Gall Bladder Removal / Cholecystectomy

 

What are Gallstones /Cholelithiasis ?

Gallstones are stones which form within the gallbladder. They may vary in number and size. For management of these stones, size/shape and number is not relevant.

What causes Gallstones /Cholelithiasis ?

The exact cause for their formation is not known, however, risk factors include

Ø  Gender: Women between 20 and 60 years of age are twice as likely to develop gallstones as men

Ø  Age: Practically all age groups but more common in the 30's & 40's

Ø  Obesity

Ø  Excess estrogen (women on oral contraceptive pills etc.)

Ø  Cholesterol-lowering drugs

Ø  Diabetes

Ø  Rapid weight loss

Ø  Prolonged fasting

Ø  Hereditary blood disorders

Ø  Unknown geological factors such as gallstones are much more common in northern and eastern part of India

 

What complications can these stones cause?

Ø  Recurrent severe abdominal pain or vomiting

Ø  Pus formation in the gallbladder (Empyema)

Ø  Cholangitis (life threatening infection of biliary system)

Ø  Gangrene and perforation of the gallbladder

Ø  Acute pancreatitis (swelling of pancreas) which can have a catastrophic sequel of multi-organ failure and other serious complications

Ø  Jaundice due to blockage of the common bile duct due to stones

Ø  Also associated with Cancer of gallbladder in the long term.

Hernia Repair

What is Hernia?

It is the protrusion of abdominal viscera through a weakened part of abdominal wall that only gets bigger with time.

What are its symptoms?

Hernia is easy to recognize. It appears as a bulge under the skin. This bulge may appear on standing or straining and disappear on lying down. It may or may not be painful. Discomfort may worsen at the end of the day and also while coughing and sneezing.

What are types of Hernia?

  • Inguinal Hernia

  • Incisional Hernia

  • Umblical Hernia

  • Hiatus Hernia

What is the treatment for Hernia?

Surgery is the only cure for majority of hernias. There is no medical treatment for it. Techniques we use to repair hernia are:

TEP Technique (Total Extraperitoneal mesh repair):- This is an advanced surgery available for the inguinal hernias. In this technique, a mesh is inserted in the two layers of the abdomen, thus the mesh is sandwiched between the two layers. No need of fixing the mesh with the screws (tackers)/ staples. This eliminates chances of pain later on.

TAPP (Trans abdominal preperitoneal mesh repair):- In this technique the mesh is implanted from inside the abdominal layers. The mesh is fixed with the help of tackers and then the peritoneum is sutured over the mesh.

 

 

 

 

 

 

Appendectomy

What is Appendix?

It is a narrow, hollow muscular tube present near the junction of the small and large intestine. It has no significant function in human beings.

What do you mean by Appendicitis?

It means inflammation of appendix (infection or swelling). The term acute means sudden development of the inflammatory process.

In whom does it occur?

It is most commonly seen in the second decade of life (adolescence), though it can occur in any age group.

What are the symptoms?

Ø  Severe pain around the navel which shifts after few hours to the right lower abdomen

Ø  Coughing and straining cause an increase in the pain

Ø  Pain is accompanied by nausea and vomiting

Ø  Less common complaints include burning on passing urine and loose stools

 

 

Anorectal Conditions

 

Anorectal symptoms and conditions are common and may be caused due to a range of conditions. however, due to lack of awareness and fear of embarrassment patients hesitate from seeking medical help. Common anal conditions, if ignored, may cause severe implications and therefore one should always consult a specialist in case of persistant symptoms.

 
1. ANAL FISTULA
 
What is Anal Fistula?

Anal fistula, or fistula-in-ano, is a common anorectal problem in which an abnormal connection develops between the inner surface of the anal canal and the skin around the anal verge thereby causing severe pain and infection.

 

Why does Anal Fistula occur?

Anal glands located between the two layers of the anal sphincters (muscles which open and close the anal orifice) and draining into the anal canal are the site where these fistulae originate. It is the blockage of the outlet of these glands which cause secretions to accumulate inside and an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.

 

What is Minimally Invasive Anal Fistula Treatment (MAFT)?

Minimally Invasive Anal Fistula Treatment technique is a major breakthrough treatment option for complex fistulas.

In this technique we first examine the fistula path with an endoscope and determine the point of the internal opening of the fistula. Then the internal opening of the fistula is closed with the help of stapler and the entire path of the fistula is destroyed by electrocautery under direct telescopic vision.

There is no surgical wound in the perianal region hence no dressings needed. The risk of faecal incontinence is negligent because no sphinter damages occur. The procedure is done under spinal anesthesia/ general anesthesia. There is minimal post-operative discomfort thereby reducing the time of recovery.

 

2.PILES

 

What are piles?

Piles or hemorrhoids are swollen blood vessels in the anal passage. There are two circular bunches of veins, one inside the anal canal and the second at the anal verge. Accordingly they are called internal and external hemorrhoids

Why do piles develop?

There are certain conditions which predispose to formation of piles. These are

Ø  Excessive straining while passing stools e.g. chronic constipation, low fibre diet, poor bowel habits

Ø  Increased backward pressure on pelvic blood vessels e.g. Pregnancy, pelvic tumors

Diagnosis is usually done by direct examination and proctoscopy. A colonoscopy may sometimes be advised if a mass lesion or other pathology is suspected in the colon.

We follow the minimally invasive technique for treatment.

Advantages of Minimally Invasive procedures for Piles

Ø  Minimal post operative pain

Ø  Much faster recovery

Ø  Shorter hospital stay

Ø  Less post operative discomfort

Ø  No dressings

Ø  Early resumption of normal activities

 

3. ANAL FISSURES

 

What is an anal fissure?

An anal fissure is a small tear or cut in the skin at the anal opening. Fissures typically cause pain and often bleed. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids. Most fissures occur along the mid-line - the top or bottom - of the anus.

What are the symptoms of an anal fissure?

The typical symptoms of an anal fissure are pain during or after defecation and fresh bleeding. The pain may be severe enough to cause the patients to avoid defecation.

What causes an anal fissure?

Ø  Injury: Most commonly due to a hard, dry bowel movement. Many women during childbirth develop an anal fissure

Ø  Digital insertion (during examination)

Ø  Foreign body insertion

Ø  Anal intercourse

A fissure may also develop following diarrhea or inflammatory conditions of the anal area.

How can a fissure be treated?

The principle of treating an anal fissure is relieving the anal spasm and correcting the constipation. At least 50 percent of anal fissures heal by medical management alone.

Ø  Drinking more fluids.

Ø  Eating a high-fiber diet to avoid constipation.

Ø  Using stool softeners.

Ø  Allowing enough time for a bowel movement

Ø  Sitz baths (soaking anal area in plain warm water)

Ø  Avoid foods that may not be well-digested (i.e., nuts, popcorn, tortilla chips)

Ø  Topical ointments

Medical treatment of an acute anal fissure may take a few days or weeks, while healing of a chronic anal fissure may take more than 6 weeks.

In case a fissure does not heal should be reexamined to determine if an underlying problem exist that prevents healing.

4. RECTAL PROLAPSE

 

What is rectal prolapse ?

A condition where in the rectum (distal most part of large intestine just above the anal canal) protrudes out of the anal opening due to stretching or disruption of its attachments to the posterior abdominal wall.

Causes of rectal prolapse?

The primary cause of rectal prolapse remains unclear. Predisposing factors include:

Ø  Prolonged straining while passing stools (chronic constipation)

Ø  Multiple pregnancies

Ø  Neurological illnesses causing muscular weakness or connective tissue disorders (genetic predisposition)

It is often seen in the elderly as aging causes the supporting ligaments to stretch the anal sphincter muscle to weaken.Diagnosis of rectal prolapse is made on history and physical examination. In case of an internal rectal prolapse sometimes a defecography is required.

How is Rectal Prolapse Treated?

Rectal prolapse occurring in children, during pregnancy and following childbirth are known to correct spontaneously and most often do not require any intervention. In most cases however surgery is required to correct rectal prolapse in adults and in some children. There are 2 procedures described for repair of rectal prolapse- Perineal Approach and Abdominal Approach.

Both procedures can be performed by Laparoscopic approach.

 

KIDNEY STONES REMOVAL WITHOUT BREAKING !

We remove Kidney stones without breaking using a technique called Laparoscopic Pyelolithotomy. Use of this technique, eliminate chances of residual stones. Even large stones can be taken out successfully using this procedure.

Stones in the ureter are taken out using a ureteroscope. The larger stones and the stones that are in the upper third of the ureter are better taken out laparoscopically, without breaking. Techniques used are:

 

1.Extra corporeal shock wave lithotripsy (ESWL) – This technique utilizes sound waves to break the stone. The stone keeps on clearing slowly after its broken. Patient needs to visit hospital multiple times and the harder stones don’t break up. Soft stones that break up have high chances of scattering into the calyces, thus leaving high chances of residual calculi. This technique is good for selected few cases only and not for all kidney stones.

2.Percutaneous Nephrolithotomy (PCNL) is an operation to remove stones from the kidney. It is a form of keyhole surgery so is performed through a small cut in the skin. This means you will have a small scar afterwards. The procedure is carried under general anaesthetic (you are asleep). PCNL is used for the treatment of stones in the kidney which are not suitable for other, less invasive treatments because they are too large, too hard or associated with abnormal kidneys. PCNL is a highly effective method of treating kidney stones. The success rate is between 75% and 99%.

 

Before operation

You will be admitted to the ward on the day before or on the day of the operation, depending on your medical history. Your admitting nurse will show you the ward and organise any further tests needed. On the morning of your procedure the anaesthetic team will visit and review you. Feel free to ask them about concerns or issues you may have in regard to being anaesthetised.You will need to sign a consent form for surgery. Before you sign this, please ensure that you fully understand the procedure and its possible risks. If you have any questions or concerns, please talk to your surgical team.

 

How is the operation performed?
 

Using x-ray guidance, a radiologist (specialist in using x-rays/scanners) makes an access track down to the kidney through a small cut in the skin. A surgical telescope (nephroscope) is passed into the kidney and used to see your stone. The stone is then broken into small pieces which are removed. At the end of the procedure a drain called a nephrostomy tube is left in the kidney. The fluid which comes out is likely to be blood-stained initially and tends to clear after a day or two. PCNL usually takes 1-2 hours.

 

After operation
 

After the operation you should move your feet and wriggle your toes to help promote circulation in your legs. This will reduce the risk of blood clots forming (venous thromboembolism). You will be able to eat and drink, after surgery, as soon as you feel like it. A few days after the procedure, dye is injected into the nephrostomy tube and an x-ray taken. Provided there is no blockage, the tube is then removed. This leaves a small wound It is important to drink plenty of fluids.

 

TOTAL LAPAROSCOPIC HYSTRECTOMY

What is Hysterectomy?

A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. It is the most commonly performed gynecological surgical procedure.

 

Causes of Hysterectomy?

  • Uterine Fibroids

  • Endometriosis

  • Uterine Prolapse

  • Cancer

  • Hyperplasia

 

What is Total Laparoscopic Hysterectomy?

The total laparoscopic hysterectomy is done by inserting a laparoscope and surgical instruments through several small incisions in the abdomen. The uterus and the cervix are removed in small pieces through one of the incisions.

 

Why TLH over conventional LAVH (Laparoscopic Assisted Vaginal Hysterectomy)?

Ø  Full length of the vagina, the birth canal, can be maintained so that the patient has no problem in sexual intercourse later on.

Ø  Full vaginal sensation is retained. The vaginal sensation comes from the nerves which are present only in the upper one third of the vagina. In TLH this upper third of the vagina can be saved, but this is not possible in LAVH..because in LAVH the surgeon has to pull down the uterus into the vagina thus the upper third of the vagina comes out with the uterus, thereby shortening the vaginal canal as well as making it insensitive to anything  thus causing feeling of numbness during the intercourse.

Ø  In TLH the uterus can be removed with complete fibroid and even the ovaries can be removed very easily wherever required.

Ø  Even the larger fibroids can be removed.

TLH is possible in cases where some earlier surgery like caesarian (C-Section) has been performed

ADVANTAGES OF LAPAROSCOPIC TECHNIQUE OVER CONVENTIONAL

Ø  Lesser post operative pain

Ø  Early recovery

Ø  Excellent cosmetic results

Ø  Chance to rule out any other pathology present in the same surgical sitting

                                       

POST OPERATIVE INSTRUCTIONS AND INFORMATION

Note: This information is not a substitute to medical advice. Please consult your doctor before you start something new.

 

Wish you a speedy recovery!

Ø  After the operation you will be kept in the recovery room. This period may vary from few minutes to few hours. The anaesthetist decides about your shifting to room. The decision depends on many technical factors.

Ø  You will be sleepy immediately after the operation due to sedation given during anaesthesia and during the recovery period.

Ø  You may have some discomfort when coming out of the effect of sedation. It gradually reduces to a tolerable level within a few minutes without any pain killer. However, if necessary you may ask for pain killer injections/tablets. You should try to avoid these drugs because they produce drowsiness and you may sleep for a longer period which is not desirable.

Ø  You may feel nauseated in the immediate post-operative period, and you may even vomit which should not cause any worry. This generally gets over after few hours.

Ø  You are generally allowed to have sips of water immediately after the operation and liquids on day of operation. In case of vomiting the liquid intake may be stopped and restarted after 30 minutes. The liquids may include water / cold drinks / tea / coffee / milk / juices or some clear soups.

Ø  You are allowed to have normal home cooked meals of your choice from the next morning at breakfast.

Ø  You should have small frequent meals for few days after operation following which you can resume your normal diet gradually. This is vital because you may feel bloated and distended if the quantity of food is in large quantities at a time.

Ø  You should try to move the limbs and can sit up immediately after operation. You should also go to the toilet on your own. There are no restrictions whatsoever for the physical movement. In fact majority of the patients will feel much better after they have started the movement. The pain also dramatically reduces once you start sitting up, moving and walking.

Ø  There is no restriction on your physical activity. You are allowed to walk as soon as you recover from your sleep. There is no restriction on climbing of stairs, lifting weight etc. You may even drive two wheelers or car as soon as you feel fit. This infact is one of the major advantages of the laparoscopic procedure.

Ø  You will be discharged on the next day of operation unless there is some associated medical/social problems. You are advised to visit again for follow up after 5 days when the dressings are removed. You should avoid wetting the dressings unless they are waterproof. After the removal of dressing, you can have normal bath with soap and water.

Ø  In very few cases there may be some bloody/whitish discharge from the wound in the post operative period. This should not bother you because it is generally harmless. You can wipe the discharge and apply band-aid so as to avoid staining the clothes. If it is more you should report to the surgeon during the next visit. Please feel free to ask any question that may come to your mind.

 

 

 

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Laparoscopic Gastric Bypass Surgery

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Dr. Kular is the founder President of MGB & OAGB International Surgeons Association  OSSI Executive;

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