Laparoscopic Surgery

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Laparoscopic Surgery

Stomach (Abdomen) Pain & Adhesions

Reflux & Hiatus Hernia

Gall Stones & Appendix infection ( Appendicitis)

Warning: Acidity, ulcer like symptoms (‘Gastric’), heartburn, indigestion (Dyspepsia), stomach discomfort after food, early satiety,, bloating, belching, burping, and other such symptoms may sometimes be due to cardiac pain (Myocardial Ischemia), hiatus hernia with acid reflux, gall stones, mild recurrent appendicitis, peptic ulcer with H.pylori infection, drugs (pain killers, steroids, etc), pernicious anemia (vitamin B12 deficiency), food allergies, stomach, intestine, liver, pancreas & bile problems or cancer,. Hence proper examination by a surgeon and investigations like ECG, Ultrasound scan, Endoscopy are important. One should not presume that the problem is acidity and ignore it or keep trying self medication, home or alternative remedies, especially if you are elderly, or have weight loss, black stools, vomiting, jaundice or stomach lump.

What is Laparoscopic Surgery?

The terms Laparoscopic surgery, Minimally invasive surgery, Endoscopic surgery and Keyhole surgery - generally mean operations that are done through small holes and are less traumatic than traditional open surgery. Advanced optical and video technology is used to look inside the body through tiny holes. Miniaturization of surgical instruments and totally new (better than laser) forms of energy to cut and seal have made surgery possible through tiny holes. Tiny holes instead of big cuts leads to a dramatic reduction in pain, disability, scars, complications like wound infection and incision hernia after surgery. It has revolutionized how surgery is perceived and performed. Recovery is rapid and one can have food and move around within a day and get back to normal activity in less than a week.

What is Diagnostic Laparoscopy and Surgery? Why is it so important?

Stomach (Abdomen) pain can be due to many reasons and is not easy to diagnose. When Scans, Endoscopy and other tests are unable to identify the cause of stomach (abdomen) pain, looking into the abdomen with a laparoscope often helps in making the diagnosis by visual identification and biopsy. Hence the term Diagnostic Laparoscopy. Once diagnosed the cause can often be eliminated or corrected by Laparoscopic surgery. A common example of this is stomach pain caused by adhesions between organs and structures inside the abdomen. These are best detected and treated (Adhesiolysis) by Laparoscopy. Thus Laparoscopy can be used both as diagnostic test and surgical treatment. It is similarly helpful for various other problems in the abdomen like fluid collections, swellings, injury, cancer staging with palliation.

What are the advantages of Laparoscopic Surgery over other treatments for appendicitis, gall stones, adhesions, etc?

laparoscopic surgery	Open operation	Other non surgical treatments
Minimal discomfort	Painful	Prolonged repeated suffering
Full recovery in 1 week	Full recovery in 6 weeks	Temporary recovery. Next attack of pain, complications any time
Glucose drip for a few hours	Glucose drip for 2-4 days	Glucose drip each time
Return home next day	Hospital stay for days	Repeated hospitalization
Less expensive on the whole	Expensive	Most expensive eventually
No obvious scar	Big obvious scar	---

What is Laparoscopic Surgery done for?

	Diagnosis and biopsy in stomach (abdomen) pain and fluid collection (ascites)
	Gall stones & Gall bladder swelling (Cholecystitis), Bile duct blockage, Liver cysts, pancreatic pseudo cysts, etc
	Appendicitis (appendix infection)
	Adhesions (of internal organs and structures)
	Gastroesophageal Reflux Disease (GERD)- Acid reflux (reverse flow of acid from stomach upwards), Hiatus Hernia
	Hernia
	Removal of endocrine tumors like pheochromocytoma and other adrenal tumors, insulinoma and other neuro-endocine tumors
	Removal of parts or whole of various organs like adrenal, kidney, ovary, uterus, intestines, stomach, spleen, liver, pancreas
	Weight loss (Bariatric surgery)
	Achalasia Cardia, Hypertrophic Pyloric stenosis
	Rectal prolapse
	Surgical emergencies like Abdominal Trauma, Gut bleeding, perforation (leak), bowel obstruction, ectopic pregnancy
	Various Urology, Gynecology, Infertility procedures

In the past, these were possible only by Open Operation and were associated with much pain, suffering, blood loss, prolonged recovery and a big, obvious scar.

FAQS ABOUT LAPAROSCOPIC SURGERY FOR (ACID) REFLUX SURGERY AND HIATUS HERNIA

What is Gastroesophageal Reflux Disease (GERD)? What are its varied manifestations and effects?

In Gastroesophageal Reflux the one way valve (LES- lower esophageal sphincter) at the lower end of the esophagus (gullet), allows reverse flow of acid and food from the stomach into the gullet. Occasional reflux is common and not harmful.

In Gastroesophageal Reflux Disease (GERD), the valve (LES) is ineffective, and permits acid to flow upwards frequently. The acid irritates the gullet (causing belching, burping, heartburn and chest pain), breathing tube (causing asthma), throat (causing frequent sore throat and sinusitis), mouth (causing erosions and sensitive teeth) - See Acid Reflux Image.

Hiatus Hernia, obesity and smoking can contribute to reflux. Acidic, fatty and spicy food stuffs can worsen the symptoms.

Prolonged damage by acid can cause stricture (narrowing) and even cancer of the esophagus (gullet).

What are the investigations? And treatment options?

Investigations include Upper GI endoscopy, Barium swallow radiograph, 24 hour pH monitoring and esophageal manometry tests
Lifestyle Changes

	If you smoke, stop.
	Avoid foods and beverages that worsen symptoms.
	Lose weight if needed.
	Eat small, frequent meals
	Wear loose-fitting clothes.
	Avoid lying down for 3 hours after a meal.
	Raise the head of your bed 6 to 8 inches by securing blocks under the head end bedposts. Just using extra pillows will not help.

Medical treatment includes above restrictions, acid blocking drugs, and drugs that facilitate early emptying of the stomach.

Endoscopic techniques: These procedures are new and are done through a flexible endoscope passed through the mouth. There long term effects are not yet known

Surgical treatment: Laparoscopic Fundoplication can permanently and effectively relieve this problem provided there are no motility problems in the esophagus. Fundoplication involves rolling up the upper end of the stomach and wrapping it around the lower end of the Gullet to strengthen the valve and reducing the hole (Hiatus) in the diaphragm through which Hiatus Hernia occurs. Any associated Hiatus Hernia is thus simultaneously repaired. Possible complications include difficulty in swallowing (Dysphagia) and bloating.

	What is Hiatus Hernia? How is it treated?
		A Hiatus Hernia is a protrusion (or hernia) of the upper part of the stomach into the chest cavity (thorax) through a weakness in the diaphragm (a muscular partition between chest and abdomen). Contributing factors include: prolonged rise in abdomen pressure due to persistent cough (e.g. smoker’s cough), constipation, frequent bending over or lifting heavy objects and obesity. Usually there is no discomfort and no treatment is required. However, when the hiatus hernia is large, it is likely to cause heartburn and other problems of reflux. Rolling (paraesophageal) type of hiatus hernia can cause difficulty in swallowing by compressing the lower end of the gullet and worse it can affect its blood supply.

Treatment including life style changes and surgery is the same as discussed for GERD above.

Faqs about laparoscopic surgery for appendicitis and gall stones

	Why are gall stone disease and appendicitis often diagnosed late?
	Gall stones (cholelithiasis) and appendicitis (appendix infection) often cause acidity and ulcer like symptoms (‘Gastric’) and the correct diagnosis is missed, sometimes for years. When the infection is mild the symptoms may be vague and misleading like indigestion(Dyspepsia), stomach discomfort after food, bloating, belching, burping

	How can I be sure I have appendicitis?
	By laparoscopic surgery, this and many other causes of similar pain can be detected and treated.

	Can my gall bladder stones/appendicitis be cured by some medicine?
	No, the only effective and permanent cure is to have the gall bladder and stones, appendix completely removed.

Is the treatment for gall stones and kidney stones the same?

No, gall stones are cholesterol rich unlike kidney stones and do not usually break up with Lithotripsy nor can they be flushed down. Since the diseased gall bladder is likely to produce more stones and is not an essential organ, it is removed with the stones unlike the kidney.

	How long will I be in hospital?
	For 1 to 3 days.

	Will I be fully normal after my gall bladder, appendix is removed?
	Yes, Completely normal. Removal of gall bladder, appendix does not cause any disability as they are non essential organs.

	What can I eat after this treatment?
	You can eat and drink normally. There will be no restrictions.

	What about my work?
	You can start normal work in 1 week.

	Will the problem organ (gall bladder &stones, appendix) grow again?
	No, it cannot if removed entirely.

	Can I have children?
	Yes, the operation does not affect childbearing and delivery.

	What can happen if the diseased gall bladder is not removed?
	Gall stones will increase in size and number. The gall bladder may get infected (Calculous Cholecystitis) causing sharp pain and fever. A Gall stone can block the neck of the Gall bladder and cause it to over distend with mucous (Mucocele), or pus and debris (Empyema of the gallbladder). Empyema leads to patchy gangrene (gangrenous Cholecystitis), leaking of pus (Perforation), and generalized Sepsis with grave implications. Gall stones can slip down into the main bile channel (cholodocholithiasis) and block it leading to fever, jaundice and potentially fatal complications like Cholangitis, Pancreatitis and Sepsis. If gall stones are suspected to be in the main bile channel (cholodocholithiasis), an ERCP (Endoscopic retrograde cholangio-pancreatography) or MRCP (akin to a MRI) is done. If there are such stones, they are removed by Endoscopic techniques after ERCP. Laparoscopic Cholecystectomy (removal of gall bladder) also called 'Lap Chole' is usually done 2 days later.

	What can happen if the diseased appendix is not removed?
	The swollen, infected appendix may perforate, and leak stools, which may then find a way out by tunnel (Fistula) formation. Spread of pus from appendix can cause serious and even potentially fatal complications like peritonitis and sepsis.


Appendix	Gall blader & Gall Stones

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