Current issues for hernia repair
The goalposts have changed over recent times for groin hernia repair. Once, the main concern was whether the repair lasted the test of time. The main area of interest was surgeons' recurrence rates. Most experienced surgeons nowadays have low recurrence rates for hernia repair, around 1-2%. We are now focusing on other aspects of hernia repair. These include speed of recovery, wound infection rate, and incidence of chronic groin pain. The last of these is of particular interest lately because it appears that technique is very important to reduce the incidence of chronic pain. The good news is that all these parameters are better achieved through laparoscopic repair, with modern techniques. Other operations can be done at the same time as laparosocpic groin hernia repair. For example, through he same incisions, a hernia at the umbilicus can be repaired as well as a groin hernia. More to follow....
Towards better colonoscopy
Colonoscopic techniques have changed over the last few years. Here are some of the important factors that have recently been shown to improve colonoscopy. Firstly, good bowel preparation is extremely important. There is no use having up-to-the minute equipment if the operator cannot see. Nowadays, we use split preparation, with the last volume of purgative taken just two hours before the procedure. It is important that the endoscopy nurse is consulted immediately prior to the procedure to check on the quality of the preparation. The procedure is nowadays done "underwater". Instead of using gas to inflate the bowel during insertion of the colonoscope, water is instilled via the colonoscope to gently fill the colon and permit navigation of the scope through to the terminal ileum. The colonoscopist should enter the terminal ileum which is the last part of the small intestine before it joins that large intestine. That way, not only can diseases of the last part of the small bowel be diagnosed but also, it is proof that the entire colon has been examined. Carbon dioxide is insufflated into the bowel during withdrawal of the scope, which is when the careful examination of the colon is done. This gas is absorbed by the body and results in less bloating and discomfort after the procedure than when air is used as it used to be. It has been shown that the longer the operator spends examining the colon, the more chance there is of picking up abnormal things such as polyps. We time the operator now to ensure that at least 6 minutes has been taken to withdraw the scope and examine the bowel. It is important that high definition scopes are used and high definition monitors to ensure that subtle lesions are not missed. It is thought that that many of the cancers that appear in the two or three years after colonoscopy actually represent benign polyps that were inadvertently missed and then grew cancerous. This type of very subtle polyp is more common on the right side. The current standard is that the operator should examine the right side of the colon twice or bend the scope backwards to look back behind the bowel folds to double-check little polyps are not hidden. Sometimes polyps can hide behind folds on the bowel and the operator can only see them by what we call retroflexing the scope. At the end of the day, what we are looking for are benign polyps that might later become cancerous. Ideally, the operator should keep a record of how often he or she finds a benign polyp. In a screening colonoscopy, polyps should be found in about 30-40% of cases. Otherwise there is a risk that polyps have not been discovered and were missed. The operator should be skilled at removing polyps. The modern trend is to remove polyps using cold snares for small polyps rather than cauterising the polyps as we used to. The operator should be skilled at using modern techniques to remove large polyps too - ones that we used to refer for surgery. Techniques have improved such that now many patients are saved major surgery by having expert endoscopic polypectomy. The endoscopist should be expert at interpreting the appearances of a polyp. With modern technology and proper training, the endoscopist nowadays should be able to to tell in most cases if a polyps is benign or malignant by looking at it.