Varicose Veins

What are varicose veins?

Veins are vessels which are designed to carry de-oxygenated blood back to the heart from the tissues of the body. Varicose veins, however, are abnormally dilated veins that cannot perform their function.
Varicose veins are larger veins that bulge above the skin surface which are commonly found in association with larger and deeper vein problems. If there is a deeper vein problem can be detected at an initial examination.
Dilated blood vessels often cause aching especially after prolonged standing. Although dilated blood vessels do carry blood they are not very efficient and are often not necessary to the circulatory system. The body has an already established alternative route for the blood to travel back more efficiently to the heart (deep venous system). Thus they can be treated without damaging the circulation. In fact, treatment actually improves venous circulation. The probability of a greatly improved appearance following treatment is about 90 per cent depending on the severity of the problem. Treatment will also usually relieve any symptoms caused by the veins.

What causes varicose veins?

Since our ancestors decided to stand upright, our leg veins have been faced with the difficult task of taking the blood up to the heart against the pulling force of gravity. To do this the leg veins depend on the contraction of the calf and thigh muscles to pump the blood. This is why walking is good for your circulation.
So when you walk, the contraction of your leg muscles pumps the blood up. However, as the saying goes "what goes up must come down" which is what happens to blood in the leg veins. Therefore, to prevent the blood from falling back down, nature has designed valves in the leg veins which open in only one direction: upwards. So the valves allow the blood to get through but when it comes back down, the valves shut and stop the blood going all the way down. The next contraction sends the blood even higher until it eventually reaches the heart.
In venous disease, the underlying problem appears to be damage to the valves. The abnormal reticular veins, for instance, act as "feeders" of the spider veins. The blood flow in these feeder veins can compared to a "two-way" street. In other words, blood in the feeder veins can go back and forth. This backward flow through the incompetent valves dilates up the smaller veins (medically called "post-capillary venules"). These dilated post-capillary venules are commonly referred to as "spider veins".
The same principle applies to varicose veins. The abnormal valve cannot stop the blood from rushing back down. The blood in these veins is oxygen low and in fact carries a lot of toxins. In the case of varicose veins, this "toxic" blood pools in the legs and cannot be returned to the circulation. This is why patients with varicose veins suffer from night cramps and their legs feel heavy at the end of the day.
Varicose veins occur in both men and women. A definitive cause is not known, however a strong family history suggests that some people inherit veins that are more likely to deteriorate. In women, oestrogen may play a role as the onset of puberty, pregnancy and taking oral contraceptives can give rise to vein abnormalities. In pregnancy, the enlarged uterus can restrict blood flow from the legs and promote the development of varicose veins. Spider veins and varicose veins are also associated with obesity. Occupations involving prolonged standing tend to increase the likelihood of veins to develop. Bone fractures and soft tissue trauma can cause localized vein abnormalities.

How to treat Varicose Vein?

The aim of varicose vein treatment by any method (surgical or non-surgical) is to close or remove the diseased and incompetent superficial varicose vein. Since most of the blood in the legs is returned to heart by the deep veins, and the superficial veins only return about 10 per cent, they can be sacrificed without serious harm.
Elevating the legs provides relief. Regular exercise has not shown to cure varicose vein. The wearing of graduated compression stockings with a pressure of 30-40 mmHg has been shown to provide temporary relief from the leg swelling. Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression stockings.

1. Open Surgery

Traditionally, open surgery was the only choice for treatment of varicose vein till few years. It involved stripping the diseased varicose vein from the body. This operation is done under general or spinal anesthesia as an inpatient procedure. Multiple cuts are made on the legs at various places starting from the groin till the ankle. The vein is stripped through the open cuts. This usually is a prolonged surgery with blood transfusion. Patient is admitted in the hospital for about five days. The post-operative period is often painful with risk of bleeding from the incision sites. Multiple surgical scars on the legs are produced due to surgery. The patient is advised rest for a period of six weeks following surgery.
The higher rate of deep vein thrombosis, pulmonary embolism, and wound complications including infection and bleeding are discouraging for a patient to undergo open surgery for varicose vein.
The open surgery has a high recurrence rate (five to 60 per cent), and a risk of nerve damage up to 15 per cent. Hence now open surgery for varicose vein is less commonly performed worldwide.

2. Endovenous Laser Ablation (EVLA)

Recent advances have improved lasers, making laser surgery a preferred method of treatment for varicose vein. By LASER, the whole lining of the diseased superficial varicose vein is destroyed, and hence a chance for new collateral veins to grow is almost zero.
The Endovenous Laser ablation for varicose vein is done under local anesthesia from a single pinhole in the leg. There is no need for any cutting or stitching on the leg. The patients walk out of the Laser suite after the procedure. Normally EVLA is done as an out patient procedure or 6 to 8 hour hospitalization may be recommended.
The Laser energy seals the abnormal vein completely and permanently. The most modern 1470 nm diode laser system produces the highly wavelength, which safely passes through the skin and is selectively absorbed by the targeted blood vessel. The vein will gradually disappear, leaving the skin intact. A crepe bandage is applied on the leg for 48 hours continuously. The patient will be advised oral pain killer for five days following the procedure. Crepe bandage or stockings are worn for a couple of weeks on the calf from morning to evening. A monthly follow-up twice with Doppler scan following the LASER ablation of varicose vein is recommended.

I. Advantages of EVLA
The advantages of Endovenous LASER ablation are many. Due to the optimal absorption spectrum of 1470 nm, the veins get closed in without affecting the neighboring tissue. The closed vein remains in its natural position in the body, which reduces the invasiveness of surgery to a minimum.
The procedure is done under local anesthesia, and there is no risk of blood transfusion. The patient does not require postoperative rest, and can resume routine activities on the next day of the procedure. The treatment duration is just about half an hour. Also, there is reduced risk of infection.

II. Side-Effects
The Laser Ablation for varicose vein is well tolerated and has few side-effects. Some patients may experience a slight ache along the shrunken veins, for which local cooling and anti-inflammatory drugs will provide quick relief. Some patients may experience bruising or paraesthesia, which are self-limiting in a few days time.

3. Radio Frequency Ablation

Radio frequency ablation of varicose vein is less invasive than open surgery, but more invasive than LASER ablation and recurrence rates are lower than open surgery but higher than LASER ablation. Not many centers across the world are now practicing RF ablation for varicose vein treatment after the advent of LASER as a modality to treat varicose vein.

4. Sclerotherapy

Sclerotherapy is a non-surgical approach in the treatment of varicose and spider veins of the legs. A sclerosing solution is injected directly into the vein, causing it to quickly disappear. It has a recurrence rate as high as 70 per cent. It is never used as a sole method of treatment for varicose vein. It can be an added therapy with other mainstay treatment.

Prevention

Varicose vein is prevented by avoiding prolonged standing. Sitting for a few minutes during prolonged standing helps prevent the disease. A good compression stocking (pressure gradient of 30 to 40 mm Hg) should be worn by persons who stands for a prolonged period routinely. Maintaining a normal weight, regular exercise, avoiding constipation and avoiding wearing high heeled shoes may also be helpful.

THE IMPORTANCE OF YOGA AND DIET MANAGMENT IN DIABETES CARE---

HOW IMPORTANT IS EXCERCISE?

Exercise plays an important role in controlling diabetes because it lowers blood sugar and helps insulin to work more efficiently in the body. Exercise also enhances cardiovascular fitness by improving blood flow and increasing the heart's pumping power. It also promotes weight loss and lowers blood pressure. Exercise only has value, however, when it is done regularly—at least three to four sessions per week for 30 to 60 minutes per session. People with type 2 diabetes who exercise regularly have been shown to lose weight and gain better control over their blood pressure, thereby reducing their risk for cardiovascular disease (a major complication of diabetes). Studies have also shown that people with type 1 diabetes who regularly exercise reduce their need for insulin injections


YOGA--WHICH YOGA IS BENIFICIAL?

Pranayama –
There are 8 types of Pranayama mentioned in Hatha Yoga. One of the basic preparations for Pranayama is Nadi Shodhan Pranayama or alternate nostril breathing, this type is found useful in diabetes as Alternate nostril breathing has calming effect on nervous system, which reduces stress levels, helping in diabetes treatment. Also research has shown that Bhramari and Bhasrika Pranayama help in diabetes. Bharamari has calming effect on mind, brain and nervous system. Bhasrika Pranayama is revitalizing Pranayama, which increases oxygen levels and reduces carbon dioxide levels in the blood. In bhasrika Pranayama, the abdominal muscles and diaphragm are used which puts pressure on the internal organs. But before practicing these Pranayama, one must learn and practice deep breathing, fast breathing, alternate nostril breathing, Bandhas (Jalandhar bandha or chin lock, moola bandha and Uddiyan bandha or abdominal lock)
Sun Salutation is very good exercise for people suffering from diabetes, it increases the blood supply to various parts of body, improving insulin administration in the body, it gives all the benefits of exercise .

HERE IS A LIST OF HERBS USEFULL FOR DIABETES--

Numerous herbs have been used traditionally to regulate glucose levels in the body.
• Onion (Allium cepa)
• Garlic (Allium sativum)
• Andrographis (Andrographis paniculata)
• Green tea (Camellia sinensis)
• Indian cluster bean (Cyamopsis tetgonolobus)
• Gurmar (Gymnema sylvestre)
• Bitter melon or karela (Momordica charantia)
• Tinospora gulancha (Tinospora cordifolia)




Dr. NITIN SHAKYA

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs can also originate in the mesentery and omentum. Overall, GISTs are rare and rank a distant third in prevalence behind adenocarcinomas and lymphomas among the histologic types of gastrointestinal tract tumors. Historically, these lesions were classified as leiomyomas or leiomyosarcomas because they possessed smooth muscle features when examined under light microscopy.

Since the term GIST was introduced by Mazur and Clark in 1983, laboratory investigations aimed at the subcellular and molecular levels have demonstrated that GISTs do not possess the ultrastructural and immunohistochemical features characteristic of smooth muscle differentiation, as are seen in leiomyomas and leiomyosarcomas.1 Therefore, the determination was made that GISTs do not arise from smooth muscle cells, but from another mesenchymal derivative such as the progenitors of spindle and epithelioid cells.

According to the work of Kindblom and associates reported in 1998, the actual cell of origin of GISTs is a pluripotential mesenchymal stem cell programmed to differentiate into the interstitial cell of Cajal.2 These are GI pacemaker cells and are largely responsible for initiating and coordinating GI motility. This finding led Kindblom and coworkers to suggest the term GI pacemaker cell tumors.2 Perhaps the most critical development that distinguished GISTs as a unique clinical entity was the discovery of c-kit proto-oncogene mutations in these tumors by Hirota and colleagues in 1998.3

These advances have led to the classification of GISTs as an entity separate from smooth muscle tumors, helped elucidate their etiology and pathogenesis at a molecular level, and led to the development of molecular-targeted therapy for this disease.
Clinical
History
•Up to 75% of GISTs are discovered when they are less than 4 cm in diameter and are either asymptomatic or associated with nonspecific symptoms. They are frequently diagnosed incidentally during endoscopic or surgical procedures or during radiologic studies performed to investigate protean manifestations of gastrointestinal tract disease or to treat an emergent condition such as hemorrhage or obstruction. Lesions greater than 4 cm in diameter are more likely to be symptomatic.
•The most common symptoms associated with GISTs are vague, nonspecific abdominal pain or discomfort.
•Patients also describe early satiety or a sensation of abdominal fullness. Rarely, an abdominal mass is palpable.
•GISTs may also produce symptoms secondary to obstruction or hemorrhage. GI bleeding is produced by pressure necrosis and ulceration of the overlying mucosa with resultant hemorrhage from disrupted vessels. Patients who have experienced significant blood loss may report malaise, fatigue, or exertional dyspnea. Obstruction can result from intraluminal growth of an endophytic tumor or from luminal compression from an exophytic lesion. The obstructive symptoms can be site-specific (eg, dysphagia with an esophageal GIST, constipation with a colorectal GIST, obstructive jaundice with a duodenal tumor).
•In some cases, the GIST is an unexpected finding during emergency surgery for a perforated viscus.
Physical
•No physical findings specifically suggest the presence of a GIST. Some patients present with a palpable abdominal mass. Others may present with nonspecific physical findings associated with GI blood loss, bowel obstruction, or bowel perforation and abscess formation.
•Patients presenting with significant GI bleeding can manifest vital sign abnormalities or overt shock. In others, fecal occult blood testing may be positive.
•Physical findings associated with bowel obstruction can include a distended, tender abdomen. Duodenal obstruction involving the ampulla may be associated with jaundice and, rarely, even a distended palpable gallbladder.
•If perforation has occurred, focal or widespread signs of peritonitis are present.
Causes
•Gain-of-function mutations in exon 11 of the c-kit proto-oncogene are associated with most GISTs. These mutations lead to constitutive overexpression and autophosphorylation of c-Kit, provoking a cascade of intracellular signaling that propels cells toward proliferation or away from apoptotic pathways.
•This discovery by Hirota and colleagues in 1998 was a landmark elucidation of the etiology of a disease on a molecular level.3 Most of these mutations are of the in-frame type, which allows preservation of c-kit expression and activation. The c-kit proto-oncogene is located on chromosome arm 4q11-12. It encodes KIT, which is a transmembrane tyrosine kinase. Stem cell factor, also called Steel factor or mast cell growth factor, is the ligand for KIT and exists primarily in dimeric form.
•Under normal circumstances, KIT activation is initiated when stem cell factor binds to the extracellular domain of c-Kit. The result is homodimerization of the normally inactive c-Kit monomers. Autophosphorylation of intracellular tyrosine residues then transpires. This exposes binding sites for intracellular signal transduction molecules. What follows is activation of a signaling cascade that involves phosphorylation of several downstream target proteins, including MAP kinase, RAS, and others. Ultimately, the signal is transduced into the nucleus, resulting in mitogenic activity and protein transcription.
•KIT is constitutively phosphorylated in the majority of GISTs. In these instances, stem cell factor is not required to initiate the sequence of c-Kit homodimerization and autophosphorylation. This is termed ligand-independent activation. The increased transduction of proliferative signals to the nucleus favors cell survival and replication over dormancy and apoptosis, leading to tumorigenesis.
•Studies have reported a small subset of KIT-negative GISTs in which mutations of platelet-derived growth factor receptor-alpha (PDGFA), protein kinase C, and FLJ10261 were detected. These mutations and c-kit mutations appear to be mutually exclusive according to the 2003 work of Heinrich and associates. These investigators discovered PDGFA mutations in 14 of 14 subjects with GISTs who lacked c-kit mutations.
•A small minority of GISTs are associated with hereditary syndromes.
•One is characterized by multiple GISTs with or without the presence of dermal and mucous membrane hyperpigmentation, numerous nevi, and urticaria pigmentosa. Mast cell dysfunction and diffuse hyperplasia of GI spindle cells are other features of this syndrome.
•GISTs occur with a higher than expected frequency in patients with type 1 neurofibromatosis.
•GISTs are also a feature of the rare Carney triad, which is observed predominantly in young women. This triad consists of epithelioid gastric stromal tumors, pulmonary chondromas, and extra-adrenal paragangliomas.

EMERGING SCENARIO OF CORONARY ARTERY DISEASE IN YOUNG INDIANS
THE MISSING LINK


Dr. Arun Goyal
MS, M.Ch, FIACS
Senior Consultant Cardiac Surgeon
Escorts Goyal Heart Centre
JODHPUR.

The heart is a pump and coronary arteries are its fuel supply pipelines. The fuel is oxygen which is carried in the blood. Coronary artery may narrow due to thickening in its walls and this reduces blood flow to the heart muscle. The process is called arteriosclerosis. When the narrowing gets worse, the lack of oxygen may cause pain called Angina. If the narrowing gets critical, it can cause a complete blockage and lead to Heart Attack.

At the threshold of the new millennium, coronary artery disease is looming large as the new epidemic afflicting Indians at a relatively younger age in severe and diffuse form of lesions. The prevalence of CAD progressively increased in the India during the later half of the last century. The conventional factors namely Hypertension, Diabetes Mellitus, Hypertriglyceridemia, lower level of HDLS, Central obesity, Lipoprotein A, LDL – C, Lower level of antioxidants (Vitamin A, E & Beta Carotene) rising affluence, rapid modernization associated with sedentary life style.

The risk of CAD in Indians is 3-4 times higher than white Americans, 6 times higher than Chinese and 20 times higher than Japanese. India will be the world capital of Coronary artery disease by the year 2020. There are as estimated 45 millions patients of coronary artery disease in India. Premature coronary artery disease is defined as cardiac event occurring before the age of 55 in men and 65 in woman. In its severe form it is defined as CAD occurring before the age of 40 years. Indians affected 5-10 years earlier than other communities. There are at least 20 million diabetics in India, which is the highest ever reported number from anywhere in the world.

Risk Factors

Tobacco Consumption in any form specially smoking is the most important of all the risk factors. It increases risk of CAD by 3-5 times. Contrary to popular belief, smoking small amounts is nearly as heavy as heavy smoking so that cutting down does not help very much. Smoking cigar and pipes is also bad as the harmful ingredients of smoke are also absorbed through the mouth. It is never too late to QUIT smoking.

Hypertension remains a standard risk factor associated with CAD. Contrary to the popular opinion, blood pressure may be raised without any symptoms at all. Therefore it is important to get it measured regularly.

Diabetes is another Condition that may exits without one’s knowledge and can be detected by testing the urine for sugar. Careful Diabetes control should reduce the extent of Coronary Artery Disease.

Hypercholestremia and other fatty substances in the blood also increase the risk. In contrast to decreasing mean cholesterol level in the USA, the mean cholesterol levels in urban Indians are rising. In Delhi the mean cholesterol level has risen from 160mg/dl in 1982 to 199mg/dl in 1994. In Indians even with low levels of serum cholesterol have higher risk of Coronary Artery Disease.

Central Obesity depicted by waist to hip ratio is an independent risk factor for CAD. Even modest increased in body fat with central distribution increases the risk further.

New Risk Factors
Lipoprotein – a (LP-a) is an independent risk factor for Coronary Artery Disease. It is genetic risk factor not affected by any life style modifications. It is 10 times more atherogenik than LDL-c.

Indians with Coronary Artery Disease have high triglyceride levels than high cholesterol levels. Indian demonstrates a triad of High Triglycerides, High LDL-C and Low HDL levels. This triad combined with high LP-a constitute the Deadly Lipid Quartet.

Insulin resistance syndrome, serum fibrinogen, hyperhomocysteinaemia and various viral and bacterial infections especially Chlamydia pneumonia is considered as an important risk factor for Coronary Artery Disease.

PREVENTION

How you live your life can greatly affect the health of your heart. Taking the following steps can help you prevent Coronary Artery Disease as well as a Heart Attack and Heart Failure.

Don’t smoke. Smoking and second hand smoke are major risk factors of Coronary Artery Disease. Nicotine constricts blood vessels and forces your heart to work harder. Carbon monoxide reduces oxygen in blood and damages the lining of blood vessels.

Control your blood pressure: Have your blood pressure checked every two years. Your doctor may recommended more frequent measurement if you have blood pressure higher than 115/75 mmHg or a history of heart disease. Your risk of coronary artery disease doubles with every 20/10mmHg increase over 115/75mmHg.

Check your Cholesterol: Have your blood cholesterol levels checked regularly. If your blood cholesterol level is undesirably high, your doctor can prescribe changes in your diet and medications to help lower your cholesterol and protect your cardiovascular health. Having an LDL level above 160 or HDL below 40, places you at a higher risk of heart disease.
Exercise regularly: Exercise helps prevent coronary artery disease by helping you to achieve and maintain a healthy weight and control diabetes, elevated cholesterol and high blood pressure, Try to exercise at least 30 minutes on most days. If it’s been a while since you exercised, check with your doctor before starting any exercise Programme and start exercising in 10 minute intervals and then gradually increased the amount of time you spend exercising.

Maintain a healthy weight: Being overweight increases your risk of coronary artery disease, but by losing weight, you can reduce that risk.

Eat a healthy diet: Too much saturated fat and cholesterol in your diet can narrow the arteries leading to your heart. A diet high in salt can raise your blood pressure. Follow your doctor’s and dietician’s advice on eating a heart healthy diet. Fish is a part of a heart healthy diet because it contains omega – 3 fatty acids, which help improve blood cholesterol levels and prevent blood clots. Eating plenty of fruits and vegetables also is encouraged. Fruits and vegetables contain antioxidants – vitamins and minerals that help prevent everyday wear and tear on your coronary arteries.

Get regular medical check ups: Some of the main risk factors for coronary artery disease – high blood cholesterol, high diabetes – have no symptoms in their early stages. Coronary artery disease itself may produce no symptoms. But your doctor can perform tests to check that you are free of these conditions. If a problem is found, you and your doctor can manage it early to prevent complications.

Manage stress: To reduce your risk of cardiovascular disease, reduce stress in your daily activities. Rethink workaholic habits and find healthy ways to minimize or deal with stressful events as well as anger in your life.

CORONARY ARTERIES ARE OUR LIFE LINES REQUIRE FRESH AIR, FIBERS & FRUITS AND NOT FRIED, FATTY & FAST FOOD.

Beware of White Poison - Salt, Sugar & Dairy Products
(Use judicially after the age of 40 years)

If Money is gone: Nothing Gone

If Character is gone: Something Gone

If Health is gone: Everything Gone

Your hernia is suitable for repair by laparoscopic (keyhole) surgery. The operation is essentially
the same as when performed by conventional methods. In other words it will involve
placing a piece of nylon mesh material over the weak area in your groin. The main difference
between the two operations is the way in which this is done. The operation is done under a
general anaesthetic.
With laparoscopic hernia repair the nylon mesh patch is placed over the weak area from the
inside of the abdomen rather than by making a cut over the hernia itself. The operation involves
making 3 very small cuts in the abdomen. One cut of 1 cm in length is made just under
the umbilicus (tummy button) and the other two (each 0.5 cm in length) on either side. One of
the cuts is used to introduce a telescope with a camera on the end so that the surgeon can see
to operate on a television monitor. The other cuts are needed to introduce instruments into the
abdomen.
What are the advantages of laparoscopic hernia repair?
Patients having laparoscopic surgery generally recover faster and experience less discomfort
than those undergoing conventional surgery. Most patients with a hernia are suitable for this
technique. There are particular advantages for patients who have hernias on both sides of the
abdomen as both can be repaired through the same 3 small cuts. The other group of patients
for whom laparoscopic hernia repair is recommended are those who have had a hernia repair
in the past which has failed.
Are there any disadvantages?
Laparoscopic hernia repair is a more major procedure than conventional hernia repair because
it involves entering the abdomen. However because the cuts are so small recovery is generally
faster. There is a slight risk of damaging bowel or blood vessels within the abdomen and
if this were to occur it might mean a more major operation to repair the damage.
Because laparoscopic hernia repair is relatively new we do not as yet know exactly what the
long term results will be. With conventional surgery the risk of recurrence (return) of the hernia
is about 1 in 200. Laparoscopic hernia repair is basically the same operation as conventional
hernia repair. Thus we expect the results to be similar but until the operation has been
performed for many years we cannot be sure of this.
Post operative care
After your operation you should be able to resume normal activities as soon as it is comfort avoided for a few days. The cuts in your abdomen will be closed by either staples or stitches. These will need
to be removed approximately 7 days after your operation. You may resume work as soon as you comfort allows.
As with a conventional
repair it is sensible to avoid strenuous physical activity or heavy lifting for 3-4 weeks. Light exercise can
be resumed within a few days.
What can go wrong?
Bruising may be noticed either beneath the scars or in the groin area. It may extend into the scrotum or
the penis. This will gradually settle within 2-3 weeks. Occasionally a lump may be felt in the groin
within the first 2-3 weeks. This is caused by a haematoma (collection of blood) near the operation site. It
may be very like the original hernia but it will disappear over a few weeks. Occasionally, if large, it may
need to be drained with a needle. This will be done at your follow up outpatient visit.
Occasionally patients notice numbness or discomfort in the groin area or down the outside of the thigh.
This is much less common than after a conventional hernia repair and will settle over the course of a few
weeks.
Questions patients often ask
Is keyhole surgery safe?
Laparoscopic surgery is now well established and many hundreds of thousands of keyhole operations
have been carried out worldwide. Laparoscopic hernia surgery has been established since the late 1980’s.
What if you find a second unexpected hernia on the other side?
One of the advantages of this technique is it allows the surgeon to view both sides of the groin. In about
30% of patients a second hernia will be detected. It makes sense to repair this at the same time as it will
prevent the need for a second operation in the future.
Is Laparoscopic hernia surgery recommended?
The National Institute for Clinical Excellence (NICE) is an organization set up to examine the evidence
behind new techniques and drugs. Guidelines on Laparoscopic hernia repair were produced in July 2004
and details can be found on the NICE website at www.nice.org.uk. The main recommendations are:
1.1 Laparoscopic surgery is recommended as one of the treatment options for the repair of inguinal hernia.
1.2 To enable patients to choose between open and laparoscopic surgery (either by the transabdominal preperitoneal [TAPP] or by
the totally extraperitoneal [TEP] procedure), they should be fully informed of all of the risks (for example, immediate serious
complications, postoperative pain/numbness and long-term recurrence rates) and benefits associated with each of the three
procedures. In particular, the following points should be considered in discussions between the patient and the surgeon:
the individual's suitability for general anaesthesia
the nature of the presenting hernia (that is, primary repair, recurrent hernia or bilateral hernia)
the suitability of the particular hernia for a laparoscopic or an open approach
the experience of the surgeon in the three techniques.
1.3 Laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by appropriately trained
surgeons who regularly carry out the procedure.