Hernia: A hernia is the protrusion of an organ through the wall of the cavity that normally contains it. The main risk is strangulation, which is a surgical emergency. Asymptomatic hernias can be safely observed, but severe pain is a symptom of strangulation. The most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or “defect”, through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatus hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.

Hernias can be classified according to their anatomical location:

Hernia Examples include:

• abdominal hernias
• diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach)
• 
• pelvic hernias, for example, obturator hernia
• anal hernias
• hernias of the nucleus pulposus of the intervertebral discs
• intracranial hernias

A sportman’s hernia is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal, although a true hernia is not present.

Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms.

Hernia Symptoms:

• Constipation – Because a hernia is often created by a portion of the small intestine pressing through the abdominal wall, it can negatively affect the digestive system. By constricting the small intestine, a hernia can cause constipation and other digestive problems.
• Lumps – While there is not always an external lump or bulge with a hernia, it is the most common indicator that a hernia is present. Often, hernia bulges in women are less visible than in men, especially when lying down, complicating a hernia diagnosis. Other times, a lump is only present in times of stress, like when coughing. If there is a bulge that feels rigid or will not go back into the body, this is referred to as a strangulated hernia, and it requires immediate medical attention.
• Pain – The earliest warning sign that a patient may be suffering from a hernia is if they feel persistent pain in their lower abdomen or groin. Hernia sufferers usually first experience pain after some sort of singular movement like lifting, coughing, or twisting that puts strain on the abdominal wall. Often this pain will slowly subside and then come back immediately the next time that motion or action is repeated. Persistent pain is the easiest determinant of a chronic problem like a hernia.

Hernia Repairs:

Most physicians believe people avoid treating their hernias because they fear painful surgery. Today, there is little reason to fear. Hernia surgery is usually performed on an outpatient basis and patients are able to return to most normal activities in a matter of a few days.

It is generally advisable to repair hernias quickly in order to prevent complications such as organ dysfunction, gangrene, and multiple organ dysfunction syndrome. Most abdominal hernias can be surgically repaired, and recovery rarely requires long-term changes in lifestyle. Uncomplicated hernias are principally repaired by pushing back, or “reducing”, the herniated tissue, and then mending the weakness in muscle tissue (an operation called herniorrhaphy).

Hernias usually need to be surgically repaired to prevent intestinal damage and further complications. The surgery takes about an hour and is usually performed on an outpatient basis (which means the patient can go home the same day of the procedure). This surgery may be performed by an open repair (small incision over the herniated area) or by laparoscopic surgery (minimally invasive). Your surgeon will determine the best method of repair for your individual situation.

Most patients will be able to go home a few hours after surgery. If needed, a 23-hour extended recovery area is available. Typically, most patients feel fine within a few days after the surgery and resume normal eating habits and activities. Strenuous activity and exercise are restricted for 4 to 6 weeks after surgery.

Rhinoplasty, also known as nose reshaping plastic surgery or nose job is a very commonly performed plastic surgery in India.

Rhinoplasty or Nose reshaping surgery generally called nose job is a commonly performed plastic surgery procedure. The surgery is performed for two main purposes:

• Cosmetic: to improve the appearance of the nose i.e. broad nostrils, bulging nose tip, hawk like nose, bump on the bridge etc.
• Functional: to correct the deviated septum to improve breathing

Nose plastic surgery or Rhinoplasty can accentuate your overall facial appearance by making the nose in proportion with other facial procedures.

Reasons to undergo Rhinoplasty / Nose job

1. Breathing Difficulties 
   Deviated septum and nostril collapse are the main reasons for difficulty in breathing.
2. Snoring
   Snoring is mainly caused by deviated septum. It can be congenital or due to trauma.
3. Shape Change
   People often complain that they have a nose bridge that is either too big or too small or, broad or narrow nostril or, short philtrum etc. These can be re-contoured with a rhinoplasty.
4. Size Change
   The size of the nose is another complaint most people have to make. A proportionate nose can make a great difference for a beautiful face which can be achieved with rhinoplasty.
5. Gaining Symmetry
   It is a proven fact that facial symmetry is one of the surest signs of a perfect beauty in all cultures. Since nose occupies the centre of the face there can be substantial disruption in overall symmetry with a crocked or off-centre nose.

Types of Rhinoplasty/ Nose reshaping

There are various treatment options with rhinoplasty which decide the final goal of surgery such as:

1. Reduction Rhinoplasty
   The commonest type of rhinoplasty to reduce the size of the nose in correlation to rest of the facial features by correcting the bridge, tip and nostrils.
   
2. Re-constructive Rhinoplasty
   Serious conditions like skin cancer, accidents or other serious diseases can lead to severe deformity and loss of nasal tissue structure. The nose is reconstructed with grafts and other advanced technology. This kind of reconstruction can take more than one surgery, and an extremely skilled surgeon.
3. Augmentation Rhinoplasty
   Bone or tissue grafts are used to build the tip and/or bridge. Graft can also be cartilage from nasal septum. Both with augmentation and reduction rhinoplasty 2D and 3D models are created for perfect results.
4. Post-traumatic Rhinoplasty
   Injury can cause serious functional and aesthetic damage. This can be dealt with by correcting the nasal septum which is often broken in trauma cases of nose. This can be done within 10 to 15 days of injury but occasionally takes months to get the surgery done if trauma is extensive.
5. Ethnic Rhinoplasty
   It follows same method as others but done for African American, Caribbean, Hispanic, Asian and Middle Eastern as they have softer nasal contours and need extra care to conserve these unique features.
6. Adolescent Rhinoplasty
   Rhinoplasty is usually not done till the growth phase is finished. However in exceptional cases of breathing difficulties or trauma it can be done in teenagers.
7. Ageing Rhinoplasty
   Ageing can cause constriction and drooping of nasal tissues. These problems can be alleviated by rhinoplasty.
   

Outcome of Rhinoplasty

• A rhinoplasty surgery done by skilled surgeons will improve the overall appearance of a person’s face.
• The shape,size,symmetry and other imperfections are smoothened out
• Breathing ability is improved and certain birth defects are corrected
• The quality of life of the person gets better leading to a fulfilling life with feelings of anxiety disappearing which were there because of poor shape of the nose.

Candidates

If you are 18 or above, are in good health, and are mentally and emotionally stable, with a dislike for your nose, have realistic expectations from the surgery, you are a good candidate for rhinoplasty or nose reshaping surgery or nose job.

Procedure

Rhinoplasty has 2 primary techniques:

1. Closed Rhinoplasty: In this all incisions are hidden inside the nose. So the scars cannot be seen and functional or cosmetic purpose is achieved.
2. Open Rhinoplasty: Here the skin is lifted off the tip to the cartilage between nostrils and the cartilage of the nose is re-contoured precisely. There is a very minor scar below the nose. So the access and precision is better with this method.
3. Advanced Techniques such as:

• Bone alterations with high power tools

• Use of patient’s own blood as adhesive to seal the incisions

These have further improved the rhinoplasty techniques.

The surgery is done under general anaesthesia and starts with incisions on the inside of nostrils to lift a flap and gain access to underlying bone and cartilage. The required addition by grafts or reductions by removing tissues gives the desired result. The flap is then closed and sutured.

Recovery

Nasal packing (if used), stays in the nostrils for one to seven days. The outside stitches, if any, are taken off with the next five to seven days. The inner stitches are however dissolve by themselves. To reduce swelling and to keep the nasal bones in place, the nasal splint is kept in place for seven days. Light activity like returning to work or school can be resumed in the next ten days. It takes about 6 – 8 weeks to resume rigorous activities.

Results

You can expect great results if you have realistic expectations from Rhinoplasty. Final results of nose reshaping cosmetic surgery may not be apparent until 6 months to a year after the surgery.

Time

Rhinoplasty is usually performed under general anaesthesia and takes about 1-2 hours.You would need to stay at some of the best plastic surgery hospitals in India for a maximum of 2 days post-surgery. The stitches are removed within a week’s time. The stitches are removed about a week after the procedure. You would need about 8 to 10 days for getting nose plastic surgery in India.

What is a brow lift?

A brow lift, also known as a forehead lift:

• Reduces the wrinkle lines that develop horizontally across the forehead, as well as those that occur on the bridge of the nose, between the eyes
• Improves frown lines, the vertical creases that develop between the eyebrows
• Raises sagging brows that are hooding the upper eyelids
• Places the eyebrows in an alert and youthful position

Other cosmetic procedures that may be performed with a brow lift include:

• Upper and or lower eyelid surgery (blepharoplasty)
• Facelifting
• Skin resurfacing techniques

Eyelid Surgery:

SCALP PSORIASIS: WHO GIVES AND CAUSES

Who gets scalp psoriasis?

Psoriasis is common on the scalp. Researchers estimate that at least half (50 percent) of the people who have plaque (plak) psoriasis will have at least one flare-up on the scalp.

What causes scalp psoriasis?

Regardless of where psoriasis forms, the cause is the same. Psoriasis develops when a person’s immune system has faulty signals that tell skin cells to grow too quickly. New skin cells form in days rather than weeks. The body does not shed these excess skin cells. The skin cells pile up on the surface of the skin, causing patches of psoriasis to appear.

SCALP PSORIASIS: SIGNS AND SYMPTOMS

Psoriasis can appear anywhere on the scalp. Sometimes a small patch develops, which can be easy to hide with hair. Scalp psoriasis also can cover the entire scalp. When psoriasis appears on the scalp, you may notice:

• Reddish patches on the scalp. Some patches are barely noticeable. Patches also can be very noticeable, thick, and inflamed.
• Dandruff-like flaking and silvery-white scale. Scalp psoriasis can look a lot like dandruff. Many people who have scalp psoriasis see flaking. But there are differences between scalp psoriasis and dandruff. Unlike dandruff, scalp psoriasis causes a silvery sheen and dry scale on the scalp.
• Dry scalp. The scalp may be so dry that the skin cracks and bleeds.
• Itching. This is one of the most common symptoms. For some the itch is mild; others have intense itching that can interfere with everyday life and cause sleepless nights.
• Bleeding. Because scalp psoriasis can be very itchy, almost everyone scratches. Scratching can make the scalp bleed. Scratching also tends to worsen the psoriasis. Scratching can make the patches larger and thicker. This is why dermatologists tell their patients, “Try not to scratch your scalp.”
• Burning sensation or soreness. The scalp can burn. It can feel extremely sore.
• Temporary hair loss. Scratching the scalp or using force to remove the scale can cause hair loss. Once the scalp psoriasis clears, hair usually regrows.

These signs and symptoms can come and go. Some people have only one mild flare on their scalps. Others have many flare-ups, which can range from mild to serious. Many things can trigger a flare-up, including stress, cold, and dry air.

How do dermatologists diagnose scalp psoriasis?

To diagnose scalp psoriasis, a dermatologist looks at the scalp.

Sometimes a dermatologist also needs to remove a bit of skin. This skin is sent to a lab. The lab report will tell the dermatologist whether the patient has scalp psoriasis.

How do dermatologists treat scalp psoriasis?

Scalp psoriasis causes many people discomfort. Some people feel embarrassed. Treatment can ease these problems. There are many safe and effective treatments. Some people get relief from a medicated shampoo or solution. A few of these can be purchased without a prescription.

But scalp psoriasis can be stubborn. Many people see a dermatologist for treatment. A dermatologist can tell you what can help. The following types of treatment can help scalp psoriasis:

• Medicine applied to the scalp.
• Medicated shampoos.
• Scale softeners.
• Injections.
• Light treatments.
• Biologics and other medicines that work throughout the body.

Urinary incontinence is when a person cannot prevent urine from leaking out.It can be due to stress factors, such as coughing, it can happen during and after pregnancy, and it is more common with conditions such as obesity.The chances of it happening increase with age. Bladder control and pelvic floor, or Kegel, exercises can help prevent or reduce it.

Treatment

Treatment will depend on several factors, such as the type of incontinence, the patient’s age, general health, and their mental state.

Stress incontinence

Pelvic floor exercises, also known as Kegel exercises, help strengthen the urinary sphincter and pelvic floor muscles – the muscles that help control urination.

Bladder training

• Delaying the event: The aim is to control urge. The patient learns how to delay urination whenever there is an urge to do so.
• Double voiding: This involves urinating, then waiting for a couple of minutes, then urinating again.
• Toilet timetable: The person schedules bathroom at set times during the day, for example, every 2 hours.

Bladder training helps the patient gradually regain control over their bladder.

Medications for urinary incontinence

If medications are used, this is usually in combination with other techniques or exercises.

The following medications are prescribed to treat urinary incontinence:

• Anticholinergics calm overactive bladders and may help patients with urge incontinence.
• Topical estrogen may reinforce tissue in the urethra and vaginal areas and lessen some of the symptoms.
• Imipramine (Tofranil) is a tricyclic antidepressant.

Medical devices

The following medical devices are designed for females.

• Urethral inserts: A woman inserts the device before activity and takes it out when she wants to urinate.
• Pessary: A rigid ring inserted into the vagina and worn all day. It helps hold the bladder up and prevent leakage.
• Radiofrequency therapy: Tissue in the lower urinary tract is heated. When it heals, it is usually firmer, often resulting in better urinary control.
• Botox (botulinum toxin type A): Injected into the bladder muscle, this can help those with an overactive bladder.
• Bulking agents: Injected into tissue around the urethra, these help keep the urethra closed.
• Sacral nerve stimulator: This is implanted under the skin of the buttock. A wire connects it to a nerve that runs from the spinal cord to the bladder. The wire emits an electrical pulse that stimulates the nerve, helping bladder control.

Surgery

Surgery is an option if other therapies do not work. Women who plan to have children should discuss surgical options with a doctor before making the decision.

• Sling procedures: A mesh is inserted under the neck of the bladder to help support the urethra and stop urine from leaking out.
• Colposuspension: Lifting the bladder neck can help relieve stress incontinence.
• Artificial sphincter: An artificial sphincter, or valve, may be inserted to control the flow of urine from the bladder into the urethra.

Other options

Urinary Catheter: A tube that goes from the bladder, through the urethra, out of the body into a bag which collects urine.

Absorbent pads: A wide range of absorbent pads is available at pharmacies and supermarkets.

What is continuous ambulatory peritoneal dialysis?

Continuous ambulatory peritoneal dialysis (CAPD) is done to remove wastes, chemicals, and extra fluid from your body. During CAPD, a liquid called dialysate is put into your abdomen through a catheter (thin tube). The dialysate pulls wastes, chemicals, and extra fluid from your blood through the peritoneum. The peritoneum is a thin lining on the inside of your abdomen. The peritoneum works like a filter as the wastes are pulled through it. The process of filling and emptying your abdomen with dialysate is called an exchange. Exchanges may be done 3 to 5 times during the day, and once during the night.

Why do I need CAPD?

You may need CAPD if your kidneys are not working well, or if they have stopped working. Your kidneys remove wastes and extra fluid from your blood and leave your body through your urine. When your kidneys are damaged, they cannot remove wastes properly. This can cause serious problems in your body. You may need CAPD if you have acute (short-term) or chronic (long-term) kidney failure. During acute kidney failure, you may only need CAPD until your kidneys get better. If you have chronic kidney failure, you will need to have dialysis exchanges for the rest of your life.

How is a CAPD catheter put in?

A procedure will be done to place the catheter. Medicine will be given to make you relax and decrease pain. Your healthcare provider will make an incision below or beside your belly button, or just below your ribs. He will cut through your muscle and tissue to make a hole where the catheter will be placed. A catheter will be pushed into your abdomen through this hole. The end of the catheter may be placed just under your skin for 3 to 5 weeks. Your healthcare provider will put some liquid through the catheter to check that it works well. He may also put blood thinner medicine in it to help prevent your catheter from getting clogged. The catheter will be held in place with stitches, and the area covered with bandages.

How are CAPD exchanges done?

CAPD exchanges should be done in a well-lit room. There should be no pets, dander, strong breezes, or fans in the room. They can increase your risk of an infection.

• Gather your supplies. Place the following supplies on a clean table close to where you will be doing your CAPD exchange:
  • Dialysate bag and waste product bag
  • Y-shaped tubing
  • IV stand (used to hang your dialysate bag)
  • Disposable medical gloves
  • Medical mask to wear over your face during CAPD
  • Tubing clamps
  • New plastic syringe without a needle (if needed)
• Wash your hands with soap and water. Rub your hands together with soap for at least 15 seconds before rinsing them. Dry your hands with a clean towel or paper towel. Do not touch the tubing or catheter without washing your hands and wearing gloves. Keep your fingernails short and clean.
• Put on your gloves and mask. Put your mask on so that it covers your mouth and nose. Do not touch anything but the catheter and your supplies after you put the gloves on.
• Flush the tubing. Flush the tubing with dialysate liquid before your exchange to help prevent infections. Connect the lower end of the Y tubing to your catheter, and connect the 2 other ends of the tubing to the dialysate bag and the waste bag. Clamp the tubing that is attached to the catheter that goes into your abdomen. This will close off the tubing so that the dialysate does not go into your abdomen yet. Allow 100 milliliters (mL) of fresh dialysate to flow out of the bag, and down the tubing into the waste bag. After 100 mL of dialysate has drained, clamp the tubing that goes to the waste bag.
• Let the dialysate flow into your abdomen. Hang the bag at a higher level than your abdomen. Take the clamp off of the tubing that is attached to the catheter that goes into your abdomen. Let the rest of the dialysate flow into your abdomen. This should take no more than 10 minutes. You may lie down, sit, or stand up while the dialysate flows in. After all of the dialysate is in your abdomen, wash your hands and put on new gloves. Disconnect your catheter from the tubing. Clamp your catheter closed. Leave the dialysate in your abdomen for 3 to 5 hours of dwell time.
• Drain the dialysate out of your abdomen, and into the waste bag.
  • After the dwell time, follow the steps of washing your hands and putting on your mask. Be sure the supplies that you need are easy to reach and use. Connect the Y tubing to your catheter again. Do this in the same way as you did to put the dialysate into your abdomen. Clamp the tubing that goes to the dialysate bag so that it is closed. Hang the bag at a lower level than your abdomen. Remove the clamps from the tubing that leads to the waste bag. Let the dialysate drain from your abdomen into the waste bag.
  • If the dialysate is not flowing out well, change your body position. If this does not make the dialysate flow out better, disconnect the end of the tubing that is attached to your catheter. Use a syringe to gently suck the dialysate out of your abdomen. It should take less than 45 minutes to drain the dialysate out of your abdomen. The dialysate that drains out should be clear. After all the dialysate has drained out, close the waste bag and dispose of it as directed. Wash your hands.