DIAGNOSTIC LAPAROSCOPY

Diagnostic laparoscopy is a surgical procedure used to view the abdominal organs. It is performed under general anaesthesia as an indoor procedure. A laparoscope is passed through a small cut in the abdomen. The doctor can look directly at the outside (peritoneal surfaces) of the intestine, appendix, liver, gallbladder, peritoneum, diaphragm, mesenteric lymph nodes, uterus, ovaries, fallopian tubes and any other abnormal finding that is encountered.

Diagnostic laparoscopy is often recommended when other diagnostic tests, such as ultrasound, X-ray and CT scan cannot confirm the cause of abdominal pain.

There may be one to 3 tiny cuts in the navel and the pubic region to do diagnostic laparoscopy. It enables us to explore and take relevant tissue biopsy or perform the surgery laparoscopically at the same time. It is performed under general anaesthesia. Diagnostic laparoscopy can be done as a day care procedure if the patient is stable.

LAPAROSCOPIC APPENDICECTOMY

What is laparoscopic appendicectomy?
It is a procedure done to remove a diseased appendix most commonly done to remove an inflamed appendix. The advantage of laparoscopy is that diagnosis of appendicitis can be confirmed before performing appendicectomy. Sometimes other diseases close to the appendix may clinically mimic appendicitis. This procedure is done with three incisions, most of which can be placed in hidden areas for cosmetic reasons.

When is it performed?
It is performed when a person is suffering from acute appendicitis. Occasionally it may be performed when a person is suffering from a right lower abdominal pain, all investigations are inconclusive and while doing a diagnostic laparoscopy if we do not find any significant pathology then an appendicectomy is performed.

What are the symptoms of acute appendicitis?
Sudden onset of pain most commonly in the right lower abdomen which may sometimes may begin with vague pain around the umbilicus. There may be fever, vomiting along with the pain. If not treated in time or in a severe case of perforated appendix the pain may spread to the whole of the abdomen and the patient might become dehydrated, in a condition of septic shock.

How soon can a person return to daily routine after laparoscopic appendicectomy?
After a laparoscopic appendicectomy generally the patient can go home the same evening or the next day morning. You can perform daily routine in about 48 hours. One can also return to work in about a week after surgery.

Are there any contraindications to laparoscopic appendicectomy?
Success of laparoscopic appendicectomy is limited only by the skill of the surgeon or technical resources but if at any point of time the surgeon feels that a laparoscopic surgery needs to be abandoned and an open surgery should be performed then this is considered as a sound decision so as to perform a safe surgery for the best outcome.

LAPAROSCOPIC CHOLECYSTECTOMY

What is laparoscopic cholecystectomy?
It is performed when a person is suffering from acute appendicitis. Occasionally it may be performed when a person is suffering from a right lower abdominal pain, all investigations are inconclusive and while doing a diagnostic laparoscopy if we do not find any significant pathology then an appendicectomy is performed.

What is the gall bladder what is its function?
Gall bladder is a bag like structure which stores bile and concentrates it while there is no active digestive process going on. When we eat and the food reaches the duodenum and the gall bladder contracts to release the bile.

Why are gall stones formed?
There could be many reasons for the formation of gallstones. The bile in the gallbladder is in a highly concentrated form it contains bile salts and bile pigments and cholesterol among many other ingredients. If the concentration of any of the above rises then it forms a supersaturated solution and precipitates to form stones. Dysfunction in contractility of the gallbladder also can lead to stasis and stone formation. Infection can also form a nidus for stone formation. Obesity and starvation is also associated with increased incidence of gallstones.

What are the symptoms of gall stone disease?
Pain under the ribs on the right side (Murphy's sign), vomiting and fever are the main symptoms, though vomiting and fever may or may not be present. Jaundice may be seen occasionally if there is stone inside the common bile duct or there is a compression of the common bile duct. The severity of pain depends on the severity of the swelling of the gallbladder and surrounding structures.

What happens to the digestion after removal of the gall bladder?
There is no impairment of the digestive process as it is only a storage organ and the bile is produced in the liver and directly secreted in the intestine.

Are there any diet restrictions after laparoscopic cholecystectomy?
There is no diet restriction after laparoscopic cholecystectomy. You can eat that you would normally be eating when you had a normal gallbladder.

How long does a person needs to stay in the hospital after the surgery?
Usually after a laparoscopic cholecystectomy the patient may be discharged on the same evening (day care procedure) or the next day. In case of a difficult laparoscopic cholecystectomy.

BARIATRIC SURGERY

What is the principle of laparoscopic 'Bariatric surgery'?
Laparoscopic Bariatric surgery is done on the stomach and small intestine. It achieves three primary goals
• ↓ food intake (restriction)
• ↑ satiety (↓hunger)
• ↓absorption of calories

What are the types of bariatric surgeries available?
The most popular and effective bariatric surgeries done are:
• Laparoscopic adjustable gastric banding
• Laparoscopic sleeve gastrectomy
• Laparoscopic gastric bypass

What is Laparoscopic adjustable gastric banding how does it work?
Laparoscopic adjustable gastric banding involves surgical placement of an inflatable silicon band on the upper part of the stomach and create a small pouch. As a person eats the food accumulates in this small pouch and gives a feeling of fullness (satiety). Due to the band below the pouch the food enters the larger part of the stomach very slowly hence giving a prolonged satiety. As a result of this mechanism the person eats very small quantity of solid food and feels full. The feeling of fullness stays for a long time till the person feels hungry again. The limitation of this technique is that the patient needs to comply very well with the doctor's advice. It is possible to 'cheat' the band by consuming high calorie liquids like ice-creams and colas. There is also the fact that a foreign body is implanted around the stomach which can sometimes create complications. It is a technically reversible procedure.

What is laparoscopic sleeve gastrectomy and how does it work?
The stomach is a large pouch with a capacity of over a litre. Laparoscopic sleeve gastrectomy (vertical sleeve gastrectomy) was first done by Marceau in 1993 involves trimming this pouch to a small tube with the capacity of about 100 ml or less. This surgery helps in restricting the food intake to less than 1/8th of the normal diet. The 'fundus' of the stomach which is responsible for the feeling of satiety and also secretes the hunger hormone 'ghrelin' is removed by this surgery, as a result there is early and prolonged satiety with delayed hunger. This surgery is done laparoscopically with endoscopic stapling device. The remnant pouch is permanently removed. It is technically irreversible procedure. Over last few years this procedure has gained tremendous popularity. It is recommended in young obese people without diabetes, hypertension or dyslipidemias and those patients who do not have severe longstanding co-morbidities associated with obesity.

What is Laparoscopic 'gastric bypass' and how does it work?
Laparoscopic gastric bypass is one of the oldest and most practiced bariatric surgeries. This surgery was developed in 1960 since then it has proven to have the best outcomes in terms of weight loss and also has shown good reversal of co-morbidities like resolution of diabetes (patient not requiring anti-diabetic medications anymore), resolution of hypertension, resolution of lipid disorders and significant reduction in risk of developing heart disease. Laparoscopic gastric bypass involves creating a small pouch of the stomach at the upper end, to this we attach a length of the intestine (intestinal bypass) so that the food and the digestive enzymes do not meet normally hence creating a partial 'mal-absorption'. The small pouch of stomach reduces the hunger and creates early satiety.

What is the nutritional effect of bariatric surgery?
After bariatric surgery a person eats a fraction of what one would normally eat. In such a case it is important to eat intelligently. The patient is counselled before the surgery and constantly monitored after surgery about what one eats. The right quantity of nutrients is needed to balance the diet after bariatric surgery. A good expert nutritional counselling and regular check up insures that the person eats the right kind of food. Also bad eating habits should be discouraged as it may give poor weight loss. Special care is taken to supplement iron, vitamins, calcium and proteins and prevent deficiencies. Care is also taken to avoid sudden rapid weight loss and prevent protein energy malnutrition.

What can be the cause for insufficient weight loss or sometimes weight regain after bariatric surgery?
If the person who has undergone bariatric does not follow the diet pattern advised by the bariatric nutritionist and resorts to consuming high calorie liquids like coke, ice creams, sweet liquid or semi-liquid food then this defeats the purpose of bariatric surgery.

What is ‘Metabolic Syndrome’?
• A large waistline.
• High triglyceride (or you’re on lipid lowering medications)
• Low level of HDL (or you’re on lipid lowering medications)
• High blood pressure (or you’re on medicine to treat high blood pressure).
• High fasting blood sugar (or you’re on medicine to treat high blood sugar).
When two or more of the above factors are present then the person is said to be suffering from ‘Metabolic Syndrome’. Obese people have a very high risk of developing metabolic syndrome. People suffering from metabolic syndrome have a significantly higher risk of developing heart diseases and Diabetes.

What is ‘Metabolic Surgery’?
Bariatric surgery which reverses diseases like Diabetes, Hypertension, Dyslipidemia (high cholesterol) is called metabolic surgery

What are the surgeries that can reverse Metabolic Syndrome?
Literally most of the bariatric surgeries have a potential to improve, cure or reverse metabolic syndrome. Some bariatric surgeries may work better than the other. In the order the surgery with least metabolic effects is the ‘Adjustable Gastric Band’ better than that is the Vertical Sleeve Gastrectomy. ‘Gastric Bypass & Mini Gastric Bypass are bariatric surgeries with excellent metabolic reversal, it means that these surgeries have extremely good cure rate for Type2 Diabetes Mellitus, Dyslipidemia, Hypertension & Ischemic heart disease. There are other surgeries like the Bilio-pancreatic diversion & duodenal switch which work well too but have severe nutritional problems hence are not preferred as primary operations. Lately surgeries like the ‘Ileal interposition’ are being performed which are supposed to be ‘purely metabolic’ with less weight loss effect and are being done for diabetics who are not morbidly obese.

LAPAROSCOPIC INGUINAL HERNIA REPAIR

What is an Inguinal Hernia?
Inguinal hernia is a weakness in the abdominal musculature at the inguinal region. It may be classified as an 'indirect' or a direct inguinal hernia due to its anatomical relation.

How to know one has an Inguinal Hernia?
Hernia may present with pain at the site or a visible palpable lump in the groin which may extend into the scrotum. The lump may disappear on lying down or by pressing on it, sometimes they remain constant and do not disappear hence are called 'irreducible'. Hernias become larger if a person has chronic cough, prostatic hypertrophy. Anyone who is diagnosed with an inguinal hernia should avoid heavy exertion and exercise till it is treated. Inguinal hernia can develop into life threatening conditions if it gets obstructed or strangulated and it requires an emergency surgery which is performed to save the person's life rather than treating the hernia primarily.

What age group is predisposed to suffering fromInguinal Hernia?
Inguinal hernia can be found in all age groups. It is seen predominantly in males. Infants and children suffer from indirect inguinal hernia due to the presence of a developmental remnant 'tunica vaginalis' while in elderly the direct hernia is seen more commonly due to the weakness of the wall of the inguinal canal.

What is the treatment for Inguinal Hernia?
Surgery is the main stay of inguinal hernia treatment. In the literature there are various techniques described and practiced all over the world. The surgery involves closing the abnormal weakness in the muscles and giving strength to the inguinal region so as to preventing the hernia from coming back. This is done either by just stitching the tissues together or by placing a polypropylene mesh in that region.

What is a laparoscopic inguinal Inguinal Surgery?
Inguinal hernia surgery can be done by an open technique or by laparoscopy. This involves making tiny holes in the abdomen and inserting and fixing a specially made mesh through these small holes. This mesh inserted laparoscopically is more physiological as it remains fixed in accordance with the 'Pascal's law'.

What are the advantages of a laparoscopic Inguinal Hernia Ssurgery?
This surgery is minimally invasive and very cosmetic. The post operative pain is significantly less and recovery is quick. A person after a laparoscopic hernia surgery can live a healthy and active lifestyle without fear of complication of hernia.

LAPAROSCOPIC INCISIONAL (VENTRAL) HERNIA REPAIR

What is incisional Ventral Hernia?
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. Commonly found on the anterior abdominal wall it can be classified depending on the location. Umbilical hernia (a swelling at the navel), epigastric hernia and incisional hernia (in the scar of previous abdominal surgery) are the commonly seen hernias. Spigelian hernia, lumbar hernia, obturator hernia and femoral hernia are rarer types of abdominal hernias.

What are the causes of Ventral Hernia?
Hernia can occur due to several reasons few of which are listed below:
• Congenital weak spots in umbilical, epigastric areas
• Obesity leading to muscular weakness and increased abdominal pressure
• Abdominal surgery with morbidity / eventful post-operative period
• Unaccustomed heavy lifting
• Chronic coughing
• Chronic straining during defecation or urination
• Chronic lung disease
• Ascitis (abdominal fluid collection due to liver disease or abdominal cancer)

What are the symptoms of a Hernia?
One sees a swelling on the abdomen which may completely disappear or reduce on lying down. It may increase in size or become tense on walking or exertion. Occasionally it may not reduce spontaneously and can be pushed in. It may be seen at the umbilicus, above the umbilicus or in the scar of previous surgery.

Can the hernia cause emergency medical conditions?
As explained above hernia is usually a 'reducible' swelling with little or no pain. But if suddenly it becomes very large, tense and painful followed by vomiting and abdominal distension, then this condition is called an 'obstructed hernia'. Obstructed hernia is a life threatening condition which requires an emergency operation to save the herniated bowel and the life of the person. In case of delay there is gangrene of the intestine, this condition is called 'strangulated hernia'.

What is laparoscopic Ventral Hernia repair?
Ventral hernia surgery has been a very morbid surgery for over a century when it is done by the conventional open technique where pain experienced is more and recovery is slower. Laparoscopic ventral hernia surgery has made tremendous difference in the patient's recovery which is quicker. The pain after laparoscopic hernia surgery is much less. Hospital stay is significantly shorter. The surgery involves inserting and fixing a special mesh through tiny incisions in the abdomen.

LAPAROSCOPIC REFLUX / HIATUS HERNIA SURGERY

What is ‘Gastroesophageal reflux?
Whenever the food or acid from the stomach regurgitates into the esophagus (food pipe), this condition is called gastroesophageal reflux.

What is ‘Hiatus hernia’?
The esophagus enters from the chest into the abdomen through the diaphragm; this area of the diaphragm is called the ‘hiatus’. This hiatus acts as a valve preventing the stomach contents from refluxing into the esophagus. Whenever this hiatus is abnormally large and the stomach can slip through it then this condition is called as ‘hiatus hernia’.

What is ‘Gastroesophageal reflux diseases’ (GERD)?
The symptoms caused due to refluxing acid and food are called GERD. They may be, heart burns, ‘acidity’ like symptoms, discomfort on swallowing, ‘food in the mouth’, water brash, chronic cough, laryngitis, bronchitis, asthma like symptoms, heaviness in chest, choking sensation all these may be aggravated after lying down.

How do you diagnose GERD?
Diagnosis of GERD has multiple aspects. One is to establish the damage to the esophageal surface, hiatus hernia, laxity of the lower esophageal sphincter by upper GI endoscopy. Second is to establish significant presence of acid in the esophagus by esophageal pH study and mannometry. Third is to rule out other abnormalities of the esophagus which can cause similar symptoms.

What is the medical treatment of GERD?
Medical therapy is the first and effective line of treatment. It involves reducing the gastric acid production with H2 receptor blockers like Ranitidine or ‘proton pump inhibitors’ like Omeprazole, Pantoprazole and Rabeprazole (plain or buffered) and prokinetics like Itopride or Domperidone. Mucoprotectors like Sucralfate, Diet and lifestyle modification are also advised.

What is the surgical treatment of GERD?
Inspite of a good number of people responding to the above treatment which may be required lifelong, there are some who do not respond well and have persistent symptoms. Some with large hiatus hernias and volume reflux may not respond well to medical treatment.
The surgical treatment is a procedure called the ‘Laparoscopic Nissen’s Fundoplication’ and this involves tightening of the hiatus and creating a new lower esophageal sphincter by doing a ‘fundic wrap’ or ‘Fundoplication’. There is rapid recovery after the surgery and the person does not require acid suppression or prokinetics. There may be slight post prandial ‘bloating’ which subsides gradually over a period of few months.

LAPAROSCOPIC COLORECTAL SURGERY

What is colon and rectum?
The last five feet of the intestine which is called as the large gut is divided in to cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum and anal canal. It functions as the reservoir for the excreta and absorbs the excess water from it.

What kind of colorectal surgeries can be done laparoscopically?
Most of the colorectal surgeries can be performed laparoscopically. Right hemicolectomy, left hemicolectomy and anterior resection for colonic cancer can be performed well laparoscopically. Rectopexy for rectal prolapse can also be performed. Other rarer surgeries like recto-vaginal fistula and recto-vesical fistula can also be repaired laparoscopically.

How is laparoscopic colorectal surgery performed?
This is done through 5-6 holes through which instruments varying in diameter from 5-12 mm are introduced. Dissection is done with special instruments like the laparoscopic Maryland, laparoscopic scissors, bipolar dissector and the ultrasonic dissector. Intestines are cut and stitched with endo staplers.

What are the advantages of laparoscopy in colorectal diseases?
Open colorectal surgery requires very large incisions as the surgery is performed in the depth of pelvic cavity and visualization of that part is relatively difficult. But this in laparoscopy very well taken care of as the telescope reaches in the depth and gives us a clear view of the surgical field. As there are no long incisions there is minimal pain and early mobilization is easy. This also reduces the possibility of post operative complications like pneumonitis and Deep Vein Thrombosis (DVT).

LAPAROSCOPIC GI CANCER SURGERY

Colorectal cancers are the most commonly performed intestinal cancer operations. Laparoscopic colon surgery is associated with a significantly lower intensity of pain, less requirement of painkillers and lesser blood loss, faster postoperative recovery and shorter length of stay. Barcelona trial also showed a significant decrease in postoperative morbidity rate after laparoscopy. Laparoscopic Colon cancer operations are becoming a standard of care all over the world.

LAPAROSCOPIC SOLID ORGAN SURGERY

What do we mean by abdominal solid organs? Solid abdominal organs are the spleen, liver, adrenals, and kidneys. In other words, they are not a part of the intestine.

What kind of surgeries may be required on these organs? It may require surgery for cancers, tumours, cyst etc. Laparoscopic surgery of these organs is also a good option. Spleen is a hemopoitic organ and can become very enlarged in certain conditions like the congenital spherocytosis or ‘Immune Thrombocytopenic Perpura’.

What is the advantage of laparoscopy in solid organ surgery? Solid organ tumours can be large and in conventional surgery may require large incisions for operations. Laparoscopic surgery gives good access to these organs. Laparoscopic surgery can be performed safely and as effectively as open operation with less blood loss, less postoperative pain, in turn faster recovery and reduced hospital stay. Of course laparoscopic surgery also gives good cosmetically acceptable scars.

SINGLE PORT LAPAROSCOPIC SURGERY (SILS)

What is single incision laparoscopic surgery (SILS)?
Single incision laparoscopic surgery is the technique of doing laparoscopic surgery through a single cut. It has many variations depending on the instruments and the way they are introduced SILS – Single incision laparoscopic surgery, LESS – Laparo endoscopic single incision surgery SPA - Single Port Access, NOTUS - Natural Orifice Trans Umbilical Surgery, TUES - Trans Umbilical Endoscopic Surgery, OPUS - One Port Umbilicus Surgery, SPL - Single Port Laparoscopic SIMPLE - Single-incision multiport laparo endoscopic Surgery are some of the names used to describe this technique.

How is SILS performed?
A cut of about 2.5 to 3.5 cms is made at the umbilicus and either multiple conventional ‘ports’ of varied sizes are introduced or a specially made ‘port’ (SILS, LESS, XCONE) is then introduced and surgery performed. Specialized hand instruments which can be bent and rotated inside are also used for convenience.

What are the advantages of SILS?
The advantage of a single incision laparoscopic surgery is mainly cosmetic. The surgery is otherwise technically difficult and needs special skills and adaptation to the previously learnt laparoscopic surgery. SILS may not be the right choice for all types of surgeries. Only the surgeon may choose to decide if SILS is a good option or not.

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