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Colorectal disease


Etymology: Gk, kolon
the portion of the large intestine extending from the cecum to the rectum. It has four segments: the ascending colon, transverse colon, descending colon, and sigmoid colon.


[rek't?m] pl. rectums, recta
Etymology: L, rectus
the lower part of the large intestine, about 12 cm long, continuous with the descending sigmoid colon, proximal to the anal canal.

The treatment of colorectal disease has evolved greatly in the past few decades. One of the most notable advances has been the utilization of minimally invasive surgical techniques safely and effectively to treat diseases such as colorectal cancer and diverticulitis. Amongst its numerous advantages are decreases in mortality, infections, postoperative pain, and earlier return of bowel function.

One of the most feared complications of bowel surgery is an anastamotic leak. It adds significant morbidity and mortality to any surgery involving the gastrointestinal tract. Risk factors for anastamotic leak include obesity, male sex, prior abdominal surgery, radiation therapy, and the need for blood transfusion prior to surgery. Once a leak is suspected, it must be diagnosed and treated immediately. Therefore, meticulous surgical technique and good judgment is of utmost importance in preventing such a complication. In cases for colorectal cancer, anastamotic leak has even demonstrated reduced disease free and overall survival. In experienced hands, the rate of leak is significantly lower when a minimally invasive approach is used. Therefore, it is not surprising that patients who undergo a laparoscopic colon resection survive longer with less complications.

Surgical site infection (SSI) is another potential complication of colon and rectal surgery. Despite tremendous advances in sterile techniques and the judicious use of antibiotics, SSI's remain a significant problem, particularly in the obese and diabetic populations. Even after adequate treatment, these infections can lead to abdominal wall hernias which often require complicated and painful reconstructions later on. With the use of multiple small incisions in the minimally invasive approach, the rate of SSI's has dramatically and indisputably decreased.

The incidence of deep venous thromboembolism (DVT) is also significantly decreased in laparoscopic versus open surgery. DVT's occur largely in part due to venous stasis from prolonged immobilization. In patient's who have undergone laparoscopic surgery, there is significantly less associated pain. This is due to the smaller size of the incisions as well as the ability to visualize the entire abdominal cavity without having to stretch and cause trauma to the abdominal wall. This translates into less postoperative narcotic use and earlier ambulation which is the mainstay in prevention of DVT's.

Another benefit of laparoscopic surgery is the decrease in post-operative ileus. With less manipulation of bowel during surgery and a reduced need for narcotics post-operatively, return of function of the gastrointestinal tract is much faster. In fact, many hospitals including ours are now utilizing a "Fast Track" protocol in which studies have shown that removing bladder catheters and starting a diet on the first postoperative day has lead to a significant decrease in hospital stay and an increase in patient satisfaction. Again, the benefits of minimally invasive surgery over open surgery is clear.

Despite these major advantages, laparoscopic colon and rectal surgery may not always be possible. The main advantage to open surgery is the ability of the surgeon to "feel" what is going on. In patients who have had multiple prior abdominal surgeries, a significant amount of scar tissue may be encountered. This leads to poor visualization and oftentimes, the safest approach is to convert to an open incision and continue the dissection by direct manipulation. Similarly, in patients who have advanced disease where significant inflammation is encountered, the anatomy may be distorted and conversion may be prudent.

This does not, however, negate the utility of laparoscopy in these cases. When conversion is necessary much can be accomplished safely prior to opening. For instance, when removing the distal part of the colon, it is often necessary to release attachments of the colon to the spleen in order to perform a safe and tension-free anastamosis. This is much easier to perform and less painful for the patient when done laparoscopically. After "mobilizing" the colon in this manner, the remainder of the procedure can be done through an open incision lower down in the abdomen which is much smaller and less visible than the traditional large midline incision.

The current guidelines state that screening for colorectal cancer should begin at age 50 for the general population. However, recent studies have noted a significant decrease in the incidence of CRC in the over 50 age group whereas a significant increase was noted in patients aged 40 to 44. Therefore, many investigations are currently underway to determine if the recommended age for screening should be decreased. With advances in minimally invasive surgery for colorectal disease, we have made its treatment safer and more efficient. Thus, we are prepared to treat more patients and catch disease processes at an earlier and more curable stage.

Hiatal hernia

HIATAL: originally denoting a physical gap or opening
HERNIA: a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it

GERD can be present without a hiatal hernia, and a hiatal hernia can be present without GERD. This is a common disorder which most of the time can be successfully controlled with medical management: antacids and proton pump inhibitors, diet modifications (avoiding chocolate, coffee, alcohol, citrus...), and eating habits (no late heavy meals).

Symptoms will vary from simple heartburn to severe regurgitations forcing the patient to sleep in the sitting position. Patients may also present with asthma, hoarseness and sore throat (from exposure of the vocal cords to acid), and persistent cough that is unresponsive to any other therapy. Chest pain is another atypical symptom.

Several anatomic components at the gastro-esophageal junction play a key role in preventing acid reflux from the stomach into the esophagus:

  • • Proper orderly propulsive contractions of the esophagus (i.e., pushing the food down)
  • • Lower esophageal sphincter (or valve)
  • • Presence of 5 to 6 cm of distal esophagus below the diaphragm (intra-abdominal pressure will help maintain it closed)
  • • Normal-sized opening in the diaphragm to allow the esophagus to pass through.
  • • Sharp angle (angle of His) at the gastro-esophageal junction below the diaphragm
  • • Gastro-esophageal membrane or attachments to help maintain the junction in place

When all or some of these components are lacking, reflux and/or hiatal herniation will take place. For example, the GE junction may still be in place, yet a large opening in the diaphragm will allow the fundus of the stomach to herniate into the chest.

The key to a successful outcome from an operation for hiatal hernia is the proper indication for surgery.

Pre-operative work up:

EGD (Upper endoscopy)
Measures the distance from the incisura, identifies retained food, the presence of bile, ulcerations, strictures, and/or inflammation. It also provides the ability to biopsy and rule out Barrett's esophagus, which has malignant potential.
UGI (Barium swallow)
Done in the upright position to verify reflux, the position of the GE junction (above the diaphragm), and the absence of the angle of His.
Esophageal Manometry
Measures the UES and LES pressures, studies the contractile waves of the esophageal muscles, and detects the presence of motility disorders such as Nutcracker esophagus, achalasia, or diffuse esophageal spasm. Manometry may help explain chest pain that is not related to the heart or the lungs. Recently, high resolution manometry (HRM) has been developed that significantly reduces the procedure time. Newer catheters also incorporate impedance monitors with HRM.
24 HR pH Monitoring
Measures the presence and duration of acid exposure to different segments of your lower esophagus and their correlation with your symptoms. It is used to diagnose GERD. It helps in determining if the chest pain is related to the reflux. This test can be performed during upper endoscopy by clipping a pH monitoring device to the lining of the esophagus. PPI and H2 blockers for 2 weeks before the test in order to obtain the most accurate results.
Gastric Emptying Study
Studies the clearance of a radio-labeled meal from the stomach (i.e., the time it takes for the stomach to evacuate a meal).

EGD and UGI are done first. They may be sufficient to confirm the diagnosis and indicate surgical intervention. However if there are doubts about the diagnosis (inconsistent findings or atypical symptoms), then esophageal manometry and 24 HR pH monitoring are done. Finally, a gastric emptying study is done if all the previous tests were not conclusive.

Usually, when the patient's symptoms are somewhat relieved with proton pump inhibitors, it is an indication that the patient will do well after surgery.

Preoperative tests will be compared to postoperative tests in order to verify the success of the surgery.

The surgery is performed laparoscopically through four small incisions. The laparoscopic approach is less invasive and has superior results to the traditional open approach. It allows for less scarring, less pain, shorter hospital stay, and earlier return to work.

The principles of the procedure are to restore physiologic activity at the gastro-esophageal junction:

  • • Maintaining the gastro-esophageal junction below the diaphragm
  • • Closure of the crura without excessive tension or tightening and/or buttressing the large opening in the crura with the fundus of the stomach
  • • Creating a valve around the gastro-esophageal junction by wrapping the gastric fundus a full 360 degrees (Nissen fundoplication) or a partial 270 degrees (Toupet repair) around the gastro-esophageal junction
  • • The vagus nerves along with their branches are identified and preserved

After surgery, care is taken to avoid increased abdominal pressure (i.e., valsalva maneuver, vomiting, constipation, heavy lifting, sit-ups, trauma...) since it may disrupt the wrap, tear the crural stitching and send the gastro-esophageal junction back into the chest.

Transient dysphagia may be experienced post-operatively. Slippage or disruption of the wrap is possible but rare. On occasion persistent reflux symptoms will require the use of antacids.

Once more, the best results after surgery are obtained when the indications are accurate (proper patient selection) and the surgery is performed correctly.

Surgical options in Obesity

Obesity, derived from the Latin word obesus meaning “having eaten until fat”, affects all ages and races. It is a worldwide epidemic with severe consequences when left untreated. Its direct effects on health include diabetes mellitus, hypertension, coronary artery disease, obstructive sleep apnea, and an increased risk of cancer. Indirectly, it also leads to higher complication risks during surgical procedures. Increased rates of surgical site infections, venous and pulmonary thromboembolisms, leaks in colon surgery, and surgical site hernias have all been demonstrated through numerous studies. Therefore, it affects many different areas of health and must be treated as aggressively as any other disease process.

When all medically correctable etiologies (hypothyroidism, eating disorders) have been ruled out and all other weight loss options (diet, exercise) have been exhausted, surgical treatment of obesity may play a pivotal role in restoring mental and physical health. Clearly, any type of surgery is not without risks and so non-surgical weight loss is always the preferred method. The primary goal of a bariatric surgeon is to assist patients with weight loss, with or without surgery. From the initial visit, it takes a minimum of six months prior to scheduling for an operation. During this time, a multidisciplinary approach is undertaken to ensure all possible efforts are made to facilitate weight loss. In conjunction with an internist, psychologist, nutritionist, and physical therapist, positive behavioral and diet modifications are reinforced as monthly vital signs and weight are closely monitored. Also during this time, patients meet with a cardiologist, gastroenterologist, and pulmonolgist to ensure that they are in optimal medical condition for surgery.

The criteria to undergo bariatric surgery are a BMI of greater than 40, or greater than 35 with obesity related comorbidities. Again, all patients being considered for surgery must have attempted a medically supervised diet and exercise program. The three most popular options are the laparoscopic band, laparoscopic sleeve gastrectomy, and laparoscopic Roux-en-Y gastric bypass.

Laparoscopic Band:
This procedure has the least amount of associated risk, usually requires less operative time, is reversible, and is adjustable. Despite these benefits, it is not the most commonly performed bariatric procedure. The reason being it works well only for a select group of patients. Essentially, the band is wrapped around the upper portion of the stomach where food enters. Using a special port that sits underneath the skin, saline can be injected to adjust the tightness of the band around the stomach, thus restricting the amount of food that can be ingested before feeling full. The caveat to this is that all high calorie liquids and soft foods such as ice cream, milk shakes, soda, and alcohol can still easily pass through. Therefore, we prefer to offer the Lap Band to those who are “binge eaters” rather than “sweet eaters.” In addition, the appropriate candidate for a Lap Band must have discipline, compliance, and commitment. All bariatric surgery patients require close followup and supervision but the Lap Band deserves particular attention. The time and cost of adjusting the band, which can be as frequent as every six weeks, can add up. Again, Lap Band patients must be able to adhere to a strict schedule. Unlike the other procedures, it will not work without periodic adjustments to compensate for the loss of fat around the stomach.

Laparoscopic Sleeve Gastrectomy:
This is similar to the Band in that it reduces the amount of food that can be ingested before feeling full. A portion of the stomach is removed permanently. The main advantages of this operation over the Band are that there is no foreign body and there is no need for constant adjustments. However, like the Band, it requires abstention from high calorie liquids. As this operation is irreversible, patients must closely followup after the surgery in order to ensure that nutritional demands are met adequately. In the case where weight loss is inadequate, this can be converted into a Roux-en-Y gastric bypass.

Laparoscopic Roux-en-Y Gastric Bypass:
This operation is currently the gold standard of all bariatric procedure. There is level one evidence to support that it is the most effective not only at inducing and maintaining weight loss, but also to cause resolution of diabetes and other obesity related comorbidities. As in the sleeve, only a portion of the stomach remains to accommodate the ingestion of food, thereby giving the sensation of fullness. However, the excluded portion of the stomach remains, thereby making this procedure reversible. In addition, a portion of the small bowel is bypassed allowing less calories to be absorbed. Therefore, this procedure has the distinct advantage of allowing high calorie liquids to pass through without significantly impeding continued weight loss. With that being said, this procedure is more drastic than the other two. Operative time is usually longer and there is a higher risk of complications, albeit still minimal. Malabsorption of certain vitamins and nutrients can occur and therefore postoperative followup and routine blood testing is of utmost importance.

Postoperative care and follow up is even more important than the operation itself. The surgeon, internist, nutritionist, physical therapist, and psychologist all meet with the patients routinely to keep track of vital signs and weight, diet and exercise regimens, blood tests, resolution of comorbidities, and mental well-being. Dietary supplements and multivitamins are given and specific blood tests measuring iron, vitamin B12, vitamin D, folate, calcium, PTH, and alkaline phosphatase are carefully monitored at routine intervals.

Obviously, the decision for which bariatric procedure to undergo is formed carefully between the patient and surgeon. Again, non-surgical weight loss is always the first and preferred option. However, bariatric surgery provides a safe and proven method of treating obesity when all other options are exhausted. We find that our patients success is truly life-changing. Not only in terms of physical health but also in terms of mental and emotional well being. With the resolution of diabetes, hypertension, sleep apnea, and the psychological stress associated with obesity, a new chapter in life can be opened.

Postop instructions

Post Laparoscopic Cholecystectomy

You may experience pain in your upper abdomen as well as at your incision sites. This is normal and the pain medication that was prescribed to you should help.

Your dressings can be removed in 24 hours and you may shower normally. You may notice some pink discharge from the wounds which should stop.

Some people have experienced bloating or diarrhea after removal of their gallbladder. This will improve as your body adjusts to the surgery. Avoiding fatty foods will decrease the likelihood of these symptoms.

You should be able to return to work within several days. However, avoid driving, particularly while taking your prescribed medications.

Normal activity can be resumed as tolerated. However, it is imperative that you are out of bed and ambulating as early as possible to avoid pneumonia and blood clots in your lungs or legs.

If you develop yellow eyes or skin, or have persistent fever, increasing pain, nausea, or foul-smelling discharge from the wounds, contact your physician immediately.

Post Laparoscopic Hernia Repair

You may experience pain at your incision sites or in your groin. This is normal and the pain medication that was prescribed to you should help.

Your dressings can be removed in 24 hours and you may shower normally. You may notice some pink discharge from the wounds which should stop.

Swelling and bruising in your scrotum is normal and will resolve. Scrotal support devices or supportive underwear can help alleviate these symptoms.

Avoid heavy lifting or straining for at least 6 weeks as your tissues heal and achieve maximum strength.

You may resume your regular diet and be sure to drink plenty of fluids. Stool softeners can be used if you are constipated.

You should be able to return to work within several days. However, avoid driving, particularly while taking your prescribed medications.

Normal activity can be resumed as tolerated. However, it is imperative that you are out of bed and ambulating as early as possible to avoid pneumonia and blood clots in your lungs or legs.

If the pain in your incisions or scrotum is not controlled with medication, or if you develop persistent fever or foul-smelling discharge from your wounds, contact your physician immediately.

Dr. George Ferzli, MD, FACS: Patient selection and pitfalls in TEP/TAPP

Large Scrotal Hernia

Preoperative Evaluation:

  • • Occupation,
  • • Family history of hernias
  • • Allergies and Medications: Steroids, anticoagulants, others
  • • Medical History: smoking, obesity, diabetes, prostatism, pulmonary disease (COPD, Sleep apnea), ascites, peritoneal dialysis, aortic aneurysm, connective disease, prior radiation therapy, most recent colonoscopy.
  • • Prior surgery: hernia repair (type, number of recurrences, obtaining the old operative report is essential), prostatectomy, suprapubic cystostomy, abdomino-pelvic surgery
  • • Pain: thorough detailed description and documentation (chronic, mesh related, hyperestheia, dysesthesia…)

Physical exam:

  • • Abdominal panniculus (thickness, redundancy, fold), central obesity, diastasis, distance from umbilicus to pubis symphysis, previous abdominal incisions.
  • • Associated hernias: umbilical, incisional, bilateral
  • • Hernia reducibility, areas of nerve involvement, size of defect, degree of descent of testicle,
  • • Scrotal exam: extent of scrotal sac, testicular or cord masses
  • • Skin exam: rashes, recent infection.

Potential risks / Informed consent:

  • • Urinary retention
  • • Bleeding, transfusion, DVT, VTE.
  • • Injury to surrounding organs: Bowel or Bladder injury, Vas deferens injury, Ischemic orchitis
  • • Seroma, hematoma, pseudo-hydrocele
  • • Recurrence.
  • • Infection
  • • Nerve injury or entrapment resulting in chronic pain

Relative Contraindications to Laparoscopic Approach:

  • • Prior laparoscopic herniorrhaphy.
  • • Prior groin irradiation
  • • Prior pelvic lymph node resection
  • • Incarcerated, strangulated inguino-scrotal hernia
  • • Massive scrotal hernia


  • • Place a Foley catheter.
  • • Attempt reduction of the sac when the patient is anesthetized before skin preparation.
  • • Helpful to completely develop the space of Retzius and dissect the contralateral groin to ensure maximal working space.
  • • The epigastric vessels are divided - allowing an easier access to the floor of the inguinal canal, and avoiding distortion of mesh coverage.
  • • Division of the transversalis sling: floor is opened to gain remote hernia access and increase working space.
  • • Reduce cord lipoma to delineate indirect sac and provide more working space.
  • • Complete dissection of the myopectineal orifice of Fruchaud is essential.
  • • Every effort should be made to reduce the sac in its entirety. If the testicle and tunica vaginalis are in the sac, then divide sac rather than reduce it to minimize devascularization.
  • • If the indirect sac is opened, it should be opened in the upper outer quadrant of the internal ring to avoid injury to the bowel. Medially be careful not injury bladder or bowel. Upon closing the sac be careful not to catch bowel.
  • • Patients with large inguinoscrotal hernias and sacs extending deep into the scrotum can benefit from reduction and fixation of the distal sac high and laterally to the posterior inguinal wall.
  • • Oversized polypropylene mesh for adequate coverage.

If the inguinoscrotal hernia is difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may be necessary.


Treatment of inguinal hernia:

  • • For large scrotal (irreducible) inguinal hernias: after major lower abdominal surgery, previous radiotherapy of pelvic organs, and when no general anesthesia is possible, the Lichtenstein repair is the generally accepted treatment.
  • • In endoscopic repair, a mesh of at least 10x15 cm should be considered.
  • • It is recommended that, in the case of large hernia sacs, transection of the hernia sac is performed and the distal hernia sac is left undisturbed, so as to prevent ischemic orchitis. Damage to the spermatic cord structures should be avoided.

How should a large direct sac be handled?:

  • • Seroma formation seems to be more common after repair of direct hernia with significantly enlarged transversalis
  • • In incarcerated hernia, the opening of the defect may be enlarged to allow safe dissection of its contents. A releasing incision is made of the anteromedial aspect of the defect to avoid injury to epigastric or iliac vessels.
  • • In large direct hernias, inversion and fixation of the extended fascia transversalis to Cooper’s ligament may reduce the frequency of occurrence of seroma/hematoma.

Post Prostatectomy


  • • An almost 4-fold increase in groin hernia repair was observed after radical prostatectomy compared with controls, and men who received radiation therapy had an almost 2-fold increase in incidence as well as postoperative changes in the abdominal wall, increased vigilance for groin hernia seems to be important for the increased incidence of groin hernia repair seen after radical prostatectomy or radiation therapy for prostate cancer.
  • • Intense fibrosis in the preperitoneal space is observed in almost all patients following radical prostatectomy.
  • • The best choice seems to be anterior (conventional) repairs, avoiding dissection of the preperitoneal space.
  • • Careful dissection is important for the creation of a retrovesical space to accommodate the medial portion of the mesh.
  • • Increased risk of recurrence may be due to inadequate dissection or bleeding because of adhesions and disturbed anatomy.
  • • Post-prostatectomy may represent a challenge but not a contraindication to TAPP.


  • • An important technical aspect is the creation of a peritoneal flap and dissection of medial space.
  • • Start the dissection laterally to elements of the spermatic cord, followed by reduction of the hernia and only perform the medial dissection, i.e. prevesical space, at the end.
  • • This technical change can help reduce the risk of bladder injury that seems to be a main problem during the dissection.
  • • The peritoneal incision must be performed clearly above the upper rim of the region of scar tissue, which is usually easily discernible.
  • • The dissection is made strictly along the anatomical landmarks (rectus muscle, epigastric vessels, symphysis and Cooper’s ligament, transverse fascia).
  • • When necessary, the medial umbilical ligament is severed in order to gain access to the symphysis through a region that is free of scar tissue.
  • • Correct direction of dissection is from normal to scar tissue, from familiar structures to scar tissue.
  • • In many cases only sharp dissection can be performed. Thorough hemostasis should always be maintained.
  • • The dissection is usually finished by completely depicting the anatomic structures, including the large blood vessels and psoas muscle, as is also the case during primary hernia.
  • • Although TAPP after radical prostatectomy is a difficult operation, skilled laparoscopic surgeons can perform it efficiently and safely.
  • • TEP after radical prostatectomy is also feasible in expert hands.


TAPP and TEP repair in-patient after previous trans abdominal radical prostatectomy:

  • • TAPP and TEP are possible treatment options.
  • • Operation time is longer and morbidity higher compared with repair of primary hernia, but time of sick leave and re-recurrence rate are similar. There is a steep learning curve..
  • • In TEP, there is a significant conversion rate to TAPP. TAPP seems easier to perform.
  • • TAPP or TEP repair may be performed, but experts in TAPP or TEP inguinal hernia repair should only attempt them.

Prostatectomy after TEP/TAPP


  • • The procedure is technically demanding, although perioperative, oncologic, and functional outcomes do not differ from those after radical prostatectomy without previous laparoscopic inguinal hernia repair.
  • • Pelvic lymph node dissection may not be safe in some patients and may compromise accurate staging.
  • • A potential future need for radical prostatectomy in a male patient with inguinal hernia should not be a determining factor against a laparoscopic approach to inguinal hernia repair.

Cord Lipoma


  • • Lipomas are the most common lesions of the spermatic cord.
  • • Etiology is unknown, most often present in the 4th or 5th decade of life.
  • • They occur more frequently on the left side, with symptoms that resemble an inguinal hernia.
  • • Lipomas are categorized together with the herniation of fat tissue, which lead to a true indirect hernia without peritoneal sac.
  • • Herniation of adipocytes occurs from the retro/preperitoneal fat, posterior and external to the internal spermatic fascia.
  • • The herniation protrudes through the internal inguinal ring along the lateral aspect of the spermatic cord.
  • • Generally, they are not seen during transperitoneal inspection unless they can be reduced at the time of operation.
  • • They should be dissected and reduced because they may mimic a recurrent hernia.
  • • An overlooked lipoma is one of the known reasons for ‘‘recurrence.’’
  • • There is some support for the view that lipoma of the cord is etiologically involved with the development of a hernia. By enlarging the deep ring and proximal portion of the inguinal canal as it ‘‘pours’’ through under pressure, lipoma can encourage the development of a true hernia.


  • • Cord lipomas or lipomas in the femoral canal may imitate primary hernia, hernia recurrence, or become symptomatic in later course.
  • • Lipomas of spermatic cord/ round ligament and the preperitoneal lipomas of direct and femoral sacs should be dissected and reduced.

Post-Operative Small Bowel Obstruction


  • • The incidence after TAPP operation varies from 0.07 to 0.4%.
  • • It may also develop after TEP operation; however, this occurs less frequently.
  • • Can develop due to adhesions between:
    • - omentum or epiploic appendices and suture line
    • - The mesh and the intestines because of inadequate closure of the peritoneum.
  • • Rare cases of bowel obstruction can be due to incarcerations in port-site hernias or in the inadequate closure of the peritoneal flap especially after TAPP.
  • • The risk is higher after a TAPP operation but not after a TEP operation.


  • • The peritoneal opening must be thoroughly closed to prevent contact of viscera with the prosthetic mesh material and to reduce the risk of bowel obstruction.


  • • It is recommended that, due to the risk of intestinal adhesion and the risk of bowel obstruction, the extraperitoneal approach (TEP) be used for endoscopic inguinal hernia operations. It is recommended that trocar openings of 10 mm or larger are closed.

Peritoneal closure:

  • • Incomplete peritoneal closure or its breakdown in endoscopic preperitoneal hernia repair increases the risk of bowel obstruction.
  • • TAPP procedure presents a higher statistical risk of small-bowel obstruction than TEP.
  • • The most appropriate peritoneal closure is achieved by running absorbable suture.
  • • A thorough closure of peritoneal incision or peritoneal tears should be done.

Patients on Anticoagulants

Drug Mechanism of Action Indications Reversal t1/2
Activates Antithrombin III which inactivates thrombin (IIa), factor IXa, and Xa Monitor aPTT DVT Prophylaxis, PE, VTE, ACS, DIC, Angioplasty, CABG, Dialysis Protamine Sulfate Dose dependent 1.5 hrs.
Inactivates factor Xa DVT Prophylaxis, PE, VTE, ACS, Orthopedic Procedures Partial with protamine 4-6 hrs.
Vitamin K Antagonist Prevents activation of prothrombin & factors VII, IX, X, and proteins C & S by blocking the γ carboxylation of their glutamate residues Monitor INR Prevent VTE progression and recurrence Mechanical Prosthetic Heart Valves, Atrial Fibrillation 2° Prevention TIA & MI Vitamin K1
(PO or IV)
Duration of Action: 2-5 days
Direct thrombin inhibitor Liver metabolism to active metabolite, Renal excretion Reduced risk of stroke Atrial Fibrillation of Non-Valvular Origin 2/3 Dialysis 12-17 hrs.
Direct Factor Xa inhibitor Liver metabolism no active metabolite 2/3 renal and 1/3 fecal excretion Reduced risk of stroke VTE Prophylaxis Orthopedic Procedures Atrial Fibrillation of Non-Valvular Origin None 7-11 hrs.
Irreversible blockade of platelet P2Y12 receptors, which prevents ADP-stimulated activation of the GPIIb/IIIa receptor preventing platelet aggregation ACS, 2° Prevention stroke & MI, Post angioplasty with stenting Platelets Effect 7-10 days
Aspirin Irreversible inhibition by acetylation of cyclooxygenase, which is required by platelets to synthesize TXA2 which promotes aggregation & vasoconstriction Inhibits synthesis of prostacyclin Primary and secondary Prophylaxis of MI and Stroke None Effect 7-10 days


  • • Each patient should be evaluated on an individual basis, taking into account their form of anticoagulation, duration of therapy, risk factors, and other comorbidities.