Single Incision Surgery

  • New Approach in laparoscopic surgery
  • Umbilical scar, less pain

Single Orifice Surgery, also known as a single incision surgery, has developed quite rapidly.

In Costa Rica, Dr. Ariel Rivera Aguerri, Surgeon Director of the Center for Laparoscopic Surgery and Chief of General Surgery at the Hospital CIMA, is pioneer in the implementation of the first Single Incision Surgery for gallbladder and appendix in the Costa Rica.

These procedures' hidden scar "require a single skin incision, and is conducted entirely through the umbilicus of the patient, either with a larger trocar or several smaller ones. The goal is to reduce postoperative pain, speed recovery and improve the aesthetic results for patients.

Many single incision procedures is now performed entirely through the umbilicus, leaving no visible scar for the patient.

The potential advantages for the patient:
1. Less postoperative pain: lower abdominal pain
2. A faster recovery: less pain and fewer incisions
3. Better cosmetic results: the scar is hidden in the navel
4. Minor complications:
a. Reduce the chance of infection site
b. Reduce the incidence of ventral hernia

Benefits of this procedure via umbilical (procedure known as SIS-single-incision surgery and single port access SPA) vs. Vaginal (procedure known as NOTES, natural orifice where the best known is the vagina)

A. Reduced rate of infection,
B. Inclusion of both male and female patients,
C. No advance preparation is required orifice (vs.  requirement in the vaginal procedure),
D. Less formal instruments, etc.


Inguinal hernia surgery – Laparoscopic Repair of Inguinal Hernia

Understanding the symptoms, causes,treatment  and surgery or laparoscopic repair of abdominal hernia

Causes: inguinal hernias occur when the soft tissues – usually part of the intestine – protrudes through a weak area or rupture in the lower part of the abdominal wall.  The result can be a painful bump – especially when you cough, bend down, or lift more than one heavy object.
Not necessarily dangerous by themselves, inguinal hernias can result in potentially mortal complications.  For this reason, the doctor can recommend a surgical repair of inguinal hernia that is painful or becoming bigger.

Nowadays, inguinal hernias can be successfully repaired through laparoscopic surgery.

Symptoms:  Some hernias do not cause any symptoms, and you cannot know about it until the physician discovers it during routine medical examination.  Often, however, you can see and feel a bump in the protuberance of the intestine.  The protuberance is generally more obvious when you stand vertically, especially if you cough or make efforts.
Inguinal signs and symptoms of hernia include:

    • Protuberance in both sides of the pubic bones
    • Discomfort of the ingle when bending down, coughing or lifting objects
    • Heavy sensation of the ingle
    • Occasionally, in men, pain and swelling in the scrotum around the testis when the intestine protuberance descends in the scrotum


    Inguinal Hernia

    When do I see a doctor? See your doctor if you have a painful or notable protuberance in the area in both sides of the pubic bone.  Probably the protuberance is more evident when you stand vertically, and you can usually feel it if you put your hand directly over the area affected.
    You should push easily and softly the hernia in the abdomen when you are lying down.  If not, applying ice in the area can reduce inflammation enough for the area to be easily displaced.  Reclining with the pelvic area higher than the head can also help.
    If you cannot reduce the hernia, the herniated intestine can be trapped (encapsulated) in the abdominal wall – a serious condition that can require immediate medical care.  This condition can be accompanied with nausea, vomit or fever, and a protuberance of hernia that might be reddish, purplish or dark.  If any of these symptoms or signs occurs, call your doctor immediately.

    Treatment:  If your hernia is small and does not bother you, your doctor can recommend observation.  But enlarged hernias or painful hernias generally require surgical repair to remove the discomfort and prevent serious complications.

    What are the advantages of laparoscopic repair of Inguinal Hernia?

    The laparoscopic research of hernia is a technique that repairs damages in the abdominal wall (muscle) through the use of the laparoscopic technique (where small incisions are made and the procedure uses telescopes and a mesh or patch).  It is possible to return faster to work and normal activities with a reduction of pain in some patients.

    Am I a candidate for laparoscopic repair of Inguinal Hernia?

    Right after a profound examination the surgeon can determine if the laparoscopic repair of hernia is convenient for you.  The procedure might not be the best indicated for some patients that have undergone previous abdominal surgery or that have an underlying medical condition.

    What preparation is required?

    • Generally, hernia operations are made as ambulatory; therefore, the patient may go home the same day of the surgery
    • The pre-surgical preparation includes blood analyses, medical assessment, chest radiography and electrocardiogram depending on the age and medical condition of the person
    • It is recommended to take a shower the night before or the morning of the surgery
    • If there is difficulty to move the intestine, the person can use enemas or similar preparations recommended by the surgeon
    • After midnight the night before the operation, the person should not eat or drink anything except for the medications permitted by the surgeon with a sip of water the morning of the surgery
    • Drugs like aspirin, anticoagulants, anti-inflammatory agents (arthritis medication( and vitamin E should be temporarily suspended during several days and up to one week before the surgery
    • There should not be diet medications or Saint John Wart during the two weeks before the operation
    • Quit smoking and make the necessary arrangements for any assistance you can get at home.

    What is expected after the surgery?

    • After the operation the patient will be transferred to the recovery room and will be under observation for one or two hours until he or she is fully awake
    • As the patient is awake and can walk, he will be sent home
    • In any hernia operation, it is expected to have some pain during the first twenty four to forty eight hours
    • The person is encouraged to get up and walk the day after the surgery
    • With the laparoscopic repair of hernia it is probable to return to the normal activities after a short period of time.  Such activities include: taking showers, driving a car, climbing up the stairs, lifting things, working or having sexual relations.

    Call and make a control appointment within two weeks of the surgery

    What is gastroesophagic reflux disease (GERD) and Hiatal Hernia surgery

    • Gastroesophagic reflux disease (GERD)

    What does it mean to have reflux?
    Normally once the food is chewed it goes from the mouth to the esophagus and to the stomach, where it is mixed with the acid gastric juice for its digestion.  The esophagus and the stomach are separated by a sphincter (lower esophagic sphincter), which is a band of muscular fibers that close the valve that prevents the food and the stomach acids from going back to the esophagus.  Different from the stomach, the esophagus is not prepared to resist the effects of the acid.

    The gastroesophagic reflux disease (GERD) is a condition where the food or liquid go back from the stomach to the esophagus.  This partially digested material is a very acid liquid that irritates the esophagus, causing a painful sensation and being able to produce inflammation through time and even a small wound in the wall of the esophagus.

    Why is there reflux?

    Gastroesophagic reflux is a common condition that usually occurs without symptoms after eating.  Reflux occurs if the sphincter does not close adequately, thus, the gastric contents can return to the esophagus and cause the symptoms.

    Not all the causes are known, but it seems to be due to the fact that the sphincter that separates the esophagus from the stomach does not close correctly and allows the acid contents of the stomach return to the esophagus.  Reflux is very frequent among the general population, and it is more common among babies (because the sphincter is not totally developed) and in adults because through the years, the sphincter stops functioning and does not close correctly.

    Among the risk factors for the development of reflux we have pregnancy, hiatal hernia and overweight among others.

    How do I know if I have reflux?

    The must frequent symptom of reflux is the burning sensation in the stomach, or in the lower part of the chest, which moves upwards behind the central part of the chest until it reaches, sometimes, the mouth.  That pain is known as heartburn and it is a type of burning pain under the sternum that increases with flexion, body inclination, and the intake of food, and is relieved with antacids.  It is more frequent or worse at night. 

    Another very frequent symptom is the sudden presence of food in the mouth without nausea or vomit (regurgitation).  There can also be an acid sensation in the mouth.
    These symptoms occur frequently when the person lies down and, above all, after eating big meals, after eating certain type of foods or when drinking alcoholic beverages.
    Other symptoms are eructs, nausea, vomit, hoarseness or voice changes,throat irritation and repeated throat infection, difficulty to swallow and chronic coughing.
    The symptoms can be different for the different people.  It can be useful to pay attention to the situations or food and beverages that produce the reflux sensation or heartburn.  Detecting and talking about these situations with the physician can facilitate the solution or the improvement of the symptoms.

    What treatment possibilities do I have?

    The surgeon will let you know if you need a test or the adequate treatment for you.  This will depend on the severity of the symptoms: if the symptoms are mild you would need medication, and you would get better by making some changes in the diet and other habits.

    The general measures include, among others: weight loss, avoid lying down after meals, sleeping with elevated head in bed, taking medicines with abundant water, avoid grease, chocolate, caffeine, and mint because this will cause low esophagic pressure, and avoid consumption of alcohol and tobacco.

    In case it is necessary, there are different types of medications.  The objective of the treatment is to make the stomach produce less acid and when the content of the stomach returns to the esophagus irritation will be lower or will disappear.

    Antacids are not the most adequate medication for the treatment of this disease.  These medications neutralize the acid avoiding its action on the wall of the esophagus and the stomach; in general terms are only indicated in minor conditions.

    The reflux disease usually improves, but after some time without symptoms it can reappear.  In recurrent cases, or when there is no relieve with medication, it is necessary to perform surgical intervention. 
    Currently we can perform the procedure laparoscopically thus decreasing the size of the scars and reducing the recovery time.
    Anti-reflux surgery (Nissen funduplicature) is recommended in patients with persistent symptoms in spite of the medical treatment.

    Hiatal hernia surgery – Laparoscopic Repair of Hiatal Hernia

    Understanding the symptoms, causes, treatment  and surgery or laparoscopic repair of hiatal hernia.

    Causes: Hiatal hernia occurs when the normal opening in the diaphragm is too big.  If the defect is not repaired, the stomach or other abdominal contents can protrude (herniate) towards the chest, causing heartburn (gastroesophagic reflux), stomach pain and severe damage to the esophagus.
    Many people 50 and over have small hiatal hernias; however, hiatal hernias can affect people of all ages.
    The causes that have been suggested for hiatal hernia include the following:

    • Cough
    • Vomit
    • Efforts
    • Sudden physical effort
    • Obesity and pregnancy can also contribute to this condition

    Symptoms:  Hiatal hernia rarely present symptoms.  Pain and discomfort are usually due to gastric acid reflux, air or bile.

    • Stomach pain
    • Heartburn: worse when the person bends over or lies down
    • Difficulty to swallow
    • Chest pain
    • Esophagus
    • Eructs   
Hiatal Hernia
Hiatal Hernia


Treatment:  The objective of the treatment is to relieve the symptoms and prevent complications.  The reduction of regurgitation of the stomach contents to the esophagus (gastroesophagic reflux) relieves the symptoms of pain.  In addition, drugs can be prescribed to neutralized stomach acidity to reduce the production of acid or to strengthen the lower esophagic sphincter.
Other measures to reduce the symptoms are:

  • Avoid heavy or abundant meals
  • Never lie down or bend over immediately after a meal
  • Loose weight and quit smoking

If the symptoms and origin of the complications cannot be controled by adopting medical or general measures, the hernia could require a surgical repair (laparoscopic repair of hiatal hernia)

What are the advantages of laparoscopic repair  of Hiatal Hernia (also known as Funduplicature; anti-reflux surgery, Nissen)?

There are numerous surgical techniques to correct the defect in the diaphragm (hiatal hernia), but the most commonly used due to its efficacy is the Nissen surgery or anti-reflux surgery. 

This surgery can and should be done laparoscopically: some small incisions are made (<1 cm.) in the abdomen through which the instruments are inserted as well as a fiber optic camera while the patient is under the effect of general anesthesia.  The stomach and the lower part of the esophagus are relocated again in the abdominal cavity, the hiatus is adjusted and the stomach is sutured in its position within the abdominal cavity. 
The upper part of the stomach (depth) is wrapped around the esophagus (funduplicature) to reduce the reflux.  The reflux is reduced greatly or eliminated in 95% of the patients.

What preparation is required?

  • As of midnight the night before the surgery, the patient cannot take anything by the mouth
  • The patient should take a shower the night before or before the surgery
  • If the patient takes some daily medication, the surgeon will indicate if he should take it the morning of the surgery with a sip of water
  • If you take aspirin, anti-aggregates or medication for arthritis, you should stop those drugs before the intervention, the surgeon will give you directions to follow
  • The day of the operations the patient should be fasting
  • Surgery will last about 1 hour
  • However, the anesthetic preparation and the surgical preparation in the OR and taking the patient out of the OR takes time; therefore, the person accompanying the patient will have to wait some more time, although the real operation time is short
  • Twelve hours after the intervention the patients begin taking liquids, increasing the diet to soft diet at 24 hours.
  • If the tolerance is good, the patient will be discharged at 48 hours, with precise indications on how to take food at home, what medication to take and when to come back for control

What to expect after the surgery?

  • The laparoscopic solution of a hiatal hernia and/or gastroesophagic reflux is a major abdominal surgery and can present some pain; nausea and vomit are not rare either
  • Once the diet is tolerated, the patients leave the hospital that same day or the following day
  • The activity depends on how the patient feels.  Walking is advisable.
  • The apposite may be removed and the person can take a shower the day after the surgery
  • The patients can probably be able to go back to their normal activities in one week, including driving, climbing up the stairs, lifting light objects and working
  • In general, recovery is progressive since the person arrives at his home

Call and make a control appointment within two weeks from the surgery


Gall Bladder Surgery – Laparoscopic Colecystectomy

Understanding the symptoms, causes, treatment and Gall Bladder Surgery or Laparoscopic Colecystectomy

What is the gall bladder?
The gall bladder is a pear shaped organ located in the upper right part of the abdomen, below the liver.

Its main function is to store bile produced by the liver.

The bile is released by the bladder when ingesting food, thus helping in the digestion.  The bile moves through some small ducts – bile ducts – to the small intestine.


Bile System

Bile System

Causes: Colelithiasis, bile calcifications or gall bladder stones, meaning the formation of calcifications (stones) in the gall bladder.  These stones are formed by the precipitation of cholesterol crystals due to an alteration in the ratio between bile salts, calcium salts, bile pigments and cholesterol.  This is a frequent disease.


Obstruction of bile duct
Obstruction of bile duct


Symptoms:  The patients with bile calcifications can be totally asymptomatic (without discomfort) for a long time or present symptoms like pain or dyspepsia (indigestion) after eating, particularly greasy meals.  It is more common among women, especially after 40 and with overweight.  Once there are symptoms, these can be bile colic that are manifested with pain in the upper right quadrant of the abdomen (upper part of the stomach and liver), which are generally irradiated to the back.  This pain can last between 2-4 hours and then it can disappear completely.  It is produced by the contraction of the gall bladder that tries to expel the bile, when a calcification is located in the neck of the bladder hindering the expel of the bile.  Other symptoms can include: chills, fever, jaundice (yellowish color in the skin and mucosa), which are generally presented as colelithiasis complications.

Generally, the stones are small and mainly made up of cholesterol and bile salts.  In some cases, these stones can obstruct the expel of the bile from the bladder, causing: pain (bile colic) or inflammation or infection of the bladder (acute colescystitis).

As these symptoms become more severe, they can be accompanied by intense abdominal pain, vomit and fever.

If the stone obstructs the bile drain ducts towards the intestine, this produces a condition known as coledocolithiasis, a condition in which the patient acquires an intense yellowish color (jaundice).

In some occasions, as a consequence of a severe condition, the cases may derive into partial obstruction of the stones in the mouth of the small intestine; this is acute pancreatitis.

How is it diagnosed? Ultrasound is the most commonly used method for the diagnosis of gall bladder stones.

Treatment:  The treatment for colelitiasis or gall bladder stones is exclusively surgical.  In some cases, a transient management with drugs or special diets is used before the operation.


What is laparoscopic surgery  of the gall bladder?

It is a major routine surgery.  It requires general anesthesia and in some cases a pre-operatory assessment by an internist in those patients that have chronic diseases such as high blood pressure and diabetes.  The approach to the patient is made with very small incisions through which the specialist introduces a lens (laparoscopic) and specialized instruments to perform the extraction of the bladder.  This is a safe procedure that provides several benefits in the post-operatory period, among them we include less pain, faster recovery, lower infection index and less post-operative hernias at the long term and a faster return to the normal activities of the patient.