Inguinal hernias are common since the spermatic cord(round ligament in women) go through this area with the resulting hole which enlarges over time. Also the abdominal wall musculature in this area only has one layer as opposed to the 3 layers in other areas. No exercises or conservative approaches will repair these defects. Multiple repairs are available to treat this problem. I do not believe that one procedure is best for all patients, and choose the best repair for each patient. An open(surgical incision) repair can be performed using local anesthesia with intravenous sedation and I generally perform a mesh free inguinal hernia repair when performing this operation, using a relaxing incision in the anterior rectus sheath which allows mobilization of the transversalis fascia so that it can be sutured to Cooper's ligament(A ligament on the inside of the pelvis bone) without tension. Usually I can get healthy strong tissue for an excellent repair and if that tissue is not available, use a piece of mesh placed behind the abdominal wall therefore avoiding the location of the major sensory nerves. Mesh repairs have known complications including nerve entrapment and infection and therefore I only use it when necessary. I generally perform a laparoscopic repair on young healthy patient's, which is performed under general anesthesia and requires mesh placement behind the muscular layer that is tacked in place to Cooper's ligament. The mesh is therefore buttressed up against the abdominal wall and additionally held in place by intra-abdominal pressure. This physiologically makes more sense than placing the mesh on the outside of the abdominal wall. In patients with a hernia recurrence following open repairs, a laparoscopic approach is used and in patients with a recurrence following a laparoscopic repair, an open repair is then performed.

Ventral/incisional hernias are generally in the abdominal midline and can be repaired with sutures if the defect is small but mesh is generally used for larger defects. An open repair can be performed or a laparoscopic repair can be performed depending on the size of the defect and possible complicating intra-abdominal processes. For massive hernias a tissue advancement(component separation ) can be performed with a posterior mesh reinforcement.

PAD peripheral arterial disease usually caused by atherosclerotic(hardening of the arteries) leading to arterial narrowing(stenosis) or occlusion. In the carotid arteries this can lead to strokes/TIA due to embolization of the plaque. The narrowing initially may be found by hearing a carotid bruit and diagnosed by ultrasound. further testing with MR I arteriogram or CT angiogram can confirm the level of stenosis. While some plaque disease may regress with statin therapy, when stenosis is 70-80% in an asymptomatic patient there should be consideration of a carotid endarterectomy(which I perform under local cervical block anesthesia with IV sedation, there for a voiding general anesthesia) to decrease the patient's risk for stroke. Carotid stenting is associated with higher procedural stroke risk and I only recommend it for recurrent stenosis following carotid endarterectomy or in patient's with a history of neck irradiation.

In the lower extremities with stenosis or occlusions patient's may develop claudication(pain and weakness in the thighs and calves with ambulation) or nonhealing ulcers and tissue gangrene which may progress to limb loss. Claudication alone is generally treated with exercise therapy to develop collateral circulation and antiplatelet therapy (to prevent progression) and generally does not lead to tissue loss in most patients. Further treatment is pursued when the claudication becomes disabling,or the patient develops rest pain(severe pain at rest sometimes relieved by lowering the extremity),as this is considered critical limb ischemia. Evaluation begins by examining for palpable pedal pulses, checking for blood return in the foot following blanching the area with mild digital pressure(capillary refill), and performing noninvasive studies including ultrasound to assess flow characteristics, PVR study which measures pressures and arterial waveforms, as well as toe oxygenation levels. If the narrowing or obstruction is above the thighs a CT angiogram can evaluate the aorta, iliac arteries and common femoral arteries. An arteriogram(placing a catheter in an artery) provides better definition of the leg arteries and can be used for intervention(treating the stenosis/occlusion). A fine wire is negotiated using a support catheter through the stenosis/occlusion over which an atherectomy device can shave down the plaque, enlarging luminal diameter, then a balloon can further enlarge the lumen(balloon angioplasty) restoring blood flow. Once blood flow is maximized wound healing can proceed using appropriate antibiotics and wound care. Limb salvage is a multimodal process determined by the extent of the disease. Toes can be saved, even with infection down to the bone, by debridement(removal of necrotic tissue) surgically for gross disease and enzymatically for lesser burden. Hyperbaric oxygen therapy is adjunctive therapy which we utilize in the Southampton Hospital wound center. Sometimes major foot infections need extensive debridement including necrotic toes and tissue and wound VAC therapy is very useful in healing complex wounds. This is a negative pressure device that eliminates daily dressing changes. It can be used anywhere on the body including hip wounds and sacral wounds with bone involvement. Collagen therapy may also be used to more rapidly closed wounds following revascularization, debridement , and antibiotic therapy. Wound care products are used to promote healing, decrease dressing change frequency, provide a moist wound environment and add silver for its antimicrobial activity.20