Please find below helpful information across different specialities treated by Mr W James B Smellie and his team – followed by general advice regarding what to expect before, during and after surgery and treatments.
There has been a great deal of interest recently in the press about problems associated with meshes in hernia repairs and the possibility of hernia repairs being performed without mesh.
A recent expert paper written by some of the world’s leading hernia surgeons continues to say that the use of mesh in inguinal hernia repairs is the best way to treat this condition.
The reason that meshes have become unpopular in recent months is related to their previois use in pelvic prolapse surgery, by gynaecologists, where the mesh is located close to the top of the vagina. This has resulted in some real problems in some women; and the use of meshes at this site is reasonably being questioned. The worry about meshes has subsequently widened into the use of this support in hernia repair although the anatomy of the hernias is completely different to the anatomy of the vagina.
The reason that meshes were introduced and popularised in the late 1980s was that up till that point the back wall of the inguinal canal was reinforced by a darn which at that time was normally done with nylon. There were three main problems with this approach, firstly that the holes left between the darn were quite large and the hernias could recur through these holes. Secondly the darn involved taking quite large bites into the muscle, nerves and ligaments of the back wall of the inguinal canal which might have been the source of pain. Thirdly nylon degrades with time and after 10 years is largely without strength. The Lichtenstein clinic in the United States first popularised the use of proline mash which was laid flat in the inguinal canal and sutured in place using proline stitches. This is a tension free repair requiring significantly less sitches than are used in a old-fashioned darn repair, and remains probably the commonest way of preparing an inguinal hernia.
The two main risks with inguinal hernias are of recurrence and of post-operative pain in the groin. No single technique avoids both of these main complications. It is known that by performing a Lichtenstein hernia repair that the recurrence rate drops to around one in 200 where it probably was as high as one in 10 with the old darn repairs. It is for this reason that there is such a strong surgical inclination to use mesh. Open repairs have half of the recurrence rate that laparoscopic ( so called key hole surgery although the incision length is similar now for laparoscopic and open surgery using my techniques.)
Post-operative pain after hernia repair is a very difficult issue. Although some authors and advertorial sites on the Internet suggest that the rate of post-operative pain is very high this does not seem to be the experience of many surgeons such as myself in their routine practice. The key issue is to distinguish patients who have groin pain related to a sports injury and who have or may not have a hernia at the same time. In these patients operation is unlikely to improve pain and may worsen it and I strongly believe that this group of patients is responsible for the high levels of post-operative pain in some series. Nevertheless good technique with minimum the section minimum sutures small incisions and preservation of both posterior nerves in the inguinal canal and minimum the section of the cord are in my opinion very important at reducing post-operative pain. Finally patients who suffer severe bruising which although inevitable occasionally can be largely avoided by meticulous technique.
One clinic in particular in the world however has made its name and operated on thousands of patients using a technique that does not use mesh but instead reinforces the posterior wall of the inguinal canal using continuous stainless steel stitches. I had the privilege of visiting the Shouldice clinic in May 2018 to experience first-hand this technique. Although my visit was enjoyable and highly educational I came away feeling that it is not probably appropriate to routinely offer this to European patients although the technique does not differ widely from other described techniques and patients who wish to have a mesh free repair, I would be more than happy to perform this repair using proline rather than stainless steel (which was used back in the days that the only synthetic material was nylon which degraded and has now been superseded by proline which does not).
Another interesting question to my mind is whether it is necessary to use any posteriorly wall reinforcement in women with small inguinal hernias and young men with indirect hernia which do not distort the internal ring. My view is that the recurrence rate in women is very low indeed I have only seen one or two in my practice and that large amounts of mesh are completely unnecessary. I normally place a mesh which is around the size of four first-class stamps but patients who wish to have no reinforcement are highly unlikely to recur in my view. The same is true for young athletes who are male with training induced small indirect hernia which can be treated either with hernia sac removal only or placement of a very small white mesh partly reabsorbable enforcement.
There is still remarkably little science in hernia surgery. I personally do not routinely advocate laparoscopic hernia repairs although I have done hundreds in the past. Laparoscopic repairs have the advantage of probably causing less post-operative early pain but undoubtedly have double the recurrence rate. Given that my patients very rarely complain of early or late pain beyond around 1 to 2 weeks after surgery it seems the additional risk of bowel and vessel injury as well as additional cost that is associated with laparoscopic surgery does not make this my first choice for patients. Without a doubt I would personally have an open access via a 4 cm groin incision Lichtenstein mesh repair by a surgeon who specialises in this technique, performs at least a hundred a year and has done more than 1000 hernia repairs in his or her consultant career.
Modern surgery involves tailoring the advice given to patients taking into account patient preference and hard scientific fact; adding in expert experience learned over decades of practice; an open mind to new scientific advances but also a healthy dose of scepticism about claims made on the Internet about new techniques from clinics keen to sell the product to many patients. It is a minefield for patients to navigate the claims and counterclaims on the internet; to be fair this is hardly surprising since there is so little agreement amongst many surgeons. The answer lies in including the patient in the discussion
The cinderella of abdominal wall hernias.
Few surgeons profess to be very interested in umbilical hernias although they are common and troublesome and are often repaired surgically. There is little teaching to the general surgeon trainees about this hernia and in the NHS most are done by trainees. The recurrence rate is high. Interestingly the wound infection rate is also higher than other clean surgery; either because of the bacterial count in the umbilicus or the frequency of serum collection under the scar after the repair. Because general surgeons treat it there is little attention to the position and length of the scar and removal of excess skin to improve the appearance. Many of these hernias happen in women during pregnancy as a result of the abdominal wall tearing at the scar beneath the umbilicus. This results in an everted umbilicus (an ‘outie’) which shows through T Shirts and is a source of embarrassment which makes the rest of the process of regaining the physique more troublesome.
My approach to umbilical hernia repairs is quite different to most of my colleagues. I am interested in this subject and do a lot of repairs each year. I place the incision withing the umbilicus so that it is well hidden rather than a big ‘smile’ below which is the commonest approach. I discuss and plan with the patient before the surgery how much skin to remove and how this will be done; having described a number of incisions such as the ; the ‘tulip-stem’; ‘Martini-glass’; ‘vertical magnifying glass’ and for very large everted umbilicus the ‘3 vane propellor’. I normally use mesh although understand the argument against this in smaller incisions. We can use collagen mesh. I never do this laparoscopically since a) the incisions are more visible for small hernias; laparoscopic does not address the fat bulging through the hernia defect c) laparoscopic does not address the excess skin and most importantly is associated with a higher recurrence rate.
For very large hernias and many recurrences it is necessary to do a mini-component separation to allow the anterior fascial planes to come together in the midline. Although this is normally rightly supported by a mesh; this mesh is incorporated between the layers of the abdominal wall and nowhere near important nerves and can be made of natural substances such as animal collagen if the patient desires or it is surgically necessary.
Finally I perform umbilical hernia repairs at the time of elective Caesarian sections in patients who develop hernias in pregnancy and use the same incision as the obstetricians. Therefore it can be truly described as an incisionless hernia repair. We now have around 40 women who have undergone this technique. I will publish this series in due course as to my knowledge this technique is unique in the world.
We offer personalised diagnosis and treatment for patients who notice lumps in their thyroid gland. Many patients can be reassured that these lumps are benign and surgery is by no means always offered in such cases. A thyroid specialist will offer immediate biopsy and radiological assessment of such nodules.
What happens during thyroid surgery?
Thyroid surgery is by a small, cosmetically sensitive central incision on the neck, often only 4cm in size. We often use nerve monitoring technology when appropriate to monitor the laryngeal nerve to the voice box, as surgery proceeds.
Parathyroid surgery is offered to patients who are diagnosed with primary hyperparathyroidism.
What is hyperparathyroidism?
This is a common disease when either one or all of the parathyroid glands, which are small endocrine glands in the neck, stop responding to the body’s calcium levels. This results in high blood calcium levels and calcium leaking into the urine. This is often diagnosed by the GP on routine blood tests. It helps to know where in the neck the abnormal glands are situated; a MIBI scan may tell us where to look for the abnormal gland.
What happens during parathyroid surgery?
Patients are admitted on the day of surgery and through a central 3-4cm incision either just the one gland or all glands are inspected and any affected glands are surgically removed. They are looked at under the microscope while the patient is asleep and blood tests are performed to verify that the parathyroid hormone levels have descended to normal levels.
What should I expect after parathyroid surgery?
Patients are almost always discharged on the morning after surgery; using this combination of techniques a very high level of permanent successful treatment of primary hyperparathyroidism can be achieved. Patients usually return to work after around a week, by which time the single stitch is removed in clinic and the dressings are all removed.
We perform further blood tests after a suitable interval to confirm that the condition is fully resolved and the patients may return to follow up with the referring doctor who may advise on calcium replacement and bone mineral density studies in the following years.
If your endocrinologist requests that you have your thyroid removed, for thyrotoxicosis, we can do this operation also. In those patients who require surgery, we immediately check the voice box in the clinic to check that the nerves behind the thyroid have not been damaged.
In addition, thyroid cancer patients may require the removal of lymph nodes: this is done at the same time in most cases. If this is required, it will have been planned at the thyroid cancer multidisciplinary meeting.
Hernias are a common problem where some of the intestine pushes through the abdominal wall. It happens in men in groins and the umbilicus, and in women who are or have been pregnant.
How do you treat hernias?
General surgeons have been successfully treating this condition for many years, although the success rates have been greatly improved since the introduction of non-absorbable meshes to support the abdominal wall.
There are a variety of ways of fixing these conditions. For groin (inguinal) hernias, most techniques now use a total incision length of 4-5cm located low in the groin. Mr Smellie can perform laparoscopic repairs using similar total incision lengths though incisions higher on the abdominal wall although this is almost never done now because of high recurrence and complications by this technique.
Hernias during pregnancy
Mr Smellie is interested in seeing patients with hernias in pregnancy and for some patients can offer a hernia repair (either inguinal or umbilical) performed at the time of an elective caesarian section after your baby is born; through the same caesarian incision, avoiding further cuts on the abdomen or in the groin, and the need for a second operation.
Hernias during sport
We offer a service to investigate groin pain in sportsmen and disruption of the normal groin anatomy.
Nerve entrapment syndromes
I will consider surgical mesh removals for patients with post hernia surgery nerve entrapment pain in collaboration with a suitable experienced pain specialist.
What happens before surgery?
You will be seen in clinic by Mr Smellie, who will examine you and book you for surgery if appropriate, and you wish it, having heard the benefits and risks. Once you have agreed to treatment, you will decide when and where to have the surgery. You will be emailed immediately an admissions form including details of any pre-operative instructions. A booking form will be sent to the hospital and the hospital will contact you directly. If any pre-admission tests are needed such as blood tests, heart checks, swabs these will be arranged for you. The admission form contains personal details of Mr Smellie throughout the surgical process.
On the Admission Day
Mr Smellie will see you and obtain your consent for your surgical procedure and you will also be seen by the anaesthetist Mark Cox. They are both aware of how stressful the day can be and will aim to reassure you and your family through the process.
Mr Smellie will email you a copy of the operation note and your personal discharge information. You will have direct access to Mr Smellie via mobile and email post operatively should you need it. You will be responded to within a few hours.