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Papers by Harsha Jayamanne

The Bulletin of the Royal College of Surgeons of England

Introduction Karl Popper’s hypothetico-deductive model contends that an assertion is true if it a... more Introduction Karl Popper’s hypothetico-deductive model contends that an assertion is true if it agrees with the facts, and that science progresses via paradigms held to be true until replaced by better approximations of reality. Our study aimed to estimate the half-life of surgical dogma. Methods The first 15 general surgery articles at 5-year intervals were extracted from the British Journal of Surgery since its inception in 1913. A statement summarising each article’s conclusion was formatted, and non-conducive articles were excluded (n=22). A total of 293 article statements were reviewed and marked as true or false by a cohort of 15 senior general surgeons, with a majority positive response denoting a true statement. Regression analysis of the relationship between perceived truth and time was performed. Results Median reviewer positive response rate was 49.5% (range 35.8–64.2%), with over 80% of responders in total agreement regarding 151 statements (51.5%) and deeming 137 (46.8%...

Hernia, 2022

A posterior rectus sheath (PRS) hernia is a rare type of interparietal hernia where the hernial s... more A posterior rectus sheath (PRS) hernia is a rare type of interparietal hernia where the hernial sac lies between the layers (parieties) of the abdominal wall. A preoperative diagnosis is difficult and management commonly starts with the treatment of intestinal obstruction. We document cross-sectional imaging which records the subtle changes in the evolution of these unusual hernias. A 78-year-old man presented with a 3-day history of colicky abdominal pain and vomiting. He had previously undergone an open appendicectomy and was known to have gallstones from a previous CT scan. His past medical history was notable for a previous myocardial infarction and investigations for recurrent abdominal pain and inflammatory bowel disease, but no diagnosis had been established. He was obese, but examination revealed only mild tenderness with no palpable abnormality. His vital signs and blood tests were normal. He was treated for assumed recurrent cholecystitis, but a further CT demonstrated an obstructed loop of small bowel herniating through a defect in the posterior rectus sheath into the retro-rectus space (Fig. 1). He underwent an emergency laparoscopic exploration where small bowel and omentum were incarcerated in a 5 cm defect in the sheath, 3 cm from the midline but medial to linea semilunaris. This was reduced and the defined defect repaired laparoscopically with a composite (polypropylene/PTFE) mesh fixed with absorbable tacs (Fig. 2). He made an uneventful recovery and at 6-week follow-up was asymptomatic. The commonest interparietal hernia is the Spigelian variety with an incidence of approximately 0.1% of all abdominal wall hernias. As no visible or palpable swelling is usually apparent, a high index of suspicion is necessary to confirm the diagnosis in the elective setting and crosssectional imaging is often helpful. PRS herniation is rarer still, and to date, there are very few cases in the literature despite the first case being described in 1937 [1]. No doubt, other cases have occurred, but have been unreported. Most patients with PRS have had well-documented symptoms prior to diagnosis [1, 2]. The aetiology of such hernias (all in the supra-umbilical region) remains unclear, and includes age, obesity, and increased abdominal pressure, as is the case with all hernias. We have been fortuitous to have previous imaging and as can be seen the subtle defect evolved slowly over the preceding 9 years (Fig. 3). Indeed, this is one of the largest defects in the literature (commonly less than 2 cm) and the

The Annals of The Royal College of Surgeons of England, 2020

Spigelian hernias are generally considered to occur through solitary defects in the fascial layer... more Spigelian hernias are generally considered to occur through solitary defects in the fascial layers of the anterior abdominal wall in the ‘Spigelian hernia belt’ but can be found anywhere along the line of the linea semilunaris. They are uncommon in children and in adults thought to be acquired and associated with obesity. We describe an unusual case of Spigelian herniation previously unreported and possibly previously unrecognised.

The Annals of The Royal College of Surgeons of England, 2016

Parastomal hernias are common and often asymptomatic. We report the first known case in which lat... more Parastomal hernias are common and often asymptomatic. We report the first known case in which later, acute symptoms developed owing to gallstone ileus in a sac containing both omentum and small bowel. Urgent computed tomography established the diagnosis.

Hernia, 2009

Background Chronic groin symptoms after inguinal hernia repair are recognised as a frustrating pr... more Background Chronic groin symptoms after inguinal hernia repair are recognised as a frustrating problem for patients and surgeons alike. The aim of our study was to determine the frequency and severity of groin symptoms 5-7 years after a 'modified' mesh-plug inguinal hernia repair. Methods Male patients undergoing a 'modified' mesh plug inguinal hernioplasty in 2002 and 2004 were investigated by means of a 'patient friendly' questionnaire evaluating the frequency and severity of groin 'discomfort' and 'pain'. Results Two hundred consecutive unselected men who had a hernia repair in 2002 (n = 89) and 2004 (n = 111) were sent a questionnaire of which 57% and 78%, respectively, replied. Significant groin discomfort, irrespective of frequency was described by three (6%) and four (5%) patients, respectively. Significant groin pain of varying severity and frequency was documented by five (6%) patients 5 years after operation and in two or 4% of patients 7 years after surgery. Overall, only four patients (3%) said their symptoms restricted their daily activity. Excluding 13 patients who had already had inguinal surgery on the other side, over 99% (105/106) of our respondents would undergo a similar future procedure on the opposite groin. This included all but one of those who had described discomfort or pain after their hernioplasty. Conclusion Significant restricting groin symptoms were uncommon. None of our patients would decline similar surgery on a contralateral hernia, suggesting a negligible impact of symptoms on their daily lives. A well dissected 'modified' mesh plug inguinal hernioplasty is associated with minimal chronic groin symptoms 5-7 years later.

Colorectal Disease, 2010

lation-based study of 1176 Hartmann’s procedure patients also observed a reversal rate of 65% [4]... more lation-based study of 1176 Hartmann’s procedure patients also observed a reversal rate of 65% [4]. This discrepancy between the literature and the study by David et al. might in part be explained by a failure to include all codes that can be used by coders to denote colectomy, colostomy formation and colostomy closure in the analyses. Specifically, in some recent work (as yet unpublished) that we have conducted using HES data investigating use of surgery following emergency admission for diverticular disease over a 2-year period, we observed that Hartmann’s procedure was recorded as the operation performed in approximately 40% of cases – as defined by the definitive Hartmann’s (i.e. H33.5) Office of Population Censuses and Surveys (OPCS) code. However 30% of the remaining operative codes assigned to this operative cohort were for sigmoid colectomy, left hemicolectomy or anterior resection without exteriorization but with an additional code for colostomy. It is therefore essential to inspect individual OPCS field codes for dual coding to ensure the correct operative procedure is accounted for. It would appear that consistent coding techniques between trusts to denote procedures involving colonic resection and proximal end stoma are lacking. It is of course clear that the authors demonstrated low restorative rates of intestinal continuity in the population that they define (i.e. those being coded directly to a Hartmann’s procedure H33.5). It is also possible that the authors would replicate similar findings (i.e. low restorative rates) when additional analyses including colectomy and colostomy codes are included. This does however require demonstration. In conclusion, the authors should be commended for their methodological approach to using this national administrative database for longitudinal cohort evaluation. Caution should be exercised regarding the results, however, as heterogeneous coding techniques render difficult the clear identification of patients undergoing Hartmann’s procedure (or colonic resection with end stoma). Yours sincerely

The Annals of The Royal College of Surgeons of England, 2018

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well ... more Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative ‘pre-emptive analgesia’ evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25–89 years) and in the GA+LA group, it was 62 years (range:...

Annals of The Royal College of Surgeons of England, 2011

We report a case of an 80-year-old man who presented with a right inguinal hernia that appeared i... more We report a case of an 80-year-old man who presented with a right inguinal hernia that appeared incarcerated. On exploration a sausage shaped mass was found in the sac, which was debulked and histologically shown to be a well differentiated malignant peritoneal mesothelioma. Rare tumours may present as inguinal hernias and palliative debulking may be effective when they present in inguinal hernia sacs.

The Annals of The Royal College of Surgeons of England, 2017

In a Richter’s hernia, only part of the anti-mesenteric border of the bowel is incarcerated withi... more In a Richter’s hernia, only part of the anti-mesenteric border of the bowel is incarcerated within the underlying defect. We report three cases presenting between 18 days and 11 years following proctectomy. As all patients had functioning stomas a high index of suspicion is necessary to avoid a delay in diagnosis.

Hepatobiliary & Pancreatic Diseases International, 2014

Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post-... more Residual cystic duct stones (CDSs) after cholecystectomy have been recognized as a cause of post-cholecystectomy pain. This study was undertaken to determine the incidence of CDSs during laparoscopic cholecystectomy (LC). A cohort of 330 consecutive patients (80 males and 250 females) undergoing LC between November 2006 and May 2010 was studied. Their age ranged between 16 and 88 years (median 50, IQR: 36.62). The data were prospectively collected of preoperative liver function tests, imaging, the presence of intraoperative CDSs, and common bile duct stones at on-table cholangiogram. CDSs were detected intraoperatively in 64 of the 330 patients (19%). Ultrasound failed to detect CDSs in any of these cases. Deranged liver function tests were noted in 73% of the patients with CDSs and in 57% without CDSs. Common bile duct stones were detected in 9% (29) of the 330 patients. CDSs occur commonly at routine cholecystectomy, and preoperative investigations are not helpful in their diagnosis. As CDSs may lead to postoperative morbidity, they should be actively sought out during surgery if present.

Gastroenterology, 2012

squamous cells (EPC1) form a 10-11 layered stratified epithelium when grown on polyester trans-we... more squamous cells (EPC1) form a 10-11 layered stratified epithelium when grown on polyester trans-well filters apically and basally supplemented with keratinocyte serum-free media with 0.6mM Ca+2. This stratified epithelium shows epithelial barrier function and expresses squamous specific genes like GRHL-1, K10, KDAP, DSG1, and IVL. Moreover, when exposed to bile acids at pH5 in short pulses, EPC1 cells demonstrate reduction in the stratification layers and in the expression of squamous specific genes. The epithelium also exhibits loss of barrier function possibly due to disruption of desmosomal junctions and phosphorylationactivation of epidermal growth factor receptor (EGFR) and down-stream pathways. In addition, the epithelium starts expressing columnar specific transcription factor CDX2 as early as day 3 of treatment. These results indicate that bile acid at low pH is responsible for skewing the differentiation status of stratified squamous esophageal epithelium In Vitro to a more columnar type possibly by initiating a mucosal restitution response through activation of EGFR signaling.

Surgery, 2009

A 34-YEAR-OLD MAN was admitted with purulent discharge from a left inguinal hernia scar. Three ye... more A 34-YEAR-OLD MAN was admitted with purulent discharge from a left inguinal hernia scar. Three years before, a hernioplasty using the mesh plug technique was performed at another hospital, with an uneventful postoperative course. Two years later, he noted purulent discharge from the operative site that was treated unsuccessfully with oral antibiotics, and he was referred to our hospital. On admission, his temperature was 36.2°C. He had a yellow-green foul-smelling discharge at the lateral edge of the operative scar. Induration was palpable under the scar, and the surrounding skin was erythematous . Laboratory findings were normal (WBC 9000/mm 3 ). Fistulography demonstrated contrast flowing past the mesh plug and into the sigmoid colon; a colocutaneous fistula caused by migration of the mesh plug was diagnosed. After partial resection of the sigmoid colon using a trans-abdominal approach, the infected mesh (plug and on-lay patch) was removed from the inguinal canal using an anterior approach. We performed an ilio-pubic tract repair with the aponeurotic arch of the transversus abdominis that was thickened, probably because of long-term inflammation. Ten months after an uneventful postoperative course, no evidence was found of infection or recurrence of the inguinal hernia. Fig 1. A yellow-green discharge was observed at the lateral edge of the previous operative scar. Erythema of the skin is located around the wound.