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Surgical options for treating Morbid Obesity

The morbidly obese have to seriously consider surgery for reducing weight to avoid its ill effects. Surgery for Morbid Obesity is for the following situations

  • The person's BMI is over 37.5 kg/m2, or is 32.5 kg/m2 or higher and a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity is present.
  • If it has not been possible to reduce or maintain weight under a medically supervised program.
Whipple Procedure

The Whipple Procedure, or pancreaticoduodenectomy, is the most commonly performed surgery to remove tumors in the pancreas. In a standard Whipple procedure, the surgeon removes the head of the pancreas, the gallbladder, part of the duodenum which is the uppermost portion of the small intestine, a small portion of the stomach called the pylorus, and the lymph nodes near the head of the pancreas. The surgeon then reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the small intestine during digestion. In another type of Whipple procedure known as pylorus preserving Whipple, the bottom portion of the stomach, or pylorus, is not removed. In both cases, the surgery usually lasts between 6-10 hours.

After a Whipple procedure, the most common complication is delayed gastric emptying, a condition in which the stomach takes too long to empty its contents. Usually, after 7-10 days the stomach begins to work properly. If delayed gastric emptying persists, supplemental feedings by a feeding tube may be started. The condition usually lasts for another 7-10 days, but could last as long as a few weeks. The most serious potential complication is abdominal infection due to leakage where the pancreas has been connected to the intestine. This occurs in approximately 10% of patients and is usually managed by a combination of draining tubes, antibiotics, and supplemental tube feedings. Patients who have undergone the Whipple procedure may experience long-term effects including digestive difficulties.

Hernia Surgery
What is a Hernia?

A hernia (external) is a protrusion of an internal body structure, or part of an organ through a weakness in the protective outer muscle-fascia covering like the protrusion of the inner tube through a weak area in the outer pneumatic tire. Hernia (internal) can also occur inside the body between spaces within like Hiatus Hernia. Hernia can cause pain, swelling or malfunction (e.g. vomiting) of a stuck protruding organ (e.g. bowels) by compressing it.

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What causes hernia?

Prolonged rise in pressure due to persistent cough (e.g. smoker’s cough), breathing difficulty (COPD), constipation, straining to pass urine, obesity, pregnancy, fluid collection (ascites) pushes internal structures through any weakness in the covering structures. Such weak spots may be a birth defect, or due to stretching as in pregnancy, obesity, or following injury/ surgery, or aging.

What are the possible complications of Hernia?

Irreducible Hernia (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.

Obstruction: compression of the herniated bowel can obstruct passage of food leading to stomach bloating, cramps, and later on vomiting, and inability to pass flatus and stools.

Strangulation: Crushing of the hernial contents may compromise blood supply and can cause death of the herniated structures (necrosis, gangrene), which may prove fatal. These signs mandate urgent surgery.

How is a Hernia treated?

As the hernia is caused by a weak spot , it needs surgery to correct it and cannot be treated by medicine. Traditional stitched repair (Herniorrhaphy) is out of flavor now because it is often under tension and the stitches can tear out producing an even bigger hernia. A ‘Tension free Hernia’ repair using a patch of synthetic material is done to treat the hernia by either open surgery or laparoscopic surgery. Open surgery can be done under Local anesthesia, as a day care procedure, and even in those unfit for General anesthesia.

Cholecystitis

Cholecystitis is defined as inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct from cholelithiasis. Ninety percent of cases involve stones in the cystic duct (ie, calculous cholecystitis), with the other 10% of cases representing acalculous cholecystitis.

Risk factors for cholecystitis mirror those for cholelithiasis and include increasing age, female sex, certain ethnic groups, obesity or rapid weight loss, drugs, and pregnancy. Although bile cultures are positive for bacteria in 50-75% of cases, bacterial proliferation may be a result of cholecystitis and not the precipitating factor.

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Acalculous cholecystitis is related to conditions associated with biliary stasis, including debilitation, major surgery, severe trauma, sepsis, long-term total parenteral nutrition (TPN), and prolonged fasting. Other causes of acalculous cholecystitis include cardiac events; sickle cell disease; Salmonella infections; diabetes mellitus; and cytomegalovirus, cryptosporidiosis, or microsporidiosis infections in patients with AIDS. (See Etiology.) For more information, see the Medscape Reference article Acalculous Cholecystopathy.

Uncomplicated cholecystitis has an excellent prognosis, with a very low mortality rate. Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. Some 25-30% of patients either require surgery or develop some complication.

Symptoms

The most common presenting symptom of acute cholecystitis is upper abdominal pain. Signs of peritoneal irritation may be present, and in some patients, the pain may radiate to the right shoulder or scapula. Frequently, the pain begins in the epigastric region and then localizes to the right upper quadrant (RUQ). Although the pain may initially be described as colicky, it becomes constant in virtually all cases. Nausea and vomiting are generally present, and patients may report fever.

Most patients with acute cholecystitis describe a history of biliary pain. Some patients may have documented gallstones. Acalculous biliary colic also occurs, most commonly in young to middle-aged females. The presentation is almost identical to calculous biliary colic with the exception of reference range laboratory values and no findings of cholelithiasis on ultrasound. Cholecystitis is differentiated from biliary colic by the persistence of constant severe pain for more than 6 hours.

Patients with acalculous cholecystitis may present similarly to patients with calculous cholecystitis, but acalculous cholecystitis frequently occurs suddenly in severely ill patients without a prior history of biliary colic. Often, patients with acalculous cholecystitis may present with fever and sepsis alone, without history or physical examination findings consistent with acute cholecystitis.

Cholecystitis in elderly persons

Elderly patients (especially patients with diabetes) may present with vague symptoms and without many key historical and physical findings. Pain and fever may be absent, and localized tenderness may be the only presenting sign. Elderly patients may also progress to complicated cholecystitis rapidly and without warning.

Cholecystitis in children

The pediatric population may also present without many of the classic findings. Children who are at higher risk for developing cholecystitis include patients with sickle cell disease, seriously ill children, those on prolonged TPN, those with hemolytic conditions, and those with congenital and biliary anomalies.

Complications

Bacterial proliferation within the obstructed gallbladder results in empyema of the organ. Patients with empyema may have a toxic reaction and may have more marked fever and leukocytosis.The presence of empyema frequently requires conversion from laparoscopic to open cholecystectomy.

In rare instances, a large gallstone may erode through the gallbladder wall into an adjacent viscus, usually the duodenum. Subsequently, the stone may become impacted in the terminal ileum or in the duodenal bulb and/or pylorus, causing a gallstone ileus.

Emphysematous cholecystitis occurs in approximately 1% of cases and is noted by the presence of gas in the gallbladder wall from the invasion of gas-producing organisms, such as Escherichia coli, Clostridia perfringens, and Klebsiella species. This complication is more common in patients with diabetes, has a male predominance, and is acalculous in 28% of cases. Because of a high incidence of gangrene and perforation, emergency cholecystectomy is recommended. Perforation occurs in up to 15% of patients. For more information, see the Medscape Reference article Emphysematous Cholecystitis. Other complications include sepsis and pancreatitis.

Treatment

Treatment of cholecystitis depends on the severity of the condition and the presence or absence of complications. Uncomplicated cases can often be treated on an outpatient basis; complicated cases may necessitate a surgical approach. In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate. Antibiotics may be given to manage infection. Definitive therapy involves cholecystectomy or placement of a drainage device; therefore, consultation with a surgeon is warranted.

Consultation with a gastroenterologist for consideration of ERCP may also be appropriate if concern exists of choledocholithiasis.

Patients admitted for cholecystitis should receive nothing by mouth because of expectant surgery. However, in uncomplicated cholecystitis, a liquid or low-fat diet may be appropriate until the time of surgery.

Initial Therapy and Antibiotic Treatment

For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, correction of electrolyte abnormalities, analgesia, and intravenous antibiotics. For mild cases of acute cholecystitis, antibiotic therapy with a single broad-spectrum antibiotic is adequate.

Conservative Treatment of Uncomplicated Cholecystitis

Outpatient treatment may be appropriate for cases of uncomplicated cholecystitis. If a patient can be treated as an outpatient, discharge with antibiotics, appropriate analgesics, and definitive follow-up care. Criteria for outpatient treatment include the following

  • Afebrile with stable vital signs.
  • No evidence of obstruction by laboratory values.
  • No evidence of common bile duct obstruction on ultrasonography.
  • No underlying medical problems, advanced age, pregnancy, or immunocompromised condition.
  • Adequate analgesia.
  • Reliable patient with transportation and easy access to a medical facility.
  • Prompt follow-up care.
Cholecystectomy

Laparoscopic cholecystectomy is the standard of care for the surgical treatment of cholecystitis. Studies have indicated that early laparoscopic cholecystectomy resulted in shorter total hospital stays with no significant difference in conversion rates or complications. The ACR 2010 criteria state that laparoscopic cholecystectomy is the primary mode of treatment for acute cholecystitis.

Early operation within 72 hours of admission has both medical and socioeconomic benefits and is the preferred approach for patients treated by surgeons with adequate experience in laparoscopic cholecystectomy.Immediate cholecystectomy or cholecystotomy is usually reserved for complicated cases in which the patient has gangrene or perforation.

Endoscopic Treatment

Endoscopy may be used for therapeutic purposes, as well as for diagnosis.

Endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) allows visualization of the anatomy and may be therapeutic by removing stones from the common bile duct.

Endoscopic ultrasound-guided transmural cholecystostomy

Studies indicate that this procedure may be safe as initial, interim, or definitive treatment of patients with severe acute cholecystitis who are at high operative risk for immediate cholecystectomy.

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.

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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 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.

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