasty are rare, but can occur. These include damage to the artery or blood clot formation, excessive bleeding from the catheter insertion site, and abrupt vessel closure (blockage of the treated area occurring within 24 hours of the procedure).
Despite these risks, the overall incidence of complications is low and the benefits of angioplasty (no general anesthesia, no surgical incision, and the ability to return to normal activities within a couple of days) outweigh its risks. Usually a one-night hospital stay is required when angioplasty is performed.
Angioplasty is used when a patient has claudication that limits his or her activities and does not respond to exercise, medications, and lifestyle measures. Most doctors also recommend angioplasty when disease is very severe, and there is a focal, localized narrowing that is accessible via catheter. If a patient is too ill to have surgery and has severe ischemia (decreased oxygen in the tissues) that threatens loss of a limb, angioplasty may also be attempted.
Some cases of peripheral artery disease may be more difficult to treat by angioplasty. For example, blockages in multiple small arteries of the legs or blockages in extremely small vessels may not be treatable by this method.
Surgery to treat peripheral vascular disease (PVD)
Surgical treatment for peripheral artery disease involves either bypass vascular surgery performed by a vascular surgeon or endarterectomy. Indications for surgical treatment of peripheral artery disease include lesions that, for anatomical reasons, may be difficult to treat by angioplasty. Examples include lesions covering long segments of a vessel, vessels with multiple narrowed areas, or long areas of narrowing. Bypass surgery involves using a vein from your body or a portion of synthetic vessel (known as grafts) to create a detour around the blockage. One end of the graft is sewn to the damaged artery above the blockage and the other end is sewn below the blocked area. Blood flow is then able to bypass the area of narrowing or blockage Bypass surgery is a major surgical procedure requiring general anesthesia and a hospital stay.
Endarterectomy is a procedure in which the surgeon cleans out plaque buildup inside the artery of the affected leg or arm.
Which specialties of doctors treat peripheral vascular disease (PVD)?
A number of different specialists may treat individuals with peripheral artery disease, for example, internists, family practitioners, or cardiologists may mange medication treatment. Interventional cardiologists or radiologists may perform angioplasty. Vascular surgeons may perform some surgical procedures to treat peripheral artery disease.
What are potential complications of peripheral artery disease (PVD)?
In rare cases, the decreased circulation to the extremities characteristic of peripheral artery disease can lead to open, non-healing sores, ulcers, gangrene, or other limb-threatening injuries to the extremities. The areas that do not receive adequate blood flow are also more prone to develop infections and, in extreme cases, amputation may be necessary.
How can I prevent from getting peripheral vascular disease (PVD)?
Peripheral vascular disease related to atherosclerosis can be prevented by minimizing the risk factors that are controllable, such as eating a heart-healthy diet, maintaining a healthy weight, not smoking, getting regular exercise, and maintaining good control of blood sugar levels if you have diabetes.
An incisional hernia happens when a weakness in the muscle of the abdomen allows the tissues of the abdomen to protrude through the muscle. The hernia appears as a bulge under the skin and can be painful or tender to the touch.
In the case of an incisional hernia, the weakness in the muscle is caused by the incision made in a prior abdominal surgery. To paint a clearer picture: during surgery, an incision is made in the muscles that make up the abdomen. For some reason, that muscle doesn’t heal, so a gap opens up as the muscles tighten and release during activities. Instead of a flat, strong piece of muscle, you have a piece of muscle that has a small gap in it.
After a while, the tissues underneath realize there is an escape route through the muscle and they start to poke through the opening, to the point where they can be felt under the skin. An incisional hernia is typically small enough that only the peritoneum, or the lining of the abdominal cavity, pushes through. In severe cases, portions of organs may move through the hole in the muscle, but this is much less common.
A history of multiple abdominal surgeries may increase the risk of an incisional hernia, as each incision provides a new opportunity for a formation. If a hernia develops in the abdomen and the patient has not had surgery, it is not an incisional hernia.
A patient who gains significant weight after abdominal surgery becomes pregnant, or participates in activities that increase abdominal pressure (like heavy lifting) is most at risk for an incisional hernia.
The incision is weakest, and most prone to a hernia, while it is still healing. While incisional hernias can develop or enlarge months or years after surgery, they are most likely to happen 3 to 6 months after surgery.
Incisional hernias may seem to appear and disappear, which is referred to as a “reducible” hernia. The hernia may not be noticeable unless the patient is involved in an activity that increases abdominal pressure, such as coughing, sneezing, pushing to have a bowel movement, or lifting a heavy object.
The visibility of a hernia makes it easy to diagnose, often requiring no testing outside of a physical examination by a physician. The physician may request that you cough or bear down in order to see the hernia while it is “out.”
Routine testing can be done to determine what area of the body is pushing through the muscle. If the hernia is large enough to allow more than the lining of the abdominal cavity to bulge through, testing may be required.
An incisional hernia may be small enough that a surgical repair is an option, not a necessity. If the hernia is large, causes pain, or is steadily growing, surgery may be recommended.
Another option is a truss, a garment that is similar to a weight belt or girdle, that applies constant pressure to a hernia.
When Is Incisional Hernia an Emergency?
A hernia that gets stuck in the “out” position is referred to as an incarcerated hernia. While an incarcerated hernia may not be an emergency, medical care should be sought, as it can quickly become an emergency.
An incarcerated hernia becomes an emergency when it becomes a “strangulated hernia,” where the tissue that bulges out is being starved of its blood supply. Untreated, a strangulated hernia can cause the death of the tissue that is bulging through the hernia.
A strangulated hernia can be identified by the deep red or purple color of the bulging tissue. It may be accompanied by severe pain, but is not always painful. Nausea, vomiting, diarrhea, and abdominal swelling may also be present.
Think of it as the hernia equivalent of typing a string around your finger until it turns purple and hurts and then you cannot get the string off.
A strangulated hernia is a medical emergency and requires immediate surgical intervention to prevent damage to the intestines and other tissues.
When Else Is Incisional Hernia Surgery Necessary?
An Incisional hernia may require surgery if:
- It continues to enlarge over time
- It is very large
- It is cosmetically unappealing
- The bulge remains even when the patient is relaxed or laying down
- The hernia causes pain
In some of these cases, the decision of whether to have surgery is up to you. You may want to have surgery if you’re feeling uncomfortable or are concerned about how the hernia looks, for example. It’s best to discuss the surgery to get the details and understand the process and what recovery looks like.
Incisional hernia surgery is typically performed using general anesthesia and is done on an inpatient basis. The surgery is typically performed using the laparoscopic method, using small incisions rather than the traditional, and much larger, open incision. Surgery is performed by a general surgeon or a colon-rectal specialist.
Once anesthesia is given, surgery begins with an incision on either side of the hernia. A laparoscope is inserted into one incision, and the other incision is used for additional surgical instruments. The surgeon then isolates the portion of the abdominal lining that is pushing through the muscle. This tissue is called the “hernia sac.” The surgeon returns it to its proper position then begins to repair the muscle defect.
If the defect in the muscle is small it may be sutured closed. The sutures will remain in place permanently, preventing the hernia from returning. For large defects, the surgeon may feel that suturing is not adequate. In this case, a mesh graft will be used to cover the hole. The mesh is permanent and prevents the hernia from returning, even though the defect remains open.
If the suture method is used with larger muscle defects (approximately the size of a quarter or larger), the chance of reoccurrence is increased. The use of mesh in larger hernias is the standard of treatment, but it may not be appropriate if the patient has a history of rejecting surgical implants or a condition that prevents the use of mesh.
Once the mesh is in place or the muscle has been sewn, the laparoscope is removed and the incision can be closed. The incision is typically closed with sutures that are removed at a follow-up visit with the surgeon, at which point a special form of glue is used to hold the incision closed. Small sticky bandages called steri-strips may also be used.
Most hernia patients are able to return to their normal activity within about three weeks. The belly will be tender, especially for the first week. During this time, the incision should be protected during the activity that increases abdominal pressure by applying firm but gentle pressure on the incision line. This is especially important for incisional hernia patients, as they are predisposed to an incisional hernia and can be at risk for another one at the new incision sites.
Activities during which the incision should be protected include:
- Rising from a seated position
- Bearing down during a bowel movement. Contact your surgeon if you are constipated after surgery, a stool softener may be prescribed.
- Lifting heavy objects
Many of the activities listed are tasks you’ll be doing every day, so avoiding them all may not be possible. However, it’s in your best interest to conduct them with caution to prevent further complications. Be sure to keep an open line of communication with your doctor if you suspect something went wrong.